title: Perioperative hyperinsulinaemic normoglycaemic clamp causes hypolipidaemia after coronary artery surgery. Glucose-insulin-potassium solutions improve outcomes in diabetics who have coronary artery operations. Validation of the DeLiT Trial intravenous insulin infusion algorithm for intraoperative glucose control in noncardiac surgery: a randomized controlled trial Control of hyperglycaemia in paediatric intensive care (CHiP): study protocol Effects of Aggressive Versus Moderate Glycemic Control on Clinical Outcomes in Diabetic Coronary Artery Bypass Graft Patients Insulin treatment of the insulin‐dependent diabetic patient undergoing minor surgery Insulin therapy of hyperglycemia in intensive care. Effect of Intensive Insulin Therapy Using a Closed-Loop Glycemic Control System in Hepatic Resection Patients Tight Glycemic Control in Diabetic Coronary Artery Bypass Graft Patients Improves Perioperative Outcomes and Decreases Recurrent Ischemic Events Blood glucose control by a model predictive control algorithm with variable sampling rate versus a routine glucose management protocol in cardiac surgery patients: a randomized controlled trial. Outcome benefit of intensive insulin therapy in the critically ill: Insulin dose versus glycemic control* The Effects of Glucose on Plasma Amino Acids and Pyruvate During Upper Abdominal Surgery A phase II randomised controlled trial of intensive insulin therapy in general intensive care patients. Comparison of Three Protocols for Tight Glycemic Control in Cardiac Surgery Patients Continuous Perioperative Insulin Infusion Decreases Major Cardiovascular Events in Patients Undergoing Vascular Surgery: A Prospective, Randomized Trial [Perioperative management of the diabetic patient in cardiac surgery with extracorporeal circulation]. Conventional approach to glucose management for diabetic patients undergoing coronary artery bypass surgery Multimodal optimization of surgical care shows beneficial outcome in gastrectomy surgery. Cardioprotective effects of glucose and insulin administration while maintaining normoglycemia (GIN therapy) in patients undergoing coronary artery bypass grafting. Intensive Intraoperative Insulin Therapy versus Conventional Glucose Management during Cardiac Surgery High-dose insulin therapy attenuates systemic inflammatory response in coronary artery bypass grafting patients. Intensive insulin therapy does not alter the inflammatory response in patients undergoing coronary artery bypass grafting: a randomized controlled trial [ISRCTN95608630] Intensive Insulin Therapy in Mixed Medical/Surgical Intensive Care Units Strict versus liberal target range for perioperative glucose in patients undergoing coronary artery bypass grafting: a prospective randomized controlled trial. Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. Intensive Perioperative Glucose Control Does Not Improve Outcomes of Patients Submitted to Open-Heart Surgery: A Randomized Controlled Trial Effect of intensive insulin therapy on insulin sensitivity in the critically ill. Strict glycaemic control in patients hospitalised in a mixed medical and surgical intensive care unit: a randomised clinical trial Insulin‐dependent diabetes during the peri‐operative period An nssessment of continuous glucose‐insulin‐potaium infusion, and traditional treatment Early postoperative glucose control predicts nosocomial infection rate in diabetic patients. Double-blind study of glycerol vs glucose in parenteral nutrition of postsurgical insulin-treated diabetic patients. A randomized evaluation of the effects of glucose-insulin-potassium infusion on myocardial salvage in patients with acute myocardial infarction treated with reperfusion therapy. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Intravenous glucose–insulin–potassium during off‐pump coronary artery bypass surgery does not reduce myocardial injury Continuous postoperative blood glucose monitoring and control by artificial pancreas in patients having pancreatic resection: a prospective randomized clinical trial. Intensive versus conventional insulin therapy: A randomized controlled trial in medical and surgical critically ill patients* Effects of glucose-insulin-potassium infusion on myocardial perfusion and left ventricular remodeling in patients treated with primary angioplasty for ST-elevation acute myocardial infarction. Effects of abciximab and preprocedural glycemic control in diabetic patients undergoing elective coronary stenting. [Impact of intensive insulin therapy on surgical critically ill patients]. Intensive versus conventional glucose control in critically ill patients. Lowering of glucose in critical care: a randomized pilot trial. Use of i.v. insulin in well-controlled non-insulin-dependent diabetics undergoing major surgery. Perioperative Glucose and Insulin Administration While Maintaining Normoglycemia (GIN Therapy) in Patients Undergoing Major Liver Resection Insulin infusion improves neutrophil function in diabetic cardiac surgery patients. [Effect of intensive insulin therapy on the clinical results of postoperative patients with gastric cancer]. [Effects of intensive insulin therapy on insulin resistance and serum proteins after radical gastrectomy]. A prospective randomised multi-centre controlled trial on tight glucose control by intensive insulin therapy in adult intensive care units: the Glucontrol study ST-segment elevation resolution and outcome in patients treated with primary angioplasty and glucose-insulin-potassium infusion. Perioperative glycemic control and the risk of infectious complications in a cohort of adults with diabetes. Preoperative Oral Carbohydrate Administration to ASA III-IV Patients Undergoing Elective Cardiac Surgery Comparison of once-daily glargine insulin with twice-daily NPH/regular insulin for control of hyperglycemia in inpatients after cardiovascular surgery. Hypotheses, design, and methods for the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) Trial. Intensive insulin therapy in critically ill patients. Comparison of a continuous glucose-insulin-potassium infusion versus intermittent bolus application of insulin on perioperative glucose control and hormone status in insulin-treated type 2 diabetics. Effect of glycemic control on early diabetic renal lesions. A 5-year randomized controlled clinical trial of insulin-dependent diabetic kidney transplant recipients. Effect of Metoclopramide on Gastric Fluid Volumes in Diabetic Patients Who Have Fasted before Elective Surgery Comparison between a glucose-fructose-xylitol solution and a sole glucose solution for surgical patients with glucose tolerance impairment. Continuous insulin infusion improves postoperative glucose control in patients with diabetes mellitus undergoing coronary artery bypass surgery. Intensive Versus Conventional Insulin Therapy in Type 2 Diabetes Patients Undergoing D2 Gastrectomy for Gastric Cancer: A Randomized Controlled Trial A Simple Glucose Insulin Regimen for Perioperative Blood Glucose Control: The Vellore Regimen Insulin glargine improves glycaemic control after coronary surgery in patients with diabetes or pre-diabetes A Comparison of Two Intravenous Insulin Regimens Among Surgical Patients With Insulin-Dependent Diabetes Mellitus Insulin subcutaneous application vs. continuous infusion for postoperative blood glucose control in patients with non-insulin-dependent diabetes mellitus. Our experience of controlling diabetes in the peri-operative period of patients who underwent cardiac surgery. Strict blood glucose control with insulin during intensive care after cardiac surgery: impact on 4-years survival, dependency on medical care, and quality-of-life. A randomized trial comparing myocardial salvage achieved by coronary stenting versus balloon angioplasty in patients with acute myocardial infarction considered ineligible for reperfusion therapy. Intraoperative glycaemic control in non-insulin-dependent and insulin-dependent diabetes. Safety and Efficacy of Intensive Insulin Therapy in Critical Neurosurgical Patients
abstract: BACKGROUND Glucose-insulin-potassium ( GIK ) administration is advocated on the premise of preventing hyperglycaemia and hyperlipidaemia during reperfusion after cardiac interventions . Current research has focused on hyperglycaemia , largely ignoring lipids , or other substrates . The present study examines lipids and other substrates during and after on-pump coronary artery bypass grafting and how they are affected by a hyperinsulinaemic normoglycaemic clamp . METHODS Forty-four patients were r and omized to a control group ( n=21 ) or to a GIK group ( n=23 ) receiving a hyperinsulinaemic normoglycaemic clamp during 26 h.  Plasma levels of free fatty acid ( FFA ) , total and lipoprotein ( VLDL , HDL , and LDL)-triglycerides ( TG ) , ketone bodies , and lactate were determined . RESULTS In the control group , mean FFA peaked at 0.76 ( sem 0.05 ) mmol litre(-1 ) at early reperfusion and decreased to 0.3 - 0.5 mmol litre(-1 ) during the remaining part of the study . GIK decreased FFA levels to 0.38 ( 0.05 ) mmol litre(-1 ) at early reperfusion , and to low concentrations of 0.10 ( 0.01 ) mmol litre(-1 ) during the hyperinsulinaemic clamp . GIK reduced the area under the curve ( AUC ) for FFA by 75 % and for TG by 53 % . The reduction in total TG was reflected by a reduction in the VLDL ( -54 % AUC ) and HDL ( -42 % AUC ) fraction , but not in the LDL fraction . GIK prevented the increase in ketone bodies after reperfusion ( -44 to -47 % AUC ) , but was without effect on lactate levels . CONCLUSIONS Mild hyperlipidaemia was only observed during early reperfusion ( before heparin reversal ) and the hyperinsulinaemic normoglycaemic clamp actually result ed in hypolipidaemia during the largest part of reperfusion after cardiac surgery BACKGROUND This study was undertaken to determine whether glucose-insulin-potassium ( GIK ) would improve myocardial performance and limit morbidity after coronary artery bypass grafting in diabetic patients . METHODS Forty consecutive coronary artery bypass grafting patients with medically treated diabetes mellitus were prospect ively r and omly assigned to either a GIK group ( n = 20 ; 500 mL D5W + 80 U regular insulin + 40 mEq KCl 30 mL/hour ) or a no-GIK group ( n = 20 ; D5W at 30 mL/hour ) . The GIK was begun at anesthetic induction and continued for 12 hours postoperatively . RESULTS Patients treated with GIK had higher postoperative cardiac indices ( 2.88 + /- 0.50 versus 2.20 + /- 0.39 L/minute per square meter ; p < 0.0001 ) , lower inotrope scores ( 0.40 + /- 0.68 versus 1.25 + /- 1.44 ; p = 0.05 ) , less weight gain ( 5.80 + /- 3.76 versus 13.85 + /- 6.52 pounds ; p < 0.0001 ) , and had shorter times of ventilator support ( 8.35 + /- 2.60 versus 13.45 + /- 7.33 hours ; p = 0.0128 ) . They had a significantly lower prevalence of atrial fibrillation ( 15 % versus 60 % ; p = 0.003 ) , and shorter hospital stays ( 6.70 + /- 1.52 versus 10.15 + /- 6.62 days ; p = 0.02 ) . CONCLUSIONS Substrate enhancement with GIK in diabetic patients improved myocardial performance and result ed in faster recovery after coronary artery bypass grafting Purpose A safe and effective insulin infusion algorithm that achieves rigorous intraoperative glycemic control in noncardiac surgery has yet to be formally characterized and evaluated . We therefore report the validation of the DeLit Trial insulin infusion algorithm . Methods Patients scheduled for major noncardiac surgery were r and omized to a target intraoperative blood glucose concentration of 4.4 - 6.1 mmoL·L−1 ( 80 - 110 mg·dL−1 ) intensive group or 10 - 11.1 mmoL·L−1 ( 180 - 200 mg·dL−1 ) conventional group . Glucose was managed with a dynamic intravenous insulin infusion algorithm . We compared the r and omized groups on glucose time-weighted average ( TWA ) , proportion of time spent within target , number of severe ( < 2.2 mmoL·L−1 or < 40 mg·dL−1 ) or moderate ( < 2.8 mmoL·L−1or < 50 mg·dL−1 ) hypoglycemic episodes , and within-patient variability in glucose concentrations expressed as st and ard deviation from the patient mean . Results One hundred eighty-seven patients were assigned to intensive glucose control , and 177 patients were assigned to conventional glucose control .  Median ( lower quartile value [ Q1 ] , upper quartile value [ Q3 ] ) of intraoperative TWA for the intensive vs conventional groups was 6 [ 5.6 , 6.7 ] mmoL·L−1vs 7.7 [ 6.9 , 9.2 ] mmoL·L−1 , respectively ; P < 0.001 . The intensive group spent 49 % ( 29 , 71 ) of the time within target , substantially more time than the conventional group spent either within the intensive target or within its own target ( both P < 0.001 ) . The intensive group had slightly lower within-patient glucose variability than the conventional group ( 0.9 [ 0.7 , 1.3 ] mmoL·L−1vs 1.3 [ 0.8 , 1.8 ] mmoL·L−1 , respectively ; P < 0.001 ) . Three patients had moderate hypoglycemia ( intensive group ) , but none experienced severe episodes . Conclusion Tight intraoperative glucose control in noncardiac surgery can be maintained successfully without serious hypoglycemic episodes . ( Clinical Trials.gov number , NCT00433251).RésuméObjectifNous ne disposons pas encore d’un algorithme de perfusion d’insuline formellement caractérisé et évalué , qui soit à la fois sécuritaire et efficace , et qui permette de maintenir un contrôle glycémique peropératoire rigoureux en chirurgie non cardiaque . C’est pourquoi nous rapportons la validation de notre algorithme de perfusion de l’insuline . MéthodeDes patients devant subir une chirurgie non cardiaque majeure ont été r and omisés à une concentration glycémique peropératoire cible de 4,4 - 6,1 mmoL·L−1 ( 80 - 110 mg·dL−1 ) dans le groupe intensif ou à une concentration de 10 - 11,1 mmoL·L−1 ( 180 - 200 mg·dL−1 ) dans le groupe conventionnel . La glycémie a été contrôlée à l’aide d’un algorithme dynamique de perfusion intraveineuse d’insuline . Nous avons comparé les groupes r and omisés en matière de moyenne pondérée dans le temps , de la proportion de temps passé à la concentration cible , du nombre d’épisodes d’hypoglycémie grave ( < 2,2 mmoL·L−1 ou < 40 mg·dL−1 ) ou modérée ( < 2,8 mmoL·L−1 ou < 50 mg·dL−1 ) , ainsi que de la variabilité chez un même patient des concentrations glycémiques , exprimée en tant qu’écart type de la moyenne du patient . RésultatsCent quatre-vingt-sept patients ont été attribués au groupe contrôle glycémique intensif , et 177 au groupe contrôle glycémique conventionnel . La médiane ( valeur du quartile inférieur [ Q1 ] , valeur du quartile supérieur [ Q3 ] ) de la moyenne pondérée dans le temps pour les groupes intensif vs conventionnel était de 6 ( 5,6 , 6,7 ) mmoL·L−1vs 7,7 ( 6,9 , 9,2 ) , respectivement ; P < 0,001 . Le groupe intensif a passé 49 % ( 29 , 71 ) du temps dans la zone cible , soit considérablement plus de temps que le groupe conventionnel n’a passé dans la zone cible intensive ou dans sa propre zone cible ( tous deux P < 0,001 ) . Le groupe intensif a présenté une variabilité chez un même patient légèrement plus basse que le groupe conventionnel ( 0,9 [ 0,7 , 1,3 ] mmoL·L−1vs 1,3 [ 0,8 , 1,8 ] mmoL·L−1 , respectivement ; P < 0,001 ) . Trois patients ont présenté une hypoglycémie modérée ( groupe intensif ) , mais aucun patient n’a manifesté d’épisode grave . Conclusion Un contrôle glycémique peropératoire rigoureux peut être maintenu en chirurgie non cardiaque sans épisode hypoglycémique grave . ( Numéro de Clinical Trials.gov , NCT00433251 ) Background There is increasing evidence that tight blood glucose ( BG ) control improves outcomes in critically ill adults . Children show similar hyperglycaemic responses to surgery or critical illness . However it is not known whether tight control will benefit children given maturational differences and different disease spectrum . Methods / Design The study is an r and omised open trial with two parallel groups to assess whether , for children undergoing intensive care in the UK aged ≤ 16 years who are ventilated , have an arterial line in-situ and are receiving vasoactive support following injury , major surgery or in association with critical illness in whom it is anticipated such treatment will be required to continue for at least 12 hours , tight control will increase the numbers of days alive and free of mechanical ventilation at 30 days , and lead to improvement in a range of complications associated with intensive care treatment and be cost effective . Children in the tight control group will receive insulin by intravenous infusion titrated to maintain BG between 4 and 7.0 mmol/l . Children in the control group will be treated according to a st and ard current approach to BG management . Children will be followed up to determine vital status and healthcare re sources usage between discharge and 12 months post-r and omisation . Information regarding overall health status , global neurological outcome , attention and behavioural status will be sought from