Management of the Hospitalized Diabetic Patient
Author: Keith R. Doram, MD, MBA, FACP, Chief, Division of General Internal Medicine, Lehigh Valley Hospital & Health Network, Allentown, Penn; Associate Clinical Professor of Medicine, Penn State University School of Medicine; Hershey, Penn.
Editor’s Note—Diabetes mellitus (DM) is a spectrum of metabolic diseases caused by absolute to relative deficiencies of insulin and is characterized by hyperglycemia and serious microvascular, neurological, and macrovascular complications. Generally, DM is broadly categorized as either type 1 (absolute deficiency of insulin) or as type 2 (relative deficiency of insulin due to insulin resistance and inadequate insulin secretion). The type 2 diabetic patient is by far the most prevalent type and often has additional co-morbidities such as obesity, hypertension, and hyperlipidemia. DM is a chronic disease and patients with DM are hospitalized more frequently1 and have a much higher incidence/prevalence of serious cardiovascular, kidney, eye, neural, and other end-organ diseases.2
The prevalence of DM in the United States has reached epidemic proportions affecting more than 16 million individuals (approximately 1 in 16 people).3 Annually, nearly 800,000 Americans develop diabetes and 182,000 deaths are associated with diabetes—representing a net DM prevalence growth rate of about 618,000 per year. These numbers have raised great concerns; in part due to the disproportionately large direct and indirect health care costs associated with the diabetic patient—estimated to be approximately $100 billion per year (nearly 15% of the entire national health care budget).4 Acute care of the hospitalized diabetic patient accounts for more than 60% of these costs (eg, the mean cost for each diabetic patient is $23,500 compared with $12,000 for patients without diabetes).5
Since DM is a chronic disease requiring life-long therapy, the treatment outcomes emphasis has historically been centered in the outpatient setting. For example, The Diabetes Control and Complications Trial (DCCT) convincingly demonstrated that tight blood glucose control significantly reduces the development of end-organ complications in the type 1 diabetic patient.6 In addition, the United Kingdom Prospective Diabetes Study (UKPDS)—which is the largest and longest study on type 2 diabetic patients ever done—showed that intensive therapy (including the use of both insulin and/or oral agents) can significantly reduce microvascular complications.7 The consensus, therefore, is that appropriately aggressive outpatient glucose control significantly reduces morbidity in diabetic patients.
Unfortunately, the proper standards of care for the hospitalized diabetic patient have been slow to evolve—in spite of the fact that hospitalization is more common for people with diabetes than for those without diabetes. One study showed that diabetics were hospitalized 2.4 times more frequently than nondiabetics and stayed in the hospital for a longer amount of time (about 30% longer).8 Until recently, most of the literature regarding the care of diabetic inpatients dealt with perioperative rather than nonsurgical situations or diabetic ketoacidosis (DKA) and nonketotic hyperglycemia. This review article will focus primarily on the general blood glucose management goals and strategies for the diabetic patient who is admitted to the hospital for an intercurrent illness or a procedure. Treatment guidelines for the diagnosis and treatment of DKA and nonketotic hyperglycemia have been published by the American Diabetes Association and will not be the focus of this review.9
Evidence Supporting Tighter Glucose Control in Hospitalized Patients
Patients who are admitted to the hospital (for an intercurrent illness or procedure) with accompanying hyperglycemia have a much higher morbidity and mortality. A prospective study by Pulsinelli and colleagues showed that stroke-related deficits were greater when the admission glucose values were greater than 120 mg/dL and that only 43% of these patients were able to return to work (compared with 76% of patients with lower glucose values being able to be re-employed).10 There is mounting clinical evidence showing that tighter glucose control of hospitalized patients with hyperglycemia and diabetes can result in significantly improved short- and long-term outcomes (see Table 1). These compelling inpatient data (combined with the well-known and accepted management goal of tighter outpatient blood glucose control) are now leading to a change in the acceptable minimum standard of care for patients admitted to the hospital with hyperglycemia (with or without a history of known diabetes). The hospital is often the place where diabetes or a prediabetes condition is first diagnosed. (Prediabetes is a condition wherein the person doesn’t meet the defined blood glucose level criteria for DM but is predisposed to acquiring diabetes and may be hyperglycemic under certain conditions, like acute illness requiring hospitalization.) The hospital represents an important place where effective diabetic screening and treatment interventions can be implemented.
