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BACKGROUND: There is a conflict evidence about the association of using ‎bilateral internal mammary ‎artery (BIMA) grafting in diabetics undergoing coronary ‎artery bypass grafting (CABG) ‎surgery and increased risk of contracting surgical site ‎infection. The direct impact of the ‎diabetics glycemic control status and using the ‎optimal grafting method on surgical ‎site infection is still not conclusive in literature. ‎The aim of the study is to evaluate the ‎impact of Bilateral internal mammary artery ‎grafting in diabetic patients, the diagnosis ‎of diabetes mellitus, and its glycemic control ‎status on different kinds of nosocomial ‎infections. The assumption was made that those ‎exposures associated with higher risk of ‎surgical site infection, urinary tract infection, ‎blood stream infection and pneumonia. METHOD: A retrospective cohort is conducted ‎by utilizing Nationwide Inpatient ‎Sample (NIS) data from the Agency of Healthcare ‎Research and Quality (AHRQ). All ‎patients who were admitted to coronary artery ‎bypass grafting (CABG) surgery were ‎retrieved from 2007 to 2012 and grouped based on ‎the exposures of the study. RESULTS: The total sample of the study was 286,487 ‎patients underwent CABG ‎surgery. There were 122,642 (42.81%) patients diagnosed ‎with Diabetes Mellitus, of ‎whom 18,065 (14.73%) had uncontrolled hyperglycemia, ‎‎3,700 (3.01%) received ‎Bilateral (IMA) and 103,577 (84.45%) unilateral or single (IMA) ‎grafting method. The ‎study population was predominantly white (79.78%) and male ‎‎(72.08%) with an average ‎age of 66 (SD ±10.89) old. About 215,740 (75.31%) of ‎patients had developed ‎nosocomial pneumonia, 16,667 (5.82%) urinary tract infections ‎‎(UTIs), 9,442 (3.3%) ‎sepsis or bloodstream infection (BSIs), and 5,302 (1.85%) surgical ‎site infection (SSIs ‎in overall sample population.‎Among diabetic patients, there was no significant difference in comparing ‎BIMA ‎versus SIMA for surgical site infection (SSI) (p-value=0.2491) and blood ‎stream ‎infections (BSI) (p-value=0.6630). The results have also indicated that UTIs ‎‎(4.2% vs. ‎‎5.5%; p-value=0.0005) was significantly lower with BIMA grafting method. ‎However, ‎results did not meet the hypothesis assumption regarding Pneumonias rate ‎‎(76.8% vs. ‎‎70.5%; p-value < 0.0001) and was significantly higher with BIMA compared ‎to SIMA ‎grafting method. Multivariable analysis showed inconsistent result and ‎confirmed that ‎BIMA grafting predicts higher odd of BSI by 44.6% in diabetic, ‎compared to SIMA ‎grafting (OR: 1.446; 95% CI: 1.22-1.71; p<.0001). ‎The cross unadjusted baseline results for all nosocomial infections ‎were ‎significantly lower in diabetic patients compared to non-diabetic; Except for UTI ‎was ‎significantly higher by the presence of diabetes in BIMA grafting population ‎‎(n=10,223) ‎‎(4.2% vs. 3.39%; p-value= 0.0393). Multivariable analysis has confirmed ‎that Diabetes ‎Miletus increase the risk of UTI by 21.7% in BIMA population (OR: ‎‎1.217; 95% CI: 1.21-‎‎1.22; p<.0001). ‎The bivariate analysis results indicated that nosocomial infections ‎were ‎significantly higher in a diabetic with uncontrolled HbA1c compared to those ‎with ‎controlled diabetes. Except for nosocomial pneumonia. Adjusted results showed ‎that ‎uncontrolled hyperglycemia in a diabetic increase risk of UTI by 20% in overall ‎and ‎SIMA population. Uncontrolled hyperglycemia increase risk of SSI by 52% and UTI ‎by ‎‎104% in diabetic undergoing BIMA grafting (SSI: OR 1.52; CI 1.50-1.53; ‎p<.0001) ‎‎(UTI: OR 2.049; CI 1.45-2.89; p<.0001). ‎CONCLUSION: In patients who underwent CABG surgery, Diabetes ‎Mellitus ‎‎(DM) was associated with significantly lower nosocomial infections. This may ‎imply a ‎better trend in nosocomial infections complications for diabetics compared to ‎the total ‎population of CABG. However, in diabetic patient’s population, those stated ‎with ‎uncontrolled hyperglycemia have significantly higher risk of surgical site infection ‎and ‎urinary tract infection. Continuous insulin infusion protocol and intensive ‎glycemic ‎control monitoring are highly recommended for patients with uncontrolled ‎diabetes ‎during admission for CABG surgery. In diabetic patients who underwent CABG ‎with ‎Bilateral versus Single internal mammary (IMA), grafting, Bilateral IMA grafting ‎was ‎significantly associated with only higher odds of bloodstream infection in the ‎diabetic ‎patient and overall CABG population.‎ BIMA grafting should be encouraged in ‎diabetic patients. Expect in the case of uncontrolled hyperglycemia; it should be avoided ‎due to the high risk of both SSI and UTI as it has been emphasized in other studies.‎

ETD_7945

Ph.D.

Includes bibliographical references

by Ali A. Al Zayer

doi:10.7282/T3SN0CR6

ETD doctoral

The author owns the copyright to this work.