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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.
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Abstract |
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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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Introduction |
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TopFootnotesAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsReferences |
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Despite recent advances in the prevention of the long-term sequelae of diabetes mellitus [1], reduction of acute infectious problems related to surgical trauma in the diabetic patient has been elusive. Diabetes mellitus has been established as an independent risk factor for postoperative surgical wound infection [2–4], with infection rates two to five times more prevalent than in the nondiabetic population [5]. Poststernotomy mediastinitis in diabetic patients after open heart surgical procedures increases operative mortality twofold to threefold [6].
It has been shown that intensive treatment of hyperglycemia in insulin-dependent diabetic patients effectively reduces the incidence of long-term complications [1]. There is a growing body of clinical and experimental evidence that hyperglycemia increases the risk of nosocomial infections and may actually be a causal factor in the development of these infections in critically ill patients [7].
This rationale led us to first investigate the relation between postoperative hyperglycemia and DSWI [6]. In that study we revealed that elevated blood glucose levels (> 200 mg/dL) on the first and second postoperative days (PODs) in diabetic patients are associated with a higher incidence of DSWI. In fact, the average blood glucose level over these 2 days was found to be the strongest predictor of any DSWI in a diabetic patient who has undergone an open heart surgical procedure. We therefore hypothesized that a continuous intravenous insulin infusion (CII) in the perioperative period would substantially reduce the incidence of hyperglycemia and therefore significantly lower the rate of DSWI in diabetic patients.
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Material and methods |
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TopFootnotesAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsReferences |
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In the intraoperative and postoperative periods, the patients’ blood glucose levels were prospectively monitored with Accu-check Easy (Boehringer Mannheim, Indianapolis, IN) every 1 to 2 hours through fingerstick or arterial line drop sample and recorded. For purposes of data analysis, daily mean blood glucose levels were then calculated by averaging all glucose levels obtained clinically during the day of operation and each of the first through fifth PODs.
Study groups
Patients were classified into two sequential groups to maintain tight diabetic protocol compliance within each group. The control group, which included 968 patients operated on between January 1, 1987, and September 1, 1991, received individualized sliding-scale–guided subcutaneous insulin injections (SQI) as a method of postoperative glucose regulation. Treatment was administered every 4 hours, with the goal of keeping blood sugar levels at or below the "safe" limit of 200 mg/dL.
The study group included diabetic patients who underwent open heart surgical procedures between September 1, 1991, and November 30, 1997 (n = 1,499). Blood sugar levels in this group were manipulated by means of a CII. The insulin drip was titrated on the basis of the most recent fingerstick glucose measurement to maintain blood glucose levels between 150 and 200 mg/dL. A standardized protocol was developed so that it could be instituted and administered entirely by the nursing staff in all postoperative diabetic patients. The Portland CII protocol (Appendix) consists of a starting intravenous insulin infusion dosage, blood glucose testing frequency requirements, insulin infusion titration, and cessation orders. The CII protocol was automatically ordered by the surgeons and was administered entirely by the critical care and telemetry floor nursing staff without physician intervention.
Surgical infection prophylaxis remained constant through the entire study period, and all procedures were performed by the same surgical team. All patients were monitored closely for infectious complications, and all charts were reviewed for any subsequent admissions for infection.
Classification of infectious complications
Deep sternal wound infection
Chest wound infections involving the sternum or mediastinal tissues, including mediastinitis, were classified as DSWI.
Superficial sternal wound infection
Chest wound infections involving the skin or subcutaneous tissues, or both, were classified as superficial sternal wound infection, not involving the sternal bone or wires.
Other definitions
Diabetic patient
A diabetic patient was defined as one who experienced chronic glucose intolerance, either insulin dependent or non–insulin dependent, at the time of operation. Patients who did not carry the preoperative diagnosis of diabetes but who temporarily required insulin in the postoperative period relative to the administration of total parental nutrition or inotropes (eg, epinephrine) and did not have glucose intolerance after the cessation of these modalities were not included in the study.
Body mass index
Body mass index was calculated as weight (kg) divided by height (m2) [8].
Biostatistical methods
Data variables were analyzed using SPSS (Chicago, IL) statistical software. Results are reported as mean ± standard error of the mean, where appropriate. Univariate analysis was performed using 2 tests for categoric variables, t tests for continuous variables, and the F test to compare variance. Forward stepwise multivariable logistic regression was used to test the independent association of multiple variables against DSWI. Multivariable results are given with 95% confidence intervals.
