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Ann Thorac Surg 1999;67:352-360
© 1999 The Society of Thoracic Surgeons
a Albert Starr Academic Center, Providence St Vincent Medical Center, Portland, Oregon, USA
Address reprint requests to Dr Furnary, 9155 SW Barnes Rd, Suite 240, Portland, OR 97225
e-mail: tfurnary{at}starrwood.com
Presented at the Thirty-fourth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 26–28, 1998.
Background. Diabetes mellitus is a risk factor for deep sternal wound infection after open heart surgical procedures. We previously showed that elevated postoperative blood glucose levels are a predictor of deep sternal wound infection in diabetic patients. Therefore, we hypothesized that aggressive intravenous pharmacologic control of postoperative blood glucose levels would reduce the incidence of deep sternal wound infection.
Methods. In a prospective study of 2,467 consecutive diabetic patients who underwent open heart surgical procedures between 1987 and 1997, perioperative blood glucose levels were recorded every 1 to 2 hours. Patients were classified into two sequential groups: the control group included 968 patients treated with sliding-scale–guided intermittent subcutaneous insulin injections (SQI); the study group included 1,499 patients treated with a continuous intravenous insulin infusion in an attempt to maintain a blood glucose level of less than 200 mg/dL. There were no differences between these groups with respect to age, sex, procedure, bypass time, antibiotic prophylaxis, or skin preparation methods.
Results. Compared with subcutaneous insulin injections, continuous intravenous insulin infusion induced a significant reduction in perioperative blood glucose levels, which led to a significant reduction in the incidence of deep sternal wound infection in the continuous intravenous insulin infusion group (0.8% [12 of 1,499]) versus the intermittent subcutaneous insulin injection group (2.0% [19 of 968], p = 0.01 by the 
2 test). Multivariate logistic regression revealed that continuous intravenous insulin infusion induced a significant decrease in the risk of deep sternal wound infection (p = 0.005; relative risk, 0.34), whereas obesity (p < 0.03; relative risk, 1.06) and use of an internal thoracic artery pedicle (p = 0.1; relative risk, 2.0) increased the risk of deep sternal wound infection.
Conclusions. Use of perioperative continuous intravenous insulin infusion in diabetic patients undergoing open heart surgical procedures significantly reduces major infectious morbidity and its associated socioeconomic costs.
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I. K. Toumpoulis, C. E. Anagnostopoulos, J. J. DeRose Jr, and D. G. Swistel The Impact of Deep Sternal Wound Infection on Long-term Survival After Coronary Artery Bypass Grafting Chest, February 1, 2005; 127(2): 464 - 471. [Abstract] [Full Text] [PDF]
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 O. Akca and R. Lenhardt Letter to the Editors: Isn't It the Time to Consider Blood Glucose Concentration as Part of the Severity Assessment of Critically Ill Patients? J Intensive Care Med, January 1, 2005; 20(1): 52 - 53. [PDF]
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O. Friberg, R. Svedjeholm, B. Soderquist, H. Granfeldt, T. Vikerfors, and J. Kallman Local Gentamicin Reduces Sternal Wound Infections After Cardiac Surgery: A Randomized Controlled Trial Ann. Thorac. Surg., January 1, 2005; 79(1): 153 - 161. [Abstract] [Full Text] [PDF]
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 C. L. Thompson, K. C. Dunn, M. C. Menon, L. E. Kearns, and S. S. Braithwaite Hyperglycemia in the Hospital Diabetes Spectr, January 1, 2005; 18(1): 20 - 27. [Abstract] [Full Text] [PDF]
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P. A. Goldberg and S. E. Inzucchi Selling Root Canals: Lessons Learned From Implementing a Hospital Insulin Infusion Protocol Diabetes Spectr, January 1, 2005; 18(1): 28 - 33. [Abstract] [Full Text] [PDF]
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J. Najarian, D. Swavely, E. Wilson, L. Merkle, T. Wasser, A. H. Quinn, S. Urffer, and M. Young Improving Outcomes for Diabetic Patients Undergoing Vascular Surgery Diabetes Spectr, January 1, 2005; 18(1): 53 - 60. [Abstract] [Full Text] [PDF]
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American Diabetes Association Standards of Medical Care in Diabetes Diabetes Care, January 1, 2005; 28(suppl_1): S4 - S36. [Full Text] [PDF]
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E. C. Douville, J. W. Asaph, R. J. Dworkin, J. R. Handy Jr, C. S. Canepa, G. L. Grunkemeier, and Y. Wu Sternal Preservation: A Better Way to Treat Most Sternal Wound Complications After Cardiac Surgery Ann. Thorac. Surg., November 1, 2004; 78(5): 1659 - 1664. [Abstract] [Full Text] [PDF]
