Coronary artery bypass surgery maintaining glucose level
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Anahita Deylamsalehi, M.D.[2] Varun Kumar, M.B.B.S. [3]
Overview
One of the recommended practices to decrease the likelihood of sternal wound infection in patients undergoing CABG is perioperative insulin infusion to control hyperglycemia and maintaining the blood sugar lower than 180 mg/dl. In addition to reducing the likelihood of infection, the administration of continuous insulin infusion has been proven to lessens the likelihood of postoperative complications, such as mediastinitis, cardiac arrhythmias, renal failure, and lengthy hospitalization.
Maintaining Glucose Level in CABG
- Even though the rate of sternal wound infection has decreased among patients undergoing CABG, its strong relation to death is not neglectable.[1][2]
- Perioperative insulin infusion to control hyperglycemia and maintaining the blood sugar lower than 180 mg/dl can prevent the likelihood of sternal wound infection in patients with known diabetes and in those with stress hyperglycemia.[3][4][5][6][7]
- Usage of continuous intravenous insulin after CABG lessens the likelihood of postoperative complications, such as mediastinitis, deep sternal wound infections, cardiac arrhythmias, renal failure, and lengthy hospitalization.[5][8][9]
- The following table represents some of the strategies proposed as best practices to reduce the risk of sternal wound infection.[10][11][12][13][14][1][7][15][16][17]
| Prophylactic antibiotics is recommended, nevertheless it should not be continued beyond 48 hours. The dose of prophylactic antibiotics must be tailored for lengthy procedures (more than two half-lives) or for those who lost excessive amount of blood during CABG. |
| Nasal swab test for Staphylococcus aureus is recommended. |
| For known carriers of Staphylococcus aureus, mupirocin 2% ointment should be applied. |
| For those with unknown nasal culture or PCR, preoperative intranasal mupirocin 2% ointment should be applied. |
| It is recommended to measure HbA1c before CABG |
| If it is a nonemergent surgical coronary revascularization, all extrathoracic infections must be treated before the surgery. |
| Guide patients to smoking cessation before elective CABG |
| For procedures involving a median sternotomy, it is recommended to apply topical antibiotics (vancomycin) to the cut edges of the sternum on opening and before closing. |
| In BIMA grafting, it is recommended to use a skeletonized harvest of IMA. |
- The target blood glucose level in order to improve the outcome of CABG is controversial. One study compared the outcome among those with a target glucose level of 100 to 140 mg/dL with glucose level of 141 mg/dL to 180 mg/dL in the intensive care unit. The result did not report reduced perioperative complications among the two different groups.[10]
- Based on a randomized controlled trial and numerous observational studies, continuous intravenous insulin infusion is superior to subcutaneous insulin in diabetic patients who undergo CABG. These studies revealed that continuous intravenous insulin infusion is associated with a more stable blood glucose concentration, shorter hospitalization, fewer ischemic events, wound complications, and an overall better outcome.[5][8][9][18][19]
2021 ACA Revascularization Guideline
| Class 1 Recommendation, Level of Evidence: B-R [20][3][4][5][10][8][9] |
| 1. In order to reduce sternal wound infection in patients undergoing CABG an intraoperative continuous infusion of insulin should be initiated with the goal to keep blood sugar lower than 180 mg/dL.
2. In order to reduce sternal wound infection in patients undergoing CABG, an postoperative continuous infusion of insulin is recommended with the goal to keep an early postoperative blood sugar lower than 180 mg/dL. |
| Class 1 Recommendation, Level of Evidence: B-NR [20][11][12][13][14][21][22] |
| A comprehensive approach to decrease the risk of sternal wound infection is recommended in patients undergoing CABG. |
| Class 2b Recommendation, Level of Evidence: B-R[20][10] |
| The effectiveness of intraoperative continuous infusion of insulin with the goal to keep blood sugar lower than 140 mg/dL in patients undergoing CABG is not certain. |
2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery (DO NOT EDIT)[23]
| Class I |
| "1. Use of continuous intravenous insulin to achieve and maintain an early postoperative blood glucose concentration less than or equal to 180 mg/dL while avoiding hypoglycemia is indicated to reduce the incidence of adverse events, including deep sternal wound infection, after CABG.[8][24][25] (Level of Evidence: B)" |
| Class IIb |
| "1. The use of continuous intravenous insulin designed to achieve a target intraoperative blood glucose concentration less than 140 mg/dL has uncertain effectiveness.[26][27][28] (Level of Evidence: B)" |
References
- ↑ 1.0 1.1 D'Agostino RS, Jacobs JP, Badhwar V, Fernandez FG, Paone G, Wormuth DW; et al. (2019). "The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2019 Update on Outcomes and Quality". Ann Thorac Surg. 107 (1): 24–32. doi:10.1016/j.athoracsur.2018.10.004. PMID 30423335.
