Running head: INTEGRATIVE REVIEW 1

Integrative Review

Faith Walker

Bon Secours Memorial College of Nursing

Christine Turner, PhD, RN

NUR 4122 Nursing Research

November 12, 2017

“I pledge…”
INTEGRATIVE REVIEW 2

Abstract

The purpose of this integrative review is to appraise literature pertaining to continuous insulin

infusions (CII) used to maintain glucose control post-operatively for cardiac surgery patients

during their post-operative care. Hyperglycemia has been shown to decrease the rate of healing;

therefore, regardless of having diabetes or not, hyperglycemia poses an increased risk for

decreased healing. Figuring out the best way to maintain glucose control post-operatively for

cardiac surgery patients is imperative for improving their outcomes. Databases such as EBSCO

Discovery Services and PubMed were utilized to locate research articles. The searches generated

28 articles, five of which met the specific research criteria set for this topic. The results of these

five articles clearly depicted the advantages of implementing CII for post-cardiac surgery

patients to improve their glucose control during their post-operative care. Limitations for this

study include the researchers lack of experience and the limited recent research on this topic.

Therefore, the researcher suggests that future research focus on other variables that may affect a

patients glycemic control during their hospital stay along with the effects of implementing CII

and computer-guided glucose management on nurses.

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Integrative Review

The purpose of this integrative review is to identify the use of continuous insulin infusion

(CII) for post-operative cardiac surgery patients and the effects of stable glucose values on post-

operative healing, morbidity, mortality, and length of hospital stay. Hyperglycemia is a common

occurrence in critically ill patients and has been linked to increased morbidity, mortality,

increased length of hospital stay and higher medical costs (Engoren, Schwann, & Habib, 2014).

The occurrence of diabetes mellitus (DM) is on the rise in the United States. Patients diagnosed

with DM are more susceptible to heart disease, but the risk of heart disease is not solely

dependent on a DM diagnoses. Regardless of having diabetes or not, hyperglycemia poses an

increased risk for decreased healing. The Society of Thoracic Surgeons (STP) Practice

Guidelines recommend that any adult undergoing cardiac surgery, with and without DM, must

maintain a serum glucose level below 180 mg/dL throughout their post-operative care

(McDonnell, Alexanian, Junqueira, Cabral & Lazar, 2013). The question of how best to meet

these guidelines is critical in ensuring improved patient outcomes. The aim of this literature

review is to collect appropriate information regarding the researcher’s PICOT question: “In post-

operative cardiac surgery patients, what is the effect of on post-operative glucose control,

compared with no CII during the first 48 hours of post-operative care?”

Design and Search Methods

The research design is an integrative review. The search for research articles was

conducted utilizing the computer-based search engines PubMed and EBSCO, specifically the

MEDLINE Complete database. The search terms included, ‘cardiac surgery’, ‘continuous insulin

infusion’, and ‘post-operative healing.’ EBSCO yielded zero results. The framework for this

search was set to cover a five-year period starting with 2012 and ending in 2017. PubMed was
INTEGRATIVE REVIEW 4

then used to try and obtain relevant articles. The same search terms and framework were used

also producing zero results. In order to obtain articles, the search terms were changed to include

multiple variables of ‘cardiac surgery’, ‘insulin infusion’, and ‘post-operative.’ The framework

of this search was also changed to cover a ten-year period starting with 2007 and ending in 2017.

This generated 28 results total among the two databases.

In order to narrow down the search and improve the quality of the articles selected, filters

were implemented. These included articles that were published in peer reviewed journals. Five

articles were selected and studied that met all of the inclusion criteria. All of these articles are

quantitative studies that directly related to the PICOT question (Abelev et al., 2011; Engorgen et

al., 2014; Li, Sun & Wu, 2006; McDonnell et al., 2013; Saager et al., 2008). Summary tables for

the articles can be located in the appendix.

Findings and Results

In a study conducted by Engoren, Schwann, and Habib (2014) the authors addressed the

possible importance of variability or complexity of the glucose time series verses the actual

glucose level itself in patients who had undergone cardiac surgery. This study utilized a

correlational, retrospective study design to determine if glycemic complexity, hypoglycemia and

hyperglycemia was associated with worse outcomes after cardiac surgery. Data was collected on

cardiac surgery patients who were placed on insulin infusions to regulate their blood glucose

levels post-operatively. To determine glycemic complexity the researchers utilized a jackknife

approximate entropy, a base scale entropy and a forbidden word entropy to assess for patterns

along with the regularity and unpredictability of fluctuations over time. It was found that

hypoglycemia and hyperglycemia are associated with increased risk of complications and greater

complexity of glucose time series was associated with increased mortality. This study suggests
INTEGRATIVE REVIEW 5

that not only is it important to control the glucose levels to avoid hyperglycemia and

hypoglycemia in post-cardiac surgery patients, but it is also important to avoid complications in

the time series that regulates glucose checks for patients on a CII.