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Results |
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Insulin-dependent diabetic patients comprised 36% of the group; diabetes was controlled by oral agents on admission in 48% and by diabetic diet only in 10%; 6% had no diabetic glucose control on admission.
Demographic and perioperative comparisons of the SQI control group and the CII study group are shown in Table 1. There were no significant differences with respect to age, sex, procedures performed, redo sternotomies, cardiopulmonary bypass time, or transfusions. The CII group had a significantly higher prevalence of hypertension, renal insufficiency, obesity, steroid usage, and greater use of ITA grafts in patients undergoing bypass grafting. The SQI group had higher prevalence of congestive heart failure, prolonged inotropic support, more transfusions, and a longer length of postoperative stay.
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Glucose control
Direct comparison of the daily mean blood glucose levels between the SQI and CII groups reflects markedly improved postoperative glucose control in the CII group. Mean blood glucose levels on the day of operation through the third POD were significantly lower within the CII group than in the SQI control group (199 ± 1.4 versus 241 ± 1.9 mg/dL on the day of operation, 176 ± 0.8 versus 206 ± 1.2 mg/dL on POD 1, 181 ± 1.2 versus 195 ± 1.3 mg/dL on POD 2, and 179 ± 1.5 versus 188 ± 1.4 mg/dL on POD 3, CII group versus SQI group, respectively; p < 0.0001 for all comparisons). The aggressive CII approach resulted in overall tighter glucose control as well, with less daily variance, as evidenced by the smaller standard deviation in the CII group (standard deviation, 36 mg/dL for SQI on POD 1 versus standard deviation, 26 mg/dL for CII on POD 1, p < 0.001). The achievement of strict glucose control with the aggressive CII method is exemplified in Figures 1A and 1B, which are distribution curves of the average blood glucose level for each patient in the CII and SQI groups on POD 1.
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2 test, p = 0.011).
Univariate analysis of deep sternal wound infection
Multiple variables were considered in addition to method of glucose control (SQI or CII) as possible predictors of DSWI. Univariate statistical analysis was carried out for each variable in relation to DSWI and is shown in Table 2.
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Comment |
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TopFootnotesAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsReferences |
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The Portland CII protocol (Appendix) consists of (1) a starting intravenous insulin infusion dosage that is based on the first blood glucose measurement greater than 150 mg/dL; (2) blood glucose testing frequency requirements that are based on the stability of the insulin infusion rate and the status of concomitant vasopressor infusions; (3) insulin infusion titration orders that are based on the most recent blood glucose level; and (4) cessation orders that are based on adequate (<150 mg/dL) blood glucose control beyond the second POD and an active oral diet. This insulin infusion protocol is designed to rapidly achieve and maintain blood glucose levels in the range of 150 to 200 mg/dL. As levels fall below 150 mg/dL, the patient is weaned off continuous intravenous insulin infusion. The distribution curve of the first POD mean blood glucose level (Fig 1A) demonstrates that target hyperglycemia (>200 mg/dL) was eliminated in 85% of patients. In contrast, SQI control (Fig 1B) resulted in levels below 200 mg/dL only 47% of the time.
Implementation of the Portland CII protocol was staged to a specific point in time to achieve the highest compliance possible on the part of the nursing staff who administered the protocol. When the protocol was initiated, mean daily glucose measurements did not immediately step down to levels below 200 mg/dL. Rather, there was a cautious initial learning period of approximately 4 months during which the nursing staff gradually became more comfortable with the idea that a CII protocol in patients with glucose levels between 150 and 200 mg/dL was a safe mode of therapy. Were the CII protocol to be administered concomitantly alongside the SQI protocol, it is likely that we would not have rapidly achieved the tight daily control exemplified by the markedly decreased variances in daily mean glucose in the CII group.
The increasing temporal compliance with the CII protocol among the nursing staff eventually (1994) allowed continuation of the CII on the telemetry floor after transfer from the intensive care unit. As this transition occurred, the CII protocol became even more compatible with "fast-track" intensive care unit transfer programs. With ever-increasing postoperative nursing compliance with the CII, DSWI rates continued to fall. The trend of DSWI in diabetic patients at our institution has been significantly downward (slope, -0.52%/year; p = 0.01) since the institution of CII in 1991 (Fig 3). Since 1994, the annual incidence of DSWI in the diabetic population has not been statistically different from that in the nondiabetic population (0.3% for each, p = 0.9). Anecdotally, we have not experienced a single DSWI after cardiac operation in a diabetic patient since August 1996 (15 months, 494 patients).