a subgroup with traumatic brain injury (TBI).A difference of 2 days in the number of ventilator-free days within the first 30 days post-r and omisation is considered clinical ly important . Conservatively assuming a st and ard deviation of a week across both trial arms , a type I error of 1 % ( 2-sided test ) , and allowing for non-compliance , a total sample size of 1000 patients would have 90 % power to detect this difference . To detect effect differences between cardiac and non-cardiac patients , a target sample size of 1500 is required . An economic evaluation will assess whether the costs of achieving tight BG control are justified by subsequent reductions in hospitalisation costs . Discussion The relevance of tight glycaemic control in this population needs to be assessed formally before being accepted into st and ard practice .Trial Registration Current Controlled Trials IS RCT Objective : This study sought to determine whether aggressive glycemic control ( 90–120 mg/dL ) would result in more optimal clinical outcomes and less morbidity than moderate glycemic control ( 120–180 mg/dL ) in diabetic patients undergoing coronary artery bypass graft ( CABG ) surgery . Summary of Background Data : Maintaining serum glucose levels between 120 and 180 mg/dL with continuous insulin infusions decreases morbidity in diabetic patients undergoing CABG surgery . Studies in surgical patients requiring prolonged ventilation suggest that aggressive glycemic control ( < 120 mg/dL ) may improve survival ; however , its effect in diabetic CABG patients is unknown . Methods : Eighty-two diabetic patients undergoing CABG were prospect ively r and omized to aggressive glycemic control ( 90–120 mg/dL ) or moderate glycemic control ( 120–180 mg/dL ) using continuous intravenous insulin solutions ( 100 units regular insulin in 100 mL : normal saline ) beginning at the induction of anesthesia and continuing for 18 hours after CABG . Primary end points were the incidence of major adverse events ( major adverse events = 30-day mortality , myocardial infa rct ion , neurologic events , deep sternal infections , and atrial fibrillation ) , the level of serum glucose , and the incidence of hypoglycemic events . Results : There were no differences in the incidence of major adverse events between the groups ( 17 moderate vs 15 aggressive ; P = 0.91 ) . Patients with aggressive control had a lower mean glucose at the end of 18 hours of insulin infusion ( 135 ± 12 mg/dL moderate vs 103 ± 17 mg/dL aggressive ; P < 0.0001 ) . Patients with aggressive control had a higher incidence of hypoglycemic events ( 4 vs 30 ; P < 0.0001 ) . Conclusions : In diabetic patients undergoing CABG surgery , aggressive glycemic control increases the incidence of hypoglycemic events and does not result in any significant improvement in clinical outcomes that can be achieved with moderate control . Clinical Trials.gov ( ID # NCT00460499 In a prospect i ve r and omised study in 20 insulin‐dependent diabetics who had minor surgery under general anaesthesia we compared the metabolic responses to intravenous glucose‐insulin‐potassium infusion with those who had conventional subcutaneous insulin administration . The former treatment result ed in lower blood glucose levels both during the infusion period ( p < 0.05 ) as well as the entire observation period ( operative , first and second postoperative days ; p < 0.01 ) . More blood glucose values were within the intended range of 5 to 10 mmol/litre in the glucose‐insulin‐potassium as compared to the conventional group ( 48 % versus 24 % ; p < 0.01 ) . The levels of lactate , 3‐hydroxybutyrate , glycerol , alanine , glucagon , insulin and growth hormone did not differ between the two groups . The infusion regimen result ed in better glycaemic control both peri‐ and postoperatively than the conventional subcutaneous insulin regimen in insulin‐dependent diabetic patients who have minor surgery BACKGROUND Hyperglycemia is common among patients admitted to intensive care units , and carries the risk for complications and prolonged ICU stay . With intensive insulin control of blood glucose , morbidity and mortality can be reduced . OBJECTIVES To determine whether intensive or conventional insulin control of blood glucose in hyperglycemic ICU patients correlated with the prognosis . METHODS Following admission to the ICU , hyperglycemic patients were r and omly assigned to a group treated intensively with insulin targeting glucose at 110 - 140 mg/dl , or to a conventional insulin therapy group , where glucose , upon exceeding 200 mg/dl , was controlled at 140 - 200 mg/dl . Rates of morbidity and mortality , hypoglycemic episodes , and insulin dosage were compared . RESULTS In the 41 patients treated intensively with insulin  the glucose level was 142 + /- 14 mg/dl , as compared to 174+/-20 mg/dl in the 48 patients on conventional insulin treatment .  Both groups were similar in age , acute physiology and chronic health evaluation score . Morbidity was also similar , except for increased vascular damage in the conventional treatment group and slightly shorter ICU stay in the intensive therapy group . Both groups had similar in-ICU , in-hospital , and 28 day mortalities , and similar rates of hypoglycemic episodes . The daily dosage of insulin  was significantly higher with the conventional treatment ( P= 0.004 ) . CONCLUSIONS Intensive insulin treatment did not affect the mortality or morbidity rates in ICU patients . The increased  insulin dosage of conventional insulin treatment was attributable to the group 's higher prevalence of diabetes . Future studies should address this bias and determine the optimal glucose target OBJECTIVE Intensive insulin therapy ( IIT ) reduces morbidity and mortality in patients in surgical intensive care units . The aim of this study is to assess the effect of IIT using a closed-loop system in hepatectomized patients . RESEARCH DESIGN AND METHODS Patients were r and omly assigned to receive IIT using a closed-loop system : an artificial pancreas ( AP group ) or conventional insulin therapy using the sliding-scale method ( SS group ) . RESULTS The incidence of surgical-site infection in the AP group was significantly lower than that in the SS group . The length of hospitalization required for patients in the AP group was significantly shorter than that in the SS group . CONCLUSIONS Total hospital costs for patients in the AP group were significantly lower than for patients in the SS group . IIT using a closed-loop system maintained near-normoglycemia and contributed to a reduction in the incidence of SSI and total hospital costs due to shortened hospitalization Background —This study sought to determine whether tight glycemic control with a modified glucose-insulin-potassium ( GIK ) solution in diabetic coronary artery bypass graft ( CABG ) patients would improve perioperative outcomes . Methods and Results —One hundred forty-one diabetic patients undergoing CABG were prospect ively r and omized to tight glycemic control ( serum glucose , 125 to 200 mg/dL ) with GIK or st and ard therapy ( serum glucose < 250 mg/dL ) using intermittent subcutaneous insulin beginning before anesthesia and continuing for 12 hours after surgery . GIK patients had lower serum glucose levels ( 138±4 versus 260±6 mg/dL ; P < 0.0001 ) , a lower incidence of atrial fibrillation ( 16.6 % versus 42 % ; P = 0.0017 ) , and a shorter postoperative length of stay ( 6.5±0.1 versus 9.2±0.3 days ; P = 0.003 ) . GIK patients also showed a survival advantage over the initial 2 years after surgery ( P = 0.04 ) and decreased episodes of recurrent ischemia ( 5 % versus 19 % ; P = 0.01 ) and developed fewer recurrent wound infections ( 1 % versus 10 % , P = 0.03 ) . Conclusions —Tight glycemic control with GIK  in diabetic CABG patients  improves perioperative outcomes , enhances survival , and decreases the incidence of ischemic events and wound complications CONTEXT Elevated blood glucose levels occur frequently in the critically ill . Tight glucose control by intensive insulin treatment markedly improves clinical outcome . OBJECTIVE AND DESIGN This is a r and omized controlled trial comparing blood glucose control by a laptop-based model predictive control algorithm with a variable sampling rate [ enhanced model predictive control ( eMPC ) ; version 1.04.03 ] against a routine glucose management protocol ( RMP ) during the peri- and postoperative periods . SETTING The study was performed at the Department of Cardiac Surgery , University Hospital . PATIENTS A total of 60 elective cardiac surgery patients were included in the study . INTERVENTIONS Elective cardiac surgery and treatment with continuous insulin infusion ( eMPC ) or continuous insulin infusion combined with iv insulin boluses ( RMP ) to maintain euglycemia ( target range 4.4 - 6.1 mmol/liter ) were performed . There were 30 patients r and omized for eMPC and 30 for RMP treatment . Blood glucose was measured in 1- to 4-h intervals as requested by each algorithm during surgery and postoperatively over 24 h. MAIN OUTCOME MEASURES Mean blood glucose , percentage of time in target range , and hypoglycemia events were used . RESULTS Mean blood glucose was 6.2 + /- 1.1 mmol/liter in the eMPC vs. 7.2 + /- 1.1 mmol/liter in the RMP group ( P < 0.05 ) ; percentage of time in the target range was 60.4 + /- 22.8 % for the eMPC vs. 27.5 + /- 16.2 % for the RMP group ( P < 0.05 ) . No severe hypoglycemia ( blood glucose < 2.9 mmol/liter ) occurred during the study . Mean insulin infusion rate was 4.7 + /- 3.3 IU/h in the eMPC vs. 2.6 + /- 1.7 IU/h in the RMP group ( P < 0.05 ) . Mean sampling interval was 1.5 + /- 0.3 h in the eMPC vs. 2.1 + /- 0.2 h in the RMP group ( P < 0.05 ) . CONCLUSIONS Compared with RMP , the eMPC algorithm was more effective and comparably safe in maintaining euglycemia in cardiac surgery patients Objectives Maintenance of normoglycemia with insulin reduces mortality and morbidity of critically ill patients . Here we report the factors determining insulin requirements and the impact of insulin dose vs. blood glucose control on the observed outcome benefits . Design A prospect i ve , r and omized , controlled trial . Setting A 56-bed predominantly surgical intensive care unit in a tertiary teaching hospital Patients and InterventionA total of 1,548 patients were r and omly assigned to either strict normalization of blood glucose ( 80–110 mg/dL ) with insulin infusion or the conventional approach , in which insulin is only given to maintain blood glucose levels at 180–200 mg/dL. Measurements and Main Results It was feasible and safe to achieve and maintain blood glucose levels at < 110 mg/dL by using a titration algorithm . Stepwise linear regression analysis identified body mass index , history of diabetes , reason for intensive care unit admission , at-admission hyperglycemia , caloric intake , and time in intensive care unit as independent determinants of insulin requirements , together explaining 36 % of its variation . With nutritional intake increasing from a mean of 550 to 1600 calories/day during the first 7 days of intensive care , normoglycemia was reached within 24 hrs , with a mean daily insulin dose of 77 IU and maintained with 94 IU on day 7 .  Insulin requirements were highest and most variable during the first 6 hrs of intensive care ( mean , 7 IU/hr ; 10 % of patients required > 20 IU/hr ) . Between day 7 and 12 ,  insulin requirements decreased by 40 % on stable caloric intake . Brief , clinical ly harmless hypoglycemia occurred in 5.2 % of intensive insulin-treated patients on median day 6 ( 2–14 ) vs. 0.8 % of conventionally treated patients on day 11 ( 2–10 ) . The outcome benefits of  intensive insulin therapy were equally present regardless of whether patients received enteral feeding . Multivariate logistic regression analysis indicated that the lowered blood glucose level rather than the insulin dose was related to reduced mortality ( p < .0001 ) , critical illness polyneuropathy ( p < .0001 ) , bacteremia ( p = .02 ) , and inflammation ( p = .0006 ) but not to prevention of acute renal failure , for which the insulin dose was an independent determinant ( p = .03 ) . As compared with normoglycemia , an intermediate blood glucose level ( 110–150 mg/dL ) was associated with worse outcome . Conclusion Normoglycemia was safely reached within 24 hrs and maintained during intensive care by using insulin titration guidelines . Metabolic control , as reflected by normoglycemia , rather than the infused insulin dose per se , was related to the beneficial effects of intensive insulin therapy & NA ; To assess the potential benefits of perioperative glucose administration , the plasma concentrations of insulin , free fatty acids , ketone bodies , amino acids , lactate , and pyruvate were measured in 20 patients undergoing partial gastrectomy .  Ten patients received intravenous glucose at 10 g/h during the operation , and the other 10 patients , as control , received no glucose .  Plasma glucose , insulin activity , pyruvate and alanine concentrations in the glucose‐receiving group increased significantly during the operation in comparison with the control group . In contrast , in the glucose‐receiving group the plasma ketone bodies and branched‐chain amino acids , especially leucine and isoleucine , decreased significantly during surgery . These results suggest that administration of glucose stimulated insulin secretion and result ed in accumulation of the substrates such as pyruvate and alanine which were utilized readily in the body . Glucose administration is useful in suppressing catabolism during upper abdominal surgery . ( Anesth Analg 1993;76:357‐61 OBJECTIVE To determine the safety and efficacy of an intensive insulin regimen compared with a conventional insulin regimen in general intensive care unit patients . METHODS A phase II , r and omised controlled trial was conducted in 70 critically ill patients in a closed multidisciplinary ICU of a university-affiliated tertiary hospital . We assessed patient characteristics at baseline . Trial process measures included number of blood glucose measurements per day and number in target range , type and quantity of caloric intake , patient outcome and insulin dosing . The primary outcome was the median blood glucose concentration . Secondary outcome measures were incidence of hypoglycaemia ( blood glucose level < 2.2 mmol/L ) , clinical sequelae of hypoglycaemia and hospital mortality . RESULTS Thirty-five patients were r and omised to each of the two groups . More blood glucose sample s were taken per day in the intensive insulin group ( 16 versus 9 ) , but the number of sample s in the normoglycaemic range was 48.5 % , compared with 79.8 % within the target glucose range in the conventional insulin group . The median ( interquartile range ) blood glucose concentrations in the intensive and conventional insulin therapy groups were 5.4 ( 5.1 - 5.7 ) mmol/L and 7.9 ( 7.2 - 9.0 ) mmol/L , respectively ( difference , 2.5 mmol/L ; P < 0.0001 ) . Five patients ( 14.3 % ) in the intensive insulin therapy group became hypoglycaemic versus none in the conventional insulin therapy group . There were no detected clinical sequelae of hypoglycaemia . CONCLUSION The intensive insulin regimen was effective in achieving the target blood glucose concentration , with clear separation from the conventional insulin regimen . Although the incidence of hypoglycaemia was increased , there was no detectable harm OBJECTIVE We performed a r and omized trial to compare three insulin-titration protocol s for tight glycemic control ( TGC ) in a surgical intensive care unit : an absolute glucose ( Matias ) protocol , a relative glucose change ( Bath ) protocol , and an enhanced model predictive control ( eMPC ) algorithm . RESEARCH DESIGN AND METHODS A total of 120 consecutive patients after cardiac surgery were r and omly assigned to the three protocol s with a target glycemia range from 4.4 to 6.1 mmol/l . Intravenous insulin was administered continuously or in combination with insulin boluses ( Matias protocol ) . Blood glucose was measured in 1- to 4-h intervals as requested by the protocol s. RESULTS The eMPC algorithm gave the best performance as assessed by time to target ( 8.8 ± 2.2 vs. 10.9 ± 1.0 vs. 12.3 ± 1.9 h ; eMPC vs. Matias vs. Bath , respectively ; P < 0.05 ) , average blood glucose after reaching the target ( 5.2 ± 0.1 vs. 6.2 ± 0.1 vs. 5.8 ± 0.1 mmol/l ; P < 0.01 ) , time in target ( 62.8 ± 4.4 vs. 48.4 ± 3.28 vs. 55.5 ± 3.2 % ; P < 0.05 ) , time in hyperglycemia > 8.3 mmol/l ( 1.3 ± 1.2 vs. 12.8 ± 2.2 vs. 6.5 ± 2.0 % ; P < 0.05 ) , and sampling interval ( 2.3 ± 0.1 vs. 2.1 ± 0.1 vs. 1.8 ± 0.1 h ; P < 0.05 ) . However , time in hypoglycemia risk range ( 2.9–4.3 mmol/l ) in the eMPC group was the longest ( 22.2 ± 1.9 vs. 10.9 ± 1.5 vs. 13.1 ± 1.6 ; P < 0.05 ) . No severe hypoglycemic episode ( < 2.3 mmol/l ) occurred in the eMPC group compared with