Wound Strength

Hyperglycemia may affect fibroblast function during the period of granulation tissue formation and maturation. Decreased levels and cross-linking of collagen may impair wound healing and wound strength. Animal and human studies have demonstrated impaired wound healing/strength when blood glucose levels exceed 200 mg/dL in the days following surgery.

PERIOPERATIVE MI, CHF, STROKE

Controlled studies have tried to define whether tight glucose control using intensive insulin therapy can improve long-term outcome following acute MI. The diabetes insulin glucose in acute myocardial infarction (DIGAMI) study randomized acute MI patients to receive either conventional diabetes care or tight glucose control using an intravenous infusion of glucose-insulin-potassium (GIK) followed by multiple daily subcutaneous insulin injections. Inhospital mortality decreased 58%, one-year mortality decreased 52%, and three-year mortality decreased 25% in diabetics managed with intensive therapy (48). Glucose-insulin-potassium infusions have been recommended to promote myocardial utilization of glucose for energy production (12,35). Fatty acids are preferentially utilized by the myocardium when insulin levels are deficient, leading to enhanced oxygen consumption, and an increased incidence of myocardial ischemia, arrhythmias, and contractile dysfunction (1,2,3).

Capes et al. performed a retrospective meta-analysis of 15 clinical studies of acute MI patients. Non-diabetics with stress hyperglycemia following an acute MI (above 109-124 mg/ dL) had a four-fold increased rate of in-hospital mortality. Diabetic patients with hyperglycemia (above 124-180 mg/dL range) had a two-fold increased rate of in-hospital mortality. Hyperglycemia was also associated with an increased incidence of post MI congestive heart failure and cardiogenic shock (49).

Independent of previous cardiac disease, diabetes, or other co morbidities, McGirt et al. determined that hyperglycemia at the time of carotid endarterectomy (CEA) was associated with an increased risk of perioperative stroke or transient ischemic attack, myocardial infarction, and death. The authors suggested that strict glucose control be attempted before surgery to minimize the risk of morbidity and mortality after CEA (50). Hyperglycemia is associated with increased infarct size and worsened long-term outcome following cerebral ischemia (51). Elevated HbA1c and blood glucose levels at the time of hospital admission have been shown to correlate with cerebral infarct size and long-term prognosis (43). Controlled trials are underway to determine whether tight glucose control can improve outcome following cerebral ischemia, stroke, or spinal cord injury.

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