Abstract and Introduction
Abstract
Objective. The optimal perioperative blood glucose range to improve surgical site infection (SSI) in surgical intensive care unit (ICU) patients remains unclear. We sought to determine whether the incidence of SSI is reduced by perioperative intensive insulin therapy (IT).
Research Design and Methods. Patients were randomly assigned to receive perioperative intensive IT, with a target blood glucose range of 4.4–6.1 mmol/L, or intermediate IT, with a target blood glucose range of 7.7–10.0 mmol/L in the surgical ICU. We defined the primary end point as the incidence of SSI.
Results. Study participants were randomly assigned to glucose control with one of two target ranges: for 225 patients in the intermediate IT group or for 222 patients in the intensive IT group, respectively. No patients in either group became hypoglycemic (<4.4 mmol/L) during their stay in the surgical ICU. In our series, the rate of SSI after hepato-biliary-pancreatic surgery was 6.7%. Patients in the intensive IT group, compared with the intermediate IT group, had fewer postoperative SSIs (9.8% vs. 4.1%, P = 0.028) and a lower incidence of postoperative pancreatic fistula after pancreatic resection (P = 0.040). The length of hospitalization required for patients in the intensive IT group was significantly shorter than that in the intermediate IT group (P = 0.017).
Conclusions. We found that intensive IT decreased the incidence of SSI among patients who underwent hepato-biliary-pancreatic surgery: a blood glucose target of 4.4 to 6.1 mmol/L resulted in lower rate of SSI than did a target of 7.7–10.0 mmol/L.
Introduction
Hyperglycemia is common in acutely ill patients, including those treated in intensive care units (ICUs).[1] Until 2001, neglecting hyperglycemia was standard ICU care because a very impressive large randomized trial involving patients admitted to a surgical ICU showed that intensive insulin therapy (IT), targeting a blood glucose concentration of 4.4–6.1 mmol/L, significantly reduced in-hospital mortality.[2] However, trials examining the effects of tight glycemic control (TGC) have had conflicting results.[1,3–6] Systematic reviews and meta-analyses have also led to differing conclusions.[7,8] The main reason these clinical trials and meta-analyses had negative results for TGC was the high incidence of hypoglycemia (10–17%) induced by intensive IT.[7,8]
In recent years, it was reported that the results of the updated meta-analysis including NICE-SUGAR study data also do not support widespread adoption of intensive IT in critically ill patients.[9] In this meta-analysis, however, intensive IT may be beneficial to patients admitted to a surgical ICU, although the characteristics of such patients remain to be clearly defined, as do the effect of different blood glucose algorithms, the method of measuring blood glucose, and the influence of nutritional strategies.[9] Furthermore, this meta-analysis including NICE-SUGAR study data described that intensive IT significantly increased the risk of hypoglycemia. Effective control of surgical site infection (SSI) can reduce the length of hospitalization and can result in enhanced recovery after surgery. Perioperative hyperglycemia in critically ill surgery patients increases the risk of SSI, which is a common surgical complication. In various surgical settings, it is important to ensure optimal blood glucose levels in order to reduce SSIs. Unfortunately, however, the optimal perioperative blood glucose range to improve surgical outcomes including SSI remains unclear. In the past 10 years, solving the problem of methodology for intensive IT, especially the incidence of hypoglycemia during intensive IT, did not progress at all. The true effect of intensive IT in clinically ill patients cannot be evaluated without solving the occurrence of hypoglycemia during intensive IT. The development of accurate, continuous blood glucose–monitoring devices and closed-loop systems for computer-assisted blood glucose control in the ICU will probably help avoid hypoglycemia in these situations.[10]
Based on these findings, we conducted this prospective study to investigate which perioperative glycemic control range was better for reducing SSI—between intensive IT, with target blood glucose range of 4.4–6.1 mmol/L, and intermediate IT, with target blood glucose range of 7.7–10.0 mmol/L—using a closed-loop glycemic control system.
Diabetes Care. 2014;37(6):1516-1524. © 2014 American Diabetes Association, Inc.
