title: Management of tight intraoperative glycemic control during off-pump coronary artery bypass surgery in diabetic and nondiabetic patients.
abstract: OBJECTIVE
  To optimize intra- and postoperative insulin management in cardiac surgical patients.
  
  
  METHODS
  A prospective, randomized, open-label, single-center study.
  
  
  METHODS
  A large nonuniversity hospital.
  
  
  METHODS
  Sixty diabetics and 60 nondiabetics undergoing off-pump cardiac bypass surgery.
  
  
  METHODS
  Intra- and postoperative tight glycemic control were achieved using different approaches with a modified insulin protocol.
  
  
  RESULTS
  Nondiabetics were divided randomly: in the ND-ind group (n = 30), insulin was started at induction according to preinduction blood glucose (BG) concentrations. In group ND >110 (n = 30), insulin was started when BG concentrations exceeded 110 mg/dL during surgery. Up to 85% of the ND >110 group started on insulin intraoperatively. Intraoperatively, the ND-ind group had more BG within target (80-110 mg/dL) (p = 0.002), less BG >130 mg/dL (p = 0.015), and more BG between 70 and 79 mg/dL (p = 0.002). In diabetics, BG concentration was checked every 30 (DM-30), n = 30) versus 60 minutes (DM-60, n = 30) to improve the protocol's performance. Intraoperatively, there were more BG concentrations within target (80-110 mg/dL) (p = 0.02) and less >130 mg/dL (p = 0.0002) in the DM-30 group. During surgery, the hyperglycemic index and the glycemic penalty index were lower in the ND-ind group (p < 0.05). Postoperatively, the mean BG concentrations, hyperglycemic index, and glycemic penalty index in diabetics and nondiabetics were comparable between groups (p < 0.05). In the overall 2,641 BG samples, the lowest BG concentration in the operating room was 71 and in the intensive care unit (ICU) it was 61 mg/dL.
  
  
  CONCLUSIONS
  In diabetics and nondiabetics undergoing off-pump coronary artery bypass surgery, tight perioperative glycemic control is feasible and efficient, with minimal risks for hypo- and hyperglycemia. In nondiabetics, starting insulin therapy from induction onwards results in more measurements within target, without affecting the mean BG. In diabetics, decreasing the sampling interval from 60 to 30 minutes results in more measurements within target and in a mean blood glucose within target at ICU arrival.
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, Onze-Lieve-Vrouw Hospital, Aalst, Belgium. Patrick.Lecomte@olvz-aalst.be
authors.forename: Patrick
authors.initials: P
authors.lastname: Lecomte
authors.forename: Luc
authors.initials: L
authors.lastname: Foubert
authors.forename: José
authors.initials: J
authors.lastname: Coddens
authors.forename: Bram
authors.initials: B
authors.lastname: Dewulf
authors.forename: Frank
authors.initials: F
authors.lastname: Nobels
authors.forename: Filip
authors.initials: F
authors.lastname: Casselman
authors.forename: Guy
authors.initials: G
authors.lastname: Cammu
mesh_terms: D000368:Aged; D000465:Algorithms; D001786:Blood Glucose / Q000032:analysis / Q000378:metabolism*; D015992:Body Mass Index; D047549:Coronary Artery Bypass, Off-Pump / Q000379:methods*; D003920:Diabetes Mellitus / Q000188:drug therapy*; D003922:Diabetes Mellitus, Type 1 / Q000097:blood / Q000150:complications / Q000188:drug therapy; D003924:Diabetes Mellitus, Type 2 / Q000097:blood / Q000150:complications / Q000188:drug therapy; D005260:Female; D006801:Humans; D006943:Hyperglycemia / Q000097:blood / Q000188:drug therapy; D007003:Hypoglycemia / Q000097:blood / Q000188:drug therapy; D007004:Hypoglycemic Agents / Q000008:administration & dosage / Q000627:therapeutic use; D007328:Insulin / Q000008:administration & dosage / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012307:Risk Factors; D016896:Treatment Outcome
chemical_list: D001786:Blood Glucose; D007004:Hypoglycemic Agents; D007328:Insulin