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PubMed2003

Carbohydrate intake and biomarkers of glycemic control among US adults: the third National Health and Nutrition Examination Survey (NHANES III).

BACKGROUND: Recommendations for preventing and treating type 2 diabetes include consuming carbohydrates, predominantly from whole grains, fruit, vegetables, and low-fat milk. However, the quantity and type of carbohydrates consumed may contribute to disorders of glycemic control. OBJECTIVE: We evaluated the association between carbohydrate intakes and biomarkers of glycemic control in a nationally representative sample of healthy US adults who participated in a cross-sectional study, the third National Health and Nutrition Examination Survey. DESIGN: The sample (5730 men and 6125 women aged > or = 20 y) was divided into quintiles of carbohydrate intake (as a percentage of energy). Carbohydrate intakes were examined in relation to glycated hemoglobin (Hb A(1c)), plasma glucose, serum C-peptide, and serum insulin concentrations by using logistic regression. RESULTS: Carbohydrate intakes were not associated with Hb A(1c), plasma glucose, or serum insulin concentrations in men or women after adjustment for confounding variables. Carbohydrate intakes were inversely associated with serum C-peptide concentrations in men and women. Odds ratios for elevated serum C-peptide concentrations for increasing quintiles of carbohydrate intake were 1.00, 0.88, 0.57, 0.39, and 0.75 (P for trend = 0.016) in men, and 1.00, 0.69, 0.57, 0.36, and 0.41 (P for trend = 0.007) in women. When carbohydrate intakes were further adjusted for intakes of total and added sugar, the association of serum C-peptide with carbohydrate intakes was strengthened in men. CONCLUSIONS: Carbohydrate intakes were not associated with Hb A(1c), plasma glucose, or serum insulin concentrations but were inversely associated with the risk of elevated serum C-peptide; this supports current recommendations regarding carbohydrate intake in healthy adults.

Adult↗

PubMed1989

Motor vehicles, hypoglycemia, and diabetic drivers.

Individuals with diabetes are increasingly persuing employment in fields previously restricted as a result of the development of chronic complications. Improved glycemic control resulting from use of sophisticated insulin delivery and monitoring systems has also led to the recognition of recurrent hypoglycemia as a potential major clinical and occupational hazard. No data concerning the occupational safety of individuals with insulin-treated diabetes mellitus (ITDM) are available. We review the literature on diabetic drivers in an effort to examine the impact of certification of ITDMs as commercial drivers. In the absence of significant worldwide experience with ITDMs as commercial drivers, the discussion is necessarily based on projected accident rates derived from data on frequency of hypoglycemia. These studies are universally flawed by variable definitions of hypoglycemia, ascertainment bias, and patient selection. They do, however, provide a worst-case/best-case scenario for discussion. It is imperative that any expansion of employment opportunities for ITDMs be followed carefully with prospective studies to assess the impact on public safety.

Automobile Driving↗

PubMed2006

Management of physiological variables in neuroanaesthesia: maintaining homeostasis during intracranial surgery.

PURPOSE OF REVIEW: The recent literature on the perioperative maintenance of cerebral homeostasis was reviewed. RECENT FINDINGS: Several studies focused on the regulation of cerebral blood flow in patients without intracranial disease; therefore, further studies in neurosurgical patients are needed. High intracranial pressure and brain swelling can be controlled by the choice of anaesthetic agents, and also by optimal positioning of the patient. The use of positive end-expiratory pressure may impair cerebral blood flow, but the effects of positive end-expiratory pressure seem to depend on the respiratory system compliance. The international multicenter study failed to show any benefit from intraoperative hypothermia in patients with subarachnoid hemorrhage; similarly, the results on corticosteroid therapy in head-injured patients are discouraging. Corticosteroid therapy has prompted studies on the control of blood glucose levels. While tight glycemic control has been recommended, it can have untoward effects manifested as cerebral metabolic stress. SUMMARY: From the clinical point of view, the recent research has added only little to the knowledge on the management of physiological parameters in neurosurgery. More adequately powered studies focusing in specific problems, and having a meaningful aim relative to outcome, are needed also in neuroanaesthesia.

