Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting

Abstract

Objective: Diabetes mellitus is a risk factor for death after coronary artery bypass grafting. Its relative risk may be related to the level of perioperative hyperglycemia. We hypothesized that strict glucose control with a continuous insulin infusion in the perioperative period would reduce hospital mortality. Methods: All patients with diabetes undergoing coronary artery bypass grafting (n = 3554) were treated aggressively with either subcutaneous insulin (1987-1991) or with continuous insulin infusion (1992-2001) for hyperglycemia. Predicted and observed hospital mortalities were compared with both internal and external (Society of Thoracic Surgeons 1996) multivariable risk models. Results: Observed mortality with continuous insulin infusion (2.5%, n = 65/2612) was significantly lower than with subcutaneous insulin (5.3%, n = 50/942, P < .001). Multivariable analysis revealed that continuous insulin infusion added an independently protective effect against death (odds ratio 0.50, P = .005) to the constellation of risk factors in the Society of Thoracic Surgeons risk model. Conclusion: Continuous insulin infusion eliminates the incremental increase in inhospital mortality after coronary artery bypass grafting associated with diabetes. The protective effect of continuous insulin infusion may stem from the effective metabolic use of excess glucose to favorably alter pathways of myocardial adenosine triphosphate production. Continuous insulin infusion should become the standard of care for glycometabolic control in patients with diabetes undergoing coronary artery bypass grafting.