American Surgical Association

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Effects of Aggressive Versus Moderate Glycemic Control on Clinical Outcomes in Diabetic Coronary Artery Bypass Graft Patients
Harold L Lazar, MD, Marie McDonnell, MD*, Stuart Chipkin, MD*, Carmel Fitzgerald, MD*, Caleb Bliss, MD*, Howard Cabral, MD*
Boston Medical Center, Boston, MA

OBJECTIVE(S): Maintaining serum glucose between 120-180mg/dl with continuous insulin infusions decreases morbidity in diabetic patients undergoing CABG surgery.Studies in surgical patients requiring prolonged ventilation suggest that aggressive glycemic control(<120mg/dl) may improve survival; however its effect in diabetic CABG patients is unknown. This study was undertaken to determine whether aggressive glycemic control(90-120mg/dl) would result in more optimal clinical outcomes and less morbidity than can be achieved with moderate glycemic control(120-180mg/dl)in diabetic patients undergoing CABG surgery.
METHODS: Seventy-two diabetic patients undergoing CABG were prospectively randomized to aggressive glycemic control(90-120mg/dl) or moderate glycemic control (120-180mg/dl) using continuous intravenous insulin solutions(100units regular insulin in 100ml normal saline) beginning at the induction of anesthesia and continuing for 18 hours following CABG. The primary endpoint was the incidence of Major Adverse Events(MAE=30 day mortality, myocardial infarction(MI), neurological events, deep sternal infections, and atrial fibrillation).Secondary endpoints included serum glucose, hypoglycemic events(glucose<80mg/dl) and free fatty acid(ffa) levels.
RESULTS: There was no difference in the incidence of MAE between the groups. Patients with aggressive control averaged lower serum glucose levels and had a higher incidence of hypoglycemic events but this did not result in an increased incidence of neurological events.
CONCLUSIONS: In diabetic patients undergoing CABG surgery, aggressive glycemic control increases the incidence of hypoglycemic events and does not result in any significant improvement of clinical outcomes than can be achieved with moderate control.
RESULTS(+/-Standard Deviation)
VariableMODERATE(n=36)AGGRESSIVE(n=36)p Value
Mortality00--
MI030.239
Neurological Events100.474
Sternal Infections00--
Atrial Fibrillation1080.597
Hypoglycemic Episodes627<0.0001
Serum glucose (mg/dl) @ 18 hours postop130+/-15103+/-18<0.0001
FFA(mEq/L)@18 hours postop0.68+/-0.240.52+/-0.240.088


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