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The CII protocol is not infallible, and diabetic patients remain at risk for DSWI, subject to proper implementation and other risk factors. In our last diabetic patient with DSWI (August 1996), the CII protocol was not aggressively implemented because of surgeon preference, and the patient retained elevated glucose levels of 240, 259, and 241 mg/dL on PODs 0, 1, and 2, respectively. Even in the setting of excellent glucose control, there are still patients who develop infections, indicating that hyperglycemia is not the only causal factor for DSWI.
Other multivariate studies of DSWI have identified several risk factors for DSWI, including obesity [2, 4, 9], diabetes [2–4, 9, 10], single [3] and bilateral ITA grafts [3, 11], steroid use [10], chronic obstructive pulmonary disease [12], prolonged ventilation [13], smoking [9], male sex [12], duration of cardiopulmonary bypass and aortic cross-clamp time [3], and positive nasal staphylococcus aureus cultures [14]. Obesity (relative risk range, 2.0 to 3.8) and diabetes (relative risk range, 2.6 to 3.8) are the risks most often cited [4, 9], with ITA grafting a close third.
The current study suggests that hyperglycemia on the first and second POD remains the single most important predictor of DSWI in the postoperative diabetic population. When the multivariate analysis was run with the mean blood glucose level from POD 1 in the variable mix, it replaced CII in the equation (Table 4) (p = 0.002; relative risk, 1.014). Essentially, CII and hyperglycemia are reciprocal surrogates for DSWI risk—hyperglycemia markedly increases the risk, whereas the CII protocol, through the direct elimination of hyperglycemia, reduces the risk. To date, there has been no multivariate study of DSWI risk in the diabetic population alone other than our previous work. Our studies of DSWI have centered on this high-risk subpopulation of patients undergoing open heart surgical procedures and the relation between hyperglycemia and infection in this group [6].
Interestingly, as our surgical team came to fully appreciate the benefits of CII in preventing hyperglycemia and in normalizing the subsequent risk of DSWI in diabetic patients, we became more aggressive in expanding the armamentarium of treatment options for diabetic patients with coronary artery disease. In the past 3 years, bilateral ITA grafts have been used in 9 diabetic patients, without a single episode of DSWI. In the CII study group we have seen an increasing incidence in ITA use and obesity in the setting of a decreasing annual incidence of DSWI. This combination has altered the multivariable analysis of DSWI risk over time as more patients were entered into the study. The use of a single or bilateral ITA pedicle was significant (p = 0.02, 98% confidence of significance) when we first analyzed these data in 1995 [6]. However, this important variable has lost significance over time (p = 0.1, 90% confidence of significance) as a consequence of higher use of ITA grafts in diabetic patients without subsequent occurrences of DSWI.
Internal thoracic artery dissection causes temporary sternal ischemia, which may predispose to DSWI. The degree of temporary sternal ischemia is nearly doubled by the use of bilateral ITA grafts [15]. Reported rates of DSWI in diabetic patients who undergo bilateral ITA grafting are as high as 12% to 17% [3, 16]. It may well be that hyperglycemia in the setting of a devascularized sternum leads to a synergistic milieu that culminates in an unacceptable rate of DSWI in diabetic patients with bilateral ITA grafts. These studies led most cardiothoracic surgeons to believe that bilateral ITA grafts in diabetic patients were to be strictly avoided. Our experience, although not conclusively proving so, suggests that institution of the Portland CII protocol may obviate the infectious risk of bilateral ITA grafts in the diabetic patient population through the elimination of significant postoperative hyperglycemia.