In a study by McDonnell, Alexanian, Junqueira, Cabral, and Lazar (2013), the authors

sought to investigate the Surgical Care Improvement Project’s (SCIP) benchmark of 6:00 AM

blood glucose levels less than 200 mg/dL on post-operative day one and day two as quality

measures of glycemic control in cardiac surgery patients. This was a multipurpose study that

looked to:

 Determine the number of (SCIP) outliers in adult patients undergoing cardiac surgery and

receiving CII to maintain peri-operative blood glucose levels less than 180 mg/dL;

 Identify these outliers;

 Determine if outliers already on the CII protocol already have increased morbidity and

mortality rates;

 Identify more relevant benchmarks to determine glycemic control in cardiac surgery

patients.

This was a quantitative, retrospective observational, single-center study that was conducted at

Boston University Medical Center. Data was collected on 832 adult patients, with or without

diabetes, who underwent cardiac surgery between January 1, 2008 and August 30, 2011. Blood

glucose measurements were obtained via arterial catheters and finger sticks that were measured

with a point-of-care meter. Data was analyzed using a statistical analysis system (SAS), version

9.0. The findings of this study reflected that those on CII to maintain a blood glucose level less

than 180 mg/dL will have some SCIP outliers, but these outliers are more likely to be insulin

dependent diabetic patients. These outliers were found to not have an increased morbidity,
INTEGRATIVE REVIEW 6

mortality or length of stay; therefore, SCIP’s isolated blood glucose levels do not accurately

predict a patient’s outcome and do not properly represent glycemic control during hospital stay.

Li, Sun and Wu (2006) conducted a correlational, prospective, randomized, controlled

study to determine the efficacy of CIIs verses glucometer-guided insulin injections in post

coronary artery bypass graft (CABG) patients, along with evaluating the incidences of operative

mortality and sternal wounds. The authors collected data on 100 consecutive patients with DM

who were undergoing a CABG procedure for the first time between January 2001 and January

2003 at Mackay Memorial Hospital in Taiwan. The patients were separated into two groups:

glucometer-guided insulin group (GGI) and CII group. Those in the GGI were given

subcutaneous insulin injections every two hours to maintain their blood glucose levels between

150 and 200 mg/dL. The dosing of the insulin was adjusted based on the patient’s response to

their previous insulin injection. Those on the CII were given intravenous (IV) insulin and the

dose was titrated according to the results of their glucose tests. The data from this study was

analyzed using SPSS for Windows Release 11.5. The study determined that CII provides a better

control over post-operative blood-glucose levels in patients with diabetes undergoing CABG

surgery than the conventional intermittent injections of insulin.

Saager et al. (2008) performed a correlational, prospective, randomized study that aimed

to compare a standard insulin protocol with a computer guided glucose management system to

determine which method achieved a better glucose control. A computer-guided glucose

management system is designed to analyze glucose reading trends specific to the patient and

formulate a patient specific insulin-resistance curve. This curve is then used to adjust the

patient’s insulin dosing in hopes of preventing episodes of hypoglycemia and hyperglycemia.

This study was conducted using diabetic patients who were scheduled for cardiac surgery and
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required cardiopulmonary bypass. Data was collected on two groups: those whose blood glucose

was controlled by the standard paper-based intensive care unit insulin protocol and those whose

blood glucose was managed with a computer-guided management system. Data was analyzed

using SPSS version 14 software. The results of this study showed that computer-guided glucose

management achieved tighter glucose control during and immediately after cardiac surgery than

the standard paper-based protocol for diabetic patients on CII.

In a study conducted by Abelev et al. (2011) the authors examine whether post-CABG

glucose management with CII in diabetic patients influenced the rate of immediate post-

operative complications and length of stay in comparison to subcutaneous insulin regimens. This

study utilized a correlational, retrospective design to examine the records of 587 adult diabetic

(type I and II) patients that underwent CABG surgery at Beth Israel Medical Center in New York

City. These patients were either placed on subcutaneous insulin regimens or a CII. Data was then

analyzed using SAS 9.1. The results of the study revealed that diabetic patients who undergo a

CABG and received CII have a shorter post-surgical length of stay than those who do not receive

a CII.