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Special Considerations in Diabetes Management in the Hospitalized Patient
It is important to not only appreciate the benefits of glucose control but also the complexities and considerations that are especially relevant to inpatient diabetic management. Table 2 highlights some of the important variables that complicate glycemic control in hospitalized patients.
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Hyperglycemia produces many pathophysiologic changes that can adversely affect the hospitalized patient. Glycosylation affects more than just hemoglobin (as measured by hemoglobin A1c)—it adversely affects other proteins (including antibodies, complement, and immunoglobulins), platelets, and leukocyte function.19 Therefore, poor wound healing, wound infections, and number of all-cause infections20 occur at a higher rate in hospitalized diabetic patients.21 Also, because of the hyperosmolarity associated with hyperglycemia, volume depletion and electrolyte imbalances are frequent complications.
Acute care hospitals are important screening sites for diabetes. More than one third of all diabetes in the United States is undiagnosed. One study showed that more than 33% of hyperglycemic surgical patients and 37.5 % of all hyperglycemic medical patients did not have a diagnosis of diabetes at the time of admission.22 Unfortunately, physicians and other health care providers often do not provide adequate diabetes-related discharge plans or inpatient diabetes education in newly identified hyperglycemic patients. For example, Graber and associates, in a prospective observational study done at a community teaching hospital, showed that among the newly identified hyperglycemic patients, only 48% had documentation of diabetes-related treatment discharge plans, 23% received dietary instruction, and 16% received education about diabetes self-management from a diabetes nurse educator.23 Therefore, the acute hospitalization represents an opportunity to not only obtain tighter control of their hyperglycemia during the hospitalization, but to also provide for earlier diagnosis, management, and treatment of patients with undiagnosed diabetes (see Table 3).
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Treatment Goals for the Hospitalized Patient with Diabetes
This article’s primary emphasis is on the nonsurgical non-hyperglycemic crisis adult patient admitted to the hospital for an acute illness and has hyperglycemia (with or without a prior diagnosis of diabetes). There are other publications more fully addressing the management of the perioperative24 or hyperglycemic crisis (DKA/nonketotic hyperosmolar syndrome)25 patient. Although a literature search revealed only a few articles addressing this topic, Ahmann,26 Hirsch,27 Levetan,28 and Sawin29 have all written excellent reviews on the management of the hospitalized patient with hyperglycemia.
The general treatment principles that apply to diabetic patients in all settings are similar: minimize hypoglycemia, normalize blood glucose levels, and maximize comprehensive and preventive care for contributing comorbidities. The major difference is one of degree. Patients admitted to the hospital with acute illnesses are more unstable and therefore treatments should avoid any hypoglycemic episodes, avoid marked hyperglycemia, and address the relevant contributing comorbities in the comprehensive care plans.
Hypoglycemia has been shown to occur in 10-16% of patients and can result in an increased length of stay.30 There are many identifiable causes of hypoglycemia that occur in the hospitalized patient including: inappropriate use of the "insulin sliding scale," nothing by mouth (NPO) or reduced caloric intake status, and over-zealous glycemic control attempts (eg, intraoperatively).31 The target average preprandial blood glucose level for the outpatient type 1 DM patient (based on the DCCT study) is 80-120 mg/dL. However, this target was associated with a 3-fold risk in severe hypoglycemia. Clearly, it would not be desirable to establish this blood glucose target/goal in the inpatient setting. Table 4 contrasts some of the diabetic treatment goal differences based on the setting.
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Developing and Implementing Treatment Strategies
Several important preliminary issues should be addressed before the best diabetic management regimen is chosen:
- Does the patient truly have hyperglycemia?
- Is the patient a known diabetic?
- Is the patient a type 1 or type 2 diabetic?
- What diabetic medications does the patient take (eg, insulin lispro, metformin, insulin glargine)?
- Does the patient have any significant renal or liver insufficiency?
- Does the patient normally take insulin, and if so what type(s) and delivery system(s) are used?
- What is the patient’s usual level of blood glucose control?
