Utkan SEVÜK, Abdulkadir BİLGİÇ, Barış YAYLAK, Nurettin AY, Erkan BAYSAL, Aylin ERKUL, Vahhaç ALP, Ünal BEYAZIT, Süleyman AKKAYA

Kalp Cerrahisi Yapılan Hastalarda Derin Sternal Yara İnfeksiyonları ile HbA1c Seviyeleri Arasındaki İlişki

Giriş: Kalp cerrahisi yapılan hastalarda, diabetes mellitus (DM)’lu hastalarda olduğu kadar diyabetik olmayan hastalarda da hiperglisemi ile sık karşılaşılır. Kalp cerrahisi sonrasında intraoperatif ve postoperatif hipergliseminin derin sternal yara infeksiyonu (DSYİ) için bağımsız risk faktörü olduğu gösterilmiştir. Ancak, preoperatif kronik glisemik kontrolün DSYİ ile ilişkisi tartışmalıdır. Hemoglobin A1c (HbA1c) geçmiş 2-3 aylık dönemdeki glukoz düzeyi hakkında bilgi verir. Bu çalışmanın amacı koroner baypas cerrahisi yapılan DM’li hastalarda, HbA1c seviyeleri ile DSYİ arasındaki ilişkiyi incelemektir. Hastalar ve Yöntem: Kliniğimizde kardiyopulmoner baypas altında koroner baypas operasyonu yapılmış olan hastaların kayıtları retrospektif olarak incelendi. DM’si olan ve perioperatif periyodda yeterli glisemik kontrol sağlanmış 180 hasta çalışmaya dahil edildi. DM’si olmayan koroner baypas cerrahisi yapılmış ardışık 200 hasta kontrol grubuna dahil edildi. Bulgular: Medyan HbA1c değerleri diyabetik hasta grubunda anlamlı olarak daha yüksekti [8.16 (7.2-10.4 vs 5.49 (5-6), p< 0.001]. DSYİ sıklığı bakımdan iki grup arasında istatistiksel olarak anlamlı bir fark saptanmadı [%5 (n= 9) vs %2 (n= 4); p= 0.1]. Yoğun bakımda kalış (p= 0.005) ve hastanede kalış süreleri (p= 0.01) diyabetik hastalarda anlamlı olarak daha uzundu. Sonuç: Preoperatif dönemdeki yüksek HbA1c seviyeleri koroner baypas sonrası DSYİ ile ilişkili bulunmamıştır. Ayrıca perioperatif periyodda yeterli glisemik kontrol sağlanmış DM’li hastalarda DSYİ sıklığında artış olmadığı saptanmıştır.

Anahtar Kelimeler:

Mediastinit, koroner arter baypas cerrahisi, hemoglobin A1c, diabetes mellitus, derin sternal yara infeksiyonu

Relationship Between Elevated HbA1c and Deep Sternal Wound Infection in Patients Undergoing Cardiac Surgery

Introduction: Hyperglycemia is common in patients with and without diabetes mellitus (DM) following cardiac surgery. Intra- and postoperative hyperglycemia has been shown to be an independent risk factor for deep sternal wound infection (DSWI) after cardiac surgery. However, whether the preoperative chronic glycemic control is associated with the risk of DSWI remains controversial. Hemoglobin A1c (HbA1c) provides a measure of glucose control over the prior 2-3 months. The aim of this study was to evaluate the relationship between preoperative HbA1c levels and DSWI in patients with DM undergoing coronary artery bypass grafting (CABG). Patients and Methods: Records of patients who underwent elective on-pump CABG were retrospectively reviewed. A total of 180 patients with DM were included in the study. Patients were excluded if their blood glucose levels were not adequately controlled in the perioperative period. A total of 200 consecutive patients without DM were taken as controls. Results: Median HbA1c levels were significantly higher in patients with DM [8.16 (7.2-10.4)] than in controls [5.49 (5-6)] (p< 0.001). There was no significant difference in DSWI incidence between patients with DM and controls [5% (n= 9) vs. 2% (n= 4); P= 0.1]. Hospital (p= 0.01) and intensive care unit stays (p= 0.005) were significantly longer in patients with DM. Conclusion: We found that DSWI was not associated with preoperative HbA1c levels in patients undergoing CABG. In addition, with adequate glycemic control in the perioperative period, our study demonstrated no significant difference with regard to DSWI between patients with DM and controls.