- ↑ Gelijns AC, Moskowitz AJ, Acker MA, Argenziano M, Geller NL, Puskas JD; et al. (2014). "Management practices and major infections after cardiac surgery". J Am Coll Cardiol. 64 (4): 372–81. doi:10.1016/j.jacc.2014.04.052. PMC 4222509. PMID 25060372.
- ↑ 3.0 3.1 Furnary AP, Zerr KJ, Grunkemeier GL, Starr A (1999). "Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures". Ann Thorac Surg. 67 (2): 352–60, discussion 360-2. doi:10.1016/s0003-4975(99)00014-4. PMID 10197653.
- ↑ 4.0 4.1 Hruska LA, Smith JM, Hendy MP, Fritz VL, McAdams S (2005). "Continuous insulin infusion reduces infectious complications in diabetics following coronary surgery". J Card Surg. 20 (5): 403–7. doi:10.1111/j.1540-8191.2005.200472.x. PMID 16153268.
- ↑ 5.0 5.1 5.2 5.3 Lazar HL, Chipkin SR, Fitzgerald CA, Bao Y, Cabral H, Apstein CS (2004). "Tight glycemic control in diabetic coronary artery bypass graft patients improves perioperative outcomes and decreases recurrent ischemic events". Circulation. 109 (12): 1497–502. doi:10.1161/01.CIR.0000121747.71054.79. PMID 15006999.
- ↑ Anderson DJ, Podgorny K, Berríos-Torres SI, Bratzler DW, Dellinger EP, Greene L; et al. (2014). "Strategies to prevent surgical site infections in acute care hospitals: 2014 update". Infect Control Hosp Epidemiol. 35 (6): 605–27. doi:10.1086/676022. PMC 4267723. PMID 24799638.
- ↑ 7.0 7.1 Lazar HL, McDonnell M, Chipkin SR, Furnary AP, Engelman RM, Sadhu AR; et al. (2009). "The Society of Thoracic Surgeons practice guideline series: Blood glucose management during adult cardiac surgery". Ann Thorac Surg. 87 (2): 663–9. doi:10.1016/j.athoracsur.2008.11.011. PMID 19161815.
- ↑ 8.0 8.1 8.2 8.3 Furnary AP, Gao G, Grunkemeier GL, Wu Y, Zerr KJ, Bookin SO; et al. (2003). "Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting". J Thorac Cardiovasc Surg. 125 (5): 1007–21. doi:10.1067/mtc.2003.181. PMID 12771873.
- ↑ 9.0 9.1 9.2 Furnary AP, Wu Y (2006). "Eliminating the diabetic disadvantage: the Portland Diabetic Project". Semin Thorac Cardiovasc Surg. 18 (4): 302–8. doi:10.1053/j.semtcvs.2006.04.005. PMID 17395026.
- ↑ 10.0 10.1 10.2 10.3 Umpierrez G, Cardona S, Pasquel F, Jacobs S, Peng L, Unigwe M; et al. (2015). "Randomized Controlled Trial of Intensive Versus Conservative Glucose Control in Patients Undergoing Coronary Artery Bypass Graft Surgery: GLUCO-CABG Trial". Diabetes Care. 38 (9): 1665–72. doi:10.2337/dc15-0303. PMC 4542267. PMID 26180108.
- ↑ 11.0 11.1 Edwards LD (1976). "The epidemiology of 2056 remote site infections and 1966 surgical wound infections occurring in 1865 patients: a four year study of 40,923 operations at Rush-Presbyterian-St. Luke's Hospital, Chicago". Ann Surg. 184 (6): 758–66. doi:10.1097/00000658-197612000-00017. PMC 1345421. PMID 999352.
- ↑ 12.0 12.1 Engelman R, Shahian D, Shemin R, Guy TS, Bratzler D, Edwards F; et al. (2007). "The Society of Thoracic Surgeons practice guideline series: Antibiotic prophylaxis in cardiac surgery, part II: Antibiotic choice". Ann Thorac Surg. 83 (4): 1569–76. doi:10.1016/j.athoracsur.2006.09.046. PMID 17383396.
- ↑ 13.0 13.1 Lazar HL, Salm TV, Engelman R, Orgill D, Gordon S (2016). "Prevention and management of sternal wound infections". J Thorac Cardiovasc Surg. 152 (4): 962–72. doi:10.1016/j.jtcvs.2016.01.060. PMID 27555340.
- ↑ 14.0 14.1 Vander Salm TJ, Okike ON, Pasque MK, Pezzella AT, Lew R, Traina V; et al. (1989). "Reduction of sternal infection by application of topical vancomycin". J Thorac Cardiovasc Surg. 98 (4): 618–22. PMID 2796369.
- ↑ Vestergaard RF, Jensen H, Vind-Kezunovic S, Jakobsen T, Søballe K, Hasenkam JM (2010). "Bone healing after median sternotomy: a comparison of two hemostatic devices". J Cardiothorac Surg. 5: 117. doi:10.1186/1749-8090-5-117. PMC 3001423. PMID 21106051.