Why, then, is hyperglycemia such a potent risk factor for DSWI? There is a growing body of clinical and experimental evidence that hyperglycemia impedes the normal physiologic responses to infection. In vitro and in vivo studies have shown that periods of hyperglycemia are associated with accelerated nonenzymatic glycosylation of body proteins, or the nonenzymatic addition of sugar molecules to the exposed lysine residues on extracellular proteins [17, 18]. Short-term glycosylation of immunoglobulin causes its inactivation [18]. Glycosylation of the C3 component of complement occurs at its opsonic binding site and renders it impotent, unable to bind to the surface of invading bacteria [19]. In addition, Hennessey and colleagues [17] have shown that glycosylation of newly synthesized collagen in hyperglycemic animals is associated with increased collagenase activity and decreased wound collagen content. The resultant wound healing impairment improves dramatically with control of glucose concentrations [17].
Several abnormalities in leukocyte function have also been identified that are caused by the hyperglycemic state. These include abnormalities in granulocyte adherence [20, 21], impaired phagocytosis [22], delayed chemotaxis [23], and depressed bacteriocidal capacity [22, 24]. The degree of hyperglycemia that has been shown to impair phagocytic function, either in vitro or in clinical trials, is as low as 11.1 mmol/L (200 mg/dL) [7]. Most interestingly, these leukocyte deficiencies appear to improve with aggressive glycemic control [25]. This correlation is further substantiated by reports that the degree of phagocytic impairment varies directly with glucose levels [26] and can be reversed with control of plasma glucose [27].
The major weakness of the present study is its temporal sequential nature. We recognize that there have been subtle cumulative improvements in all areas of open heart surgical intervention over the past 11 years, which may play a role in both the diminution of mortality and DSWI seen during the course of this study. Nonetheless, the reduction of hyperglycemia through the use of a CII protocol is a safe and cost-effective mode of postoperative diabetic therapy. This therapy is easy to administer, takes less nursing time than SQI, is less invasive to the postoperative patient, and has the added potential of effecting improved outcomes.
The socioeconomic costs of DSWI are staggering. A single DSWI in our institution during the present study generated an average of $26,400 in additional charges and increased the average length of stay by 16 days. These figures are comparable to those previously published [28]. Psychological morbidity from pain, suffering, and altered body image is immeasurable. The increase in mortality from DSWI is directly measurable at five times baseline (3.8% versus 19%). Assuming that most cardiac centers in this country use the sliding-scale SQI method of postoperative control as a standard, we can directly estimate the socioeconomic savings if the Portland CII protocol were to be implemented nationwide (Table 5). There were approximately 742,000 adult open heart procedures performed in the United States in 1995 [29]. If the prevalence of diabetes in the population undergoing cardiac surgical procedures is constant at 20% [3], then 148,400 diabetic patients underwent cardiac surgical intervention with nearly a 2% risk of developing DSWI (2,968 potential DSWIs). According to our multivariate analysis, the risk of developing DSWI in these patients could have been reduced by 66% (a relative risk of 0.34) through the use of the CII protocol, reducing the potential number of DSWIs to 1,009. Use of the CII protocol would have resulted in 1,959 fewer DSWIs, thus saving $51.7 million in hospital charges, 31,342 hospital days, and 372 patient lives.
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The present study further suggests that uncontrolled postoperative hyperglycemia in diabetic patients, not the diagnosis of diabetes itself, is the true risk factor for DSWI; that the use of bilateral ITA pedicled grafts in diabetic patients need not be avoided if hyperglycemia is controlled; and that the national socioeconomic costs of DSWI in diabetic patients are staggering and could potentially be reduced through the universal use of the Portland CII protocol for postoperative glucose control.
