Article

Strict versus liberal target range for perioperative glucose in patients undergoing coronary artery bypass grafting: A prospective randomized controlled trial

Inova Heart and Vascular Institute, Falls Church, VA 22042, USA.
The Journal of thoracic and cardiovascular surgery (Impact Factor: 4.17). 12/2011; 143(2):318-25. DOI: 10.1016/j.jtcvs.2011.10.070
Source: PubMed

ABSTRACT

The purpose of this study was to test the hypothesis that a liberal blood glucose strategy (121-180 mg/dL) is not inferior to a strict blood glucose strategy (90-120 mg/dL) for outcomes in patients after first-time isolated coronary artery bypass grafting and is superior for glucose control and target blood glucose management.
A total of 189 patients undergoing coronary artery bypass grafting were investigated in this prospective randomized study to compare 2 glucose control strategies on patient perioperative outcomes. Three methods of analyses (intention to treat, completer, and per protocol) were conducted. Observed power was robust (>80%) for significant results.
The groups were similar on preoperative hemoglobin A(1c) and number of diabetic patients. The liberal group was found to be noninferior to the strict group for perioperative complications and superior on glucose control and target range management. The liberal group had significantly fewer patients with hypoglycemic events (<60 mg/dL; P < .001), but severe hypoglycemic events (<40 mg/dL) were rare and no group differences were found (P = .23). These results were found with all 3 methods of analysis except for blood glucose variability, maximum blood glucose, and perioperative atrial fibrillation.
This study demonstrated that maintenance of blood glucose in a liberal range after coronary artery bypass grafting led to similar outcomes compared with a strict target range and was superior in glucose control and target range management. On the basis of the results of this study, a target blood glucose range of 121 to 180 mg/dL is recommended for patients after coronary artery bypass grafting as advocated by the Society of Thoracic Surgeons.

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Available from: Linda L Henry, Oct 23, 2015
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    • "In a prospective randomized controlled study, Desai and colleagues [4] demonstrated that maintenance of blood glucose in a liberal range (121-180 mg/dl) after coronary artery bypass surgery led to similar outcomes compared with a strict target range (90-120 mg/dl) and was superior in glucose control and target range management . On the basis of the results of this study, a target blood glucose range of 121- 180 mg/dl was recommended for patients after coronary artery bypass surgery, as advocated by the Society of Thoracic Surgeons [2] [4]. Although we agree that the optimal range for glycaemic control in cardiac surgical patients is 120-180, we should all remember that the exact value for optimal glycaemic control is still unknown and the subject of numerous studies. "

    Full-text · Article · Sep 2013 · Interactive Cardiovascular and Thoracic Surgery
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    • "Perioperative hyperglycaemia has been shown to be associated with adverse surgical outcomes in cardiac surgery patients [13,14]. Effective hyperglycaemic treatment is, therefore, of significant benefit in all patients after cardiac surgery [15]. Here, we present the results of a number of studies where protocol-directed insulin infusions improve perioperative hyperglycaemia in critical care. "
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    ABSTRACT: Perioperative hyperglycaemia is associated with poor outcomes in patients undergoing cardiac surgery. Frequent postoperative hyperglycaemia in cardiac surgery patients has led to the initiation of an insulin infusion sliding scale for quality improvement. A systematic review was conducted to determine whether a protocol-directed insulin infusion sliding scale is as safe and effective as a conventional practitioner-directed insulin infusion sliding scale, within target blood glucose ranges. A literature survey was conducted to identify reports on the effectiveness and safety of an insulin infusion protocol, using seven electronic databases from 2000 to 2012: MEDLINE, CINAHL, EMBASE, the Cochrane Library, the Joanna Briggs Institute Library and SIGLE. Data were extracted using pre-determined systematic review and meta-analysis criteria. Seven research studies met the inclusion criteria. There was an improvement in overall glycaemic control in five of these studies. The implementation of protocols led to the achievement of blood glucose concentration targets more rapidly and the maintenance of a specified target blood glucose range for a longer time, without any increased frequency of hyperglycaemia. Of the seven studies, four used controls and three had no controls. In terms of the meta-analysis carried out, four studies revealed a failure of patients reaching target blood glucose levels (P < 0.0005) in the control group compared with patients in the protocol group. The risk of hypoglycaemia was significantly reduced (P <0.00001) between studies. It can be concluded that the protocol-directed insulin infusion sliding scale is safe and improves blood glucose control when compared with the conventional practitioner-directed insulin infusion sliding scale. This study supports the adoption of a protocol-directed insulin infusion sliding scale as a standard of care for post-cardiac surgery patients.
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    ABSTRACT: Objective: Postoperative hyperglycemia is associated with poor clinical outcomes in patients undergoing cardiac surgery. However, some experts consider hyperglycemia to be an epiphenomenon related to acute stress. We investigated whether preoperative patient characteristics can predict hyperglycemia after cardiac surgery in nondiabetic patients. Methods: This is a retrospective study of nondiabetic patients undergoing cardiac surgery at a single center during the years 2004 to 2009. Hyperglycemia was defined as 2 consecutive blood glucose readings of 150 mg/dL or greater during the 72 hours after cardiac surgery. Results: This study included 1453 patients with hyperglycemia and 2205 patients without hyperglycemia. Hyperglycemic patients were older, were more likely to be men, had higher body mass index, were more likely to be hypertensive and hypercholesterolemic, and had lower left ventricular ejection fractions; in addition, a greater proportion had a history of cardiovascular disease and renal failure. Multivariate logistic regression analysis showed age, gender, body mass index, preoperative serum creatinine, left ventricular ejection fraction, previous cardiac surgery, and preoperative cardiogenic shock to be independently associated with hyperglycemia (P < .05 for all). Hyperglycemic patients had more intraoperative and postoperative complications. Conclusions: Preoperative patient characteristics are associated with hyperglycemia after cardiac surgery.
    No preview · Article · Aug 2012 · The Journal of thoracic and cardiovascular surgery
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