Tight glycemic control in diabetic coronary artery bypass graft patients improves perioperative outcomes and decreases recurrent ischemic events. The effect of intensive insulin therapy on infection rate, vasospasm, neurologic outcome, and mortality in neurointensive care unit after intracranial aneurysm clipping in patients with acute subarachnoid hemorrhage: a randomized prospective pilot trial. Continuous insulin infusion improves postoperative glucose control in patients with diabetes mellitus undergoing coronary artery bypass surgery. Intensive intraoperative insulin therapy versus conventional glucose management during cardiac surgery: a randomized trial. Reduction of nosocomial infections in the surgical intensive-care unit by strict glycemic control.
This study sought to determine whether tight glycemic control with a modified glucose-insulin-potassium (GIK) solution in diabetic coronary artery bypass graft (CABG) patients would improve perioperative outcomes.
                One hundred forty-one diabetic patients undergoing CABG were prospectively randomized to tight glycemic control (serum glucose, 125 to 200 mg/dL) with GIK or standard therapy (serum glucose <250 mg/dL) using intermittent subcutaneous insulin beginning before anesthesia and continuing for 12 hours after surgery. GIK patients had lower serum glucose levels (138+/-4 versus 260+/-6 mg/dL; P<0.0001), a lower incidence of atrial fibrillation (16.6% versus 42%; P=0.0017), and a shorter postoperative length of stay (6.5+/-0.1 versus 9.2+/-0.3 days; P=0.003). GIK patients also showed a survival advantage over the initial 2 years after surgery (P=0.04) and decreased episodes of recurrent ischemia (5% versus 19%; P=0.01) and developed fewer recurrent wound infections (1% versus 10%, P=0.03).
                Tight glycemic control with GIK in diabetic CABG patients improves perioperative outcomes, enhances survival, and decreases the incidence of ischemic events and wound complications. It is unclear if avoiding hyperglycemia during intensive care after acute brain injury improves morbidity, mortality, and neurologic outcome. This prospective randomized trial tested whether intensive insulin therapy affected infection rates, vasospasm, mortality, or long-term neurologic outcome in subarachnoid hemorrhage patients during their intensive care unit (ICU) stay. Comparison was made against conventional insulin therapy using a randomized trial design. The primary outcome measure was infection rate until the fourteenth postoperative day in the ICU or until patient discharge. Secondary end points were the incidence of vasospasm until the fourteenth postoperative day in the ICU or until patient discharge, and neurologic outcome and mortality at 6 months follow-up. A total of 78 patients were prospectively enrolled and randomly assigned either to conventional insulin therapy or to intensive insulin therapy (38 and 40 patients, respectively). The infection rate during the study was significantly higher in patients who received conventional insulin therapy than in patients who received intensive insulin therapy (42% vs. 27%; P<0.001). The incidence of vasospasm during the study was also similar in conventional and intensive therapy groups (31.5% vs. 27.6% in the conventional and intensive insulin therapy groups; P=0.9). Overall mortality rates at 6 months were similar in the 2 groups (18% vs.15%; P=0.9), as was the neurologic outcome at 6 months [modified Rankin score >3 in 22/38 patients (57.8%) in the conventional therapy group vs. 21/40 patients (52.5%) in the intensive insulin therapy group; P=0.7]. Intensive insulin therapy in patients with acute subarachnoid hemorrhage admitted to a postoperative neurosurgical ICU after surgical clipping of intracranial aneurysms decreases infection rates. The benefit of strict glycemic control on postoperative vasospasm, neurologic outcome, and mortality rates does not seem to be affected by intensive insulin therapy. Postoperative glucose control directly affects the incidence of deep sternal wound infection and death after patients with diabetes have undergone coronary artery bypass grafting. We compared the effect upon glucose control of continuous insulin infusion with that of glucometer-guided insulin injection after coronary artery bypass. Our prospective, randomized, controlled study involved patients with diabetes mellitus who underwent coronary artery bypass grafting in our hospital from January 2001 through January 2003. Immediately after surgery, patients were randomly assigned to receive continuous insulin infusion or conventional glucometer-guided injection to maintain blood glucose at a level between 150 and 200 mg/dL. The adequacy of postoperative blood glucose control and clinical outcome were evaluated. Of 93 patients studied, the incidence of sternal wound infection was 3.9% among infusion patients and 4.8% among injection patients (P=0.587). There was no significant difference in mortality rates (infusion, 3.9%; injection, 2.4%; P=0.573). Satisfactory blood glucose levels were achieved in significantly more patients undergoing infusion than injection (64.7% vs 28.6%, P <0.001). In the injection group, significantly more blood glucose measurements were required to achieve control (23.4 vs 16.5, P=0.001), and good control was attained much sooner in the infusion group (21.4 vs 30.5 hr, P=0.013). We conclude that continuous insulin infusion provides better control of postoperative blood glucose levels after coronary artery bypass grafting in patients with diabetes than does glucometer-guided insulin injection. It is not known whether rigorous intraoperative glycemic control reduces death and morbidity in cardiac surgery patients.