Discussion and Implications

After review of all five articles, four of the studies indicate a positive correlation between

CII for post-cardiac surgery patients and their post-operative glucose control. The research

included in this review mostly supports the PICOT question set by the researcher. The studies by

Li et al., (2006) and Abelev et al. (2011), diabetic patients who underwent a CABG procedure

and were receiving CII had a shorter post-surgical length of stay than those who did not receive

CII. Additionally, Li et al., (2006) further supported this finding by discovering CII provides

better blood glucose control in DM patients undergoing a CABG than the conventional
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intermittent insulin injections. Saager et al. (2008), found that having CII managed via a

computer guided glucose management system verses a standard paper-based protocol yielded

tighter glucose control. Although, glucose levels are important in helping maintain tight glucose

control post-operatively in cardiac surgery patients, it is also important to avoid great complexity

of the glucose time series set forth by the computerized glucose management system (Engorgen

et al., 2014).

In the one article that did not fully support the researchers PICOT question, McDonnell et

al., (2013), found that isolated blood glucose levels alone do not accurately predict a patient’s

outcome nor do they appropriately represent glycemic control during the patient’s hospital stay.

In accordance to these findings, the researcher suggests that in the future research should focus

on other variables that may predict a patient’s outcome or glycemic control during their hospital

stay. In addition, research should focus on the effects implementing CII monitored via a

computer guided glucose management system have on the nursing staff. Some of these systems

require a blood glucose check every hour, which can be very demanding on the nurse; therefore,

efforts must be in place to determine the effects this has on nurses and their overall workload.

Limitations and Conclusion

In regards to this integrative review, there were numerous limitations. The five articles

that were studied were not the strongest due to limited sample size and questionable data

collection methods; therefore, it is hard to generalize the results of these studies. Also, this topic

has been greatly researched in the past and has been implemented as evidence-based practice;

therefore, making recent research on the topic very difficult to locate. Much of the research

found was beyond the five-year limit set for this assignment. Lastly, the researcher lacks

experience in completing an integrative review.

INTEGRATIVE REVIEW 9

In summary, the purpose of this integrative review was to investigate the effectiveness of

CII verses no CII on post-operative glucose control in post-cardiac surgery patients. The findings

discussed highlight the importance of CII for post cardiac surgery patients and supports the

presented PICOT question of “In post-operative cardiac surgery patients, what is the effect of on

post-operative glucose control, compared with no CII during the first 48 hours of post-operative

care?” The researcher concludes that CII be the standard treatment for all post-cardiac surgery

patients to help maintain a tighter glucose control, decrease morbidity, mortality, and improve

healing during the first 48 hours of post-operative care. Education on the benefits of the

computer guided glucose management for patients on CII should be extended to nurses, doctors

and other medical personnel who work in cardiac surgery departments across the world. Along

with extensive education on how to use the computer guided glucose management systems for

patients on CII, because it important to avoid complications in the time series that regulates

blood glucose checks set forth by the computerized glucose management systems. In doing this,

blood glucose management via CII for post-cardiac surgery patients will help improve their post-

operative care during the first 48 hours.

INTEGRATIVE REVIEW 10

References

Abelev, A., Seth, A., Patel, R., Goldstein, S., Paliou, M., Schlosser, J., . . . Poretsky, L. (2011).

Continuous insulin infusion is associated with a reduced post-surgical length of stay, but

not with the complication rate, in patients with diabetes mellitus undergoing coronary

artery bypass graft. Journal of Endocrinological Investigation, 34(10), 770-774.

doi:10.3275/7760

Engorgen, M., Schwann, T.A., & Habib, R.H. (2014). Hyperglycemia, hypoglycemia, and

glycemic complexity are associated with worse outcomes after surgery. Journal of

Critical Care, 29(4), 611-617. doi:10.1016/j/jcrc.2014.03.014

Li, J.-Y., Sun, S., & Wu, S.-J. (2006). Continuous Insulin Infusion Improves Postoperative

Glucose Control in Patients with Diabetes Mellitus Undergoing Coronary Artery Bypass

Surgery. Texas Heart Institute Journal, 33(4), 445–451.