Adrenal Cortex Hormones↗

PubMed2004

Association of serum sialic acid with cardiovascular metabolic risk factors in Kuwaiti children and adolescents with type 1 diabetes.

The aim of the present study was to investigate the relation of serum total sialic acid (TSA) concentrations with cardiovascular metabolic risk factors in Kuwaiti children and adolescents with uncomplicated type 1 diabetes. This case-control study included 150 (57 males and 93 females) type 1 diabetic children aged 6 to 18 years matched by age and sex to 150 nondiabetic children as controls. Measured variables included weight, height, systolic, diastolic blood pressure, and biochemical variables: blood glucose, glycated hemoglobin (HbA(1C)), triglycerides (TG), total cholesterol (TC), high-density lipoprotein cholesterol (HDL), apolipoproteins (apo) A1 and B, and urine microalbumin. There was no significant difference between mean serum TSA of the type 1 diabetic children (671.0 mg/L) and their controls (663.7 mg/L). In diabetic children, mean serum TSA was significantly higher in females (699.1 mg/L) than in males (625.2 mg/L) (P =.003). Significant correlations were found between serum TSA and the cardiovascular risk factors TC (P =.002), TG (P <.001), and apo B (P =.008). TSA mean level was significantly higher in diabetic children with poor glycemic control (HbA(1C) > 9.0%; P =.015), raised TC (P =.013), raised TG (P =.014), and in children with family history of cardiovascular disease (CVD; P =.02). In conclusion, the study suggests that serum TSA levels were not elevated in young type 1 diabetic children as compared with controls. The study also confirmed significant correlation of TSA concentrations with CVD risk factors TC, TG, and apo B, and as such serum TSA may be considered as a marker for CVD risk, especially in diabetic patients. A long-term prospective study is recommended to ascertain the longitudinal relationship of serum TSA with the adverse metabolic changes in type 1 diabetic children as complications prevail.

Adolescent↗

PubMed2006

A comparison of glycemic effects of glimepiride, repaglinide, and insulin glargine in type 2 diabetes mellitus during Ramadan fasting.

Although diabetics may be exempted from Ramadan fasting, many patients still insist on this worship. Aim of the present study is to compare the effects of glimepiride, repaglinide, and insulin glargine in type 2 diabetics during Ramadan fasting on the glucose metabolism. Patients, who were willing to fast, were treated with glimepiride (n=21), repaglinide (n=18), and insulin glargine (n=10). Sixteen non-fasting control type 2 diabetics matched for age, sex, and body mass index were also included. Fasting blood glucose (FBG), post-prandial blood glucose (PBG), HbA1c, and fructosamine as well as lipid metabolism were evaluated in pre-Ramadan, post-Ramadan, and 1-month post-Ramadan time points. There was no significant change from pre-Ramadan in FBG, PBG, and HbA1c variables in fasting diabetics at post-Ramadan and 1-month post-Ramadan. However, PBG was found higher in non-fasting control diabetics at post-Ramadan and 1-month post-Ramadan (p<0.05 and p<0.001, respectively). In fructosamine levels, a significant increase was noted both in fasting group and non-fasting group at 1-month post-Ramadan (p<0.01 for all). However, no significant difference was found in the comparison of the changes in fructosamine levels between fasting group and non-fasting group. Risk of hypoglycemia did not significantly differ between fasting and non-fasting diabetics. There was no significant difference between three drug therapies regarding glucose metabolism and rate of hypoglycemia. No adverse effects on plasma lipids were noted in fasting diabetics. In this fasting sample of patients with type 2 diabetes, glimepiride, repaglinide, and insulin glargine did not produce significant changes in glucose and lipid parameters.

Adult↗

PubMed1989

A preliminary trial of the programmable implantable medication system for insulin delivery.

