Diabetes mellitus is a risk factor for deep sternal wound infection after open heart
surgical procedures. We previously showed that elevated postoperative blood glucose
levels are a predictor of deep sternal wound infection in diabetic patients. Therefore,
we hypothesized that aggressive intravenous pharmacologic control of postoperative
blood glucose levels would reduce the incidence of deep sternal wound infection.
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.
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 chi2 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.
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.