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Acknowledgments |
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TopFootnotesAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsReferences |
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Appendix |
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The Portland protocol for continuous intravenous insulin infusion in postoperative diabetic patients undergoing cardiac surgical procedures is available online at www.starrwood.com/research/insulin.html
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 P. F. White, H. Kehlet, J. M. Neal, T. Schricker, D. B. Carr, F. Carli, and the Fast-Track Surgery Study Group The Role of the Anesthesiologist in Fast-Track Surgery: From Multimodal Analgesia to Perioperative Medical Care Anesth. Analg., June 1, 2007; 104(6): 1380 - 1396. [Abstract] [Full Text] [PDF]
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 P. J. Robinson, B. Billah, K. Leder, C. M. Reid, and on behalf of the ASCTS Database Committee Factors associated with deep sternal wound infection and haemorrhage following cardiac surgery in Victoria Interactive CardioVascular and Thoracic Surgery, April 1, 2007; 6(2): 167 - 171. [Abstract] [Full Text] [PDF]
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L. R. Schmeltz, A. J. DeSantis, V. Thiyagarajan, K. Schmidt, E. O'Shea-Mahler, D. Johnson, J. Henske, P. M. McCarthy, T. G. Gleason, E. C. McGee, et al. Reduction of Surgical Mortality and Morbidity in Diabetic Patients Undergoing Cardiac Surgery With a Combined Intravenous and Subcutaneous Insulin Glucose Management Strategy Diabetes Care, April 1, 2007; 30(4): 823 - 828. [Abstract] [Full Text] [PDF]
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E. C. Douville Invited commentary Ann. Thorac. Surg., March 1, 2007; 83(3): 1007 - 1007. [Full Text] [PDF]
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M. Paul, A. Raz, L. Leibovici, H. Madar, R. Holinger, and B. Rubinovitch Sternal wound infection after coronary artery bypass graft surgery: Validation of existing risk scores J. Thorac. Cardiovasc. Surg., February 1, 2007; 133(2): 397 - 403. [Abstract] [Full Text] [PDF]
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American Diabetes Association Standards of Medical Care in Diabetes--2007 Diabetes Care, January 1, 2007; 30(suppl_1): S4 - S41. [Full Text] [PDF]
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J. Sjogren, M. Malmsjo, R. Gustafsson, and R. Ingemansson Poststernotomy mediastinitis: a review of conventional surgical treatments, vacuum-assisted closure therapy and presentation of the Lund University Hospital mediastinitis algorithm Eur. J. Cardiothorac. Surg., December 1, 2006; 30(6): 898 - 905. [Abstract] [Full Text] [PDF]
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S. E. Inzucchi Management of Hyperglycemia in the Hospital Setting N. Engl. J. Med., November 2, 2006; 355(18): 1903 - 1911. [Full Text] [PDF]
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 S. Donaldson, G. Villanuueva, L. Rondinelli, and D. Baldwin Rush University Guidelines and Protocols for the Management of Hyperglycemia in Hospitalized Patients: Elimination of the Sliding Scale and Improvement of Glycemic Control Throughout the Hospital The Diabetes Educator, November 1, 2006; 32(6): 954 - 962. [Abstract] [Full Text] [PDF]
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A. M. Eklund, O. Lyytikainen, P. Klemets, K. Huotari, V.-J. Anttila, K. A. Werkkala, and M. Valtonen Mediastinitis After More Than 10,000 Cardiac Surgical Procedures Ann. Thorac. Surg., November 1, 2006; 82(5): 1784 - 1789. [Abstract] [Full Text] [PDF]
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 M. J. Hiesmayr Hyperglycemia and outcome after myocardial infarction and cardiac surgery: so what? Seminars in Cardiothoracic and Vascular Anesthesia, September 1, 2006; 10(3): 220 - 223. [Abstract] [PDF]
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K. G. Shann, D. S. Likosky, J. M. Murkin, R. A. Baker, Y. R. Baribeau, G. R. DeFoe, T. A. Dickinson, T. J. Gardner, H. P. Grocott, G. T. O'Connor, et al. An evidence-based review of the practice of cardiopulmonary bypass in adults: A focus on neurologic injury, glycemic control, hemodilution, and the inflammatory response. J. Thorac. Cardiovasc. Surg., August 1, 2006; 132(2): 283 - 290.e3. [Full Text] [PDF]
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The ACE/ADA Task Force on Inpatient Diabetes American College of Endocrinology and American Diabetes Association Consensus Statement on Inpatient Diabetes and Glycemic Control: A call to action Diabetes Care, August 1, 2006; 29(8): 1955 - 1962. [Full Text] [PDF]
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D. Aragon Evaluation of nursing work effort and perceptions about blood glucose testing in tight glycemic control. Am. J. Crit. Care., July 1, 2006; 15(4): 370 - 377. [Abstract] [Full Text] [PDF]
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C. W. Hogue Jr, C. A. Palin, and J. E. Arrowsmith Cardiopulmonary bypass management and neurologic outcomes: an evidence-based appraisal of current practices. Anesth. Analg., July 1, 2006; 103(1): 21 - 37. [Abstract] [Full Text] [PDF]
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 K. A. Wintergerst, B. Buckingham, L. Gandrud, B. J. Wong, S. Kache, and D. M. Wilson Association of Hypoglycemia, Hyperglycemia, and Glucose Variability With Morbidity and Death in the Pediatric Intensive Care Unit Pediatrics, July 1, 2006; 118(1): 173 - 179. [Abstract] [Full Text] [PDF]
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 S. A. Nasraway Jr Hyperglycemia During Critical Illness JPEN J Parenter Enteral Nutr, May 1, 2006; 30(3): 254 - 258. [Abstract] [Full Text] [PDF]
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Z. T. Bloomgarden Cardiovascular Disease Diabetes Care, May 1, 2006; 29(5): 1160 - 1166. [Full Text] [PDF]
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A. S. Dronge, M. F. Perkal, S. Kancir, J. Concato, M. Aslan, and R. A. Rosenthal Long-term Glycemic Control and Postoperative Infectious Complications Arch Surg, April 1, 2006; 141(4): 375 - 380. [Abstract] [Full Text] [PDF]
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Does use of a right internal thoracic artery increase deep wound infection and risk after previous use of a left internal thoracic artery? J. Thorac. Cardiovasc. Surg., March 1, 2006; 131(3): 609 - 613.