We undertook a trial to determine whether an implanted insulin-delivery system, the programmable implantable medication system (PIMS), could be used to treat patients with insulin-dependent diabetes. PIMS is a pulsatile, programmable pump with a battery life expectancy of five years. The reservoir is refilled transcutaneously every two months with a surfactant-stabilized human insulin preparation containing 400 U of insulin per milliliter. Eighteen patients received PIMS-delivered insulin for 4 to 25 months (mean, 18). The total PIMS-implantation experience comprised 28 patient-years. Good glycemic control was established and sustained during treatment (mean plasma glucose level, 7.3 mmol per liter; mean glycohemoglobin level, 8 percent [upper limit of normal, 7.5 percent]), with significantly reduced glycemic fluctuations. The total mean daily insulin dose did not change. Insulin solutions withdrawn from the pump reservoirs contained 92 percent native insulin and preserved biologic activity. There were no surgical or skin complications, severe hypoglycemic episodes, or instances of diabetic ketoacidosis. One pump was replaced because of a manufacturing defect, and four patients had catheter blockages due to omental-tissue encapsulation; two withdrew from the study and two had devices that were repaired successfully. The actuarial rate of survival of catheter function was 78 percent at 1.5 years. We conclude from this pilot study that insulin treatment with an implanted, variable-rate, programmable pump is feasible for periods up to two years.

Adult↗

PubMed1996

Postprandial glucose, insulin, and lipid responses to four meals containing unpurified dietary fiber in non-insulin-dependent diabetes mellitus (NIDDM), hypertriglyceridemic subjects.

OBJECTIVE: To evaluate the effects of two levels of total dietary fiber (10 g vs. 20 g) and two soluble:insoluble fiber ratios (1:4 vs. 2:3) on postprandial glucose and lipid metabolism in hypertriglyceridemic subjects with non-insulin-dependent diabetes mellitus (NIDDM). METHODS: Eight NIDDM, mildly hypertriglyceridemic subjects consumed four test breakfasts, each containing variable proportions of the same cereal and fruit fiber sources. Blood samples were obtained during the 4 hours following the test meals and analyzed for glucose, insulin, triglyceride, total cholesterol and high density lipoprotein cholesterol. RESULTS: The incremental area under the curve for glucose and insulin was lowered after consuming 20 g as compared to 10 g of dietary fiber (p < 0.05), but was not affected by the soluble insoluble fiber ratio. The postprandial lipemia was similar after all test meals. CONCLUSION: The proportion of soluble to insoluble fiber in cereal and fruit does not necessarily predict the effect of fiber on the glycemic response, while the overall quantity of fiber does appear to affect postprandial glucose metabolism in NIDDM.

Analysis of Variance↗

PubMedDate not supplied

The relationship between evidence-based practices and survival in patients requiring prolonged mechanical ventilation in academic medical centers.

Studies suggest variable adoption of evidence-based practice guidelines. The authors hypothesized that compliance with guidelines for patients requiring mechanical ventilation would vary among academic medical centers and that this variation might be associated with survival. A total of 1463 intensive care unit cases receiving continuous mechanical ventilation for >96 hours were reviewed. The variation in mortality based on compliance with 6 evidence-based practices was determined, and the effect of each intervention was estimated using a logistic regression model. Compliance varied widely across the participating centers. A strong association with survival was seen for 2 of the 6 practices: sedation management and glycemic control (odds ratios for death of 0.30 and 0.46, respectively, each P < .01). Spontaneous breathing trials, deep venous thrombosis prophylaxis, semi-recumbent positioning, and stress ulcer prophylaxis were not associated with survival in the model. More consistent adoption of these practices represents an opportunity for academic medical centers and was associated with enhanced survival.

Academic Medical Centers↗

PubMed2000

A 16-week comparison of the novel insulin analog insulin glargine (HOE 901) and NPH human insulin used with insulin lispro in patients with type 1 diabetes.

