Perioperative Tight Glucose Control Reduces Postoperative Adverse Events in Nondiabetic Cardiac Surgery Patients
Abstrakt
Tight glucose control (TGC) reduces morbidity and mortality in patients undergoing elective cardiac surgery, but only limited data about its optimal timing are available to date. To compare the effects of perioperative (PERI) versus postoperative (POST) initiation of TGC on postoperative adverse events in cardiac surgery patients.
Design: Single center, single-blind, parallel-group, randomized controlled trial. Settings: Academic tertiary hospital.
Participants: 2383 hemodynamically stable patients undergoing major cardiac surgery with expected postoperative ICU treatment for at least 2 consecutive days. Intervention: Perioperatively or postoperatively initiated intensive insulin therapy with target glucose range 4.4-6.1 mmol/l.
Main Outcome Measures: Adverse events from any cause during postoperative hospital stay. Results: In the whole cohort, perioperatively initiated TGC markedly reduced the number of postoperative complications (23.2 vs. 34.1%, 95% CI 0.60-0.78) in spite of only minimal improvement in glucose control (blood glucose 6.6+/-0.7 vs. 6.7+/-0.8 mmol/l, p<0.001; time in target range 39.3+/-13.7 vs. 37.3+/-13.8%, p<0.001).
The positive effects of TGC on postoperative complications were driven by non-diabetic subjects (21.3 vs. 33.7%, 95% CI 0.54-0.74; blood glucose 6.5+/-0.6 vs. 6.6+/-0.8 mmol/, n.s.; time in target range 40.8+/-13.6 vs. 39.7+/-13.8%, n.s.), whilenosignificant effect was seen in diabetic patients (29.4 vs. 35.1%, 95% CI 0.66-1.06) despite significantly better glucose control in the PERI group (blood glucose 6.9+/-1.0 vs. 7.1+/-0.8 mmol/l, p<0.001; time in target range 34.3+/-12.7 vs. 30.8+/-11.5%, p<0.001). Conclusions: Perioperative initiation of intensive insulin therapy during cardiac surgery reduces postoperative morbidity in non-diabetic patients while having minimal effect in diabetic subjects.