Keywords:

Mediastinitis, coronary artery bypass grafting, hemoglobin A1c, diabetes mellitus, deep sternal wound infection,

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1. Salehi Omran A, Karimi A, Ahmadi SH, Davoodi S, Marzban M, Movahedi N, et al. Superficial and deep sternal wound infection after more than 9000 coronary artery bypass graft (CABG): incidence, risk factors and mortality. BMC Infect Dis 2007;7:107-12.
2. Kramer R, Groom R, Weldner D, Gallant P, Heyl B, Knapp R, et al. Glycemic control and reduction of deep sternal wound infection rates. Arch Surg 2008;143:451-6.
3. Lu J, Grayson A, Jha P, Srinivasan A, Fabri B. Risk factors for sternal wound infection and mid-term survival following coronary artery bypass surgery. Eur J Cardiothorac Surg 2003;23:943-9.
4. Toumpoulis IK, Anagnostopoulos CE, Derose JJ Jr, Swistel DG. The impact of deep sternal wound infection on longterm survival after coronary artery bypass grafting. Chest 2005;127:464-71.
5. Risnes I, Abdelnoor M, Almdahl SM, Svennevig JL. Mediastinitis after coronary artery bypass grafting. Risk factors and long-term survival. Ann Thorac Surg 2010;89:1502-9.
6. Milano CA, Kesler K, Archibald N, Sexton DJ, Jones RH. Mediastinitis after coronary bypass graft surgery. Risk factors and long-term survival. Circulation 1995;92:2245-51.
7. Abboud CS, Wey SB, Baltar VT. Risk factors for mediastinitis after cardiac surgery. Ann Thorac Surg 2004;77:676-83.
8. Aldemir M, Eroğlu D, Adalı F, Emmiler M. Comparison of complications in elderly patients undergoing coronary artery bypass surgery with or without use of the left internal thoracic artery. Koşuyolu Heart Journal 2014;17:118-23.
9. Carson JL, Scholz PM, Chen AY, Peterson ED, Gold J, Schneider SH. Diabetes mellitus increases short-term mortality and morbidity in patients undergoing coronary artery bypass graft surgery. J Am Coll Cardiol 2002;40:418-23.
10. Szabo Z, Hakanson E, Svedjeholm R. Early post-operative outcome and medium-term survival in 540 diabetic and 2239 nondiabetic patients undergoing coronary artery bypass grafting. Ann Thorac Surg 2002;74:712-9.
11. Doenst T, Wijeysundera D, Karkouti K, Zechner C, Maganti M, Rao V, et al. Hyperglycemia during cardiopulmonary bypass is an independent risk factor for mortality in patients undergoing cardiac surgery. J Thorac Cardiovasc Surg 2005;130:1144.e1-1144.e8.
12. Tas S, Yazıcı D, Dönmez AA, Tunçer EY, Adademir T, Yanartas M, et al. Impact of diabetes and blood glucose control on surgical site infections in cardiac surgery. Kosuyolu Kalp Derg 2013;16:199-204
13. Furnary AP, Gao G, Grunkemeier GL, Wu Y, Zerr KJ, Bookin SO, et al. Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg 2003;125:1007-21.
14. Finfer S, Chittock DR, Su SY, Blair D, Foster D, Dhingra V, et al; NICE-SUGAR Study Investigators. Intensive versus conventional glucose control in critically Ill patients. N Engl J Med 2009;360:1283-97.
15. Zerr K, Furnary A, Grunkemeier G, Bookin S, Kanhere V, Starr A. Glucose control lowers the risk of wound infection in diabetics after open heart operations. Ann Thorac Surg 1997;63:356-61.
16. American Diabetes Association. Standards of medical care in diabetes- 2011. Diabetes Care 2011;34:S11-S61.
17. Nathan DM, Kuenen J, Borg R, Zheng H, Schoenfeld D, Heine R. Translating the A1C assay into estimated average glucose values. Diabetes Care 2008;31:1-6.
18. Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitions for nosocomial infections, 1988. Am J Infect Control 1988;16:128-40.
19. Loop FD, Lylte BW, Cosgrove DM, Mahfood S, McHenry MC, Goormastic M, et al. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care. Ann Thorac Surg 1990;49:179-87.
20. Trick WE, Scheckler WE, Tokars JI, Jones KC, Reppen ML, Smith EM, et al. Modifiable risk actors associated with deep sternal site infection after coronary artery bypass grafting. J Thorac Cardiovasc Surg 2000;119:108-14.
21. Nagachinta T, Stephens M, Reitz B, Polk BF. Risk factors for surgical-wound infection following cardiac surgery. J Infect Dis 1987;156:967-73.
22. Badawy MA, Shammari FA, Aleinati T, Eldin MS, Tarazi R, Alfadli J. Deep sternal wound infection after coronary artery bypass: How to manage? Asian Cardiovasc Thorac Ann 2014;22:649-54.
23. Engoren M, Schwann TA, Habib RH. Elevated hemoglobin A1c is associated with readmission but not complications. Asian Cardiovasc Thorac Ann 2014;22:800-6.
24. Knapik P, Cieśla D, Filipiak K, Knapik M, Zembala M. Prevalence and clinical significance of elevated preoperative glycosylated hemoglobin in diabetic patients scheduled for coronary artery surgery. Eur J Cardiothorac Surg 2011;39:484-9.
25. Matsuura K, Imamaki M, Ishida A, Shimura H, Niitsuma Y, Miyazaki M. Off-pump coronary artery bypass grafting for poorly controlled diabetic patients. Ann Thorac Surg 2009;15:18-22.
26. Hudson CC, Welsby IJ, Phillips-Bute B, Mathew JP, Lutz A, Chad Hughes G, et al. Cardiothoracic Anesthesiology Research Endeavors (C.A.R.E.) Group Glycosylated hemoglobin levels and outcome in non-diabetic cardiac surgery patients. Can J Anesth 2010;57:565-72.
27. Tsuruta R, Miyauchi K, Yamamoto T, Dohi S, Tambara K, Dohi T, et al. Effect of preoperative hemoglobin A1c levels on long-term outcomes for diabetic patients after off-pump coronary artery bypass grafting. J Cardiol 2011;57:181-6.
28. Latham R, Lancaster AD, Covington JF, Pirolo JS, Thomas CS Jr. The association of diabetes and glucose control with surgical-site infections among cardiothoracic surgery patients. Infect Control Hosp Epidemiol 2001;22:607-12.
29. Alserius T, Anderson RE, Hammar N, Nordqvist T, Ivert T. Elevated glycosylated haemoglobin (HbA1c) is a risk marker in coronary artery bypass surgery. Scand Cardiovasc J 2008;42:392-8.
30. Fohl AL, Butler SO, Patil PV, Christina Zrull CA, Kling-Colson S, Dubois E, et al. The association between hemoglobin A1C values and deep sternal wound infections in diabetes patients undergoing cardiac surgery. Cardiovascular Endocrinology 2013;2:15-22.
31. Faritous Z, Ardeshiri M, Yazdanian F, Jalali A, Totonchi Z, Azarfarin R. Hyperglycemia or high hemoglobin A1C. Which one is more associated with morbidity and mortality after coronary artery bypass graft surgery? Ann Thorac Cardiovasc Surg 2014;20:223-8.
32. Halkos ME, Thourani VH, Lattouf OM, Kilgo P, Guyton RA, Puskas JD. Preoperative hemoglobin a1c predicts sternal wound infection after coronary artery bypass surgery with bilateral versus single internal thoracic artery grafts. Innovations 2008;3;131-8.

ISSN: 2149-2972
Yayın Aralığı: Yılda 3 Sayı
Başlangıç: 1990
Yayıncı: Sağlık Bilimleri Üniversitesi, Kartal Koşuyolu Yüksek İhtisas Eğitim ve Araştırma Hastanesi