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Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline

Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038 January 18, 2022 e67 CLINICAL STATEMENTS AND GUIDELINES

increase several-fold,17 while the associated morbidity and expense can be considerable.7 Management of hyperglycemia with perioperative insulin infusion to maintain a glucose level <180 mg/dL, both in patients with known diabetes and in patients with stress hyperglycemia, has emerged as an important strategy to prevent infection, as well as to improve survival and reduce recurrent ischemic events.1-3,18,19 Continuous intravenous insulin infusion after CABG reduces postoperative complications, such as mediastinitis, cardiac arrhythmias, deep sternal would infections, renal failure, and length of stay.3,5,6 In addition to standard antibiotic prophylaxis, several other strategies have emerged as best practices to reduce the risk of sternal infection (Table 13).

Recommendation-Specific Supportive Text

1.	 Continuous intravenous infusion of insulin is effective in maintaining blood glucose <180 mg/dL in patients undergoing CABG with the intent of reducing the risk of sternal wound infection. Perioperative glucose management has been found to be effective both in patients who are recognized to have diabetes and in those who experience stress hyperglycemia.1-3,19 2.	 The optimal level of glycemic control needed to improve outcomes in patients undergoing cardiac surgery remains controversial. One study evaluating intensive insulin therapy to target a glucose level of between 100 mg/dL and 140 mg/dL in the intensive care unit did not demonstrate reduced perioperative complications after CABG compared with a target glucose level of between 141 mg/dL and 180 mg/dL.4 An RCT and multiple observational studies have demonstrated that continuous intravenous insulin infusion is associated with reduced variability in glucose concentration, reduced hospital length of stay, reduced ischemic events, reduced wound complications, and improved survival compared with subcutaneous insulin in patients with diabetes who undergo CABG.3,5,6,20,21

3.	 With an aggressive preventive approach, some centers report zero incidence of sternal infection.14,22 However, there is no evidence-based preventive “bundle.”7,23-25 Strong evidence supports the perioperative administration of antibiotics,9,26 with general agreement that continuation of prophylactic antibiotics for >48 hours lacks additional benefit. Mupirocin has been found to be effective in reducing Staphylococcus aureus infection in patients who are nasal carriers, and there is no evidence that it is beneficial for those who are not. Topical vancomycin paste may have benefit,11,14,22 whereas the formerly ubiquitous use of bone wax is falling into increasing disfavor.12,13,27 The use of BIMAs as bypass conduits has generally been associated with an increased risk of sternal wound infection,28 although there is considerable center-specific evidence that this risk can be ameliorated by use of the “skeletonized” technique,29 which may cause less disruption of sternal perfusion and lymphatic drainage. 4.	 An RCT of 400 patients compared intraoperative intensive treatment (glucose levels 80–100 mg/dL) or conventional treatment (insulin given only for a glucose concentration ≥200 mg/ dL)15 and found no difference between groups in a composite endpoint of death, deep sternal wound infection, prolonged ventilation, cardiac arrhythmias, stroke, or renal failure within 30 days. There was an increased incidence of death and stroke in the patients who received intensive treatment.15 In another RCT, 381 patients without diabetes undergoing isolated CABG were given intraoperative infusions of insulin or placebo when their blood glucose concentrations exceeded 100 mg/dL. Insulin infusion during cardiopulmonary bypass had no significant effect on the combined incidence of neurological, neuro-ophthalmologic, or neurobehavioral deficits or neurological death and did not shorten the length of hospital stay.30 Thus, these data highlight the evidence that extremely tight control of blood glucose after CABG is not associated with improved outcomes.

Table 13.  Best Practices to Reduce Sternal Wound Infection in Patients Undergoing CABG Perform nasal swab testing for Staphylococcus aureus.8 Apply mupirocin 2% ointment to known nasal carriers of S aureus.8 Apply preoperative intranasal mupirocin 2% ointment to those patients whose nasal culture or PCR result is unknown.8 Redose prophylactic antimicrobials for long procedures (>2 half-lives of the antibiotic) or in cases of excessive blood loss during CABG.10,11,27 Measure perioperative HbA1c.31 Treat all distant extrathoracic infections before nonemergency surgical coronary revascularization.19 Advise smoking cessation before elective CABG surgery.7 Apply topical antibiotics (vancomycin) to the cut edges of the sternum on opening and before closing in cardiac surgical procedures involving a median sternotomy.4,32 Use skeletonized harvest of IMA in BIMA grafting.16 Do not continue prophylactic antibiotics beyond 48 hours.9,11 BIMA indicates bilateral internal mammary artery; CABG, coronary artery bypass graft; HbA1c, glycated hemoglobin A1c; IMA, internal mammary artery; and PCR, polymerase chain reaction. Downloaded from http://ahajournals.org by on October 7, 2026