Diabetes Mellitus: Preoperative Concerns and Evaluation

Society for Ambulatory Anesthesia Updated Consensus Statement on Perioperative Blood Glucose Management in Adult Patients With Diabetes Mellitus Undergoing Ambulatory Surgery

This consensus statement is a comprehensive update of the 2010 Society for Ambulatory Anesthesia (SAMBA) Consensus Statement on perioperative blood glucose management in patients with diabetes mellitus (DM) undergoing ambulatory surgery. Since the original consensus guidelines in 2010, several novel therapeutic interventions have been introduced to treat DM, including new hypoglycemic agents and increasing prevalence of insulin pumps and continuous glucose monitors. The updated recommendations were developed by an expert task force under the provision of SAMBA and are based on a comprehensive review of the literature from 1980 to 2022. The task force included SAMBA members with expertise on this topic and those contributing to the primary literature regarding the management of DM in the perioperative period. The recommendations encompass preoperative evaluation of patients with DM presenting for ambulatory surgery, management of preoperative oral hypoglycemic agents and home insulins, intraoperative testing and treatment modalities, and blood glucose management in the postanesthesia care unit and transition to home after surgery. High-quality evidence pertaining to perioperative blood glucose management in patients with DM undergoing ambulatory surgery remains sparse. Recommendations are therefore based on recent guidelines and available literature, including general glucose management in patients with DM, data from inpatient surgical populations, drug pharmacology, and emerging treatment data. Areas in need of further research are also identified. Importantly, the benefits and risks of interventions and clinical practice information were considered to ensure that the recommendations maintain patient safety and are clinically valid and useful in the ambulatory setting. What Other Guidelines Are Available on This Topic? Since the publication of the SAMBA Consensus Statement for perioperative blood glucose management in the ambulatory setting in 2010, several recent guidelines have been issued by the American Diabetes Association (ADA), the American Association of Clinical Endocrinologists (AACE), the Endocrine Society, the Centre for Perioperative Care (CPOC), and the Association of Anaesthetists of Great Britain and Ireland (AAGBI) on DM care in hospitalized patients; however, none are specific to ambulatory surgery. How Does This Guideline Differ From the Previous Guidelines? Previously posed clinical questions that were outdated were revised to reflect current clinical practice. Additional questions were developed relating to the perioperative management of patients with DM to include the newer therapeutic interventions.

Preparation and Characterization of Chitosan Nanofiber: Kinetic Studies and Enhancement of Insulin Delivery System

Insulin-loaded nanofibers were prepared using chitosan as a natural polymer. The loaded insulin with polyethylene oxide was used for preparing monolayer batch S1. Nanofiber S1 was coated by seven layers of film on both sides to form batch S2 as a sandwich containing Layer A (CS, PEG and PEO) and Layer B (PEG and PEO) using electrospinning apparatus. SEM, TEM and FT-IR techniques were used to confirm the drug loading within the composite nanofibers. The in vitro activity that provided a sustained and controlled release of the drug from the nanofiber batch was studied at different pH values spectrophotometrically using a dialysis method. In batches S1 and S2, the release of insulin from nanofiber proceeds via burst release necessary to produce the desired therapeutic activity, followed by slow step. The rate and the percentage release of insulin in batch S2 are found to be higher at all pH values.

Lentinus edodes mycelium polysaccharide inhibits AGEs-induced HUVECs pyroptosis by regulating LncRNA MALAT1/miR-199b/mTOR axis and NLRP3/Caspase-1/GSDMD pathway