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Committee Members, K. A. Eagle, R. A. Guyton, R. Davidoff, F. H. Edwards, G. A. Ewy, T. J. Gardner, J. C. Hart, H. C. Herrmann, L. D. Hillis, et al. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: Summary article: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery) J. Am. Coll. Cardiol., September 1, 2004; 44(5): 1146 - 1154. [Full Text] [PDF]
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Y. Deng, K. Byth, and H. S Paterson Semi-skeletonized Internal Mammary Artery Grafts and Sternal Wound Complications Asian Cardiovasc Thorac Ann, September 1, 2004; 12(3): 227 - 232. [Abstract] [Full Text] [PDF]
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C. M. Cely, P. Arora, A. A. Quartin, D. H. Kett, and R. M. H. Schein Relationship of Baseline Glucose Homeostasis to Hyperglycemia During Medical Critical Illness Chest, September 1, 2004; 126(3): 879 - 887. [Abstract] [Full Text] [PDF]
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K. A. Eagle, R. A. Guyton, R. Davidoff, F. H. Edwards, G. A. Ewy, T. J. Gardner, J. C. Hart, H. C. Herrmann, L. D. Hillis, A. M. Hutter Jr, et al. ACC/AHA 2004 Guideline Update for Coronary Artery Bypass Graft Surgery: Summary Article: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery) Circulation, August 31, 2004; 110(9): 1168 - 1176. [Full Text] [PDF]
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Z. T. Bloomgarden Inpatient Diabetes Control: Rationale Diabetes Care, August 1, 2004; 27(8): 2074 - 2080. [Full Text] [PDF]
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G. Carvalho, A. Moore, B. Qizilbash, K. Lachapelle, and T. Schricker Maintenance of Normoglycemia During Cardiac Surgery Anesth. Analg., August 1, 2004; 99(2): 319 - 324. [Abstract] [Full Text] [PDF]
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C. R Zimmerman, M. E Mlynarek, J. A Jordan, C. A Rajda, and H M. Horst An Insulin Infusion Protocol in Critically Ill Cardiothoracic Surgery Patients Ann. Pharmacother., July 1, 2004; 38(7): 1123 - 1129. [Abstract] [Full Text] [PDF]
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K. S Lewis, S. L Kane-Gill, M. B. Bobek, and J. F Dasta Intensive Insulin Therapy for Critically Ill Patients Ann. Pharmacother., July 1, 2004; 38(7): 1243 - 1251. [Abstract] [Full Text] [PDF]
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O. Lev-Ran, R. Braunstein, N. Nesher, Y. Ben-Gal, G. Bolotin, and G. Uretzky Bilateral versus single internal thoracic artery grafting in oral-treated diabetic subsets: comparative seven-year outcome analysis Ann. Thorac. Surg., June 1, 2004; 77(6): 2039 - 2045. [Abstract] [Full Text] [PDF]
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 M. J. O'Neill Jr Supplemental Oxygen and Risk of Surgical Site Infection JAMA, April 28, 2004; 291(16): 1958 - 1958. [Full Text] [PDF]
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K. B. Campbell and S. S. Braithwaite Hospital Management of Hyperglycemia Clin. Diabetes, April 1, 2004; 22(2): 81 - 88. [Full Text] [PDF]
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O. Lev-Ran, R. Mohr, D. Pevni, N. Nesher, Y. Weissman, D. Loberman, and G. Uretzky Bilateral internal thoracic artery grafting in diabetic patients: Short-term and long-term results of a 515-patient series J. Thorac. Cardiovasc. Surg., April 1, 2004; 127(4): 1145 - 1150. [Abstract] [Full Text] [PDF]
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L.-G. Dahlin, H. Granfeldt, and H. Hultkvist A multimodal approach for reducing wound infections after sternotomy Interactive CardioVascular and Thoracic Surgery, March 1, 2004; 3(1): 206 - 210. [Abstract] [Full Text] [PDF]
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 R. C Groom, A. J Rassias, J. E Cormack, G. R DeFoe, C. DioDato, C. K Krumholz, R. J Forest, J. W Pieroni, B. O'Connor, C. S Warren, et al. Highest core temperature during cardiopulmonary bypass and rate of mediastinitis Perfusion, March 1, 2004; 19(2): 119 - 125. [Abstract] [PDF]
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 S. K. Andersen, J. Gjedsted, C. Christiansen, and E. Tonnesen The roles of insulin and hyperglycemia in sepsis pathogenesis J. Leukoc. Biol., March 1, 2004; 75(3): 413 - 421. [Abstract] [Full Text] [PDF]
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 K. Wheeler, R. Crawford, D. McAdams, S. Benel, V. G. Dunbar, J. M. Caudle, C. George, I. El-Kebbi, D. L. Gallina, D. C. Ziemer, et al. Inpatient to Outpatient Transfer of Care in Urban Patients With Diabetes: Patterns and Determinants of Immediate Postdischarge Follow-up Arch Intern Med, February 23, 2004; 164(4): 447 - 453. [Abstract] [Full Text] [PDF]
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