Pro and Con

o S m N THE AUTHORS’ previous article on tight glucose control and outcome in cardiovascular surgery, the following quesions that are clinically important for perioperative glycemic ontrol were outlined1: (1) What are the clinical hazards of cute perioperative hyperglycemia? (2) What level of glycemia s dangerous for the surgical patient? and (3) When should reatment be initiated, and what should the target blood glucose oncentration be? The authors believe these questions remain relevant because ecent investigations have been insufficient to promote a hange in clinical practice. In response to studies performed in ritically ill patients, most institutions have established protools for controlling blood glucose levels in the intensive care nit (ICU) and less frequently in the operating room. However, he lack of uniformity of insulin glucose regimens and the iverse populations studied make it difficult for the reader to ecipher what glycemic range to aim for and how best to chieve it. The authors think that normoglycemia is the ideal nd have shown that it can be accomplished perioperatively by sing large doses of insulin in tandem with exogenous glucose.2 igh-dose insulin therapy possesses nonmetabolic effects with otential benefit for surgical patients and in particular for atients with cardiovascular disease. Normoglycemia per se educes mortality in critical illness and prevents liver, kidney, nd endothelial dysfunction, but, in order to fully exploit insuin’s anti-inflammatory, cardioprotective, and inotropic effects, oth normoglycemia and high-dose insulin are required.3 In linical reality, the fear of hypoglycemia has confined insulin herapy to be neither high dose nor to be sufficiently effective o achieve normoglycemia. Current insulin therapy regimens re reactive and permit moderate hyperglycemia before they re initiated. Because hyperglycemia begins preoperatively or n the operating room, treating hyperglycemia and maintaining ormoglycemia as early as possible may prove beneficial. The ailure to do so leads to an extended period of poor glucose ontrol in the ICU that is harmful but preventable with greater ntraoperative vigilance. This review focuses on evidence from recent investigations nvolving patients undergoing cardiac surgery. Its purpose is to upplement the previous review and concentrate on intraopertive glycemic control. That hyperglycemia is hazardous the authors think is now ndisputable in the cardiac surgery patient population. Over the ast 3 years, observational studies have been published corrobrating the association between hyperglycemia and poor outomes after cardiac surgery. Although links cannot establish