- Is the patient pregnant?
- Is the patient able to eat adequately or will he/she be NPO?
- If the patient will be NPO, how long will it be?
- How long will the patient be in the hospital?
- Is the patient going to be in an intensive care unit or on a regular med/surg hospital unit?
- What is the patient’s intravascular and cognitive status?
Type 1 and Type 2 Diabetes Mellitus: Noncritical Care Admissions
Type 1 diabetics have an absolute deficiency of insulin; therefore, they always require insulin regardless of oral caloric intake. Their blood glucose levels tend to be more labile in an acute care setting and one must watch closely for hypoglycemia. If the patient is not intravascularly deplete or has a significant cardiovascular insufficiency, the insulin can be given subcutaneously (SC); otherwise intravenous (IV) infusion is preferred (or intramuscularly if necessary). Generally, patients who will be NPO for longer than 12 hours should have IV insulin infusions at a rate of 0.015 units/kg/h (given with dextrose infusion of D5 one half NS with/without 20 mEq KCl/L. A rough estimate of a patient’s daily insulin requirements can be made by multiplying the patient’s weight in kilograms by 0.5-0.7. This amount is then split into two thirds of total daily dose in the morning and one third of dose in the evening. The am dose is often given as two thirds intermediate-acting insulin and one third short-acting, and the pm dose is often split 50-50. Regular insulin (short-acting) should be given SC 30-45 minutes prior to the meal and lispro or aspart insulin (rapid-acting) SC 1-15 min prior to the meal. Glargine insulin (very long acting—24 h—with no true peak) is usually given SC at bedtime and if switching from NPH insulin 80% of the total NPH U/d is given. Although IV insulin has several advantages (eg, predictable and rapid effect with a short duration) over the SC route, there are no conclusive studies demonstrating a clinical advantage of one route vs. the other; IV or glargine to be used in the noneating state and SC in the eating state.
Type 2 diabetics are usually overweight and have insulin resistance. Estimating their insulin requirements in the acute care setting can be more challenging, especially if one doesn’t have a baseline history of insulin requirements. The formula used above for the type 1 diabetic can be used but will usually result in an underestimate due to the insulin resistance factor. Usually oral hypoglycemic drugs can be stopped on the day of a diagnostic or surgical procedure. Often a patient can remain on their outpatient diabetic regimen (diet alone, oral diabetic drugs with or without insulin) during the hospitalization and maintain satisfactory glucose control. However, adequate glucose monitoring should occur (at least 2 or more times a day). Many times, during more severe illnesses (eg, infections), type 2 diabetics who were not previously on insulin will require its administration during the hospitalization.
Oral Diabetic Medications
The past 10 years have seen a rapid proliferation in the number and types of oral medication used in diabetes treatment, including newer insulin secretagogues (sulfonylureas and meglitinides),32 the alpha-glucosidase inhibitors,33 metformin,34 and the thiazolidinediones.35 These agents are often used in combination (with or without insulin). Hospitalized diabetic patients may have absolute or relative contraindications in using many or all of these oral diabetic drugs.
Renal insufficiency may be a relative or absolute contraindication for the use of sulfonylureas or metformin (absolutely contraindicated with metformin if creatinine greater than 1.4 mL/min in females and greater than 1.5 mL/min in males because of the risk for lactic acidosis). Metformin must be stopped prior to any contrast-requiring procedure and not restarted for 48 hours afterward—the other oral agents should also be used with caution due to the increased risk for acute renal insufficiency following contrast administration. Thiazolidinediones and metformin should not be used in patients with hepatic insufficiency. The thiazolidinediones can also complicate congestive heart failure (CHF) management and is contraindicated in patients with New York Heart Association Class III or Class IV CHF. Caution must be exercised in any patient that is NPO if the insulin secretagogues are (or have been recently) used because of the risk for hypoglycemia. Oral diabetic medications should not be used in pregnant patients. The default agent of choice for hyperglycemia in the inpatient setting is insulin.