- ↑ Cardona S, Pasquel FJ, Fayfman M, Peng L, Jacobs S, Vellanki P; et al. (2017). "Hospitalization costs and clinical outcomes in CABG patients treated with intensive insulin therapy". J Diabetes Complications. 31 (4): 742–747. doi:10.1016/j.jdiacomp.2017.01.003. PMID 28161384.
- ↑ Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG; et al. (2011). "2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. 124 (23): 2610–42. doi:10.1161/CIR.0b013e31823b5fee. PMID 22064600.
- ↑ Abelev Z, Seth A, Patel R, Goldstein S, Bogun M, Paliou M; et al. (2011). "Continuous insulin infusion is associated with a reduced post-surgical length of stay, but not with the complication rate, in patients with diabetes mellitus undergoing coronary artery bypass graft". J Endocrinol Invest. 34 (10): 770–4. doi:10.3275/7760. PMID 21623155.
- ↑ Ogawa S, Okawa Y, Sawada K, Goto Y, Yamamoto M, Koyama Y; et al. (2016). "Continuous postoperative insulin infusion reduces deep sternal wound infection in patients with diabetes undergoing coronary artery bypass grafting using bilateral internal mammary artery grafts: a propensity-matched analysis". Eur J Cardiothorac Surg. 49 (2): 420–6. doi:10.1093/ejcts/ezv106. PMID 25825261.
- ↑ 20.0 20.1 20.2 Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM; et al. (2022). "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". J Am Coll Cardiol. 79 (2): e21–e129. doi:10.1016/j.jacc.2021.09.006. PMID 34895950 Check
|pmid=value (help). - ↑ Steingrímsson S, Gustafsson R, Gudbjartsson T, Mokhtari A, Ingemansson R, Sjögren J (2009). "Sternocutaneous fistulas after cardiac surgery: incidence and late outcome during a ten-year follow-up". Ann Thorac Surg. 88 (6): 1910–5. doi:10.1016/j.athoracsur.2009.07.012. PMID 19932261.
- ↑ Kieser TM, Rose MS, Aluthman U, Montgomery M, Louie T, Belenkie I (2014). "Toward zero: deep sternal wound infection after 1001 consecutive coronary artery bypass procedures using arterial grafts: implications for diabetic patients". J Thorac Cardiovasc Surg. 148 (5): 1887–95. doi:10.1016/j.jtcvs.2014.02.022. PMID 24613159.
- ↑ Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG; et al. (2011). "2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0b013e31823c074e. PMID 22064599.
- ↑ Ingels C, Debaveye Y, Milants I, Buelens E, Peeraer A, Devriendt Y, Vanhoutte T, Van Damme A, Schetz M, Wouters PJ, Van den Berghe G (2006). "Strict blood glucose control with insulin during intensive care after cardiac surgery: impact on 4-years survival, dependency on medical care, and quality-of-life". European Heart Journal. 27 (22): 2716–24. doi:10.1093/eurheartj/ehi855. PMID 16608860. Retrieved 2011-12-14. Unknown parameter
|month=ignored (help) - ↑ van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P, Bouillon R (2001). "Intensive insulin therapy in the critically ill patients". The New England Journal of Medicine. 345 (19): 1359–67. doi:10.1056/NEJMoa011300. PMID 11794168. Retrieved 2011-12-14. Unknown parameter
|month=ignored (help) - ↑ Butterworth J, Wagenknecht LE, Legault C, Zaccaro DJ, Kon ND, Hammon JW, Rogers AT, Troost BT, Stump DA, Furberg CD, Coker LH (2005). "Attempted control of hyperglycemia during cardiopulmonary bypass fails to improve neurologic or neurobehavioral outcomes in patients without diabetes mellitus undergoing coronary artery bypass grafting". The Journal of Thoracic and Cardiovascular Surgery. 130 (5): 1319. doi:10.1016/j.jtcvs.2005.02.049. PMID 16256784. Retrieved 2011-12-14. Unknown parameter
|month=ignored (help) - ↑ Duncan AE, Abd-Elsayed A, Maheshwari A, Xu M, Soltesz E, Koch CG (2010). "Role of intraoperative and postoperative blood glucose concentrations in predicting outcomes after cardiac surgery". Anesthesiology. 112 (4): 860–71. doi:10.1097/ALN.0b013e3181d3d4b4. PMID 20216389. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Gandhi GY, Nuttall GA, Abel MD, Mullany CJ, Schaff HV, O'Brien PC, Johnson MG, Williams AR, Cutshall SM, Mundy LM, Rizza RA, McMahon MM (2007). "Intensive intraoperative insulin therapy versus conventional glucose management during cardiac surgery: a randomized trial". Annals of Internal Medicine. 146 (4): 233–43. PMID 17310047. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help)