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 J. S. Krinsley and R. L. Jones Cost Analysis of Intensive Glycemic Control in Critically Ill Adult Patients Chest, March 1, 2006; 129(3): 644 - 650. [Abstract] [Full Text] [PDF]
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 M. Egi, R. Bellomo, E. Stachowski, C. J. French, G. Hart, P. Stow, W. Li, and S. Bates Intensive Insulin Therapy in Postoperative Intensive Care Unit Patients: A Decision Analysis Am. J. Respir. Crit. Care Med., February 15, 2006; 173(4): 407 - 413. [Abstract] [Full Text] [PDF]
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I. K. Toumpoulis, C. E. Anagnostopoulos, S. Balaram, D. G. Swistel, R. C. Ashton Jr, and J. J. DeRose Jr Does Bilateral Internal Thoracic Artery Grafting Increase Long-Term Survival of Diabetic Patients? Ann. Thorac. Surg., February 1, 2006; 81(2): 599 - 607. [Abstract] [Full Text] [PDF]
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 L. Langouche, I. Vanhorebeek, and G. Van den Berghe Glycaemic control in trauma patients, is there a role? Trauma, January 1, 2006; 8(1): 13 - 19. [Abstract] [PDF]
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American Diabetes Association Standards of Medical Care in Diabetes-2006 Diabetes Care, January 1, 2006; 29(suppl_1): S4 - S42. [Full Text] [PDF]
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 S. V Ghotkar, A. D Grayson, and W. C Dihmis Effect of Prolonged Intensive Care Stay on Survival Following Coronary Surgery Asian Cardiovasc Thorac Ann, December 1, 2005; 13(4): 345 - 350. [Abstract] [Full Text] [PDF]
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 R. Bellomo and M. Egi Glycemic Control in the Intensive Care Unit: Why We Should Wait for NICE-SUGAR Mayo Clin. Proc., December 1, 2005; 80(12): 1546 - 1548. [PDF]
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 A. M. Calafiore, L. Weltert, M. D. Mauro, G. Actis-Dato, A. L. Iaco, P. Centofanti, M. L. Torre, and F. Patane Internal mammary artery MMCTS, November 29, 2005; 2005(1129): 1008. [Abstract] [Full Text] [PDF]
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E. D. Davis, K. Harwood, L. Midgett, M. Mabrey, and L. F. Lien Implementation of a New Intravenous Insulin Method on Intermediate-Care Units in Hospitalized Patients The Diabetes Educator, November 1, 2005; 31(6): 818 - 823. [Abstract] [Full Text] [PDF]
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 D. Dilkhush, J. Lannigan, T. Pedroff, A. Riddle, and M. Tittle Insulin infusion protocol for critical care units Am. J. Health Syst. Pharm., November 1, 2005; 62(21): 2260 - 2264. [Abstract] [Full Text] [PDF]
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J. Butterworth, L. E. Wagenknecht, C. Legault, D. J. Zaccaro, N. D. Kon, J. W. Hammon Jr, A. T. Rogers, B. T. Troost, D. A. Stump, C. D. Furberg, et al. Attempted control of hyperglycemia during cardiopulmonary bypass fails to improve neurologic or neurobehavioral outcomes in patients without diabetes mellitus undergoing coronary artery bypass grafting J. Thorac. Cardiovasc. Surg., November 1, 2005; 130(5): 1319 - 1319. [Abstract] [Full Text] [PDF]
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A. X. Freire, L. Bridges, G. E. Umpierrez, D. Kuhl, and A. E. Kitabchi Admission Hyperglycemia and Other Risk Factors as Predictors of Hospital Mortality in a Medical ICU Population Chest, November 1, 2005; 128(5): 3109 - 3116. [Abstract] [Full Text] [PDF]