one in the Matias group and two in the Bath group . CONCLUSIONS The eMPC algorithm provided the best TGC without increasing the risk of severe hypoglycemia while requiring the fewest glucose measurements . Overall , all protocol s were safe and effective in the maintenance of TGC in cardiac surgery patients Background : A growing body of evidence suggests that hyperglycemia is an independent predictor of increased cardiovascular risk . Aggressive glycemic control in the intensive care decreases mortality . The benefit of glycemic control in noncardiac surgery is unknown . Methods : In a single-center , prospect i ve , unblinded , active-control study , 236 patients were r and omly assigned to continuous insulin infusion ( target glucose 100–150 mg/dl ) or to a st and ard intermittent insulin bolus ( treat glucose > 150 mg/dl ) in patients undergoing peripheral vascular bypass , abdominal aortic aneurysm repair , or below- or above-knee amputation . The treatments began at the start of surgery and continued for 48 h. The primary endpoint was a composite of all-cause death , myocardial infa rct ion , and acute congestive heart failure . The secondary endpoints were blood glucose concentrations , rates of hypoglycemia ( < 60 mg/dl ) and hyperglycemia ( > 150 mg/dl ) , graft failure or reintervention , wound infection , acute renal insufficiency , and duration of stay . Results : The groups were well balanced for baseline characteristics , except for older age in the intervention group . There was a significant reduction in primary endpoint ( 3.5 % ) in the intervention group compared with the control group ( 12.3 % ) ( relative risk , 0.29 ; 95 % confidence interval , 0.10–0.83 ; P = 0.013 ) . The secondary endpoints were similar . Hypoglycemia occurred in 8.8 % of the intervention group compared with 4.1 % of the control group ( P = 0.14 ) . Multivariate analysis demonstrated that continuous insulin infusion was a negative independent predictor ( odds ratio , 0.28 ; 95 % confidence interval , 0.09–0.87 ; P = 0.027 ) , whereas previous coronary artery disease was a positive predictor of adverse events . Conclusion : Continuous insulin infusion reduces perioperative myocardial infa rct ion after vascular surgery The hyperglycemia usually observed in patients undergoing heart surgery with extracorporeal circulation ( EC ) represents a difficult therapeutic problem . We studied the effects of several regimens of insulin therapy on serum glucose ( SG ) in 24 noninsulin dependent diabetic patients ( NIDDs ) . The patients were r and omly divided in five groups ; group A received on IV bolus of 10.0 - 50.0 U/h according to glycosuria ; groups B , C , D and E were given a continuous iv insulin infusion of 2.5 , 5.0 , 7.5 and 10.0 U/h respectively . In 10 non-diabetic patients ( NDP )  SG levels were also measured , but insulin was not given . A mean of 5.0 l/m2 of body surface of fluids containing 300 g of glucose were administered to all patients during surgery . At the operations SG levels rose progressively soon after the anesthesia was started , reached the highest values during the period of EC , and decreased slowly in blood sample s taken after the EC phase and by 24h . This patterns was shown by all groups studied statistically significant lower SG levels , however , were observed in patients of group C , whose values were similar to those seen in the NDP group . Groups D and E had slightly higher SG levels than those of group C. An additional NIDDM patient with advanced chronic renal failure ( CRF ) , had a tendency to hypoglycemia even during the EC period in response to relatively low doses of insulin ( 2.5 U/h ) , given by a continuous iv infusion and , although the insulin administration was stopped , his SG levels remained well below the mean values of the other patients for the rest of the operation . ( ABSTRACT TRUNCATED AT 250 WORDS Continuous insulin infusion was not an effective mode of treatment in maintaining safe blood glucose levels ( < 200 mg/dl ) during the intraoperative period of diabetic patients requiring open-heart surgery . The two modifications investigated to gain better control of the blood glucose were a change in the base solution of the cardioplegia and the use of a sliding insulin scale . Fifty patients including Type I and Type II diabetics were selected for the purpose of this study . The patients were then r and omly divided into two groups categorized by the type of cardioplegic solution administered and the mode of insulin treatment . Group I patients received a dextrose 5%-based cardioplegic solution and blood glucose was treated via continuous intravenous insulin infusion . Group II patients received normal saline 0.9%-based cardioplegic solution and blood glucose was treated via sliding scale .  Blood glucose levels were monitored pre- and postcardio- pulmonary bypass ( CPB ) and every 30 min while on CPB . Glucose values were analyzed by group t test . A p value of < 0.05 was considered statistically significant . When comparing Group I ( mean=258 mg/dl ) with Group II ( mean= 158 mg/dl ) , there was a statistically significant difference between the glucose values at each of the time intervals when the glucose values were recorded . In conclusion , Group II maintained an acceptable blood glucose level ( < 200 mg/dl ) throughout the entire intra- operative period , which suggests that the combination of the sliding insulin scale and modification of the base cardioplegic solution was an effective mode of treatment BACKGROUND The aim of this trial was to compare multimodal optimization with conventional perioperative management in a consecutive series of patients undergoing gastrectomy procedures . METHODS According to r and omized controlled studies and conclusions made by meta-analyses in colorectal surgery , optimized perioperative measures were design ed and applied in gastrectomy surgery . Thirty-three patients were r and omized to the optimized group and 30 patients to a control group .  Two groups were treated in 1 center by a single surgical team in different wards . Both groups used patient-controlled intravenous analgesia for postoperative analgesia . The primary end point was length of postoperative hospital stay . Secondary outcomes included bowel function recovery after surgery , perioperative changes of inflammatory factors , glucocorticoid , insulin resistance , and body composition . Perioperative complications and adverse events were also recorded . RESULTS The groups were similar in terms of age , sex ratio , and Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity ( POSSUM score ) . The optimized group was associated with a significantly shorter postoperative hospital stay compared with the conventional care group ( P < .001 ) . Duration s of urinary catheterization and abdominal drainage were also less ( P < .001 ) . The diet program in the optimization group was well tolerated and was associated with an earlier recovery of gut function ( P < .001 ) . Proinflammatory factors were less elevated and body composition was more stable in the optimized group than in controls . There were no differences in morbidity or mortality between the groups . CONCLUSIONS Optimization of care in gastrectomy can shorten postoperative hospital stay and provides multiple beneficial outcomes , including hastening the return of gut function , without increasing morbidity CONTEXT Coronary artery bypass grafting ( CABG ) is complicated by ischemia-reperfusion injury jeopardizing myocyte survival . OBJECTIVE The aim of the study was to investigate whether glucose and insulin administration , while maintaining normoglycemia ( GIN therapy ) using a hyperinsulinemic-normoglycemic clamp technique , is cardioprotective in patients undergoing CABG . DESIGN AND SETTING We conducted a r and omized controlled trial at a tertiary care university teaching hospital . PATIENTS We studied 99 patients undergoing elective CABG . INTERVENTION Patients were r and omly assigned to receive either GIN from the beginning of surgery until 24 h after CABG ( GIN , n = 49 ) or st and ard metabolic care ( control , n = 50 ) . MAIN OUTCOME MEASURES We measured plasma concentrations of cardiac troponin I and free fatty acids , cardiac function as assessed by transesophageal echocardiography , glycogen content , glycogen synthase activity , and the expression of AMP-activated protein kinase ( AMPK ) and protein kinase B ( AKT ) in cardiomyocytes . RESULTS Patients receiving GIN therapy showed an attenuated release of cardiac troponin I ( P < 0.05 ) and improved myocardial function ( P < 0.05 ) . Systemic free fatty acid concentrations were suppressed ( P < 0.05 ) , whereas intracellular glycogen content and glycogen synthase activity were not altered . The AMPK activity remained unchanged during ischemia in the GIN group , whereas it increased in the control group ( P < 0.05 ) . Enhanced AKT phosphorylation before ischemia was observed ( P < 0.05 ) in the presence of GIN . However , there was no evidence for AKT-dependent AMPK inhibition . CONCLUSIONS GIN therapy protects the myocardium and inhibits ischemia-induced AMPK activation Context Intensive insulin therapy used to maintain normoglycemia during intensive care after cardiac surgery improves perioperative outcomes . Its effect during cardiac surgery is unknown . Contributions The authors r and omly assigned 400 cardiac surgical patients to tight glycemic control ( blood glucose level , 4.4 to 5.6 mmol/L [ 80 to 100 mg/dL ] ) during surgery or usual intraoperative care . All patients received tight glycemic control in the cardiac intensive care unit . The groups had the same risk for perioperative adverse events ( risk ratio , 1.0 [ 95 % CI , 0.8 to 1.2 ] ) . The intensive treatment group had more strokes ( 8 vs. 1 ) and more deaths ( 4 vs. 0 ) than the conventional treatment group . Caution The authors performed the study at a single center . Implication s Maintaining normoglycemia during cardiac surgery does not improve outcomes and might worsen them . The Editors Hyperglycemia occurs frequently in patients with and without diabetes during cardiac surgery , especially during cardiopulmonary bypass surgery ( 1 , 2 ) . In a study by Van den Berghe and colleagues ( 3 ) , intensive insulin therapy after surgery reduced morbidity and death in critically ill patients , most of whom underwent cardiac surgery . As a result , professional organizations have recommended rigorous glycemic control in hospitalized patients ( 4 ) and strict glycemic control is now routine practice during the postoperative period in cardiac surgical patients . However , no consensus exists on the optimal management of intraoperative hyperglycemia in cardiac surgical patients because of the lack of evidence from r and omized trials . Research ers are increasingly extrapolating evidence from studies that assess the role of strict postoperative glycemic control in critically ill patients to advocate for intravenous insulin therapy for patients in the operating room ( 3 , 57 ) . Evidence , strictly from observational studies , suggests that tight intraoperative glycemic control may reduce postoperative complications ( 810 ) . We recently reported , in a retrospective , observational study of 409 cardiac surgical patients , that intraoperative hyperglycemia was an independent risk factor for perioperative complications , including death , after adjustment for postoperative glucose concentrations . Each 1.1-mmol/L ( 20 mg/dL ) increase in glucose concentration greater than 5.6 mmol/L ( > 100 mg/dL ) during surgery was associated with a 34 % increase in the likelihood of postoperative complications ( 8) . An association between intraoperative hyperglycemia and adverse outcomes based on observational studies does not prove causality . Because hyperglycemia can adversely affect immunity , wound healing , and vascular function , the concept that normoglycemia be maintained during the relatively brief duration of cardiac surgery seems plausible ( 1116 ) . On the other h and , the degree of intraoperative hyperglycemia may merely reflect the severity of underlying stress . If so , prevention of hyperglycemia might not reduce perioperative complications , and the risks and costs of intensive intraoperative glycemic management may outweigh the benefits . Simple , safe , and effective insulin infusion algorithms that achieve rigorous intraoperative glycemic control are lacking . To address these questions , we conducted a r and omized , controlled trial at 1 center to determine whether maintenance of near normoglycemia during cardiac surgery by using intraoperative intravenous insulin infusion reduced perioperative death and morbidity when added to rigorous postoperative glycemic control . Methods Design Overview This was a r and omized , open-label , controlled trial with blinded assessment . We r and omly assigned patients to receive intensive insulin therapy to maintain intraoperative glucose levels between 4.4 ( 80 mg/dL ) and 5.6 mmol/L ( 100 mg/dL ) or conventional treatment . By design , both groups were postoperatively treated with strict glycemic control to ensure that the observed difference in outcome could be attributed to the effects of intraoperative glycemic control . Setting We performed the study at St. Marys Hospital , Rochester , Minnesota , which is a tertiary care teaching hospital with 1157 beds and an average of more than 41000 admissions per year . Participants Adults undergoing elective cardiac surgery between July 2004 and April 2005 were eligible for enrollment in our study . We excluded patients who had off-pump cardiopulmonary bypass procedures . The Mayo Foundation Institutional Review Board , Rochester , Minnesota , approved the protocol . R and omization and Interventions Before we enrolled patients in our r and omized trial , we enrolled 20 patients in a 2-week pilot trial to ensure that the anesthesiologists in the operating room and the nursing staff in the intensive care units ( ICUs ) had adequate experience with the study insulin infusion algorithm . The 20 patients received intensive insulin therapy during surgery and for 24 hours after surgery . The pilot period data allowed us to modify the grade d insulin infusion to achieve desired glucose concentration goals . We built safety features into our infusion protocol to minimize hypoglycemia . We discontinued the infusion when glucose levels were less than 4.4 mmol/L ( < 80 mg/dL ) and initiated dextrose infusion . When glucose levels decreased to less than 3.3 mmol/L ( < 60 mg/dL ) , we treated hypoglycemia according to a st and ardized hypoglycemia protocol . Per protocol , patients treated in the pilot phase were not included in the analyzed cohort . Study coordinators obtained written informed consent from all patients who met eligibility criteria . We r and omly assigned patients to receive intensive or conventional intraoperative insulin therapy . R and omization was computer-generated with permuted blocks of 4 , with stratification according to surgeon , surgical procedure ( coronary artery bypass grafting [ CABG ] with or without other procedures and no CABG ) , and diabetes . The r and omization assignments were concealed in opaque , sealed , tamper-proof envelopes that were opened sequentially by study personnel after participants signed the patient consent form . We could not possibly know , before obtaining consent , the few patients who would not have intraoperative hyperglycemia ( glucose concentration of 5.6 mmol/L or more [ 100 mg/dL ] ) . Therefore , per protocol , patients who gave consent were r and omly assigned , and those whose glucose levels were less than 5.6 mmol/L ( < 100 mg/dL ) during surgery were not included in the final analyses . Intraoperative Period Intensive Treatment Patients in the intensive treatment group received a continuous intravenous insulin infusion , 250 units of NovoLin R ( Novo Nordisk , Princeton , New Jersey ) in 250 mL of 0.45 % sodium chloride , when their blood glucose levels exceeded 5.6 mmol/L ( > 100 mg/dL ) . We adjusted the infusions to maintain blood glucose levels between 4.4 ( 80 mg/dL ) and 5.6 mmol/L ( 100 mg/dL ) . We adjusted the dose according to a st and ardized algorithm used by anesthesiologists ( Appendix Table 1 ) . Appendix Table 1 . Insulin Infusion Protocol * Conventional Treatment Patients in the conventional treatment group did not receive insulin during surgery unless their glucose levels exceeded 11.1 mmol/L ( 200 mg/dL ) . If glucose concentration was between 11.1 ( 200 mg/dL ) and 13.9 mmol/L ( 250 mg/dL ) , patients received an intravenous bolus of 4 units insulin every hour until the glucose concentration was less than 11.1 mmol/L ( < 200 mg/dL ) . If the intraoperative glucose concentration was greater than 13.9 mmol/L ( > 250 mg/dL ) , patients received an intravenous infusion of insulin that was continued until the glucose level was less than 8.3 mmol/L ( < 150 mg/dL ) . In both study groups , we measured arterial plasma glucose concentration every 30 minutes , starting just before anesthetic induction by using hexokinase method on a Double P Modular System ( Roche Diagnostics , Indianapolis , Indiana ) . Intraoperative procedures , including cardiopulmonary bypass , monitoring , laboratory testing , and treatment , were left to the discretion of anesthesiologists and cardiac surgeons . There was no st and ard protocol for monitoring and managing intraoperative potassium levels . Postoperative Period Intravenous insulin infusion was started in patients in the conventional treatment group on their arrival in the ICU . Thereafter , both study groups were treated identically , with the intravenous insulin infusion rates adjusted by a nursing staff that was not involved with the study according to a st and ard protocol . The target blood glucose range was 4.4 ( 80 mg/dL ) to 5.6 mmol/L ( 100 mg/dL ) ( Appendix Table 1 ) . Arterial blood glucose levels were measured every 1 to 2 hours by using the Accu-Check Inform blood glucose monitoring system ( glucometer ) ( Roche Diagnostics ) . During the first 24 hours after surgery , patients were given only clear liquids by mouth ; we did not administer subcutaneous insulin or oral diabetic medications during this time . Thereafter , the hospital diabetes consulting service saw all patients and provided individualized recommendations for ongoing care . Outcomes and Measurements The primary outcome variable was a composite of death , sternal wound infections , prolonged pulmonary ventilation , cardiac arrhythmias ( new-onset atrial fibrillation , heart block requiring permanent pacemaker , or cardiac arrest ) , stroke , and acute renal failure within 30 days after surgery . Secondary outcome measures were length of stay in the ICU and hospital . Trained study personnel identified the occurrence of a complication through chart abstract ion by using confirmable , objective criteria in accordance with st and ardized definitions from the Society of Thoracic Surgeons ( STS ) data base committee ( 17 ) . Personnel who assessed outcomes were not aware of patient treatment assignment or of the study hypothesis . Follow-up Procedures We contacted patients by telephone and used a st and ardized telephone survey at 30 days after surgery to assess outcomes that occurred after discharge . We considered BACKGROUND Cardiac surgery with cardiopulmonary bypass ( CPB ) induces an acute phase reaction that is implicated in the pathogenesis of several postoperative complications . Studies have shown that proinflammatory cytokines are increased by acute hyperglycemia . Recent evidence suggests that insulin has antiinflammatory properties . Therefore , we hypothesized that high-dose insulin therapy would attenuate the systemic inflammatory response to cardiopulmonary bypass and surgery in coronary artery bypass patients while maintaining normoglycemia . METHODS A total of 52 patients who presented for elective coronary artery bypass were r and omized to receive intraoperative intravenous insulin infusion , titrated to maintain blood glucose concentrations less than 180 mg/dL ( group I , n = 25 ) , or receive intraoperative fixed high dose of intravenous insulin infusion ( 5 mU/kg/min ) with dextrose 20 % infused separately to maintain a blood glucose level between 70 and 110 mg/dL ( group II , n = 27 ) . Blood sample s were collected at different time points to determine tumor necrosis factor alpha ( TNFalpha ) , interleukin 6 and 8 ( IL6 and IL8 ) , and complement factor 3 and 4 ( C3 and C4 ) . RESULTS Patients in both groups had similar preoperative characteristics . Patients in the high-dose insulin group had higher blood insulin concentrations and tighter blood glucose control . There were lower levels of IL6 ( 150 pg/dL vs 245 pg/dL , p = 0.03 ) , IL-8 ( 49 pg/dL vs 74 pg/dL , p = 0.05 ) , and TNFalpha ( 2.2 pg/dL vs 3.0 pg/dL , p = 0.04 ) in group II in the early postoperative period . CONCLUSIONS High-dose insulin therapy blunts the early postoperative surge in inflammatory response to CPB as reflected by decreased levels of IL6 , IL8 , and TNFalpha Introduction Strict control of plasma glucose in diabetic and non-diabetic patients has been shown to improve outcome in several clinical setting s. There is extensive evidence that glucose can stimulate the production of pro-inflammatory cytokines such as tumor necrosis factor (TNF)-α and IL-6 , with no effect on the anti-inflammatory cytokine IL-10 . We hypothesized that strict glucose regulation results in a change in cytokine balance from a pro-inflammatory state to a more balanced anti-inflammatory condition . In a r and omized controlled trial we studied the effect of strict glycemic control on the local and systemic pro-inflammatory and anti-inflammatory balance in non-diabetic patients undergoing elective coronary artery bypass grafting with cardiopulmonary bypass . Methods After surgery patients were r and omly assigned to intensive insulin therapy ( blood glucose between 80 and 110 mg/dl ) or conventional insulin therapy ( blood glucose less than 200 mg/dl ) . At 0 , 1 , 2 , 4 , 8 , 12 , 16 and 24 hours after admission to the intensive care unit , plasma sample s and sample s from the mediastinal drains were obtained . We measured the concentrations of the pro-inflammatory cytokines TNF-α and IL-6 and the anti-inflammatory cytokine IL-10 by enzyme-linked immunosorbent assay . Results Both patient groups were comparable in demographics , clinical characteristics and peri-operative data . In the intensive treatment group , glucose levels were significantly lower than in the conventionally treated group . No differences were found between both groups in the concentrations of TNF-α , IL-6 and IL-10 in plasma sample s or in fluid draining the mediastinal cavity . Levels of IL-6 and IL-10 were significantly higher in mediastinal fluid sample s than in plasma sample s , suggesting a compartmentalized production of cytokines . Conclusion The protective effect of intensive insulin therapy in patients after cardiac surgery with cardiopulmonary bypass is not related to a change in cytokine balance from a pro-inflammatory to an anti-inflammatory pattern . Systemic cytokine levels are not representative of the local inflammatory response Intensive insulin therapy ( IIT ) improves the outcome of prolonged critically ill patients , but concerns remain regarding potential harm and the optimal blood glucose level . These questions were addressed using the pooled data set of two r and omized controlled trials . Independent of parenteral glucose load , IIT reduced mortality from 23.6 to 20.4 % in the intention-to-treat group ( n = 2,748 ; P = 0.04 ) and from 37.9 to 30.1 % among long stayers ( n = 1,389 ; P = 0.002 ) , with no difference among short stayers ( 8.9 vs. 10.4 % ; n = 1,359 ; P = 0.4 ) . Compared with blood glucose of 110–150 mg/dl , mortality was higher with blood glucose > 150 mg/dl ( odds ratio 1.38 [ 95 % CI 1.10–1.75 ] ; P = 0.007 ) and lower with < 110 mg/dl ( 0.77 [ 0.61–0.96 ] ; P = 0.02 ) . Only patients with diabetes ( n = 407 ) showed no survival benefit of IIT . Prevention of kidney injury and critical illness polyneuropathy required blood glucose strictly < 110 mg/day , but this level carried the highest risk of hypoglycemia . Within 24 h of hypoglycemia , three patients in the conventional and one in the IIT group died ( P = 0.0004 ) without difference in hospital mortality . No new neurological problems occurred in survivors who experienced hypoglycemia in intensive care units ( ICUs ) . We conclude that IIT reduces mortality of all medical/surgical ICU patients , except those with a prior history of diabetes , and does not cause harm . A blood glucose target < 110 mg/day was most effective but also carried the highest risk of hypoglycemia OBJECTIVE The purpose of this study was to test the hypothesis that a liberal blood glucose strategy ( 121 - 180 mg/dL ) is not inferior to a strict blood glucose strategy ( 90 - 120 mg/dL ) for outcomes in patients after first-time isolated coronary artery bypass grafting and is superior for glucose control and target blood glucose management . METHODS A total of 189 patients undergoing coronary artery bypass grafting  were investigated in this prospect i ve r and omized study to compare 2 glucose control strategies on patient perioperative outcomes . Three methods of analyses ( intention to treat , completer , and per protocol ) were conducted . Observed power was robust ( > 80 % ) for significant results . RESULTS The groups were similar on preoperative hemoglobin A(1c ) and number of diabetic patients . The liberal group was found to be noninferior to the strict group for perioperative complications and superior on glucose control and target range management . The liberal group had significantly fewer patients with hypoglycemic events ( < 60 mg/dL ; P < .001 ) , but severe hypoglycemic events ( < 40 mg/dL ) were rare and no group differences were found ( P = .23 ) . These results were found with all 3 methods of analysis except for blood glucose variability , maximum blood glucose , and perioperative atrial fibrillation . CONCLUSIONS This study demonstrated that maintenance of blood glucose in a liberal range after coronary artery bypass grafting led to similar outcomes compared with a strict target range and was superior in glucose control and target range management . On the basis of the results of this study , a target blood glucose range of 121 to 180 mg/dL is recommended for patients after coronary artery bypass grafting as advocated by the Society of Thoracic Surgeons 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 < .0001 ) . Likewise , glucose control was significantly better with continuous insulin infusion ( 177 + /- 30 mg/dL vs 213 + /- 41 mg/dL , P < .0001 ) . For internal comparison , multivariable analysis showed that continuous insulin infusion was independently protective against death ( odds ratio 0.43 , P = .001 ) . Conversely , cardiogenic shock , renal failure , reoperation , nonelective operative status , older age , concomitant peripheral or cerebral vascular disease , decreasing ejection fraction , unstable angina , and history of atrial fibrillation increased the risk of death . For external comparison , observed mortality with continuous insulin infusion was significantly less than that predicted by the model ( observed/expected ratio 0.63 , 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 in-hospital 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 st and ard of care for glycometabolic control in patients with diabetes undergoing coronary artery bypass grafting BACKGROUND : The objective of this study was to investigate the relationship between different target levels of glucose and the clinical outcomes of patients undergoing cardiac surgery with cardiopulmonary bypass . METHODS : We design ed a prospect i ve study in a university hospital where 109 consecutive patients were enrolled during a six-month period . All patients were scheduled for open-heart surgery requiring cardiopulmonary bypass . Patients were r and omly allocated into two groups . One group consisted of 55 patients and had a target glucose level of 80–130 mg/dl , while the other contained 54 patients and had a target glucose level of 160–200 mg/dl . These parameters were controlled during surgery and for 36 hours after surgery in the intensive care unit . Primary outcomes were clinical outcomes , including time of mechanical ventilation , length of stay in the intensive care unit , infection , hypoglycemia , renal or neurological dysfunction , blood transfusion and length of stay in the hospital . The secondary outcome was a combined end-point ( mortality at 30 days , infection or length of stay in the intensive care unit of more than 3 days ) . A p-value of < 0.05 was considered significant . RESULTS : The anthropometric and clinical characteristics of the patients from each group were similar , except for weight and body mass index . The mean glucose level during the protocol period was 126.69 mg/dl in the treated group and 168.21 mg/dl in the control group ( p<0.0016 ) . There were no differences between groups regarding clinical outcomes , including the duration of mechanical ventilation , length of stay in the intensive care unit , blood transfusion , postoperative infection , hypoglycemic event , neurological dysfunction or 30-day mortality ( p>0.05 ) . CONCLUSIONS : In 109 patients undergoing cardiac surgery with cardiopulmonary bypass , both protocol s of glycemic control in an intraoperative setting and in the intensive care unit were found to be safe , easily achieved and not to differentially affect clinical outcomes CONTEXT Hyperglycemia and hyperinsulinemia are common in intensive care unit ( ICU ) patients and relate to illness severity . Intensive insulin therapy ( IIT ) to maintain normoglycemia reduces morbidity and mortality . Blood glucose control explains this benefit because a high insulin dose is associated with adverse outcome . Mitogenic insulin effects could theoretically explain this link . OBJECTIVE To investigate further the association between insulin dose and adverse outcome , we studied the effect of IIT on circulating insulin levels , markers of insulin sensitivity , and the metabolic and mitogenic insulin signaling molecules in key tissues . DESIGN This is a sub analysis of a large r and omized , controlled study . SETTING The study was performed in a university hospital surgical ICU . PATIENTS A total of 339 critically ill patients , treated in ICU for at least a week , were included in this sub analysis . INTERVENTION Strict normoglycemia with IIT compared with conventional insulin therapy was performed . RESULTS Severalfold higher insulin doses than with conventional insulin therapy were required to maintain normoglycemia with IIT . However , serum insulin levels were only transiently higher with IIT , despite the much lower blood glucose levels . IIT normalized the elevated serum C-peptide levels and increased circulating adiponectin levels . The metabolic insulin signal was increased by IIT in muscle , but not in liver . The mitogenic insulin signal in either tissue was not affected by IIT . CONCLUSIONS Normoglycemia can be maintained in ICU patients without a sustained further elevation of insulinemia . Together with the increased adiponectin levels , this finding suggests that IIT may improve insulin sensitivity . Skeletal muscle , but not liver , revealed an increased metabolic insulin signal . The therapy did not impose mitogenic risk in these tissues Introduction Critically ill patients can develop hyperglycaemia even if they do not have diabetes . Intensive insulin therapy decreases morbidity and mortality rates in patients in a surgical intensive care unit ( ICU ) and decreases morbidity in patients in a medical ICU . The effect of this therapy on patients in a mixed medical/surgical ICU is unknown . Our goal was to assess whether the effect of intensive insulin therapy , compared with st and ard therapy , decreases morbidity and mortality in patients hospitalised in a mixed ICU . Methods This is a prospect i ve , r and omised , non-blinded , single-centre clinical trial in a medical/surgical ICU . Patients were r and omly assigned to receive either intensive insulin therapy to maintain glucose levels between 80 and 110 mg/dl ( 4.4 to 6.1 mmol/l ) or st and ard insulin therapy to maintain glucose levels between 180 and 200 mg/dl ( 10 and 11.1 mmol/l ) . The primary end point was mortality at 28 days . Results Over a period of 30 months , 504 patients were enrolled . The 28-day mortality rate was 32.4 % ( 81 of 250 ) in the st and ard insulin therapy group and 36.6 % ( 93 of 254 ) in the intensive insulin therapy group ( Relative Risk [ RR ] : 1.1 ; 95 % confidence interval [ CI ] : 0.85 to 1.42 ) . The ICU mortality in the st and ard insulin therapy group was 31.2 % ( 78 of 250 ) and 33.1 % ( 84 of 254 ) in the intensive insulin therapy group ( RR : 1.06 ; 95%CI : 0.82 to 1.36 ) . There was no statistically significant reduction in the rate of ICU-acquired infections : 33.2 % in the st and ard insulin therapy group compared with 27.17 % in the intensive insulin therapy group ( RR : 0.82 ; 95%CI : 0.63 to 1.07 ) . The rate of hypoglycaemia ( ≤ 40 mg/dl ) was 1.7 % in the st and ard insulin therapy group and 8.5 % in the intensive insulin therapy group ( RR : 5.04 ; 95 % CI : 1.20 to 21.12 ) . Conclusions IIT used to maintain glucose levels within normal limits did not reduce morbidity or mortality of patients admitted to a mixed medical/surgical ICU . Furthermore , this therapy increased the risk of hypoglycaemia . Trial Registration clinical trials.gov Identifiers : 4374 - 04 - 13031 ; 094 - 2 in Twenty seven insulin‐dependent diabetics , and six non‐diabetic subjects undergoing elective surgery have been studied . Twelve diabetics