OBJECTIVE: To determine the safety and efficacy of the long-acting insulin analog, insulin glargine, as a component of basal bolus therapy in patients with type 1 diabetes. RESEARCH DESIGN AND METHODS: Patients with type 1 diabetes receiving basal-bolus insulin treatment with NPH human insulin and insulin lispro were randomized to receive insulin glargine (HOE 901), a long-acting basal insulin analog, once a day (n = 310) or NPH human insulin (n = 309) as basal treatment with continued bolus insulin lispro for 16 weeks in an open-label study NPH insulin patients maintained their prior schedule of administration once or twice a day, whereas insulin glargine patients received basal insulin once a day at bedtime. RESULTS: Compared with all NPH insulin patients, insulin glargine patients had significant decreases in fasting blood glucose measured at home (means +/- SEM, -42.0 +/- 4.7 vs. -12.4 +/- 4.7 mg/dl [-2.33 +/- 0.26 vs. -0.69 +/- 0.26 mmol/l]; P = 0.0001). These differences were evident early and persisted throughout the study More patients in the insulin glargine group (29.6%) than in the NPH group (16.8%) reached a target fasting blood glucose of 119 mg/dl (< 6.6 mmol/l). However, there were no differences between the groups with respect to change in GHb. Insulin glargine treatment was also associated with a significant decrease in the variability of fasting blood glucose values (P = 0.0124). No differences in the occurrence of symptomatic hypoglycemia, including nocturnal hypoglycemia, were observed. Overall, adverse events were similar in the two treatment groups with the exception of injection site pain, which was more common in the insulin glargine group (6.1%) than in the NPH group (0.3%). Weight gain was 0.12 kg in insulin glargine patients and 0.54 kg in NPH insulin patients (P = 0.034). CONCLUSIONS: Basal insulin therapy with insulin glargine once a day appears to be as safe and at least as effective as using NPH insulin once or twice a day in maintaining glycemic control in patients with type 1 diabetes receiving basal-bolus insulin treatment with insulin lispro.

Adult↗

PubMed1987

Environmental control of energy metabolism in rats.

Food availability was arranged so that episodes of feeding were separated by long periods of deprivation. Distinctly different contexts were associated with each condition. For other animals, relatively short periods of deprivation stood in contrast to relatively long opportunities to free-feed, and were also embedded in widely differing physical contexts. These temporal relationships among the conditions were adjusted to sharpen the saliency of each metabolic condition and thereby enhance its associability with the distinctive environment in which each occurred. To avoid the possibility of circadian entrainment, the feeding or deprivation episodes occurred at unpredictable times according to a variable-time schedule. Following several training cycles and an extended period of free-feeding in a neutral environment, the animals were reexposed to the various contexts and sacrificed for metabolite assays. The environment predictive of feeding elevated adipocyte lipoprotein lipase activity and lowered the levels of serum free fatty acids. The deprivation context boosted serum triglycerides and blood urea nitrogen. The conditioned responses were all of a compensatory nature: Feeding cues resulted in accelerated caloric deposition, deprivation cues elicited conditioned mobilization of stored energy. While protein catabolism and several indices of fat metabolism appear to be conditionable, no evidence of environmental control of glycemic responses was observed.

Animals↗

PubMed2004

Possible link between glycated hemoglobin and lipid peroxidation in hyperthyroidism.

BACKGROUND: Glycated hemoglobin (HbA1C) levels are enhanced by elevated glucose concentrations. Glycation of hemoglobin is also modulated by lipid peroxides, ascorbic acid and reduced glutathione (GSH). We determined the strength of the relationships among these variables in a group of hyperthyroid patients. METHODS: Twenty-two untreated hyperthyroid patients and 17 healthy controls were recruited for the study. Whole blood GSH, HbA1C, plasma lipid peroxides, ascorbic acid and fasting glucose were analyzed in both the groups. Direct and partial correlation analysis was performed to explore the possible relationships between these variables. RESULTS: In hyperthyroid patients, HbA1C and lipid peroxides levels were found to be significantly increased than the controls. Ascorbic acid and GSH were decreased significantly in the test group when compared with the healthy control group. With partial correlation analysis, fasting glucose and lipid peroxides were found to have a significant positive correlation with HbA1C. Ascorbic acid and GSH showed no significant association with HbA1C levels. CONCLUSION: These data suggest that HbA1C levels are closely associated with fasting glucose and lipid peroxides in hyperthyroid patients. Therefore, serum lipid peroxides level should be kept in mind while interpreting HbA1C as a long-term glycemic index in hyperthyroid cases.