A novel Lentinus edodes mycelia polysaccharide (LMP) prepared in our laboratory has been identified to be effective in inhibiting the damage of islet β cells induced by glucose toxicity. However, whether it can effectively alleviate the pyroptosis of human umbilical vein endothelial cells (HUVECs) induced by advanced glycation end products (AGEs) remains unclear. Bioinformatics and cell biology techniques were used to explore the mechanism of LMP inhibiting AGEs-induced HUVECs damage. The results indicated that AGEs significantly increased the expression of LncRNA MALAT1, decreased cell viability to 79.67 %, increased intracellular ROS level to 248.19 % compared with the control group, which further led to cell membrane rupture. The release of LDH in cellular supernatant was increased to 149.42 %, and the rate of propidium iodide staining positive cells increased to 277.19 %, indicating the cell pyroptosis occurred. However, the above trend was effectively retrieved after the treatment with LMP. LMP effectively decreased the expression of LncRNA MALAT1 and mTOR, promoted the expression of miR-199b, inhibited AGEs-induced HUVECs pyroptosis by regulating the NLRP3/Caspase-1/GSDMD pathway. LncRNA MALAT1 might be a new target for LMP to inhibit AGEs-induced HUVECs pyroptosis. This study manifested the role of LMP in improving diabetes angiopathy and broadens the application of polysaccharide.

Perioperative glycemic management in adults presenting for elective cardiac and non-cardiac surgery

Perioperative dysglycemia is associated with adverse outcomes in both cardiac and non-cardiac surgical patients. Hyperglycemia in the perioperative period is associated with an increased risk of postoperative infections, length of stay, and mortality. Hypoglycemia can induce neuronal damage, leading to significant cognitive deficits, as well as death. This review endeavors to summarize existing literature on perioperative dysglycemia and provides updates on pharmacotherapy and management of perioperative hyperglycemia and hypoglycemia in surgical patients.

Neuraxial anesthesia in hepato-pancreatic-bilio surgery: a first western pilot study of 46 patients

The most common anesthetic approach in hepato-pancreatic-biliary (HPB) surgery is general anesthesia (GA), but it may result in increased morbidity and mortality and peri-operative risks especially in frail patients. The aim of this study was to assess the safety and effectiveness of neuraxial anesthesia (NA) in HPB in a pilot clinical series. This analysis was conducted on 46 consecutive patients undergoing HPB surgery in an Italian Tertial referral center. Data were prospectively collected and retrospectively analyzed. continuous spinal anesthesia (CSA), combined spino-epidural anesthesia (CSEA) and peridural anesthesia (PA) were used in major and minor hepatectomies and bilio-pancreatic surgery instead of GA. NA was evaluated by analyzing the surgical and anesthesiological short-term outcomes. 46 patients were considered eligible for the study between February 2018 and May 2020. The average age was 69.07 (±  9.95) years. 22 were males and 24 were females. According to the ASA score, 19 (41.30%) patients had ASA II, 22 (47.83%) had ASA III and 5 (10.87%) had ASA IV. 22 (47.83%) patients underwent CSA, 20 (43.48%) CSEA and 4 (8.69%) PA. We performed 8 major and 19 minor hepatectomies, 7 bilio-digestive derivations, 5 Whipple procedures, 4 iatrogenic biliary duct injuries, 2 splenopancreatectomies and 1 hepatic cyst fenestration. Clavien-Dindo ≥ 3 was observed in 3 patients. The conversion rate to endotracheal intubation occurring in 3 of 46 (6.52%) patients. After surgery, no local or pulmonary complications and delirium were reported in our series. The present study demonstrates that NA is a safe and feasible option in selected patients, if performed in referral centers by well-trained anaesthesiologists and surgeons.

Simvastatin alleviates epithelial‑mesenchymal transition and oxidative stress of high glucose‑induced lens epithelial cells in vitro by inhibiting RhoA/ROCK signaling

