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Optimizing intraoperative blood glucose concentrations as a management strategy for reducing the incidence of deep sternal wound infection after cardiac surgery

The occurrence of hyperglycemia (elevated blood glucose) during open cardiac surgery is high. Hyperglycemia may be associated with increased vulnerability to surgical site infections.

In 2013, the mean deep sternal wound Infection rate was 0.72%. The following strategies were employed in National Heart Centre, Singapore in reducing the incidence of Deep Sternal Wound Infection,

1. Decontamination of skin bacterial flora with Chlorhexidine bath.
2. Prophylactic antibiotic (cephalosporin) therapy within 60 minutes of surgery starts time.
3. Reduction of contamination of surgical wound by employment of laminar airflow system in the operating theatre.
4. Maintenance of intraoperative blood glucose concentrations within the range of 4-8mmol/l.

Percentage of post -op cardiac patients with blood glucose concentration maintained between 4-8 mmol

Maintenance of Intraoperative Blood Glucose Concentrations  
The anaesthesiologist in charge of the patient is responsible for facilitating optimal intraoperative blood glucose control. The medical team will monitor the intraoperative blood glucose concentration every 30 to 60 minutes. The objective is to maintain intraoperative blood glucose concentrations within the range of 4-8mmol/l. As part of patient monitoring, an infusion of insulin at 50units of insulin in 50 mls of water is made available for all cardiac surgical patients. Generally, a sliding scale method of guiding insulin administration for the blood glucose control is employed; however, the dosage and rate of infusion insulin can be modified at the discretion of the attending anaesthesiologist and according to each patient’s clinical requirements.

Monitoring of outcome

After open heart surgery, the cardiac patients are left intubated and transferred to the CTSICU for mechanically ventilated and early postoperative care. The team would monitor the first blood glucose concentration on admission to CTS ICU.

A monthly report on blood glucose concentrations observed in cardiac patient is submitted to the Head of department and the anaesthesiologists of the Department of Cardiothoracic Anaesthesia. In addition, the individual anaesthesiologist receives a monthly personal report on the median blood glucose concentrations of patients under his or her care compared to the median of the group.