Adolescent↗

PubMedDate not supplied

No correlation between glycemic control and an increase in erythrocyte aldose reductase activity in type I and type II diabetic patients.

Aldose reductase, the first enzyme of the polyol pathway, has been related to the pathogenesis of diabetic complications. The regulation of the enzyme in diabetes patients, however, has not yet been clarified. We recently reported that the activity of aldose reductase was increased in erythrocytes of insulin-dependent diabetes mellitus patients but short-term hyperglycemia did not affect the enzyme activity. It is still unclear, however, whether or not the increase in the enzyme activity is caused by long-term hyperglycemia and thus would be seen equally in both type I (insulin-dependent diabetes mellitus) and type 2 (non-insulin-dependent diabetes mellitus) individuals. To further clarify these issues we measured erythrocyte aldose reductase activity in 46 type I patients and 30 type II patients who had variable glucose control and in 16 nondiabetic subjects. We compared the enzyme activity with plasma glucose levels and hemoglobin A1c levels. The results show that erythrocyte aldose reductase activity is increased in both type I and type II patients as compared with nondiabetic subjects (7.1 +/- 0.3 U/L and 6.8 +/- 0.4 U/L erythrocytes versus 5.6 +/- 0.2 U/L erythrocytes, p less than 0.001 and p less than 0.01, respectively), but there were no significant differences between the two groups of diabetic patients. The enzyme activity varied by approximately four times among the diabetic individuals but there was no correlation between the enzyme activity and plasma glucose or hemoglobin A1c levels. We conclude that the increased activity of erythrocyte aldose reductase seen in diabetes is not related to hyperglycemia.

Adult↗

PubMed2005

Are ethnic differences in insulin sensitivity explained by variation in carbohydrate intake?

AIMS/HYPOTHESIS: Minority populations are disproportionately affected by diabetes. This health disparity may be due to less healthy diets and/or heritable factors in minority populations. These factors must be assessed concurrently to better appreciate their contribution to insulin sensitivity. METHODS: We analysed overweight, healthy adults using the National Health and Nutrition Examination Survey 1999-2000. Means for dietary intake variables and insulin sensitivity were calculated by ethnicity. Linear regressions were performed to evaluate the association between ethnicity, dietary variables, dietary glycaemic index and insulin sensitivity. Fasting insulin was used to characterise insulin sensitivity. RESULTS: Non-Hispanic whites have higher energy and fat intake, while Hispanics have higher carbohydrate intake and African-Americans have lower fibre intake. In unadjusted analyses both Hispanics and African-Americans have lower insulin sensitivity, but only Hispanics are more likely to have lower insulin sensitivity after controlling for dietary variables and BMI. CONCLUSIONS/INTERPRETATION: Ethnic differences in insulin sensitivity remain after controlling for dietary differences and other factors, suggesting that inherent metabolic differences exist. Further studies are needed to define inherent metabolic factors, as well as other non-dietary factors that affect insulin sensitivity.

Adult↗

PubMed2003

Blood glucose threshold and the metabolic responses to incremental exercise tests with and without prior lactic acidosis induction.