Critical Care Admissions
The growing body of evidence seems to support the use of intensive insulin regimens in patients admitted to critical care units—mobidity and mortality rates were significantly better (see Table 1). For example, in stroke patients, Strandgaard argues that hyperglycemia promotes volume depletion, which in turn contributes to hyperviscosity, and hyperviscosity is associated with increased morbidity and mortality.36 However, Jorgenson,37 and Weir38 have shown that great care has to be used to avoid hypoglycemia (keep blood glucose > 120 mg/dL) in particular patient subgroups such as acute stroke. Levetan et al39 further point out that tight glucose control should be discouraged in any diabetic patient with stroke and a history of coma or seizures, and with an unstable cardiovascular condition such as acute CHF and arrhythmias.
Abbud,40 Johnson,41 Kannel,42 and Soler43 have shown that diabetes is a disproportionately high independent risk factor for morbidity and mortality among patients with acute myocardial infarctions. The DIGAMI study by Malmberg et al clearly supports aggressive attempts to normalize the blood glucose levels in these patients (see Table 1).
Therefore, all critical care hyperglycemic patients should have close blood glucose monitoring, reduction of marked hyperglycemia, and definite avoidance of hypoglycemia.
The Sliding Scale Insulin
Another special consideration is the use of "sliding scale" insulin. This entrenched tradition of using the sliding scale has persisted in spite of directed criticism by many diabetologists (eg, Katz,44 MacMillan,45 and Queale46). One prospective study done in a urban university hospital showed that even though sliding scale insulin regimens were prescribed for the majority of their hospitalized diabetic patients, they were not beneficial and were associated with a 3-fold higher risk of hyperglycemia when compared to patients on no diabetic medications.47 They recommended that if a sliding scale were to be used, it should be used only as an adjuvant to a standing intermediate-acting insulin or oral agent regimen. Diabetic patients receiving a combination of intermediate-acting insulin plus aggressive sliding scale insulin appear to do the best. The sliding scale, though flexible and convenient, is crude and is not easily adjustable for individual needs. This is particularly the case in hospitalized patients, wherein there is such wide variability between patients on their insulin dosing requirements—in part based on varying insulin resistance and counterregulatory stress hormone levels. It is better management to be proactive and anticipate the insulin requirements, than to be reactive and relying primarily on the sliding scale insulin regimen. Also, type 1diabetics may need periodic urinary ketone measurements if the premeal blood glucose levels are > 250 mg/dL. One may also need to lengthen the time between the regular insulin administration and the meal if the premeal blood glucose is elevated—this will allow time for better normalization of blood glucose levels prior to caloric intake. Table 5 lists some of the important guiding principles when one uses the sliding scale insulin.
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The sliding scale insulin should be viewed as useful adjuvant treatment—always to be combined with a standing hyperglycemic treatment regimen (includes standing intermediate or long-acting insulin and/or may include appropriate oral diabetic medications).
Perioperative Management
There is a growing consensus on the importance of perioperative diabetes and glucose control.49 Gordon et al demonstrated an association with HgbA1c levels and postoperative infections in bypass surgery.50 There are many suggested and published glucose control protocols, but none with any certain superiority. Type 2 diabetics can usually stop their oral diabetic medications on the day of the procedure. Levetan uses a simple approach of initiating an insulin drip of 1 U/h along with a 5% dextrose solution (the glucose infusion rate ranges from 5-10 g per hour). Another common approach is to give 50% of the patient’s usual intermediate-acting insulin on the morning of the surgery along with a dextrose infusion. Preferably, the insulin infusions can be begun the night before surgery or at least 2 hours before surgery. Target blood glucose levels range from 120 to 180 mg/dL. Monitoring should be performed every 1 hour after initiating the drip, then every hour in operating room and with any change in the infusion rate, then every 2 hours if no 2 serial 1-hour interval changes, then every 4 hours if no 2 serial 2-hour interval changes. The perioperative period can be associated with many variables making the glucose management challenging. Common sense, efficiency, efficacy, and sound clinical judgment should be the operating principles. Jacober et al in a review article conclude, "perioperative management of diabetes is generally more art than science."51
Summary
Diabetes mellitus (and prediabetes) has reached an epidemic level in the United States and individuals with diabetes are more likely to be hospitalized. There is a growing number of well-designed studies showing a decreased morbidity and mortality in hospitalized hyperglycemic patients who are treated aggressively with standing insulin regimens designed to keep the blood glucose level < 200 mg/dL. The patients showing these benefits include: critical care patients, patients with acute myocardial infarctions, and perioperative patients (particularly those undergoing coronary artery bypass surgery). However, it is also equally important to not induce hypoglycemia in hospitalized hyperglycemic patients—ie, keep the blood glucose level > 120 mg/dL. Avoidance of hypoglycemia is especially important in stroke patients and patients who are unstable. Stand alone sliding scale insulin should not be used because it is ineffective and often leads to greater hyperglycemia. The hospital is also an important place where diabetes education, prevention, and treatment interventions can be initiated-followed by appropriate discharge planning.
