Achieving tight glycemic control in the operating room: lessons learned from 12 years in the trenches of a paradigm shift in anesthetic care.

Intensive insulin therapy to control perioperative hyperglycemia has become the new standard of care for cardiac surgery patients. Although there are several published protocols for achieving tight glycemic control in the postoperative period, there are no such published protocols or even suggested methods for intraoperative control. At Providence St. Vincent Hospital in Portland, Oregon, we have been using postoperative insulin infusions under study protocol since 1992 and have been using intravenous insulin to control intraoperative glucose levels since 1995. Over the past 12 years of tight intraoperative glycemic control with intravenous insulin, four distinct, equally effective methods of intraoperative insulin administration have evolved at our institution. All four have evolved in the hands of experienced cardiac anesthesiologists. Each of these anesthesiologists was faced with the daily task of individualizing patient therapy with the common goal of eliminating intraoperative hyperglycemia. In this article we will describe each of these four generalized methodologies to give the practicing anesthesiologist a starting point from which they can develop and hone their own technique further.