McDonnell, M. E., MD, Alexanian, S. M., MD, Junqueira, A., MD, Cabral, H., PhD, & Lazar, H.

L., MD. (2013). Relevance of the Surgical Care Improvement Project on glycemic

control in patients undergoing cardiac surgery who receive continuous insulin

infusions. The Journal of Thoracic and Cardiovascular Surgery,145(2), 590-597.

http://dx.doi.org/10.1016/j.jtcvs.2012.09.031

Saager, L., MD, Collins, G. L., MD, Burnside, B., BA, Tymkew, H., MHS, Zhang, L., MD,

Jacobsohn, E., MBChB, MHPE, FRCPC, & Avidan, M., MBBCh, FCA. (2008). A

randomized study in diabetic patients undergoing cardiac surgery comparing computer-

guided glucose management with a standard sliding scale protocol. Journal of

Cardiothoracic and Vascular Anesthesia,22(3), 377-382. doi:10.1053/j.jvca.2007.09.013

Running head: INTEGRATIVE REVIEW 11

Appendix

Table 1 – Qualitative and Quantitative Article Evaluation

First Author  Engoren (2014) – Medical Doctor apart of the Department of Anesthesiology & Internal
(Year)/Qualifications Medicine at Mercy St. Vincent Medical Center in Toledo, OH & the Department of
Anesthesiology, University of Michigan at Ann Arbor, MI
Background/Problem  Hyperglycemia is common in critically ill patients and is associated with increased morbidity
Statement and mortality, longer lengths of stay and higher costs
 Variability or complexity of the glucose time series is more important than the actual glucose
levels
Conceptual/theoretical  Correlational study
Framework  Determine if glycemic complexity, hypoglycemia, and hyperglycemia are associated with
worse outcomes after cardiac surgery
Design/  Quantitative, retrospective analysis of data collected on post cardiac surgery patients between
Method/Philosophical 2/1/08 – 7/30/10 at Mercy St. Vincent Medical Center in Toledo, OH who were placed on
Underpinnings insulin infusion to regulate their blood glucose levels post-operatively
Sample/ Setting/Ethical  970 adult patients who underwent cardiac surgery between the time frame listed above
Considerations  IRB approved this study; therefore, consent was waved.
Major Variables Studied  Glycemic complexity: the glucose time series
(and their definition), if  Hypoglycemia: glucose level <71 mg/dL
appropriate  Hyperglycemia: glucose level of >140mg/dL
Measurement Tool/Data  A-line until removed then fingertip capillary puncture with point-of-care glucometer
Collection Method  Retrospective analysis
Data Analysis  Inferential statistical tests to help determine significant differences and relationships between
variables
 To determine glycemic complexity: jackknife approximate entropy, base scale entropy &
forbidden word entropy
 Logistic regression to help adjust for confounders
Findings/Discussion  Hypoglycemia and hyperglycemia are associated with increased risk of complications
 Greater complexity of glucose time series was associated with mortality
INTEGRATIVE REVIEW
Appraisal/Worth to practice
First Author
(Year)/Qualifications
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
12
 Suggests that not only is it important to control the glucose levels – avoiding hyperglycemia
& hypoglycemia post cardiac surgery – but it is also important to avoid great complexity of
the glucose time series
Table 2 – Quantitative and Qualitative Article Evaluation
 McDonnell (2013) – Endocrinology, Diabetes & Nutrition department at Boston Medical
Center
 Surgical care improvement project (SCIP) has benchmarked 0600 BG <200 on POD1 & 2 as
quality measures of glycemic control in cardiac surgery; therefore, this study was undertaken
to: 1) determine the incidence of SCIP outliers in adults undergoing cardiac surgery and
receiving CII target to maintain peri-operative blood glucose levels >180 mg/dL 2) identify
the SCIP outliers in this cohort 3) do outliers already on CII protocol have an increased
morbidity and mortality 4) identify more relevant benchmarks that could be used to determine
glycemic control in cardiac surgery patient
 The Society of Thoracic Surgeons (STS) Practice Guidelines now recommend that all adults
undergoing cardiac surgery (with and without diabetes mellitus) maintain serum glucose
levels below 180 mg/dL for the duration of their postoperative care
 No theoretical framework was discussed
 Quantitative, retrospective observational, single-center study
 Patients divided into two groups: compliant SCIP and SCIP outliers
 832 adult patients, with or without diabetes who underwent cardiac surgery between January
1, 2008 and August 30, 2011
o Aneurysm repair with or without hypothermic circulatory arrest were excluded
 Approved by Boston University Medical Center Institutional Review Board & informed
consent was obtained from each patient
 30- day mortality
 Incidences of:
o Myocardial Infarction: assessed by both enzyme and EGK changes
o Cerebrovascular accidents: persistent neurological deficit lasting longer than 24 hours
o Deep sternal wounds: any infection that reached or directly involved the sternum
o Atrial fibrillation: lasted longer than 15 minutes
INTEGRATIVE REVIEW
Measurement Tool/Data
Collection Method
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
First Author Li (2006) – Medical doctor for the Department of Surgery at Mackay Memorial Hospital in Taiwan
(Year)/Qualifications
Background/Problem  Patients with diabetes are more susceptible to perioperative death and shorter long-term survival
Statement
 This study’s purpose was to evaluate the efficacy of continuous insulin infusion versus glucometer-
13
 Time on ventilator: time of admission to the ICU to time of extubation
 Length of stay: length of hospital stay
 Assessed for any clinical reasons for SCIP failure by an endocrinologist
 Blood glucose measurements were obtained via arterial catheters and finger sticks that were
measured with point-of-care meters
 Mean hospital glucose: average of all glucose values during the hospital stay
 Three-day blood glucose: average of all glucose values obtained from end of anesthesia
through POD2
 SCIP glucose values: mean 0600 glucose values for patients on POD1&2
 Mean ± standard deviation for continuous variables
 The number and percentage for categorical variables using statistical analysis system
 Bivariate analysis – 2 sample t-tests and 𝓍 2 or Fisher’s exact tests for categorical data
 Cardiac surgery patients receiving CII to maintain a blood glucose level of <180mg/dL will
have some SCIP outliers, but are more likely to be insulin dependent diabetics, have higher
HbA1c levels and an increased BMI
 SCIP outliers though do not have an increased risk for morbidity, mortality or length of stay
 Isolated blood glucose levels do not accurately predict a patient’s outcome and do not
appropriately represent glycemic control during the hospital stay
 Failure to meet SCIP guidelines should not imply inadequate care for cardiac surgery patients
because adherence is only one aspect of effective patient care
 SCIP benchmarks for glucose control should not be the only measurement for reporting post-
operative outcomes
Table 3 – Qualitative and Quantitative Article Evaluation
after coronary artery bypass grafting (CABG) along with having a higher incidence of
postoperative complications such as deep sternal wound infections and death.
guided insulin injection post-CABG and evaluate incidences of operative mortality and sternal
wounds.
INTEGRATIVE REVIEW 14

