Coronary artery bypass surgery maintaining glucose level

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Saphenous Vein Graft Disease
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Anahita Deylamsalehi, M.D.[2] Varun Kumar, M.B.B.S. [3]

Overview

One of the recommended practices to decrease the likelihood of sternal wound infection in patients undergoing CABG is perioperative insulin infusion to control hyperglycemia and maintaining the blood sugar lower than 180 mg/dl. In addition to reducing the likelihood of infection, the administration of continuous insulin infusion has been proven to lessens the likelihood of postoperative complications, such as mediastinitis, cardiac arrhythmias, renal failure, and lengthy hospitalization.

Maintaining Glucose Level in CABG

Prophylactic antibiotics is recommended, nevertheless it should not be continued beyond 48 hours.
The dose of prophylactic antibiotics must be tailored for lengthy procedures (more than two half-lives) or for those who lost excessive amount of blood during CABG.
Nasal swab test for Staphylococcus aureus is recommended.
For known carriers of Staphylococcus aureus, mupirocin 2% ointment should be applied.
For those with unknown nasal culture or PCR, preoperative intranasal mupirocin 2% ointment should be applied.
It is recommended to measure HbA1c before CABG
If it is a nonemergent surgical coronary revascularization, all extrathoracic infections must be treated before the surgery.
Guide patients to smoking cessation before elective CABG
For procedures involving a median sternotomy, it is recommended to apply topical antibiotics (vancomycin) to the cut edges of the sternum on opening and before closing.
In BIMA grafting, it is recommended to use a skeletonized harvest of IMA.

2021 ACA Revascularization Guideline

Class 1 Recommendation, Level of Evidence: B-R [20][3][4][5][10][8][9]
1. In order to reduce sternal wound infection in patients undergoing CABG an intraoperative continuous infusion of insulin should be initiated with the goal to keep blood sugar lower than 180 mg/dL.

2. In order to reduce sternal wound infection in patients undergoing CABG, an postoperative continuous infusion of insulin is recommended with the goal to keep an early postoperative blood sugar lower than 180 mg/dL.

Class 1 Recommendation, Level of Evidence: B-NR [20][11][12][13][14][21][22]
A comprehensive approach to decrease the risk of sternal wound infection is recommended in patients undergoing CABG.
Class 2b Recommendation, Level of Evidence: B-R[20][10]
The effectiveness of intraoperative continuous infusion of insulin with the goal to keep blood sugar lower than 140 mg/dL in patients undergoing CABG is not certain.

2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery (DO NOT EDIT)[23]

Class I
"1. Use of continuous intravenous insulin to achieve and maintain an early postoperative blood glucose concentration less than or equal to 180 mg/dL while avoiding hypoglycemia is indicated to reduce the incidence of adverse events, including deep sternal wound infection, after CABG.[8][24][25] (Level of Evidence: B)"
Class IIb
"1. The use of continuous intravenous insulin designed to achieve a target intraoperative blood glucose concentration less than 140 mg/dL has uncertain effectiveness.[26][27][28] (Level of Evidence: B)"

References

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