received continuous glucose‐insulin‐potassium ( GIK ) infiion for at least 4 hours after surgery terminated . Six diabetic patients having morning surgery received a proportion of their morning insulin dose with intravenous glucose ( 25 g ) before surgery and the remaining jve operated on in the afternoon received their morning insulin with breakfast . Non‐GIK groups were combined and compared with GIK . Postoperative diabetic treatment was the same in both groups . Plasma glucose changes were studied in all patients and other metabolites whenever possible OBJECTIVES To determined the relationship between perioperative glucose control and postoperative nosocomial infection rate is 100 consecutive diabetic patients undergoing elective surgery . DESIGN AND PATIENTS One hundred initially uninfected diabetic patients undergoing elective surgery were prospect ively monitored for perioperative glucose control and postoperative nosocomial infection rate . Glucose control was determined by the attending surgeon or diabetologist . SETTING A large tertiary care hospital that serves as the in-patient facility for a local diabetes center . MAIN OUTCOME MEASURES All patients were screened for infection preoperatively . Only initially uninfected patients were enrolled , and all patients received perioperative antibiotic coverage . Perioperative glucose control and postoperative nosocomial infection rate were monitored prospect ively . APACHE II scores were determined on all patients . Patients were stratified into two groups : those with relatively " good " perioperative glucose control ( all values < or = 220 mg/dL ) and those with " poor " control ( at least one value > 220 mg/dL ) . Contingency tables were generated , comparing nosocomial infection rates vs perioperative glucose control . Correlation coefficients between APACHE II score and maximum and mean glucose values were also determined . RESULTS A serum glucose > 220 mg/dL on postoperative day one ( POD 1 ) was a sensitive ( 87.5 % ) but relatively nonspecific ( 33.3 % ) predictor of the later development of postoperative nosocomial infection . In patients with hyperglycemia ( > 220 mg/dL ) on POD 1 , the infection rate was 2.7 times that observed ( 31.3 % vs 11.5 % ) in diabetic patients with all serum glucose values < 220 mg/dL. When minor infection of the urinary tract was excluded , the relative risk for " serious " postoperative infection increased to 5.7 when any POD 1 blood glucose level was > 220 mg/dL. On the basis of correlation coefficients between serum glucose values and APACHE II score , only 18 % of the variance in the highest serum glucose could be explained by disease severity alone . CONCLUSIONS We conclude that diabetic patients undergoing major cardiovascular or abdominal surgery have an increased risk of infection that is further exacerbated by early postoperative hyperglycemia . The high rate of nosocomial infection observed in diabetic patients with poor glucose control suggests that hyperglycemia itself may be an independent risk factor for the development of infection . Efforts to improve perioperative glucose homeostasis in diabetic patients may reduce the incidence of nosocomial infection and thereby improve outcome Twenty-five insulin-treated diabetic patients were r and omly assigned postoperatively to 5 days of intravenous infusions of ProcalAmine ( 3 % amino acids , 3 % glycerol , and electrolytes ) or FreAmineIII + dextrose and electrolytes . The solutions were given isocalorically and isonitrogenously . Insulin was adjusted to keep glycemia at the level of 150 - 200 mg/dl . The ProcalAmine group by the 5th day had plasma glucose of 158 + /- 25 mg/dl and required 1.20 + /- 0.10 U/hr insulin . The FreAmine + dextrose group had plasma glucose of 169 + /- 53 mg/dl and required 2.28 + /- 0.13 U/hr . At all time points postsurgically , the ProcalAmine group required less insulin BACKGROUND Intravenous glucose-insulin-potassium ( GIK ) may have a positive metabolic influence in patients with acute myocardial infa rct ion ( AMI ) who receive reperfusion therapy .  The objective of this r and omized trial was to assess for the first time whether GIK improves myocardial salvage in patients with AMI . METHODS The Reevaluation of Intensified Venous Metabolic Support for Acute Infa rct Size Limitation ( REVIVAL ) trial is a r and omized , open-label study conducted among 312 patients with AMI . Patients were r and omly assigned to either the  GIK therapy group ( n = 155 ) or the control group ( n = 157 ) . All patients were intended to receive reperfusion treatment , which was given in all but 5 patients ( 1.6 % ) . The primary end point of the study was salvage index , measured as the proportion of initial perfusion defect ( acute technetium-99 m sestamibi scintigraphy ) salvaged by therapy ( follow-up scintigraphy performed after 7 to 14 days ) . RESULTS The primary end point of the study , the salvage index , was in median 0.50 ( 25th , 75th percentiles : 0.18 , 0.87 ) in the GIK group and 0.48 ( 25th , 75th percentiles : 0.27 , 0.78 ) in the control group ( P = .96 ) . By 6 months , the mortality rate was 5.8 % in the GIK group and 6.4 % in the control group ( P = .85 ; relative risk , 0.92 ; 95 % CI , 0.37 to 2.26 ) . Subgroup analyses showed that GIK therapy was associated with increased salvage index only among diabetic patients ( mean difference , 0.19 ; 95 % CI , 0.01 to 0.37 ) . CONCLUSIONS The routine use of GIK therapy in patients with AMI is not associated with enhanced myocardial salvage . This therapy appears to improve myocardial salvage only among diabetic patients BACKGROUND 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 . METHODS In a prospect i ve 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 . RESULTS 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 . CONCLUSIONS 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 Background : This r and omized , double‐blind , placebo‐controlled study was design ed to determine whether an intra‐operative , intravenous infusion of glucose – insulin – potassium ( GIK ) could be helpful in the prevention of myocardial ischemia and in the maintenance of intra‐operative cardiac performance in patients undergoing off‐pump coronary artery bypass ( OP‐CAB ) surgery OBJECTIVE To evaluate a closed-loop system providing continuous monitoring and strict control of perioperative blood glucose following pancreatic resection . DESIGN Prospect i ve , r and omized clinical trial . PATIENTS Thirty patients who had pancreatic resection for pancreatic neoplasm . INTERVENTIONS Patients were prospect ively r and omized . Perioperative blood glucose levels  were continuously monitored using an artificial endocrine pancreas ( STG-22 ) . Glucose levels were controlled using either the sliding scale method ( sliding scale group , n = 13 ) or the artificial pancreas ( artificial pancreas group , n = 17 ) . MAIN OUTCOME MEASURES Incidence of severe hypoglycemia ( < 40 mg/dL ) during the intensive care period following pancreatic resection in patients monitored with the artificial pancreas . The secondary outcome measure was the total amount of insulin required for glycemic control in the first 18 hours after pancreatic resection in each patient group . RESULTS In the sliding scale group , postoperative blood glucose levels rose initially before reaching a plateau of approximately 200 mg/dL between 4 and 6 hours after pancreatectomy . The levels remained high for 18 hours postoperatively . In the artificial pancreas group , blood glucose levels reduced steadily , reaching the target zone ( 80 - 110 mg/dL ) by 6 hours after surgery . The total insulin dose administered per patient during the first postoperative 18 hours was significantly higher in the artificial pancreas group ( mean [ SD ] , 107 [ 109 ] IU ) than the sliding scale group ( 8 [ 6 ] IU ; P < .01 ) . Neither group showed hypoglycemia . CONCLUSIONS Perioperative use of an artificial endocrine pancreas to control pancreatogenic diabetes after pancreatic resection is an easy and effective way to maintain near-normal blood glucose levels . The artificial pancreas shows promise for use as insulin treatment for patients with pancreatogenic diabetes after pancreatic resection Objective : The role of intensive insulin therapy in medical surgical intensive care patients remains unclear . The objective of this study was to examine the effect of intensive insulin therapy on mortality in medical surgical intensive care unit patients . Design : R and omized controlled trial . Setting s : Tertiary care intensive care unit . Patients : Medical surgical intensive care unit patients with admission blood glucose of > 6.1 mmol/L or 110 mg/dL. Intervention : A total of 523 patients were r and omly assigned to receive intensive insulin therapy ( target blood glucose 4.4–6.1 mmol/L or 80–110 mg/dL ) or conventional insulin therapy ( target blood glucose 10–11.1 mmol/L or 180–200 mg/dL ) . Measurements and Main Outcomes : The primary end point was intensive care unit mortality . Secondary end points included hospital mortality , intensive care unit and hospital length of stay , mechanical ventilation duration , the need for renal replacement therapy and packed red blood cells transfusion , and the rates of intensive care unit acquired infections as well as the rate of hypoglycemia ( defined as blood glucose ≤2.2 mmol/L or 40 mg/dL ) . There was no significant difference in intensive care unit mortality between the intensive insulin therapy and conventional insulin therapy groups ( 13.5 % vs. 17.1 % , p = 0.30 ) . After adjustment for baseline characteristics , intensive insulin therapy was not associated with mortality difference ( adjusted hazard ratio 1.09 , 95 % confidence interval 0.70–1.72 ) . Hypoglycemia occurred more frequently with intensive insulin therapy ( 28.6 % vs. 3.1 % of patients ; p < 0.0001 or 6.8/100 treatment days vs. 0.4/100 treatment days ; p < 0.0001 ) . There was no difference between the intensive insulin therapy and conventional insulin therapy in any of the other secondary end points . Conclusions : Intensive insulin therapy was not associated with improved survival  among medical surgical intensive care unit patients and was associated with increased occurrence of hypoglycemia . Based on these results , we do not advocate universal application of intensive insulin therapy in intensive care unit patients . Trial Registration : Current Controlled Trials registry ( IS RCT N07413772 ) http://www.controlled-trials.com/IS RCT N07413772/07413772 ; 2005 The role of glucose-insulin-potassium ( GIK ) infusion in the management of  acute coronary syndrome  is controversial . Limited data are available on the effects of adjunctive high-dose GIK ( 30 % glucose , 50 IU of insulin , 80 mEq of potassium chloride infused at 1.5 ml/kg/hour over 24 hours ) on myocardial perfusion and left ventricular ( LV ) remodeling in patients treated with primary percutaneous coronary intervention ( PCI ) for ST-segment elevation myocardial infa rct ion . In this prospect i ve study , 73 patients were r and omized to receive GIK infusion ( n = 40 ) or saline ( placebo , n = 33 ) in addition to st and ard therapy . The primary end points were myocardial perfusion after PCI and LV remodeling at 6 months . Thrombolysis In Myocardial Infa rct ion frame count and myocardial blush grade were evaluated before and after reperfusion treatment . LV end-diastolic and end-systolic volumes , ejection fraction , and wall motion score index were assessed in each patient after PCI and after 6 months . Although no differences in final Thrombolysis In Myocardial Infa rct ion flow were observed between the 2 groups , myocardial blush grade 3 was more frequently achieved in the GIK group ( p < 0.05 ) . At 6 months , ventricular remodeling was more often observed in the control group ( 24 % vs 3 % , p < 0.05 ) . In conclusion , GIK infusion in adjunct to primary PCI in patients with ST-segment elevation myocardial infa rct ion was safe , improved myocardial perfusion after revascularization , and was associated with less LV remodeling at follow-up BACKGROUND In diabetic patients , the combination of abciximab with stenting has been demonstrated to be the st and ard of care to reduce target vessel revascularization ( TVR ) and mortality . Moreover , a preprocedural hyperglycemia has been associated with a higher rate of TVR after an elective stent implantation . We sought to evaluate the effects of abciximab and /or preprocedural glycemic control on 30 and 180 days of TVR and on 1-year major adverse cardiac events ( MACE-cardiac mortality , TVR , and myocardial infa rct ion ) in diabetic patients undergoing elective coronary stenting .  METHODS From January 2002 through May 2003 , diabetic patients undergoing elective stenting of de novo coronary artery lesions were r and omized to abciximab or placebo infusion . Preprocedural hyperglycemia was defined as fasting plasma glucose > or=126 mg/dL ( 7.0 mmol/L ) immediately before the procedure . RESULTS A total of 122 consecutive patients with diabetes ( 62.4 + /- 10.2 years , 80 men ) were enrolled in the study . Sixty-nine ( 56.5 % ) were r and omly assigned to receive abciximab ( 34 with and 35 without preprocedural hyperglycemia ) and 53 ( 43.5 % ) to placebo ( 23 with and 30 without hyperglycemia ) . Target vessel revascularization was significantly lower in diabetic patients who received abciximab at 30 days ( 2.9 % and 2.8 % vs 8.7 % and 6.6 % in nonabciximab group with or without hyperglycemia , respectively , P < .01 ) but not at 6 months ( 31.4 % and 26.5 % vs 30 % and 28.7 % , P = NS ) . Conversely , the cumulative incidence of MACE was significantly higher among diabetic patients with preprocedural hyperglycemia ( 64.7 % and 65.2 % ) versus diabetic patients with preprocedural glycemic control ( 37.1 % and 40 % ) , treated with or without abciximab , respectively ( P < .05 ) . CONCLUSIONS A preprocedural hyperglycemia is associated with a higher rate of MACE , regardless of the use of abciximab , in diabetic patients undergoing elective coronary stenting OBJECTIVE To evaluating the effect of different levels of blood glucose control on inflammatory response and prognosis of the patients in surgical intensive care unit ( SICU ) . METHODS One hundred and eighty-eight patients admitted to SICU were r and omly divided into three groups , blood glucose were controlled by insulin infusion . Group A ( 75 cases ) : the mean blood glucose ( MBG ) was maintained at the level of 4.4 - 6.1 mmol/L. Group B ( 75 cases ) : MBG was maintained at the level of 6.7 - 8.3 mmol/L. Group C ( 38 cases ) : MBG was maintained at the level of 10.0 - 11.1 mmol/L. Blood glucose control was achieved with an effected computerized protocol . The outcome was evaluated by days in ICU , days to wean mechanical ventilation , infection , amount of red blood cell transfusion , hospital mortality and ICU cost . RESULTS Compared with other groups , hypoglycemia ( < 3.3 mmol/L ) in Group A was significantly increased ( P < 0.05 ) . Compared with Group C , red blood cell transfusion and infection were significantly reduced in Group A and Group B ( P < 0.05 ) . Compared with Group C , days of mechanical ventilation and days in ICU in Group A were significantly reduced ( P < 0.05 ) . Hospital mortality and ICU cost were reduced in Group A compared with the other groups ( P > 0.05 ) . CONCLUSIONS To maintain blood glucose in normal range with intensive insulin therapy has potential positive impact on SICU patients ' outcome and can reduce days in ICU and ICU cost . Further correlation research is needed to determine the best levels of blood glucose in ICU patients BACKGROUND The optimal target range for blood glucose in critically ill patients remains unclear . METHODS Within 24 hours after admission to an intensive care unit ( ICU ) , adults who were expected to require treatment in the ICU on 3 or more consecutive days were r and omly assigned to undergo either intensive glucose control , with a target blood glucose range of 81 to 108 mg per deciliter ( 4.5 to 6.0 mmol per liter ) , or conventional glucose control , with a target of 180 mg or less per deciliter ( 10.0 mmol or less per liter ) . We defined the primary end point as death from any cause within 90 days after r and omization . RESULTS Of the 6104 patients who underwent r and omization , 3054 were assigned to undergo intensive control and 3050 to undergo conventional control ; data with regard to the primary outcome at day 90 were available for 3010 and 3012 patients , respectively . The two groups had similar characteristics at baseline . A total of 829 patients ( 27.5 % ) in the intensive-control group and 751 ( 24.9 % ) in the conventional-control group died ( odds ratio for intensive control , 1.14 ; 95 % confidence interval , 1.02 to 1.28 ; P=0.02 ) . The treatment effect did not differ significantly between operative ( surgical ) patients and nonoperative ( medical ) patients ( odds ratio for death in the intensive-control group , 1.31 and 1.07 , respectively ; P=0.10 ) . Severe hypoglycemia ( blood glucose level , < or = 40 mg per deciliter [ 2.2 mmol per liter ] ) was reported in 206 of 3016 patients ( 6.8 % ) in the intensive-control group and 15 of 3014 ( 0.5 % ) in the conventional-control group ( P<0.001 ) . There was no significant difference between the two treatment groups in the median number of days in the ICU ( P=0.84 ) or hospital ( P=0.86 ) or the median number of days of mechanical ventilation ( P=0.56 ) or renal-replacement therapy ( P=0.39 ) . CONCLUSIONS In this large , international , r and omized trial , we found that intensive glucose control increased mortality among adults in the ICU : a blood glucose target of 180 mg or less per deciliter result ed in lower mortality than did a target of 81 to 108 mg per deciliter . ( Clinical Trials.gov number , NCT00220987 . BACKGROUND Similar to cardiac surgery patients , medical-surgical critically ill patients may benefit from intensive insulin therapy . The objectives of this pilot trial were to evaluate the feasibility of a r and omized trial of intensive insulin therapy with respect to ( a ) achieving target glucose values in the 2 ranges of 5 to 7 and 8 to 10 mmol/L and ( b ) uncovering problems with the protocol in anticipation of a larger trial . SETTING The trial was conducted in a 15-bed medical-surgical university-affiliated intensive care unit ( ICU ) . METHODS We included patients older than 18 years , expected to be in ICU for more than 72 hours , with a glucose value of more than 10 mmol/L within 48 hours of ICU admission . Exclusion criteria were diabetic ketoacidosis , severe hepatic failure or hepatic resection , pancreatitis , glucose of less than 2.2 mmol/L on admission to hospital , insulin infusion on admission to ICU , planned withdrawal of life support , and inability to obtain informed consent . Patients underwent concealed r and om allocation to a target glucose range of 5 to 7 or 8 to 10 mmol/L using pretested algorithms of insulin infusions . Dedicated glucometer measurement of arterial glucose values was calibrated daily to values measured in the laboratory . RESULTS We enrolled 20 patients with a mean ( SD ) Acute Physiology and Chronic Health Evaluation ( APACHE ) II score of 32 ( 10.2 ) ; 14 were insulin-dependent pre-ICU , and all were medical admissions .  