Diabetic cataracts (DC) is one of the main causes of blindness among patients with diabetes mellitus. The aim of the present study was to examine the effect of simvastatin on lens epithelial cells in DC and the underlying mechanism. The viability of SRA01/04 cells treated with different concentrations of simvastatin was detected using a Cell Counting Kit-8 assay before and after high glucose (HG) treatment. The expression levels of E-cadherin, N-cadherin, Vimentin and α-smooth muscle actin (α-SMA), proteins associated with epithelial-mesenchymal transition (EMT), in addition to RhoA, Rho-associated kinases (ROCK)1 and ROCK2, proteins related to RhoA/ROCK signaling, were also measured in SRA01/04 cells treated with HG and simvastatin, with or without U46619, using western blot analysis. DCFH-DA dyes, superoxide dismutase (SOD) and glutathione (GSH)/glutathione disulfide (GSSG) kits were used to measure the levels of oxidative stress parameters in SRA01/04 cells treated with HG and simvastatin with or without U46619. The cell viability of SRA01/04 cells treated with simvastatin was found to be significantly elevated after HG treatment. The protein expression levels of E-cadherin were increased but those of N-cadherin, Vimentin and α-SMA decreased after HG and simvastatin treatment, and this was reversed by U46619. The levels of SOD and GSH-GSSG were found to be increased whereas reactive oxygen species levels were decreased, effects that were reversed by U46619. Additionally, the protein expression levels of RhoA, ROCK1 and ROCK2 were markedly decreased. These findings provided evidence that simvastatin increased HG-induced SRA01/04 cell viability and exerted inhibitory effects on EMT and oxidative stress that occurs during DC.

Optimal preoperative timing for prevention of deep vein thrombosis (DVT) in patients over 60 years of age with intertrochanteric fractures

PURPOSE

To investigate the incidence and risk factors of preoperative DVT in elderly patients with intertrochanteric fracture of the femur and determine the optimal preoperative time.

METHODS

Electronic medical records of 358 patients over 60 years of age with intertrochanteric fractures from May 1, 2016, to May 1, 2019, were retrospectively analyzed. The preoperative group was divided into DVT and non-DVT. Univariate analysis was used for preliminary comparison, and multivariate logistic regression analysis was used to identify independent risk factors associated with DVT development. ROC curve was drawn to analyze the specificity and sensitivity of risk factors for DVT diagnosis. The diagnostic value of the model was analyzed by the ROC curve of multivariable combined diagnosis.

RESULTS

A total of 358 patients who met the criteria were enrolled. The total prevalence of DVT before surgery was 8.38%. Multivariate logistic regression analysis showed that smoking status, preoperative time, albumin (ALB), D-dimer level, diabetes mellitus, and hypertension were independent risk factors for preoperative DVT. Preoperative time has the best sensitivity and specificity for diagnosing the occurrence of preoperative DVT. The ROC curve analysis model of multivariable combined diagnosis has a better diagnostic value.

CONCLUSIONS

In this study, elderly patients with intertrochanteric femur fracture had a higher incidence of deep vein thrombosis before surgery. Early identification of DVT-related risk factors may contribute to individualized risk assessment and preventing adverse outcomes in patients with intertrochanteric fractures.

Perioperative challenges in management of diabetic patients undergoing non-cardiac surgery

Prediabetes and diabetes are important disease processes which have several perioperative implications. About one third of the United States population is considered to have prediabetes. The prevalence in surgical patients is even higher. This is due to the associated micro and macrovascular complications of diabetes that result in the need for subsequent surgical procedures. A careful preoperative evaluation of diabetic patients and patients at risk for prediabetes is essential to reduce perioperative mortality and morbidity. This preoperative evaluation involves an optimization of preoperative comorbidities. It also includes optimization of antidiabetic medication regimens, as the avoidance of unintentional hypoglycemic and hyperglycemic episodes during the perioperative period is crucial. The focus of the perioperative management is to ensure euglycemia and thus improve postoperative outcomes. Therefore, prolonged preoperative fasting should be avoided and close monitoring of blood glucose should be initiated and continued throughout surgery. This can be accomplished with either analysis in blood gas samples, venous phlebotomy or point-of-care testing. Although capillary and arterial whole blood glucose do not meet standard guidelines for glucose testing, they can still be used to guide insulin dosing in the operating room. Intraoperative glycemic control goals may vary slightly in different protocols but overall the guidelines suggest a glucose range in the operating room should be between 140 mg/dL to 180 mg/dL. When hyperglycemia is detected in the operating room, blood glucose management may be initiated with subcutaneous rapid-acting insulin, with intravenous infusion or boluses of regular insulin. Fluid and electrolyte management are other perioperative challenges. Notably diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic state are the two most serious acute metabolic complications of diabetes that must be recognized early and treated.