Conceptual/theoretical  Correlational study: glucometer guided insulin injections versus CII post CABG to evaluate their
Framework relationship to operative mortality and sternal wounds
Design/  Quantitative, prospective, randomized study used to test hypothesis
Method/Philosophical  Two groups: glucometer-guided insulin group and continuous insulin infusion (CII) group
Underpinnings
Sample/ Setting/Ethical  Approved by the IRB of the hospital
Considerations  Department of Surgery, Mackay Memorial Hospital and Mackay Junior College of Nursing
 100 consecutive patients with diabetes mellitus who were to undergo CABG for the 1st time
between January 2001 and January 2003
Major Variables Studied  Primary endpoint: incidence of operative mortality and sternal wound infections
(and their definition), if  Secondary endpoint: adequacy of blood glucose control
appropriate
Measurement Tool/Data  Glucose was measured per protocol depending on the group, average postoperative glucose was
Collection Method calculated as the average of daily mean glucose levels from immediately after surgery to post-
operative day 5.
 Intravenous glucose infusion was discontinued for all patients on the 2nd postoperative day
Data Analysis  Data was analyzed using SPSS for Windows Release 11.5
Findings/Discussion  POD 1 & 2 showed significant lower mean glucose values for the CII group verses the GGI group
Appraisal/Worth to  Continuous insulin infusion provides a better control over postoperative blood-glucose levels in
practice patients with diabetes after undergoing a CABG than the conventional intermittent injections of
insulin

