Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
Department of Quality Management, Singapore General Hospital, Singapore.
J Thorac Cardiovasc Surg. 2015 Jan;149(1):323-8. doi: 10.1016/j.jtcvs.2014.08.076. Epub 2014 Sep 17.
Hyperglycemia is associated with surgical site infection and mortality in cardiac surgical patients. There is overriding evidence that glycemic control improves morbidity and mortality. However, the optimal glucose range in these patients remains controversial. Intensive glucose control can lead to mortality among critically ill adults because of episodic, moderate hypoglycemia. Therefore, we examined the effect of different glucose target control on the incidence of surgical site infection in our prospective cohort of diabetic and nondiabetic patients undergoing coronary artery bypass grafting.
Data from 1442 patients who underwent elective coronary artery bypass grafting at a tertiary heart center in Singapore from 2009 to 2011 were obtained. The first glucose level on arrival in the cardiothoracic intensive care unit was set at 4 to 8 mmol/L in 2009 and 2010 and 4 to 10 mmol/L in 2011. Glucose control was achieved with intravenous insulin infusion with a strict glucose monitoring protocol. Clinical covariates were analyzed, with surgical site infection as the primary outcome.
The majority of patients presenting for coronary artery bypass grafting were male, Chinese, and diabetic. Diabetic patients had significantly higher glucose levels on arrival in the cardiothoracic intensive care unit. The change in target glucose control was independently associated with an increase in surgical site infection (odds ratio, 2.280; 95% confidence interval, 1.250-4.162; P = .007). Subgroup analysis revealed that unlike in nondiabetic patients, a less stringent target was independently associated with a significant increase in surgical site infection incidence from 2.2% to 6.9% for the diabetic patients (odds ratio, 3.131; 95% confidence interval, 1.431-6.851; P = .004).
A target blood glucose of less than 8 mmol/L was associated with a lower incidence of surgical site infection in diabetic patients presenting for elective coronary artery bypass grafting in the local Southeast Asian population.
高血糖与心脏外科患者的手术部位感染和死亡率有关。有压倒性的证据表明，血糖控制可改善发病率和死亡率。然而，这些患者的最佳血糖范围仍存在争议。强化血糖控制可导致危重症成人死亡，因为会出现间歇性、中度低血糖。因此，我们在接受择期冠状动脉旁路移植术的糖尿病和非糖尿病患者的前瞻性队列中，研究了不同血糖目标控制对手术部位感染发生率的影响。
从 2009 年至 2011 年，在新加坡的一家三级心脏中心接受择期冠状动脉旁路移植术的 1442 名患者的数据被获得。2009 年和 2010 年，心胸重症监护病房到达时的第一血糖水平设定为 4 至 8mmol/L，2011 年设定为 4 至 10mmol/L。通过静脉内胰岛素输注和严格的血糖监测方案来实现血糖控制。分析了临床协变量，以手术部位感染为主要结局。
大多数接受冠状动脉旁路移植术的患者为男性、中国人和糖尿病患者。糖尿病患者到达心胸重症监护病房时的血糖水平明显较高。目标血糖控制的变化与手术部位感染的增加独立相关（比值比，2.280；95%置信区间，1.250-4.162；P =.007）。亚组分析显示，与非糖尿病患者不同，对于糖尿病患者，目标设定较不严格与手术部位感染发生率从 2.2%显著增加至 6.9%独立相关（比值比，3.131；95%置信区间，1.431-6.851；P =.004）。
在当地东南亚人群中，接受择期冠状动脉旁路移植术的糖尿病患者，血糖目标低于 8mmol/L 与手术部位感染发生率降低相关。