This study compared the metabolic-ventilatory responses and the glycemic threshold identified during lactate minimum (LM) and individual anaerobic threshold (IAT) tests. In addition, the ability to determine the anaerobic power, aerobic-anaerobic transition (Trans) (e.g. ventilatory threshold; VT) and the maximal oxygen consumption (VO(2max)) all within a single incremental treadmill test (IT) was investigated. Fifteen physically fit men [25.9 (5.5) years; 77.4 (6.5) kg] performed the following: test 1, IT for IAT; and test 2, LM: 30-s Wingate test followed by 8 min rest and then an IT that was the same as test 1. Blood lactate concentration [lac], glucose concentration [gluc], pH, PO(2), PCO(2), base excess (BE) and ventilatory variables were measured. At the beginning of the IT for LM, the ventilation, PO(2) and VO(2) were higher and the pH, BE and PCO(2) were lower in relation to IAT ( P<0.05), while no differences were observed after reaching LM intensity during IT. Moreover, the Trans could be identified by [lac] (IAT, LM), minute ventilation [V(E;) VT identified during IAT protocol (VT-IAT) and VT identified during LM protocol (VT-LM)], and [gluc] (IGT, GM) during the IT for IAT and LM. The velocities (kilometers per hour) corresponding to IAT (12.6+/-1.6), VT-IAT (12.5+/-1.7), IGT (12.6+/-1.6), LM (12.5+/-1.5), VT-LM (12.3+/-1.5), and GM (12.6+/-1.9) were not different from each other and the LM and IAT protocols resulted in the similar VO(2max). We concluded that: (1) after reaching the LM the metabolic responses during IT are similar to IAT; (2) performing a Wingate test prior to an IT does not interfere with the Trans and VO(2max) attainment; (3) and the IGT and GM can predict the Trans.

Acidosis, Lactic↗

PubMed2003

Increasing physical activity in people with type 2 diabetes.

OBJECTIVE: To evaluate effect of exercise consultation on physical activity and resultant physiological and biochemical variables at 6 months in people with type 2 diabetes. RESEARCH DESIGN AND METHODS: A total of 70 inactive people with type 2 diabetes were given standard exercise information and were randomized to receive an exercise consultation (n = 35) or not (n = 35). Exercise consultation, based on the transtheoretical model, combines motivational theory and cognitive behavioral strategies into an individualized intervention to promote physical activity. Changes from baseline to 6 months were assessed in 1) physical activity (7-day recall, accelerometer, cardiorespiratory fitness, stage, and processes of change), 2) physiological variables (blood pressure and BMI), and 3) biochemical variables (HbA(1c), lipid profile, and fibrinogen). RESULTS: Between-group differences were recorded for the change in minutes of moderate activity (P < 0.001) and activity counts (P < 0.001) per week. Experimental participants recorded an increase in activity counts per week and minutes of moderate activity per week (P < 0.001). The control group recorded no significant changes. More experimental participants increased stage of change (chi(2) = 22.6, P < 0.001). Between-group differences were recorded for the change in total exercise duration and peak gradient (P < 0.005), HbA(1c) (P = 0.02), systolic BP (P = 0.02), and fibrinogen (P = 0.03). CONCLUSIONS: Exercise consultation increased physical activity and improved glycemic control and cardiovascular risk factors in people with type 2 diabetes.

Age of Onset↗

PubMed2005

Postprandial glycaemic, lipaemic and haemostatic responses to ingestion of rapidly and slowly digested starches in healthy young women.

The objective of the present study was to investigate the postprandial metabolism of two starches with contrasting rates of hydrolysis in vitro. Characterized using the Englyst method of in vitro starch classification, C*Set 06 598 contained predominantly rapidly digestible starch and C*Gel 04 201 contained predominantly slowly digestible starch. Each test starch, naturally enriched with 13C, was fed to ten healthy female volunteers as part of a moderate fat test meal (containing 75 g test starch and 21 g fat), in a double-blind randomized crossover design. The metabolic response to each starch was measured after an overnight fast, in an acute 6 h study, before and after 14 d of daily consumption of 75 g test starch. During each acute study, blood samples were taken at 15 min intervals for the first 2 h and at 30 min intervals for the remaining 4 h. Breath 13CO2 enrichment was measured at the same time points and indirect calorimetry was performed for 20 min every 40 min immediately before and throughout the study. Significantly more rapid, greater changes in postprandial plasma glucose, NEFA and serum insulin concentrations were observed after consumption of the rapidly digestible starch. Breath 13CO2 output over the first 3-4 h rose rapidly then began to decline following consumption of the rapidly digestible starch, but plateaued for the slowly digestible starch. The 14 d adaptation period did not affect any of the glycaemic or lipaemic variables but there was a reduction in postprandial plasminogen activator inhibitor-1 concentrations. These data confirm that starches characterized as predominantly rapidly digestible versus slowly digestible by the Englyst procedure provoke distinctly different patterns of metabolism postprandially.