Table 4 – Qualitative and Quantitative Article Evaluation

First Author  Saager (2008) – Medical doctor from the Department of Anesthesiology, Washington
(Year)/Qualifications University School of Medicine, St. Louis, MO
Background/Problem  Studies have shown a decreased rate of atrial fibrillation, inotrope requirements, need for
Statement pacing, intensive care unit (ICU) stay, recurrent myocardial ischemia, renal failure, wound
infection and postoperative mortality, yet with even brief elevations in blood glucose levels
may be associated with complications, such as wound infections
 One of the main limitations of some insulin protocols is the adjustments to insulin dosage
being based on a single blood glucose reading, neglecting the trend of blood sugar results of
the patient
INTEGRATIVE REVIEW
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
15
 The purpose of this study was to compare a standard insulin protocol with a computer-guided
glucose management system to determine which method achieves a higher control
 Correlational study: standard insulin protocol versus a computer-guided glucose management
system to determine which method achieves a higher control
 Quantitative, prospective, randomized trial
 Two groups: (1) blood glucose was controlled by the standard paper-based ICU insulin
protocol (2) computer guided group whose blood glucose was managed with the EndoTool
software
 Blood glucose was measured at least hourly while the glucose infusion was running and
insulin administered given according to either the standard-of-care paper-based protocol or the
computer guided recommendations that were calculated by the software
 40 patients with known diabetes (type 1 and/or 2) scheduled for elective cardiac surgery that
required cardiopulmonary bypass
 24 men and 16 women between 50 and 85 years of age
 Approved by the Human Research Protection Office and written informed consent was
obtained before enrollment into the study
 Length of surgery, cross-clamp, or cardiopulmonary bypass time
 ICU and hospital length of stay
 Postoperative complications (arrhythmias, prolonged intubation, infection, stroke or
myocardial infection)
 Glucose control
 Blood glucose was measured via atrial catheter
 Whole-blood glucose was measured by a SureStrep Flexx point-of-care testing device
 Kolmogorov-Smirnov test was used to test normal distribution
 Continuous variables were compared using a student t test (2 sided)
 Categoric variables were assessed via chi-square tests and Fisher exact tests
 All analysis was performed using SPSS version 14 software
 Patients in the computer-guided group achieved a blood glucose level within the desired range
notably faster than those in the paper-based group
 Computer-guided glucose management achieved tighter glucose control during and
immediately after cardiac surgery than the standard paper-based protocol in diabetic patients
INTEGRATIVE REVIEW 16

Table 5 – Qualitative and Quantitative Article Evaluation

First Author Abelev (2011) – Division of Endocrinology and Metabolism and Friedman Diabetes Institute at
(Year)/Qualifications Beth Israel Medical Center in New York, New York
Background/Problem  Patients undergoing coronary artery bypass graft (CABG) surgery that are diabetic are at a
Statement higher risk for poor surgical outcomes than those without diabetes
o Perioperative mortality
o Prolonged length of stay
o Increased hospitalization costs
o Higher incidence of deep sternal wound infections
o Post-surgical stroke
 The purpose of this study was to examine whether post-CABG glucose management with
continuous insulin infusion in diabetic patients influenced the rate of immediate post-operative
complications and length of hospital stay in comparison subcutaneous (SC) insulin regimens

Conceptual/theoretical  Correlational study: CII versus SC insulin regimens and their relationship to the rate of
Framework immediate post-operative complications and hospital length of stay

Design/  Quantitative, retrospective review of records on all patients who underwent CABG surgery at
Method/Philosophical Beth Isreal Medical Center in New York City from January 1999 to January 2008
Underpinnings
Sample/ Setting/Ethical  587 known diabetic (type I or II) patients
Considerations  Excluding those with stress induced hyperglycemia (capillary blood glucose >150 twice)
without a known history of diabetes
 Final sample: 232 patients in the non-continuous insulin infusion group and 285 patients in the
continuous insulin infusion group
Major Variables Studied  Average capillary blood glucose at 24 hours and 72 hours post-operatively
(and their definition), if  Post CABG complications: stroke, transmural myocardial infarction, deep sternal wound
appropriate infection, heart block requiring placement of pacemaker, sepsis, endocarditis, renal failure and
respiratory failure
 Total length of stay and length of stay after surgery
INTEGRATIVE REVIEW
Measurement Tool/Data
Collection Method
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
17
 Data collection was not discussed
 All data analysis was carried out using SAS 9.1
 Data described in terms of mean ± SD in the case of normally distributed continuous variables
 Categorical data was reported in terms of frequency (%)
 Complication rates between the two groups showed no difference
 Shorter length of stay after surgery was associated with the implementation of the continuous
insulin infusion
 Diabetic patients that undergo a CABG and receive continuous insulin infusion appear to have
a shorter post-surgical length of stay than those who do not receive it