Mean glucose values were different in the 2 groups ( 7.1 + /- 2.6 vs 9.4 + /- 2.1 mmol/L , P < .001 ) . Although the intensive insulin therapy group had more glucose measurements performed than the control group , a similar proportion of values were within the target range ( 682 [ 42.4 % ] of 1607 values in the 5- to 7-mmol/L range ; 250 [ 38.7 % ] of 660 values in the 8- to 10-mmol/L range , P = .35 ) . Glucose values of less than 2.5 mmol/L developed 7 times in 5 patients , 4 of whom were in the intensive insulin therapy group ; however , no adverse consequences were documented . As expected , there were no differences in clinical ly important outcomes . CONCLUSIONS In this pilot trial of ICU patients with high illness severity , glucose values were in the 2 target ranges only 40 % of the time , using well-accepted initiation and maintenance insulin infusion algorithms . A large r and omized trial of glycemic control is feasible in this population to examine clinical ly important outcomes , but will require refined insulin algorithms and more comprehensive behavior change strategies to achieve target values We conducted a r and omized , prospect i ve study to assess the effect of i.v . insulin on blood glucose control , development of ketone bodies and hormonal changes in 60 well-controlled , non-insulin-dependent diabetics ( NIDDM ) undergoing major surgery . In group A , patients were given only 0.9 % saline ; in group B , patients were given insulin as a continuous i.v . infusion ( 1.25 u. h-1 ) ; in group C , patients were given insulin 10 u. i.v . boluses every 2 h. Patients in all three groups were given insulin 5 u. when their intraoperative blood glucose concentration increased to greater than 11.1 mmol litre-1 . Blood glucose concentrations were measured every 15 min , from just before induction of anaesthesia to 2 h after surgery . Plasma lactate , pyruvate , ketone body , C-peptide and counter-regulatory hormone concentrations were also measured . Blood glucose concentrations in the three groups did not differ significantly . There was a mild-to-moderate increase in plasma ketone body concentrations in group A , but without any deleterious consequences . Plasma C-peptide concentrations decreased significantly in groups B and C , especially in patients given bolus injections of insulin . Plasma growth hormone concentrations also increased significantly in group B and C patients . This study indicated that the " no insulin -- no glucose " regimen was a simple , effective way to control blood glucose in well-controlled NIDDM patients , provided blood glucose was measured frequently and insulin used appropriately BACKGROUND : Although hyperglycemia is a well-recognized risk factor in the context of cardiac surgery , the relevance of perioperative glycemic control for patients undergoing major noncardiac operations has received little attention . We design ed this study to assess the hyperglycemic response to liver resection , and to test the hypothesis that perioperative glucose and insulin administration while maintaining normoglycemia ( GIN therapy ) provides glycemic control superior to that achieved by the conventional use of insulin . METHODS : Patients were r and omly assigned to GIN therapy or st and ard therapy ( control group ) . In the GIN therapy group , insulin was administered at 2 mU · kg−1 · min−1 during surgery . At the end of surgery , the insulin infusion was decreased to 1 mU · kg−1 · min−1 and continued for 24 hours . Dextrose 20 % was infused at a rate adjusted to maintain blood glucose within the target range of 3.5 to 6.1 mmol · L−1 ( 63–110 mg · dL−1 ) . Patients in the st and ard therapy group received a conventional insulin sliding scale during and after surgery . The mean and SD of blood glucose as well as the percentage of blood glucose values within the target range were calculated . To evaluate intrasubject variability , the coefficient of variability ( CV ) of blood glucose was calculated for each patient . Episodes of severe hypoglycemia , i.e. , blood glucose < 2.2 mmol · L−1 ( 40 mg · dL−1 ) , were recorded . The primary outcome was the proportion of normoglycemic measurements . RESULTS : We studied 52 patients .  The mean blood glucose value in patients receiving GIN therapy always remained within the target range . The blood glucose levels were lower in the GIN therapy group than in the st and ard therapy group ( during surgery , P < 0.01 ; after surgery , P < 0.001 ) . In nondiabetic patients receiving GIN therapy ( n = 19 ) , target glycemia was achieved in 90.1 % of the blood glucose measurements during surgery and in 77.8 % of the measurements after surgery . In diabetic patients receiving GIN therapy ( n = 7 ) , target glycemia was achieved in 81.2 % of the blood glucose measurements during surgery and in 70.5 % of the measurements after surgery . In nondiabetic patients receiving st and ard therapy ( n = 19 ) , target glycemia was achieved in 37.4 % of the blood glucose measurements during surgery and in 18.3 % of the measurements after surgery . In diabetic patients receiving st and ard therapy ( n = 7 ) , target glycemia was achieved in 4.3 % of the blood glucose measurements during surgery and in 2.9 % of the measurements after surgery . The SD and CV of blood glucose were smaller in the GIN therapy group than in the st and ard therapy group , especially in nondiabetic patients after surgery ( SD , P < 0.001 ; CV , P = 0.027 ) . No patients receiving GIN therapy experienced severe hypoglycemia during surgery . One patient receiving GIN therapy experienced hypoglycemia in the intensive care unit after surgery without neurological sequelae . CONCLUSIONS : GIN therapy effectively provides normoglycemia in patients undergoing liver resection ( clinical trials.gov , NCT00774098 ) UNLABELLED Diabetic patients are at increased risk of wound infection after major surgery , but the effect of perioperative glucose control on postoperative wound infection rates after surgery is uncertain . We tested the effect of an insulin infusion on perioperative neutrophil function in diabetic patients scheduled for coronary artery bypass surgery . Participants ( n = 26 ) were r and omly allocated to receive either aggressive insulin therapy ( AIT ) or st and ard insulin therapy ( SIT ) during surgery . Blood was drawn for neutrophil testing before surgery , 1 h after the completion of cardiopulmonary bypass , and on the first postoperative day . Neutrophil phagocytic activity decreased to 75 % of baseline activity in the AIT group and to 47 % of baseline activity in the SIT group ( P < 0.05 between groups ) . No important differences in neutrophil antibody-dependent cell cytotoxicity were found . This study documents a potentially beneficial effect of continuous insulin therapy in diabetic patients who require major surgery . IMPLICATION S A continuous insulin infusion and glucose control during surgery improves white cell function in diabetic patients and may increase resistance to infection after surgery OBJECTIVE To investigate the influence of intensive insulin therapy on the results of postoperative patients with gastric cancer . METHODS Forty-six patients with gastric cancer underwent radical operation were r and omly divided into two groups : intensive group ( n=23 , to control blood glucose at 4.4 to 6.1 mmol/L ) and conventional group ( n=23 , to control blood glucose at 10.0 to 11.1 mmol/L ) .  Fasting blood glucose ( FBG ) , fasting insulin ( FINS ) , tumor necrosis factor-alpha ( TNF-alpha ) , interleukin-6 ( IL-6 ) and C reaction protein ( CRP ) in 46 patients were detected dynamically during perioperative period . Insulin resistance index ( HOMA-IR ) were calculated using Homeostasis Model Assessment ( HOMA ) to evaluate insulin sensitivity . Postoperative complications and other clinical data were recorded . RESULTS No hypoglycemia occurred in the two groups . Compared with conventional group , morbidity and postoperative duration of fever , antibiotic use and the length of hospital stay in intensive group were significantly reduced ( P < 0.05 ) . On the day 1 and 3 after surgery , HOMA-IR and serum levels of TNF-alpha , IL-6 and CRP in patients of intensive group were significantly lower than those in conventional group ( P < 0.05 ) . CONCLUSIONS Intensive insulin therapy could counteract the state of high-inflammation and then improve the outcome of postoperative patients OBJECTIVE To investigate the effects of intensive insulin therapy on insulin resistance(IR ) and serum proteins  after radical gastrectomy . METHODS Twenty-two gastric cancer patients were r and omly divided into the control ( n=11 ) and intensive insulin therapy group ( n=11 ) , and underwent  distal radical subtotal gastrectomy under epidural anesthesia .  Fasting blood glucose ( FBG ) , fasting insulin ( FINS ) and serum proteins were assayed preoperatively and at day 1 , 3 , 7 postoperatively . Insulin resistance index was calculated using homeostasis model assessment ( HOMA ) . The length of hospital stay and postoperative complications were recorded respectively . RESULTS (1)The levels of FBG , FINS , lnHOMA-IR ( P<0.01,P<0.05 ) and the incidence of insulin resistance were remarkably decreased by intensive insulin therapy after the surgical procedure.(2)The levels of serum transferrin ( TRF ) , prealbumin ( PRE ) and retinal binding protein ( RBP ) in the intensive insulin therapy group were significantly improved as compared to control group after operation(P<0.05 ) . ( 3 ) The duration of fever , antibiotic use , passage of gas by anus , length of hospital stay and the occurrence of postoperative complications were also significantly lower than those in control group(P<0.01,P<0.05 ) . CONCLUSION Compared to routine therapy , the intensive insulin therapy has more beneficial effects on the patients undergone distal radical subtotal gastrectomy in decreasing the insulin resistance , improving the status of nutrition and preventing postoperative complications Purpose An optimal target for glucose control in ICU patients remains unclear . This prospect i ve r and omized controlled trial compared the effects on ICU mortality of intensive insulin therapy ( IIT ) with an intermediate glucose control . Methods Adult patients admitted to the 21 participating medico-surgical ICUs were r and omized to group 1 ( target BG 7.8–10.0 mmol/L ) or to group 2 ( target BG 4.4–6.1 mmol/L )  . Results While the required sample size was 1,750 per group , the trial was stopped early due to a high rate of unintended protocol violations . From 1,101 admissions , the outcomes of 542 patients assigned to group 1 and 536 of group 2 were analysed . The groups were well balanced . BG levels averaged in group 1 8.0 mmol/L ( IQR 7.1–9.0 ) ( median of all values ) and 7.7 mmol/L ( IQR 6.7–8.8 ) ( median of morning BG ) versus 6.5 mmol/L ( IQR 6.0–7.2 ) and 6.1 mmol/L ( IQR 5.5–6.8 ) for group 2 ( p < 0.0001 for both comparisons ) . The percentage of patients treated with insulin averaged 66.2 and 96.3 % , respectively . Proportion of time spent in target BG was similar , averaging 39.5 % and 45.1 % ( median ( IQR ) 34.3 ( 18.5–50.0 ) and 39.3 (26.2–53.6)% ) in the groups 1 and 2 , respectively . The rate of hypoglycaemia was higher in the group 2 ( 8.7 % ) than in group 1 ( 2.7 % , p < 0.0001 ) . ICU mortality was similar in the two groups ( 15.3 vs. 17.2 % ) . Conclusions In this prematurely stopped and therefore underpowered study , there was a lack of clinical benefit of intensive insulin therapy ( target 4.4–6.1 mmol/L ) , associated with an increased incidence of hypoglycaemia , as compared to a 7.8–10.0 mmol/L target . ( Clinical Trials.gov # NCT00107601 , EUDRA-CT Number : 200400391440 ) BACKGROUND To evaluate the impact of adjunctive high-dose glucose-insulin-potassium ( GIK ) on ST-segment elevation resolution in patients with ST-segment elevation myocardial infa rct ion ( MI ) . METHODS As part of a r and omized controlled trial of GIK versus no GIK in patients treated with primary percutaneous coronary intervention ( PCI ) for ST-elevation MI in a tertiary referral center , we analyzed ST-segment elevation resolution . Paired electrocardiographic recordings ( baseline and 3 hours after primary PCI ) were available in 612 ( 65 % ) of 940 patients . RESULTS We analyzed paired electrocardiograms of 310 patients r and omized to GIK and 302 control patients . Baseline characteristics of the groups were comparable . Combined complete ( > 70 % ) and partial ( 30%-70 % ) resolution was more commonly observed in the GIK group ( 87 % ) when compared with the control group ( 78 % ) , odds ratio 1.92 ( 95 % CI 1.23 - 3.02 , P = .004 ) ; 1-year mortality was lower in patients with combined complete and partial resolution compared with patients without resolution ( 3.8 % vs 10.3 % , P = .011 ) . There was no difference in 1-year mortality between GIK and control patients ( 5.5 % vs 4.3 % , P = .58 ) . CONCLUSIONS In patients with ST-elevation MI treated with primary PCI , addition of GIK is associated with improved ST-segment elevation resolution . ST-segment elevation resolution is related to improved 1-year survival . No benefit of GIK on 1-year outcome was observed . Future trials should investigate whether GIK-induced improvement of ST-segment elevation resolution results in more favorable clinical outcome OBJECTIVE Although hyperglycemia is hypothesized to increase the short-term risk of infection , this hypothesis has not been well tested in a clinical setting . This study was design ed to assess the relationship of perioperative glycemic control to the subsequent risk of infectious complications . RESEARCH DESIGN AND METHODS A total of 411 adults with diabetes who underwent coronary artery surgery from 1990 to 1995 in the cardiac surgery service of an urban university hospital were included in a nonconcurrent prospect i ve cohort study based on chart review . Perioperative glycemic control was characterized by the mean of six capillary glucose measurements taken during the 36-h interval following surgery . The major outcomes studied were infections of leg and chest wounds , pneumonia , and urinary tract infections . RESULTS Mean postoperative glucose levels ranged from 121 to 352 mg/dl and were divided into quartiles : quartile 1 ( 121 - 206 mg/dl ) , quartile 2 ( 207 - 229 mg/dl ) , quartile 3 ( 230 - 252 mg/dl ) , and quartile 4 ( 253352 mg/dl ) . After simultaneous adjustment for age , sex , race , underlying comorbidity , acute severity of illness , and the length of the stay in the surgical intensive care unit , patients with higher mean capillary glucose readings were at increased risk of developing infections . Compared with people in the lowest quartile of postoperative glucose , those in quartiles 2 ( relative odds of infection [ 95 % CI ] = 1.17 [ 0.57 - 2.40 ] ) , 3 ( 1.86 [ 0.94 - 3.68 ] ) , and 4 ( 1.78 [ 0.86 - 3.47 ] ) were at progressively higher risk for infection ( P = 0.05 for trend ) . CONCLUSIONS In patients with diabetes who undergo coronary artery surgery , postoperative hyperglycemia is an independent predictor of short-term infectious complications . Physicians should consider a glucose concentration target of < or = 200 mg/dl to reduce the risk of infection In this study we investigated the effects of preoperative oral carbohydrate administration on postoperative insulin resistance ( PIR ) , gastric fluid volume , preoperative discomfort , and variables of organ dysfunction in ASA physical status III-IV patients undergoing elective cardiac surgery , including those with noninsulin-dependent Type-2 diabetes mellitus . Before surgery , 188 patients were r and omized to receive a clear 12.5 % carbohydrate drink ( CHO ) , flavored water ( placebo ) , or to fast overnight ( control ) . CHO and placebo were treated in double-blind format and received 800 mL of the corresponding beverage in the evening and 400 mL 2 h before surgery . Patients were monitored from induction of general anesthesia until 24 h postoperatively . Exogenous insulin  requirements to control blood glucose levels ≤10.0 mmol/L were used as a marker for PIR . Gastric fluid volume was measured by passive gastric reflux and preoperative discomfort using visual analog scales . Postoperative clinical and surgical data were recorded . Blood glucose levels and insulin requirements did not differ between groups . Patients receiving CHO and placebo were less thirsty compared with controls ( P < 0.01 and P = 0.06 , respectively ) . Ingested liquids did not cause increased gastric fluid volume or other adverse events . The CHO group required less intraoperative inotropic support after initiation of cardiopulmonary bypass weaning ( P < 0.05 ) . In conclusion , preoperative CHO administration before cardiac surgery does not affect PIR . Clear fluids reduce thirst and may be recommended as a safe procedure in ASA III-IV patients . Further research is indicated to investigate possible cardioprotective effects of preoperative CHO intake BACKGROUND Traditionally hyperglycemia in surgical in patients has been managed with six-hourly sliding-scale regular insulin . However , this approach is usually ineffective in preventing hyperglycemia since no basal insulin is provided . We compared glycemic control using NPH and regular insulin versus glargine insulin alone in patients after cardiovascular surgery on a general surgical ward . METHODS Ninety-four hyperglycemic patients were r and omized to subcutaneous insulin using twice-daily NPH/regular or once-daily glargine if they required at least 1 unit/h of intravenous insulin at the time of transfer from the ICU . NPH/regular was adjusted twice daily ; glargine was adjusted once daily . Blood glucose was measured four times daily and targeted to 80 - 140 mg/dL. RESULTS The mean blood glucose after NPH/regular ( 124 mg/dL ) and glargine ( 131 mg/dL ) was similar ( P = 0.065 ) . In the subgroup of patients with a history of diabetes , mean blood glucose was significantly lower after NPH/regular ( 133 mg/dL ) versus glargine ( 154 mg/dL ) ( P = 0.016 ) . Blood glucose less than 60 mg/dL was significantly less common after glargine ( 0.5 % ) as compared with NPH/regular ( 2 % ) ( P = 0.036 ) . CONCLUSIONS Once-daily glargine insulin provides good glycemic control in hyperglycemic patients after cardiovascular surgery . Although twice-daily NPH/regular insulin provided better control than glargine insulin monotherapy , the simplicity and safety of glargine insulin make it an attractive option for the management of postoperative hyperglycemia . Patients with established diabetes will achieve better glucose control with NPH/regular insulin as compared with glargine but have a higher incidence of hypoglycemia The Bypass Angioplasty Revascularization Investigation 2 Diabetes ( BARI 2D ) is a National Institutes of Health (NIH)-sponsored r and omized clinical trial that evaluates treatment efficacy for patients with type 2 diabetes mellitus and angiographically documented stable coronary artery disease . Using a 2 x 2 factorial design , BARI 2D compares revascularization combined with aggressive medical treatment versus aggressive medical treatment alone ; simultaneously , BARI 2D compares 2 glycemic control strategies , insulin sensitization versus insulin provision .  All patients have goals of glycosylated hemoglobin values < 7.0 % and uniform control of hypertension , dyslipidemia , and obesity following recommended medical guidelines . The primary end point of BARI 2D is all-cause 5-year mortality analyzed by intention to treat , and the principal secondary end point is the combination of death , myocardial infa rct ion , and stroke .  A total of 2,368 patients have been enrolled at 49 clinical centers throughout North America , South America , and Europe . The study enrollment period was January 2001 through March 2005 , and the patient treatment and follow-up phase is expected to extend at least through May 2007 . Participants are treated at the local BARI 2D clinical sites on a monthly basis for the first 6 months and then every 3 months until the end of the study . Within BARI 2D , central management centers oversee the control of glycemia , plasma lipid levels , hypertension , and obesity . The r and omized clinical trial collects data on patient symptoms , clinical measurements , medications , and clinical events as well as data from central ized evaluations of angiograms , electrocardiograms , nuclear stress tests , blood and urine specimens , and relative economic costs BACKGROUND Hyperglycemia and insulin resistance are common in critically ill patients , even if they have not previously had diabetes . Whether the normalization of blood glucose levels with insulin therapy improves the prognosis for such patients is not known . METHODS We performed a prospect i ve , r and omized , controlled study involving adults admitted to our surgical intensive care unit who were receiving mechanical ventilation . On admission , patients were r and omly assigned to receive intensive insulin therapy ( maintenance of blood glucose at a level between 80 and 110 mg per deciliter [ 4.4 and 6.1 mmol per liter ] ) or conventional treatment ( infusion of insulin only if the blood glucose level exceeded 215 mg per deciliter [ 11.9 mmol per liter ] and maintenance of glucose at a level between 180 and 200 mg per deciliter [ 10.0 and 11.1 mmol per liter ] ) . RESULTS At 12 months , with a total of 1548 patients enrolled , intensive insulin therapy reduced mortality during intensive care from 8.0 percent with conventional treatment to 4.6 percent ( P<0.04 , with adjustment for sequential analyses ) . The benefit of intensive insulin therapy was attributable to its effect on mortality among patients who remained in the intensive care unit for more than five days ( 20.2 percent with conventional treatment , as compared with 10.6 percent with intensive insulin therapy , P=0.005 ) . The greatest reduction in mortality involved deaths due to multiple-organ failure with a proven septic focus . Intensive insulin therapy also reduced overall in-hospital mortality by 34 percent , bloodstream infections by 46 percent , acute renal failure requiring dialysis or hemofiltration by 41 percent , the median number of red-cell transfusions by 50 percent , and critical-illness polyneuropathy by 44 percent , and patients receiving intensive therapy were less likely to require prolonged mechanical ventilation and intensive care . CONCLUSIONS Intensive insulin therapy to maintain blood glucose at or below 110 mg per deciliter reduces morbidity and mortality among critically ill patients in the surgical intensive care unit STUDY OBJECTIVE To compare the effect of two different perioperative insulin management regimes on patients undergoing either major surgery ( vascular surgery ) or minor surgery ( vitrectomy ) .  DESIGN Prospect i ve , double-blind r and omized trial . PATIENTS 48 insulin-treated type 2 diabetics aged 18 to 85 years were studied . SETTING University medical center . INTERVENTIONS Patients were divided into four groups of 12 patients each : Groups A and B ( major surgery ) , Groups C and D ( minor surgery ) . Group A and C patients were treated with a continuous modified glucose-insulin-potassium infusion according to blood glucose levels after intubation . Patients assigned to Groups B and D were treated with intermittent intravenous ( IV ) insulin injections when glucose levels exceeded 12 mmol L(-1 ) . MEASUREMENTS Glucose and potassium levels were measured every 15 minutes and 30 minutes during surgery and up to 4 hours post-surgery . Plasma levels of lactate , cortisol , glycerol , and free fatty acids were measured in arterial sample s after intubation ( S1 ) , after extubation ( S2 ) , and 4 hours after surgery ( S3 ) . MAIN RESULTS There were no significant differences of the patient characteristics among the four groups . There was no significant difference in the time course of plasma glucose levels and hormone variables measured among the four groups . One episode of hyperglycemia in Group D during the postoperative period was treated with 12 IV units of insulin . One patient in Group A and one in Group B received  potassium  intraoperatively ( 15 and 29 mmoL , respectively ) . Postoperatively , two other patients of Group A received 19 and 12,5 mmoL , respectively , and one of Group B received 20 mmoL potassium . CONCLUSIONS Both regimens result ed in relatively stable and comparable blood glucose levels throughout the perioperative period of the minor and major surgeries without differences in metabolic control as measured by levels of lactate , cortisol , glycerol and free fatty acids . Simplicity would favor the intermittent regimen to manage insulin treated type 2 diabetics OBJECTIVE To determine whether optimized glycemic control in type I diabetic recipients of renal allografts will prevent or delay diabetic renal lesions in the allograft . DESIGN Prospect i ve , controlled , and r and omized trial of glycemic control in an inception cohort of type I diabetic renal allograft recipients . The experimental group underwent maximized glycemic control , and the st and ard group was treated in the same way as other patients in the transplant clinic . Patients underwent baseline ( before transplant ) and 5-year posttransplant allograft biopsies . SETTING University of Minnesota Hospital and Clinic and the Clinical Research Center and Hennepin County Medical Center , Minneapolis . PATIENTS Type I diabetics with terminal diabetic renal failure undergoing renal transplantation . Forty-eight patients r and omized to maximized or st and ard control completed the trial . INTERVENTION Subcutaneous insulin given several times a day or continuously ( maximized group ) and once or twice each day ( st and ard group ) was used throughout the trial . A significant difference for hemoglobin A1 level was maintained ( mean + /- SD : st and ard , 0.117 + /- 0.013 ; maximized , 0.096 + /- 0.016 ; P < 0.001 ) . MAIN OUTCOME The primary end point of this trial was the difference between the groups in renal glomerular mesangial expansion as determined by electron microscopy . RESULTS There was a more than twofold increase in the volume fraction of mesangial matrix per glomerulus in the st and ard group ( mean + /- SD , 0.043 + /- 0.034 ) compared with the maximized group ( 0.019 + /- 0.038 ; P = .024 ) . The threefold increase in arteriolar hyalinosis , the greater widening of the glomerular basement membrane , and increase of volume fraction of the total mesangium in the patients who received st and ard treatment all approached significance ( P = .10 or less ) . The incidence of severe hypoglycemic episodes was greater in the maximized group ( 1.7 per patient per year ) than in the st and ard treatment group ( < 0.1 per patient per year ; P < .001 ) . CONCLUSIONS This trial indicates a causal relationship between hyperglycemia and an important lesion of diabetic nephropathy , mesangial matrix expansion , in renal allografts transplanted into diabetic recipients . In addition , the results with other lesions central to the development of diabetic nephropathy support the major conclusion Background : Diabetes-induced gastroparesis is believed to increase fasting gastric fluid volume before elective surgery . Metoclopramide is routinely administered preoperatively to reduce gastric fluid volume in these patients . This study compared nondiabetic controls to non – insulin-dependent and insulin-dependent diabetics to determine the effect of metoclopramide , administered before surgery , on gastric volumes in patients who fasted before surgery . Methods : Control and diabetic patients fasted preoperatively before receiving either placebo or 10 mg intravenous metoclopramide 20 min before induction of anesthesia . After intubation , a gastric tube was placed , and stomach contents were aspirated with volumes compared among the groups . Results : Both groups of diabetic patients were older than the control group , and insulin-dependent patients had a higher incidence of comorbidities compared with the non – insulin-dependent group .  Fasting blood sugar and hemoglobin A1C values were higher in both insulin-dependent and non – insulin-dependent patients . Gastric fluid volumes were similar in control , non – insulin-dependent , and insulin-dependent patients ( 8.0 ± 2.6 vs. 9.6 ± 4.1 vs. 17.7 ± 2.5 ml , respectively ) . In insulin-dependent diabetic patients , metoclopramide decreased gastric volume compared with placebo treatment ( 17.7 ± 2.5 vs. 7.8 ± 2.9 ml ; P = 0.027 ) . After stratification , a sub population of patients with poorly controlled diabetes , regardless of type , were identified to have increased gastric residual volumes . Conclusion : In elective surgical patients who have fasted before surgery  , gastric volumes are minimal , even in diabetics with severe neuropathic symptoms . Metoclopramide prophylaxis to reduce gastric volumes seems to be unnecessary unless the patient has a prolonged history of poor blood glucose control The metabolic response to the postoperative delivery of a sole glucose solution or a glucose-fructose-xylitol solution , and their effects upon carbohydrate metabolism , in patients with glucose tolerance impairment , were evaluated . Twenty four patients who showed an abnormal 75g-OGTT or were noninsulin-dependent diabetics were divided in two groups . The GFX-B group ( n = 11 ) received a 10.5 % solution , containing glucose , fructose and xylitol at 4:2:1 ratio , and the PHY-3 group ( n = 13 ) received a 10 % glucose solution , both , continuously infused for 3 days postoperatively . The infusion of PHY-3 tended to produce a higher increase in blood glucose than the infusion of GFX-B , that was significantly different on the 3POD ( P less than 0.05 ) . The increase in IRI and CPR was also significantly greater in PHY-3 group than in GFX-B group on the 3POD ( P less than 0.05 ) . We concluded that it was not only the slight lower glucose load of the GFX-B solution , but also , the different infused carbohydrate substrate which had influenced the magnitude of insulin secretion and the blood glucose level . Then , its use in glucose intolerant patients may be of some benefit to partially minimize the postoperative hyperglycemic response Postoperative glucose control directly affects the incidence of deep sternal wound infection and death  after patients with diabetes have undergone coronary artery bypass grafting . We compared the effect upon glucose control of continuous insulin infusion with that of glucometer-guided insulin injection after coronary artery bypass . Our prospect i ve , r and omized , controlled study involved patients with diabetes mellitus who underwent coronary artery bypass grafting in our hospital from January 2001 through January 2003 . Immediately after surgery , patients were r and omly assigned to receive continuous insulin infusion or conventional glucometer-guided injection to maintain blood glucose at a level between 150 and 200 mg/dL. The adequacy of postoperative blood glucose control and clinical outcome were evaluated . Of 93 patients studied , the incidence of sternal wound infection was 3.9 % among infusion patients and 4.8 % among injection patients ( P=0.587 ) . There was no significant difference in mortality rates ( infusion , 3.9 % ; injection , 2.4 % ; P=0.573 ) . Satisfactory blood glucose levels were achieved in significantly more patients undergoing infusion than injection ( 64.7 % vs 28.6 % , P < 0.001 ) . In the injection group , significantly more blood glucose measurements were required to achieve control ( 23.4 vs 16.5 , P=0.001 ) , and good control was attained much sooner in the infusion group ( 21.4 vs 30.5 hr , P=0.013 ) . We conclude that continuous insulin infusion provides better control of postoperative blood glucose levels after coronary artery bypass grafting in patients with diabetes than does glucometer-guided insulin injection Background This study was to compare the effect of intensive insulin therapy ( IIT ) to conventional insulin therapy ( CIT ) on postoperative outcomes among type 2 diabetes mellitus ( DM ) patients who underwent D2 gastrectomy for gastric cancer . Methods We r and omly assigned gastric cancer patients with type 2 DM who underwent radical gastrectomy to receive  IIT ( maintenance of blood glucose at a level between 4.4 and 6.1 mmol/l ) with insulin infusion or CIT ( maintenance of blood glucose at a level between 10 and 11.1 mmol/l ) during the postoperative period . Results Of the 179 eligible patients , 92 patients were assigned to receive IIT and 87 patients to receive  CIT . Mean blood glucose concentrations were lower in the intensive group ( IG ) than in the conventional group ( CG ) ( 5.5 ± 0.8 vs. 9.9 ± 1.0 mmol/l , P < 0.001 ) . Hypoglycemia occurred in 6 patients ( 6.5 % ) in the IG ( P = 0.029 ) versus in 1 patient ( 1.1 % ) in the CG . Hospital mortality did not differ significantly between two groups ( 4.3 % vs. 5.7 % , P = 0.742 ) . However , IIT significantly reduced morbidity ( from 18.4 to 7.6 % , P = 0.031 ) . Also , IIT shortened the days to suture removal , postoperative hospital stay , and postoperative duration of antibiotic use . The HOMA-IR score was lower at all time points in IG . Moreover , IIT increased the postoperative HLA-DR expression on monocytes on postoperative days 3 and 5 . Conclusions IIT significantly reduced short-term morbidity but not mortality among type 2 DM patients who underwent D2 gastrectomy for gastric cancer . Furthermore , a possible mechanism of suppression of the insulin resistance and improvement of HLA-DR expression may partially explain the benefits of IIT In this study , we sought a simple , easily implemented method of intraoperative control of blood glucose in diabetic patients in a large multispecialty teaching hospital .  