References
1. Moss SE, et al. Risk factors for hospitalization in people with diabetes. Arch Intern Med. 1999;159:2053.
2. US Center for Health Statistics: 1997 National Hospital Discharge Survey (public use data tape). Washington, DC, US Department of Health and Human Services, 1999.
3. Centers for Disease Control and Prevention: The public health of diabetes mellitus in the United States, Atlanta, GA, 1997, US Department of Health and Human Services.
4. Ray N, et al. Direct and indirect costs of diabetes in the United States in 1992. Alexandria, VA, American Diabetes Association; 1993.
5. American Diabetes Association: Economic consequences of diabetes mellitus in the U.S. in 1997. Diabetes Care. 1998;21: 296-309.
6. The Diabetes Control and Complications Trail Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329:977-986.
7. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with Type II diabetes. Lancet. 1998;352:837-853.
8. Peck SB, et al. Diabetes Coverage by Commercial Insurers in the U.S.A. Washington, DC, Health Insurance Association of America, 1986.
9. American Diabetes Assocation. Hospital admission guidelines for diabetes mellitus. Diab Care. 2000;23(Supp 1):S83.
10. Pulsinelli WA, et al. Increased damage after ischemic stroke in patients with hyperglycemia with or without established diabetess mellitus. Am J Med. 1983;74:540.
11. Van Den Berghe G, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345:1359.
12. Malmberg K, et al. Glycometabolic state at admission: Important risk marker of mortality in conventionally treated patients with diabetes mellitus and acute myocardial infarction: long-term results from the Diabetes and Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) study. Circulation. 1999;99:2626-2637.
13. Zerr KJ, et al. Glucose control lowers the risk of wound infection in diabetics after open heart operations. Ann Thorac Surg. 1997;63:356-361.
14. Kalin MF, et al. Intensive intervention by a diabetes team diminishes excess hospital mortality in patients with diabetes who undergo coronary artery bypass graft [abstract]. Diabetes. 1991;47(suppl. 1):A87.
15. Golden SH, et al. Perioperative glycemic control and the risk of infectious complications in a cohort of adults with diabetes. Diabetes Care. 1999;22:1408.
16. Garratt KN, et al. Sulfonylurea drugs increase early mortality in patients with diabetes mellitus after direct balloon angioplasty for acute myocardial infarction. J Am Coll Cardiol. 1999;33:119-124.
17. Cavan DA, et al. Ruducing hospital inpatient length of stay for patients with diabetes. Diabetic Medicine. 2001;18:162-164.
18. McCowen KC, et al. Stress-induced hyperglycemia. Crit Care Clin. 2001;17:107-124.
19. Black CT, et al. Short-term hyperglycemia depresses immunity through nonenzymatic glycosylation of circulating immunoglobulin. J Trauma. 1990;30:830-833.
20. Joshi N, et al. Infections in patients with diabetes mellitus. N Engl J Med. 1999;341:1906-1912.
21. Carton JA, et al. Diabetes mellitus and bacteremia: A comparative study between diabetic and non-diabetic patients. Dur J Med. 1992;1:281.
22. Levetan CS, et al. Unrecognized diabetes among hospitalized patients. Diabetes Care. 1998;21:246-249.
23. Graber AL, Mcdonald T. Newly identified hyperglycemia among hospitalized patients. South Med J. 2000;93(11): 1070-1072.
24. Jacober SJ, Sowers JR. An update on perioperative management of diabetes. Arch Intern Med. 1999;159:2405-2411.
25. American Diabetes Association. Management of hyperglycemic crisis (Position Statement). Diabetes Care. 2001;24(suppl 1):S83.