Adult↗

PubMed1996

Comparisons of studies on diabetic complications hampered by differences in GHb measurements.

OBJECTIVE: To compare glycated hemoglobin (GHb) values of the relationship between glycemic control and complications of diabetes from laboratories involved in long-term studies (Steno, Oslo, Stockholm, Diabetes Control and Complications Trial, and Linköping.) RESEARCH DESIGN AND METHODS: Blood samples were collected from 25 subjects selected to represent the clinically relevant measurement range. Fresh whole-blood samples were distributed and analyzed within 4 days of sample collection. Pretreatment of samples and analyses of GHb were performed according to the routine method of each study's central or reference laboratory. Results from each laboratory were compared with the group mean, i.e., the mean of all results for each sample. RESULTS: Regression analyses with the group mean values as independent variables and results from each laboratory as dependent variables showed that Oslo's result had a slope significantly different from the group mean. Laboratories used by the DCCT, Oslo, and Steno studies gave, on average, 0.4, 0.4, and 0.7% higher HbA1c readings than the group mean, respectively, while HbA1c results from Linköping and Stockholm were, on average, 0.6 and 1.0% lower, respectively. CONCLUSIONS: There were large differences in GHb values among laboratories participating in studies of diabetic complications. The present data offer a guide to the comparison of results from the studies and underscores the need for standardization of GHb measurements.

Diabetes Complications↗

PubMed2005

Intraoperative glucose control in diabetic and nondiabetic patients during cardiac surgery.

OBJECTIVE: The purpose of this study was to evaluate intraoperative glucose control. DESIGN: Prospective unblinded study. SETTING: Tertiary care center. PARTICIPANTS: Diabetic (n = 17) and nondiabetic (n = 23) patients undergoing elective cardiac surgery. INTERVENTIONS: Diabetics received a modified insulin regimen consisting of a fixed rate infusion of regular insulin, 10 U/m2/h, and a variable infusion of D10W, adjusted to maintain glucose between 101 to 140 mg/dL. MEASUREMENTS AND MAIN RESULTS: Baseline glucose was higher in diabetics versus nondiabetics (mean +/- standard error of the mean: 203 +/- 27 v 117 +/- 3 mg/dL, p < 0.005). After baseline, insulin levels were increased in diabetics to 410 to 568 microU/mL. Corresponding insulin levels in nondiabetics were 12 to 40 microU/mL. Compared with baseline, glucose was decreased by 10% +/- 29% in diabetics during hypothermic cardiopulmonary bypass and increased by 21% +/- 30% in nondiabetics (p < 0.005). After discontinuation of bypass, glucose was lower in diabetics (137 +/- 12 mg/dL) versus nondiabetics (162 +/- 8 mg/dL, p < 0.005). Nine diabetics had adequate intraoperative glycemic control during hypothermic bypass (glucose 123 +/- 8 mg/dL, insulin 550 +/- 68 microU/mL, glucose infusion rate 1.87 +/- 0.29 mg/kg/min), 6 approached adequate control near the end of surgery (glucose 147 +/- 8 mg/dL, insulin 483 +/- 86 microU/mL, glucose infusion rate 0.35 +/- 0.05 mg/kg/min), and 2 never achieved control. Diabetics with elevated initial glucose >300 mg/dL did not achieve adequate glycemic control. Four diabetics (3 with renal failure) required injection of 50% dextrose after bypass for hypoglycemia. CONCLUSION: Adequate glycemic control can be achieved in most diabetics during cardiac surgery using a modified insulin clamp technique provided initial glucose is <300 mg/dL.

Aged↗