Perioperative Tight Glucose Control Reduces Postoperative Adverse Events in Nondiabetic Cardiac Surgery Patients.

CONTEXT: Tight glucose control (TGC) reduces morbidity and mortality in patients undergoing elective cardiac surgery, but only limited data about its optimal timing are available to date. OBJECTIVE: The purpose of this article was to compare the effects of perioperative vs postoperative initiation of TGC on postoperative adverse events in cardiac surgery patients. DESIGN: This was a single center, single-blind, parallel-group, randomized controlled trial. SETTINGS: The setting was an academic tertiary hospital. PARTICIPANTS: Participants were 2383 hemodynamically stable patients undergoing major cardiac surgery with expected postoperative intensive care unit treatment for at least 2 consecutive days. INTERVENTION: Intensive insulin therapy was initiated perioperatively or postoperatively with a target glucose range of 4.4 to 6.1 mmol/L. MAIN OUTCOME MEASURES: Adverse events from any cause during postoperative hospital stay were compared. RESULTS: In the whole cohort, perioperatively initiated TGC markedly reduced the number of postoperative complications (23.2% vs 34.1%, 95% confidence interval [CI], 0.60-0.78) despite only minimal improvement in glucose control (blood glucose, 6.6 ± 0.7 vs 6.7 ± 0.8 mmol/L, P < .001; time in target range, 39.3% ± 13.7% vs 37.3% ± 13.8%, P < .001). The positive effects of TGC on postoperative complications were driven by nondiabetic subjects (21.3% vs 33.7%, 95% CI, 0.54-0.74; blood glucose 6.5 ± 0.6 vs 6.6 ± 0.8 mmol/L, not significant; time in target range, 40.8% ± 13.6% vs 39.7% ± 13.8%, not significant), whereas no significant effect was seen in diabetic patients (29.4% vs 35.1%, 95% CI, 0.66-1.06) despite significantly better glucose control in the perioperative group (blood glucose, 6.9 ± 1.0 vs 7.1 ± 0.8 mmol/L, P < .001; time in target range, 34.3% ± 12.7% vs 30.8% ± 11.5%, P < .001). CONCLUSIONS: Perioperative initiation of intensive insulin therapy during cardiac surgery reduces postoperative morbidity in nondiabetic patients while having a minimal effect in diabetic subjects.

New recommendations for thromboelastography reference ranges for pregnant women.

INTRODUCTION: The target of this study was to compare thromboelastography coagulation parameters in pregnant and non-pregnant women. If appropriate, we would propose recommendations for new reference ranges for pregnant women in their third trimester. MATERIALS AND METHODS: Prospective observational study, comparing, by using thromboelastography, the blood samples of 60 healthy women in third trimester of pregnancy (group GRAV) to the samples of the control group of 43 healthy non-pregnant fertile women (group NON-GRAV). Selective percentiles were used to determine new reference limits. RESULTS: Mean values and standard deviations (SD) in both groups were as follows (GRAV vs NON-GRAV): time r 4.7 min (SD 1.7) vs. 7.8 (SD 2.8); time k1.5 min (SD 0.5) vs. 2,7 (SD 0,9); alpha angle 69.6° (SD 5.5) vs. 54.4 (SD 11.5); maximum amplitude 71.3mm (SD 4.5) vs. 63.1 (SD 5.4); coagulation index 2.7 (SD 1.8) vs. -1.9 (SD 3.0); LY60 1.1% (SD 1.8) vs. 4.8 (SD 3.6). Due to statistically significant differences between both groups, we established, based on our results, these new thromboelastography reference limits for pregnant women: time r 2-8 min ("common" range 4-8 min), time k 1-3 min ("common" range 1-4 min), alpha angle 60-77° ("common" range 47-74°), maximum amplitude 64-76 mm ("common" range 55-73 mm), LY60 0-3% ("common" range 0-15%), coagulation index 0-5 ("common" range (-3) - (+3)). CONCLUSIONS: It may not be suitable to use the same reference ranges for pregnant women as for the general population. Therefore, we suggest new reference limits for thromboelastography in pregnant women.