26. Ahmann A. Comprehensive management of the hospitalized patient with diabetes. The Endocrinologist. 1998;8:250.
27. Hirsch IB, Paauw DS, Brunzell J. Inpatient management of adults with diabetes. Diabetes Care. 1995;18:870.
28. Levetan CS, Magee MF. Hospital management of diabetes. Endocrinol Metab Clin North Am. 2000;29:745-770.
29. Sawin CT, McCulloch DK. Management of diabetes mellitus in the acute care setting. www.uptodateonline.com/application/topic/print.asp?file=diabetes/16926 (Accessed December 2001)
30. Geraci JM, et al. In-hospital complications among survivors of admission for congestive heart failure, chronic obstructive pulmonary disease, or diabetes mellitus. J Gen Intern Med. 1995; 10:307-314.
31. Chaney MA, et al. Attempting to maintain normoglycemia during cardiopulmonary bypass with insulin may initiate postoperative hypoglycemia. Anesth Analg. 1999;89:1091-1095.
32. Groop LC. Sulfonylureas in NIDDM. Diabetes Care. 1992; 15:737-754.
33. Toeller M.Alpha-glucosidase inthibitors in diabetes: efficacy in NIDDM subjects. Eur J Clin Invest. 1994;24(suppl 3):31-35.
34. Bailey CJ, Turner RC. Drug therapy: Metformin. N Engl J Med. 1996;334:574-579.
35. Saltiel AR, Olefsky JM. Thiazolidinediones in the treatment of insulin resistance and type II diabetes. Diabetes. 1996;45: 1661-1669.
36. Strandgaard S. Hypertension and stroke. J Hypertens. 1996;14(suppl 3):S23.
37. Jorgensen JS, et al. Stroke in Patients with Diabetes: The Copenhagen Stroke Study. Stroke. 1994;25:1977-1984.
38. Weir CJ, et al. Is hyperglycemia an independent predictor of poor outcome after acute stroke? Rusults of a long-term followup study. BMJ. 1997;314:1303-1306.
39. Levetan CS, Magee MF. Hospital management of diabetes. Endocrinology and Metabolism Clinics of North America. 2000;29:766.
40. Abbud Z, et al. Effect of diabetes mellitus on chort and long-term mortality cases of patients with acute myocardial infarction: A state-wide study. Am Heart J. 1995;130:51-58.
41. Johnson WD, et al. Coronary artery surgery in diabetics: 261 Consecutive patients followed 4 to 7 years. Am Heart J. 1982; 104(4 pt 1):823-827.
42. Kannel WB, McGee DL. Diabetes and cardiovascular disease: The Framingham Study. JAMA. 1979;241:2035-2038.
43. Soler G, Frank S. Value of glycosylated hemoglobin measurements after acute myocardial infarction. JAMA. 1981;246: 1690-1693.
44. Katz CM. How efficient is sliding-scale insulin therapy? Problems with a cookbook’ approach in hospitalized patient. Postgrad Med. 1991;89:46-48.
45. MacMillan DR. The fallacy of insulin adjustment by the sliding scale. J Ky Med Assoc. 1970;68:577-579.
46. Queale WS, et al. The use of sliding scales in medical inpatients with diabetes mellitus. J Gen Intern Med. 1995;10(suppl):47.
47. Queale WS, Seidler AJ, Brancati FL. Arch Intern Med. 1997; 157:545-552.
48. Hirsch IB, Paauw DS, Brunzell J. Inpatient management of adults with diabetes. Diabetes Care. 1995;18:870-878.
49. Latham R, et al. The association of diabetes and glucose control with surgical-site infections among cardiothoracic surgery patients. Infect Control Hosp Epidemiol. 2001;22:607-612.
50. Gordon SM, et al. The relationship between glycosylated hemoglobin (HgbA1c) levels and postoperative infections in patients undergoing primary coronary artery bypass surgery (CABG) [abstract]. Infect Control Hosp Epidemiol. 1997;18(5, Part 2):29.
51. Jacober SJ, Sowers JR. An update on perioperative management of diabetes. Arch Intern Med. 1999;159:2405-2411.
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