Combination of endothelial progenitor cells and BB-94 significantly alleviates brain damage in a mouse model of diabetic ischemic stroke

Ischemic stroke is a complication of chronic macrovascular disease in type 2 diabetes. However, the pathogenesis of diabetic ischemic stroke has not yet been fully clarified. The aim of the present study was to investigate the underlying effects of endothelial progenitor cells (EPCs) and the matrix metalloproteinase inhibitor BB-94 on diabetic stroke. In vitro experiments were performed using oxygen-glucose deprivation/reoxygenation (OGD/R) model cells, established using HT22 mouse hippocampal cells. MTT assays and flow cytometry revealed that BB-94 prominently induced the proliferation of the OGD/R model cells and prevented their apoptosis. When EPCs and BB-94 were applied to the OGD/R model cells in combination, proliferation was further accelerated and oxidative damage was attenuated. In vivo experiments were also performed using a middle cerebral artery occlusion (MCAO) mouse model. The results of modified neurological severity scoring and oxidative stress marker analysis demonstrated that EPCs and BB-94 prominently alleviated cerebral ischemia/reperfusion injury in the MCAO model mice. Furthermore, reverse transcription-quantitative PCR and western blot assays revealed that EPCs in combination with BB-94 significantly downregulated the expression of matrix metalloproteinases (MMPs) and upregulated the expression of tissue inhibitor of metalloproteinases 1 in OGD/R cells and MCAO model mice. The results suggest that EPCs were successfully isolated and identified, and the OGD/R cell and MCAO mouse models were successfully established. They also indicate that EPCs alone or in combination with BB-94 may exert protective effects against ischemic stroke via the reduction of MMP expression.

Correlation between diabetes mellitus and number of restored, carious lesions and missing teeth: A retrospective radiographic evaluation

Aim

This study aimed to evaluate the prevalence of carious, restored, and missing teeth among diabetic and non-diabetic patients who visited dental clinics in Dammam, Saudi Arabia.

Method

This retrospective study was conducted between April and November 2018. The data collection procedure was conducted in two steps: (1) review of patient records for the demographic variables and (2) screening of digital panoramic radiographs (OPGs). The patients who visited the restorative and prosthetic clinics in the period of 2016–2017 were included in the study.

Results

A total of 1186 patient records and OPGs were reviewed to extract the data. The average age of the patients in the study sample was 40.96 (±16.29). The sample included 751 (63.3%) female and 435 (36.7%) male patients. Among the patients, 192 (16.2%) had diabetes mellitus and 994 (83.8%) were non-diabetic. The average numbers of fixed partial dentures and missing teeth were significantly high among diabetic patients (P < 0.001). Conversely, the average numbers of carious lesions and restored teeth were higher among the non-diabetic patients. Only the number of restored teeth was found to be significant (P < 0.001).

Conclusion

The diabetic patients were found to be at high risk of losing teeth compared with the non-diabetic patients. The prevalence of fixed partial dentures was also higher among diabetic patients. The oral health status of dental patients with diabetes needs urgent attention to prevent these patients from having teeth loss, and it can be done by improving their oral health.

Distance from the endocrinology clinic and diabetes control in a rural pediatric population

OBJECTIVE

We analyzed the impact of geographic distance from the clinic on adherence to recommended clinic visits and diabetes control among patients with type 1 diabetes (T1D) seen in a pediatric endocrinology clinic serving a rural region in eastern North Carolina.

