Use of a postoperative insulin protocol decreases wound infection in diabetics undergoing lower extremity bypass

Abstract

Strict glucose control in patients undergoing coronary bypass grafting has been shown to decrease infectious complications, arrhythmias, and mortality. Our objective was to determine if strict glucose control reduced morbidity after lower extremity bypass (LEB). Methods: A prospective pilot study at a single institution within the Vascular Study Group of New England was conducted from January 2009 to December 2010. Patients with diabetes and without undergoing LEB were placed on an intravenous (IV) insulin infusion for 3 days after surgery with titration of blood glucose from 80 to 150 mg/dL. The IV insulin study group (n ‫؍‬ 104) was compared to a historic control group (n ‫؍‬ 189) that received standard insulin treatment from the preceding 3 years. The Fisher exact test, t-tests, Wilcoxon rank-sum tests, 2 , and logistic regression analyses were used to compare in-hospital morbidity. Stratified analyses were conducted to determine if findings differed based on the presence or absence of diabetes. Results: There was no difference in postoperative complications between the two groups with regard to graft infection, myocardial infarction, dysrhythmia, primary patency at discharge, or mortality. Patients in the IV insulin group had significantly fewer in-hospital wound infections (4% vs 11%; odds ratio [OR], 0.32; 95% confidence interval [CI], 0.11-0.96; P ‫؍‬ .047). This association strengthened after adjusting for potentially confounding baseline differences in gender, body mass index, and smoking status (adjusted OR, 0.22; 95% CI, 0.05-0.84; P ‫؍‬ .03). When stratified by presence of diabetes, wound infections were decreased in the IV insulin group (0/44 [0%] vs 9/90 [10%]; P ‫؍‬ .03). In patients without diabetes treated with IV insulin, there was no significant difference in wound infections (7% vs 12%; P ‫؍‬ .42). Conclusions: Strict glucose control with a postoperative insulin infusion protocol significantly decreased the incidence of postoperative in-hospital wound infection in the diabetic population. These previously unreported findings from this single-institution prospective study warrant further investigation.

The association of postoperative glycemic control and lower extremity procedure outcomes

“…They concluded that strict glucose control with a postoperative insulin infusion protocol significantly decreased the incidence of postoperative in-hospital wound infection in the diabetic population but did not lower other postoperative complications. 20 An unexpected finding from this analysis was that after multivariable adjustment, diabetes was not associated with increased infection risk but was associated with shorter hospital stays and decreased mortality. It has been previously reported that in-hospital hyperglycemia is a common finding and represents an important marker of poor clinical outcome and mortality in patients with and without a history of diabetes and that patients with newly diagnosed hyperglycemia have worse outcomes.…”

Controle glicêmico no perioperatório: evidências para a prevenção de infecção de sítio cirúrgico

“…O regime de controle glicêmico por meio ICI foi adotado em seis estudos primários (28,(32)(33)(34)(35)(36) . Uma pesquisa delimitou o controle glicêmico de 100-150mg/dL no perioperatório, usando o regime de ICI em pacientes com e sem diabetes, sendo que os resultados não apresentaram diferença estatisticamente significante na incidência de infecções pós-operatórias entre os grupos (28) .…”

“…Três pesquisas que os autores investigaram o controle glicêmico rigoroso foram conduzidas com diferentes níveis de glicemia alvo (34)(35)(36) . No estudo de coorte, ao final do primeiro ano de experiência, os dados apontaram diminuição da taxa anual de ISC em 50% (34) .…”

“…Já em pacientes sem diabetes tratados com insulina IV, os resultados não demonstraram diferença estatisticamente significante referente à infecção da ferida. A conclusão da pesquisa apontou que o controle rigoroso da glicose por meio de protocolo de infusão de insulina IV, no pós-operatório, diminui significativamente a incidência de infecção da ferida cirúrgica na amostra com diabetes (36) . recomendaram o controle glicêmico no perioperatório para a prevenção deste tipo de infecção (11)(12)(13)(14)(15)(16)(17)(18)(19)(20)22,(24)(25)(26)(27)(29)(30)(31)(32)(33)(34)(35)(36) .…”

Use of a Glucose Management Service Improves Glycemic Control Following Vascular Surgery: An Interrupted Time-Series Study

“…Although some investigators offer data to support close glucose control via the use of insulin infusion in vascular surgery patients, 4,5 other investigators suggest that overly aggressive control may be harmful, 6 leading to higher rates of hypoglycemia and postoperative complications. This controversy has resulted in significant variation in strategies for managing perioperative glucose among diabetic patients undergoing vascular surgery.…”