                To compare outcomes of intensive insulin therapy during cardiac surgery with those of conventional intraoperative glucose management.
                A randomized, open-label, controlled trial with blinded end point assessment.
                Tertiary care center.
                Adults with and without diabetes who were undergoing on-pump cardiac surgery.
                The primary outcome was a composite of death, sternal infections, prolonged ventilation, cardiac arrhythmias, stroke, and renal failure within 30 days after surgery. Secondary outcome measures were length of stay in the intensive care unit and hospital.
                Patients were randomly assigned to receive continuous insulin infusion to maintain intraoperative glucose levels between 4.4 (80 mg/dL) and 5.6 mmol/L (100 mg/dL) (n = 199) or conventional treatment (n = 201). Patients in the conventional treatment group were not given insulin during surgery unless glucose levels were greater than 11.1 mmol/L (>200 mg/dL). Both groups were treated with insulin infusion to maintain normoglycemia after surgery.
                Mean glucose concentrations were statistically significantly lower in the intensive treatment group at the end of surgery (6.3 mmol/L [SD, 1.6] [114 mg/dL {SD, 29}] in the intensive treatment group vs. 8.7 mmol/L [SD, 2.3] [157 mg/dL {SD, 42}] in the conventional treatment group; difference, -2.4 mmol/L [95% CI, -2.8 to -1.9 mmol/L] [-43 mg/dL {CI, -50 to -35 mg/dL}]). Eighty two of 185 patients (44%) in the intensive treatment group and 86 of 186 patients (46%) in the conventional treatment group had an event (risk ratio, 1.0 [CI, 0.8 to 1.2]). More deaths (4 deaths vs. 0 deaths; P = 0.061) and strokes (8 strokes vs. 1 strokes; P = 0.020) occurred in the intensive treatment group. Length of stay in the intensive care unit (mean, 2 days [SD, 2] vs. 2 days [SD, 3]; difference, 0 days [CI, -1 to 1 days]) and in the hospital (mean, 8 days [SD, 4] vs. 8 days [SD, 5]; difference, 0 days [CI, -1 to 0 days]) was similar for both groups.
                This single-center study used a composite end point and could not examine whether outcomes differed by diabetes status.
                Intensive insulin therapy during cardiac surgery does not reduce perioperative death or morbidity. The increased incidence of death and stroke in the intensive treatment group raises concern about routine implementation of this intervention. To investigate whether hyperglycemia in glucose-intolerant patients without diabetes could lead to increased nosocomial infections in the surgical intensive-care unit (ICU).
                A prospective, randomized, controlled clinical trial was conducted in the surgical ICU of a large teaching hospital in Hartford, Connecticut. Adult patients admitted to a 12-bed surgical ICU requiring treatment of hyperglycemia (glucose values > or = 140 mg/dL) were randomly assigned to receive standard insulin therapy (target glucose range, 180 to 220 mg/dL) or strict insulin therapy (target glucose range, 80 to 120 mg/dL) throughout their ICU stay. Demographic data, comorbidities, and confounding variables were analyzed. Outcome measures included mean daily serum glucose values, mean daily insulin doses, and number of nosocomial infections during the ICU stay.
                The study was completed by 61 critically ill surgical patients (27 in the standard glucose control group and 34 in the strict glucose control group). A significant reduction (P<0.001) in mean daily glucose level was achieved in the strict glycemic control group (125 +/- 36 mg/dL) in comparison with the standard glycemic control group (179 +/- 61 mg/dL). Furthermore, a significant reduction (P<0.05) in the incidence of total nosocomial infections, including intravascular device, bloodstream, intravascular device-related bloodstream, and surgical site infections, was observed in the strict glucose control group in comparison with the standard glucose control group. The incidence of hypoglycemia (glucose levels <60 mg/dL) was significantly increased (P<0.001) in the strict glycemic control group in comparison with the standard glycemic control group (32% versus 7.4% of patients or 0.8% versus 0.1% of total serum glucose values, respectively).
                Strict glycemic control is a safe and effective method for reducing the incidence of nosocomial infections in a predominantly nondiabetic, general surgical ICU patient population.
There is insufficient evidence to support strict glycaemic control versus conventional management (maintenance of glucose < 200 mg/dL) for the prevention of SSIs. No trials were found that evaluated strict glycaemic control in the immediate pre-operative period or outside the setting of an intensive care unit. The trials were limited by small sample size, inconsistencies in the definitions of the outcome measures and methodological quality. Further large randomised trials are required to address this question and may be most appropriately performed in patients at high risk for SSIs.