The Vellore regimen , which offers the advantages of a combined glucose insulin and variable rate infusion was evaluated . For every 1 to 50-mg/dL increase in blood glucose concentration more than 100 mg/dL , 1 U of insulin was added to the injection port of a 100-mL measured volume set containing 5 % dextrose in water . Hourly monitoring of blood glucose was performed . The blood glucose control was compared with the different existing techniques followed in the hospital in 204 r and omized patients : 98 in the study and 106 in the control group . The study group had a mean ±sd blood glucose value of 156 ± 36 mg/dL , and the control group ’s value was 189 ± 63 mg/dL ( P = 0.003 ) . The percentage of patients who were poorly controlled ( outside 100 to 200-mg/dL range ) decreased from 51 % to 28 % ( no patient less than 60 mg/dL ) with this regimen as compared with the control group in which it increased from 49 % to 72 % ( 10 patients less than 60 mg/ dL ) ( P = 0.0013 ) . We conclude that the Vellore regimen is simple , effective , and safe for intraoperative blood glucose control Objectives . Determine if pre-emptive daily insulin glargine surpasses regular insulin when needed for glycaemic control after cardiac surgery . Design . Prospect i ve , r and omized study of 43 patients ( scheduled for coronary artery bypass grafting ) with preoperatively diagnosed diabetes ( DM ) or pre-DM . Lantus group received insulin glargine daily from start of surgery while Actrapid group received regular insulin ( sliding scale ) when needed ( plasma glucose ( P-glu ) > 10 mmol/l ) . Primary endpoint was percent of pre- and post-pr and ial P-glu values within Target Intervals : Pre-pr and ial P-glu : 4.5–7 mmol/l ; post-pr and ial P-glu : 4.5–9 mmol/l . Study period 1–4 days after surgery . Tissue glucose was also measured continuously . Results . More than twice as many P-glu values were within Target Interval for Lantus patients as compared with Actrapid patients ( p < 0.001 ) . One of 504 timed measurements was < 4 mmol/l . Area under the curve for glucose > 7 mmol/l was reduced by 61 % by Lantus ( p < 0.001 ) . Conclusion . The routine protocol with pre-emptive glargine insulin studied here provides a major improvement in glycaemic control with a minimal incidence of hypoglycaemia and without an excessive increase in nursing burden We compared two intravenous insulin regimens among 58 consecutive surgical patients who required perioperative insulin infusions .  Patients were r and omized to either a st and ard glucose-insulin-potassium ( GIK ) infusion or a more complex , tailored two-pump protocol . Both methods provided similar overall glycemic control . However , the two-pump regimen result ed in a significantly greater proportion of finger-prick results in the target range both preoperatively ( 47.4 % vs 60.1 % ) and postoperatively ( 52.0 % vs 66.4 % ) . The length of stay ( 15 vs 16 days ) , duration of infusion ( 15 vs 16 hours , and number of medical and nursing incidents ( 18 % vs 20 % ) were similar : Although the two-punip protocol required more changes to the administration rate ( 2 vs 10 ) , this method was preferred by the nursing staff over the GIK regimen , result ed in more stable glucose control , and is likely to be associated with fewer clinical errors BACKGROUND Frequently , the use of insulin is considered for metabolic control in postoperative patients with non-insulin-dependent diabetes mellitus ( NIDDM ) . We sought to determine the best method for control of glucose in NIDDM non-insulin patients during postoperative care . METHODS Two algorithms were developed : subcutaneous administration of insulin ( SC ) , and continuous intravenous infusion ( IV ) . A r and omized , controlled clinical trial was design ed . In addition , both experimental groups were compared with a non-concurrent routinely managed group ( RM ) with insulin administration under no predetermined algorithm .  Eligible patients were those subjected to major surgery under general anesthesia or spinal blockade . They were followed for 48 h after surgery . Target variables were capillary and central blood glucose , insulin dose administered , urine glucose and ketone strip determination , and development of hyper- or hypoglycemia . RESULTS A total of 62 patients were studied ( RM = 25 , SC = 19 , IV = 18 ) . Results for both experimental algorithms were similar except for the IV group that required less insulin per hour compared to SC ( 0.64 vs. 0.34 U/h ; p = 0.0003 ) . The RM control group showed poor control in all capillary glucose measurements ( 194.9 + /- 26.8 mg/dL ) compared with the two experimental algorithms ( SC = 129.9 + /- 21 ; IV = 131.6 + /- 20.4 ) ( p < 0.05 ) . More hyperglycemia events appeared in the RM group ( p = 0.016 ) . Only one hypoglycemia event occurred in the IV group . CONCLUSIONS Postoperative control of NIDDM is similar with both tested methods . The use of any of the algorithms studied improves metabolic control substantially because it st and ardizes postoperative management of the diabetic patient with timely determination of capillary blood glucose and insulin administration . However , IV administration has the advantage of accomplishing adequate control with a smaller insulin dose AIMS We have different protocol s applied in our cardiac center for control of blood glucose ( BG ) , we like to see which protocol can achieve our goal . METHODS From a prospect i ve study of 120 diabetic patients r and omly assigned to either simple sliding scale or Braithwaite protocol who underwent open heart surgical procedures between 2005 and 2008 . The study group included 80 patients treated with Braithwaite protocol ;  the control group included 40 patients treated with simple sliding scale in an attempt to maintain BG level less than 200 mg/dl . RESULTS In the study group all the patients were under 200 mg/dl at the end of 48 h postoperatively , which was not achieved in the control group ( P<0.01 ) . There was a significant reduction in hospital stay in the study group compared to the control group ( mean in days 9.1+/-2.3/12.3+/-7.6 ) ( P<0.001 ) and also there was no wound infection compared to the control group ( 0/5 cases ) . CONCLUSION The study showed that control of DM in peri-operative period using Braithwaite regimen was of great benefit and safety AIMS To document the impact of intensive insulin therapy during intensive care on long-term ( 4 years ) outcome of high-risk cardiac surgery patients . METHODS AND RESULTS In this pre-planned sub- analysis and follow-up study of a large , r and omized controlled trial on the effects of intensive insulin therapy during critical illness , we assessed long-term outcome in the 970 patients who had been admitted after high-risk cardiac surgery ( mean+/-SD EuroSCORE of 6.0+/-3.7 ; EuroSCORE-predicted hospital mortality of 9.9 % ; observed hospital mortality of 7.5 % in the conventional insulin group and 3.4 % in the intensive insulin group ) . Long-term outcome was quantified as : ( a ) 4 years survival ; ( b ) incidence of hospital re-admission ; ( c ) level of activity and medical care requirements at 4 years as assessed by the Karnofsky score ; and ( d ) perceived health-related quality -of-life at 4 years as assessed by the Nottingham Health Profile . Four years after ICU admission , the number of post-hospital discharge deaths was similar in the two study groups , reflecting maintenance of the acute survival benefit with intensive insulin therapy . Survivors who had been treated with intensive insulin during ICU stay revealed a similar risk for hospital re-admission and a comparable level of dependency on medical care . There was no effect on quality -of-life in the total group , whereas the increased survival of sicker patients with at least 3 days of insulin therapy evoked a more compromised perceived quality -of-life , in particular regarding social and family life . CONCLUSION The short-term survival benefit obtained with insulin-titrated glycaemic control during intensive care after cardiac surgery was maintained after 4 years , without inducing increased medical care requirements but possibly at the expense of compromised perceived quality of social and family life OBJECTIVES We assessed myocardial salvage achieved by reperfusion with percutaneous coronary interventions ( PCI ) and compared stenting with balloon angioplasty ( PTCA ) in patients with acute myocardial infa rct ion ( AMI ) ineligible for thrombolysis . BACKGROUND A substantial proportion of patients with AMI are currently considered ineligible for thrombolysis , and reperfusion treatment is frequently not recommended for them . It is not known whether these patients benefit from PCI . METHODS The Stent or PTCA for Occluded Coronary Arteries in Patients with Acute Myocardial Infa rct ion Ineligible for Thrombolysis ( STOPAMI-3 ) trial , a r and omized , open-label study , included 611 patients with AMI who were ineligible for thrombolysis ( lack of ST-segment elevation on the electrocardiogram , late presentation > 12 h after symptom onset , and contraindications to thrombolysis ) . Patients were r and omly assigned to receive either coronary artery stenting ( n = 305 ) or PTCA ( n = 306 ) . Scintigraphic myocardial salvage index ( proportion of the initial myocardial perfusion defect that was salvaged by reperfusion ) was the primary end point of the study . RESULTS A considerable myocardial salvage was achieved with both stenting and PTCA . In patients assigned to receive stenting , the median size of the salvage index was 0.54 ( 25th and 75th percentiles , 0.29 and 0.87 ) , as compared with a median of 0.50 ( 25th and 75th percentiles , 0.26 and 0.82 ) in the group assigned to receive PTCA ( p = 0.20 ) . Mortality at six months was 8.2 % in the group of patients assigned to receive stenting and 9.2 % in the group of patients assigned to receive PTCA ( p = 0.69 ) . CONCLUSIONS Patients with AMI who are currently considered ineligible for thrombolysis by conventional guidelines may greatly benefit from primary PCI . The benefit seems to be comparable when a strategy of stenting is compared with a strategy of PTCA in these patients We have compared intraoperative glycaemic control , insulin requirements and metabolic and endocrine variables in 40 non-insulin-dependent diabetic patients ( NIDDM ) and 40 insulin-dependent diabetic patients ( IDDM ) undergoing general anaesthesia for elective procedures . Two i.v . insulin regimens were used : continuous i.v . infusion ( group A : 1.25 u.h-1 ) and repeated i.v . boluses ( 10 u./2 h ) . Blood concentrations of glucose  were measured every 15 min from just before induction of anaesthesia until 2 h after surgery . Plasma lactate and pyruvate concentrations , ketone bodies , C-peptide and counter-regulatory hormones were also measured . Glycaemia did not differ significantly in the two types of diabetes , regardless of the insulin therapy used . The amounts of insulin administered were similar in NIDDM and IDDM . There was no significant difference for other metabolic variables . Plasma concentrations of growth hormone ( GH ) increased significantly during surgery , especially in IDDM patients , but this change did not alter intraoperative glycaemic control . We conclude that mean glycaemic control , insulin requirements and development of ketone bodies in NIDDM and IDDM patients did not differ during the operative period , regardless of the insulin regimen used . Therefore , during the operative period , it is not necessary to modify the insulin regimen according to the type of diabetes . The consequences of increased plasma GH concentrations on glycaemic control in IDDM patients after operation are unknown Background : Intensive insulin therapy to maintain blood glucose at or below 6.11 mm reduces morbidity and mortality after cardiac surgery and morbidity in medical intensive care unit ( ICU ) patients . The authors investigated the clinical safety and outcome effects of intensive insulin therapy compared to conventional insulin therapy in patients receiving postoperative intensive care after neurosurgical procedures . Methods : In this prospect i ve r and omized controlled trial , 483 patients undergoing elective or emergency brain surgery were prospect ively and r and omly assigned either to intensive insulin therapy ( 241 patients ) , receiving insulin titrated to maintain blood glucose levels within the range of 4.44–6.11 mm , or to conventional insulin therapy ( 242 patients ) , receiving insulin to maintain blood glucose levels below 11.94 mm . Primary endpoint was incidence of hypoglycemia ( defined as blood glucose < 2.78 mm ) . Efficacy measures included the length of ICU stay , infection rate , and 6 months follow-up Glasgow outcome scale score and overall survival . Results : Hypoglycemia episodes were more frequent in patients receiving intensive insulin therapy , median ( min – max ) : 8 ( 0–23 ) versus 3 ( 0–4 ) ; P < 0.0001 . The length of stay in the ICU was shorter ( 6 vs. 8 days ; P = 0.0001 ) , and the infection rate was lower ( 25.7 % vs. 39.3 % ; P = 0.0018 ) . Glasgow outcome scale score and overall survival at 6 months were similar in the two groups . Conclusions :  Intensive insulin therapy  in patients admitted to a postoperative neurosurgical ICU after brain surgery is associated with iatrogenic hypoglycemia , but it can also reduce the infection rate and shorten the ICU stay
target: None of the trials examined the effects of the interventions in terms of costs .
  AUTHORS ' CONCLUSIONS The included trials did not demonstrate significant differences for most of the outcomes when targeting intensive perioperative glycaemic control compared with conventional glycaemic control in patients with diabetes mellitus .
  However , posthoc analysis indicated that intensive glycaemic control was associated with an increased number of patients experiencing hypoglycaemic episodes .
background: BACKGROUND Patients with diabetes mellitus are at increased risk of postoperative complications .
  Data from r and omised clinical trials and meta-analyses point to a potential benefit of intensive glycaemic control , targeting near-normal blood glucose , in patients with hyperglycaemia ( with and without diabetes mellitus ) being su bmi tted to surgical procedures .
  However , there is limited evidence concerning this question in patients with diabetes mellitus undergoing surgery .
  OBJECTIVES To assess the effects of perioperative glycaemic control for diabetic patients undergoing surgery .