Tight glycaemic control and surgical site infections post cardiac surgery: a systematic review

Objective: Surgical site infection (SSI) is one of the most serious potential complications post cardiac surgery among patients with diabetes and has a number of adverse health outcomes. The literature shows discrepancies regarding the effect of different glycaemic control protocols on reducing adverse health outcomes including SSIs. The aim of this study was to conduct a systematic review that investigated the effect of the optimal range of tight glycaemic control protocols using a continuous insulin infusion on reducing the incidence of SSIs in adult patients with diabetes undergoing cardiac surgery. Method: A systematic review was conducted following the PRISMA statement and guidelines. Search terms were used to identify research studies published between 2000 and 2019 across five key databases, including CINAHL, Medline, PubMed, Cochrane Database and Google Scholar. Results: A total of 12 studies met the review inclusion criteria. The reviewed literature tended to support the implementation of a tight glycaemic control protocol, particularly in the postoperative phase, that demonstrated fewer potential complications associated with cardiac surgery. On the other hand, the literature also supported the application of a moderate glycaemic control protocol in the intraoperative phase to obtain better glycaemic stability with fewer potential complications among those patients with diabetes undergoing cardiac surgery. Conclusion: This analysis concludes that tight glycaemic control is more effective than moderate glycaemic control intraoperatively in terms of glycaemic stability among patients with diabetes undergoing cardiac surgery. Results also emphasised the importance of time-based protocol implementation to ensure better health outcomes and better quality of care for patients.

What role for metformin in type 1 diabetes?

Tight glycaemic control is key to reducing the risk of cardiovascular and microvascular complications in people with type 1 diabetes.1 Standard treatment involves optimising insulin therapy to achieve an HbA1c level of 48mmol/mol (6.5%) or lower. Although not licensed for use in type 1 diabetes, metformin is included in some clinical guidelines as adjuvant therapy for people with type 1 diabetes who are overweight and wish to improve glycaemic control while minimising the dose of insulin.1,2 The REMOVAL study is the largest trial to date that has investigated the longer-term effects of metformin in people with type 1 diabetes.3 Here, we consider the role of metformin in individuals with type 1 diabetes in light of these results and other study findings.

European Stroke Organisation (ESO) guidelines on glycaemia management in acute stroke

Background Hyperglycaemia is a frequent complication in acute stroke that has been shown to be independently associated with larger infarct size, haematoma growth, poor clinical outcome and mortality. This Guideline Document presents the European Stroke Organisation (ESO) Guidelines for the management of blood glucose levels in patients with acute ischemic or haemorrhagic stroke. Methods The working group identified related questions and developed its recommendations based on evidence from randomised controlled trials following the standard operating procedure of the ESO. This Guideline Document was reviewed and approved by the European Stroke Organisation Guidelines Committee and the European Stroke Organisation Executive Committee. Results We found low-quality evidence from clinical trials in ischemic or haemorrhagic stroke exploring the use of intravenous insulin aimed to achieve a tight glycaemic control with different glucose level targets and several other sources of heterogeneity. None of these trials neither the meta-analysis of them have demonstrated any significant benefit of tight glycaemic control with intravenous insulin in acute ischemic or haemorrhagic stroke patients on functional outcome or in survival and they have shown an increased risk for hypoglycaemia. Conclusions We suggest against the routine use of tight glycaemic control with intravenous insulin as a means to improve outcomes. The currently available data about the management of glycaemia in patients with acute stroke are limited and the strengths of the recommendations are therefore weak. Nevertheless, this does not prevent that hyperglycaemia in acute stroke patients could be treated as any other hospitalised patient.