METHODS

We retrospectively included patients with T1D age ≤20 years seen in our clinic during 2017. Outcomes were tracked until June 2018. Distance from the clinic was determined according to the zone improvement plan (ZIP) code of patient address. Visit adherence was defined based on the number of attended visits during the study period, aiming for 1 every 3 months. Glycated hemoglobin (HbA1c) was measured at the first and last visits during the review period.

RESULTS

The analysis included 368 patients, of whom 218 (59%) completed at least 1 visit every 3 months. The median HbA1c was 9.1 (interquartile range [IQR]: 8.0, 10.3) at the initial visit, and 9.3 (IQR: 8.0, 11.1) at the final visit. Median distance from the clinic was 56 km (IQR: 35, 86). On multivariable logistic regression, greater distance from the clinic was associated with lower odds of visit adherence (odds ratio per 10 km: 0.93; 95% confidence interval: 0.87, 0.99; p=0.030). Neither distance to the clinic nor clinic visit adherence were associated with HbA1c.

CONCLUSIONS

Patients living further away from the clinic were less likely to adhere to the recommended visit schedule, but distance was not correlated with HbA1c levels. Further work is needed to assist families living far from the clinic with adhering to recommended visits.

Effects of N-acetylcysteine on kidney tissue, matrix metalloproteinase-2, irisin and oxidative stress in a diabetes mellitus model

DM mellitus (DM) is a prevalent chronic disease; diabetic nephropathy (DN) is a primary cause of chronic kidney disease. Oxidation, energy imbalance, and enzyme and cytokine changes contribute to the development and progression of DN. We investigated the possible effects of the antioxidant, N-acetylcysteine (NAC), on kidney morphology, apoptosis, matrix metalloproteinase-2 (MMP2) activity, irisin levels and oxidative stress in an experimental DM model. We used four equal groups of Wistar albino male rats: control, DM, DM + NAC and NAC. Kidney tissues were evaluated for oxidation state, MMP-2, irisin, caspase-3 and histopathology. In the DM group, total oxidant status level, MMP-2 and caspase-3 immunoreactivity were increased, irisin immunoreactivity and total antioxidant status (TAS) were decreased and histological damage was evident. In the DM + NAC group, all changes were significantly improved. NAC exhibited protective effects against DN.

A Systematic Review on Synthetic Drugs and Phytopharmaceuticals Used to Manage Diabetes

BACKGROUND

Diabetes is a multifactorial disease and a major cause for many microvascular and macrovascular complications. The disease will ultimately lead to high rate mortality if it is not managed properly. Treatment of diabetes without any side effects has always remained a major challenge for health care practitioners.

INTRODUCTION

The current review discusses the various conventional drugs, herbal drugs, combination therapy and the use of nutraceuticals for the effective management of diabetes mellitus. The biotechnological aspects of various antidiabetic drugs are also discussed.

METHODS

Structured search of bibliographic databases for previously published peer-reviewed research papers was explored and data was sorted in terms of various approaches that are used for the treatment of diabetes.

RESULTS

More than 170 papers including both research and review articles, were included in this review in order to produce a comprehensive and easily understandable article. A series of herbal and synthetic drugs have been discussed along with their current status of treatment in terms of dose, mechanism of action and possible side effects. The article also focuses on combination therapies containing synthetic as well as herbal drugs to treat the disease. The role of pre and probiotics in the management of diabetes is also highlighted.

CONCLUSION

Oral antihyperglycemics which are used to treat diabetes can cause many adverse effects and if given in combination, can lead to drug-drug interactions. The combination of various phytochemicals with synthetic drugs can overcome the challenge faced by the synthetic drug treatment. Herbal and nutraceuticals therapy and the use of probiotics and prebiotics are a more holistic therapy due to their natural origin and traditional use.

Perioperative Assessment of High-Risk Abdominal Surgery: A Case Study

Objectives • To outline the key components of a pre-operative cardiac risk assessment. • To review the major guidelines utilized to assess patients' surgical risks. • To discuss the perioperative management of surgical patients to prevent cardiac and pulmonary complications. • To review the utility of biomarkers in the pre- and post-operative period.