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J. Sjogren, J. Nilsson, R. Gustafsson, M. Malmsjo, and R. Ingemansson The Impact of Vacuum-Assisted Closure on Long-Term Survival After Post-Sternotomy Mediastinitis Ann. Thorac. Surg., October 1, 2005; 80(4): 1270 - 1275. [Abstract] [Full Text] [PDF]
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J.-S. Choi, K. R. Cho, and K.-B. Kim Does Diabetes Affect the Postoperative Outcomes After Total Arterial Off-Pump Coronary Bypass Surgery in Multivessel Disease? Ann. Thorac. Surg., October 1, 2005; 80(4): 1353 - 1360. [Abstract] [Full Text] [PDF]
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T. Doenst, D. Wijeysundera, K. Karkouti, C. Zechner, M. Maganti, V. Rao, and M. A. Borger Hyperglycemia during cardiopulmonary bypass is an independent risk factor for mortality in patients undergoing cardiac surgery J. Thorac. Cardiovasc. Surg., October 1, 2005; 130(4): 1144 - 1144. [Abstract] [Full Text] [PDF]
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N. W. Cheung, B. Napier, C. Zaccaria, and J. P. Fletcher Hyperglycemia Is Associated With Adverse Outcomes in Patients Receiving Total Parenteral Nutrition Diabetes Care, October 1, 2005; 28(10): 2367 - 2371. [Abstract] [Full Text] [PDF]
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A. M. Calafiore, M. Di Mauro, G. Di Giammarco, G. Teodori, A. L. Iaco, V. Mazzei, G. Vitolla, and M. Contini Single Versus Bilateral Internal Mammary Artery for Isolated First Myocardial Revascularization in Multivessel Disease: Long-Term Clinical Results in Medically Treated Diabetic Patients Ann. Thorac. Surg., September 1, 2005; 80(3): 888 - 895. [Abstract] [Full Text] [PDF]
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J. M. Carr, F. W. Sellke, M. Fey, M. J. Doyle, J. A. Krempin, R. de la Torre, and J. R. Liddicoat Implementing Tight Glucose Control After Coronary Artery Bypass Surgery Ann. Thorac. Surg., September 1, 2005; 80(3): 902 - 909. [Abstract] [Full Text] [PDF]
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G. Y. Gandhi, G. A. Nuttall, M. D. Abel, C. J. Mullany, H. V. Schaff, B. A. Williams, L. M. Schrader, R. A. Rizza, and M. M. McMahon Intraoperative Hyperglycemia and Perioperative Outcomes in Cardiac Surgery Patients Mayo Clin. Proc., July 1, 2005; 80(7): 862 - 866. [Abstract] [PDF]
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C. Kubal, A. K. Srinivasan, A. D. Grayson, B. M. Fabri, and J. A.C. Chalmers Effect of Risk-Adjusted Diabetes on Mortality and Morbidity After Coronary Artery Bypass Surgery Ann. Thorac. Surg., May 1, 2005; 79(5): 1570 - 1576. [Abstract] [Full Text] [PDF]
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 I. B. Hirsch, R. M. Bergenstal, C. G. Parkin, E. Wright Jr., and J. B. Buse A Real-World Approach to Insulin Therapy in Primary Care Practice Clin. Diabetes, April 1, 2005; 23(2): 78 - 86. [Full Text] [PDF]
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S. E. Inzucchi and J. Rosenstock Counterpoint: Inpatient Glucose Management: A premature call to arms? Diabetes Care, April 1, 2005; 28(4): 976 - 979. [Full Text] [PDF]
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 T. M Conner, K. R Flesner-Gurley, and J. C Barner Hyperglycemia in the Hospital Setting: The Case for Improved Control Among Non-Diabetics Ann. Pharmacother., March 1, 2005; 39(3): 492 - 501. [Abstract] [Full Text] [PDF]
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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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