Perioperative care of the geriatric patient with diabetes or hyperglycemia

Management of diabetes medications for patients undergoing ambulatory surgery

A stress-free actively managed perioperative experience is crucial to successful ambulatory surgery for diabetes patients. Practitioners who integrate diabetes treatment regimens into their perioperative management can facilitate a good outcome, smooth recovery, and rapid return to normal life. Hypoglycemia, hyperglycemia, and glucose variability must be avoided and patients should be maintained near their usual blood glucose.

The trends in treatment of femoral neck fractures in the Medicare population from 1991 to 2008

BACKGROUND

We examined trends in the treatment of femoral neck fractures over the last two decades.

METHODS

We used Medicare Part A administrative data to identify patients hospitalized for closed femoral neck fracture from 1991 to 2008. We used codes from the International Classification of Diseases, Ninth Revision, to categorize treatment as nonoperative, internal fixation, hemiarthroplasty, and total hip arthroplasty. We examined differences in treatment according to hospital hip fracture volume, hospital location (rural or urban), and teaching status.

RESULTS

Our sample consisted of 1,119,423 patients with intracapsular hip fractures occurring from 1991 to 2008. We found a generally stable trend over time in the percentage of patients managed with nonoperative treatment, internal fixation, hemiarthroplasty, and total hip arthroplasty. We found little difference in surgical treatment across different groups of hospitals (high volume compared with low volume, urban compared with rural, and teaching compared with nonteaching). The percentage of acute care hospitals treating hip fractures remained fairly constant (74.8% in 1991 to 1993 and 69.0% in 2006 to 2008). The median number of hip fractures treated per hospital did not change (thirty-three in 1991 to 1993 and thirty-three in 2006 to 2008). There was no increase in the percentage of fractures treated in high-volume hospitals over time (57.7% in 1991 to 1993 and 57.1% in 2006 to 2008) and little reduction in the percentage of fractures treated in low-volume hospitals (5.8% in 1991 to 1993 and 5.5% in 2006 to 2008).

CONCLUSIONS

There has been little change in the trends of operative and nonoperative treatment for proximal femoral fractures over the last two decades, and there was little evidence of regionalization of hip fracture treatment to higher-volume hospitals.

Alta hospitalar e o cuidado do recém-nascido prematuro no domicílio: vivência materna

Objetivou-se conhecer a percepção da mãe sobre a alta hospitalar e o cuidado do recém-nascido prematuro no domicílio após a primeira semana de alta. Pesquisa descritiva, de abordagem qualitativa, com uso da entrevista semiestruturada para coleta de dados, desenvolvida no ambulatório de seguimento do prematuro (follow-up) do Hospital da Rede Pública Estadual de Fortaleza, em outubro e novembro de 2011. As participantes foram nove mães de recém-nascido prematuro após primeira semana de alta. Aplicou-se análise do conteúdo. Os resultados apontaram para as categorias: Orientações sobre o cuidado com o prematuro durante a alta hospitalar; Sentimentos e dificuldades com a chegada do bebê no domicílio; e Apoio familiar no cuidado do prematuro. O estudo evidenciou que algumas mães não receberam orientações da equipe multiprofissional da neonatologia acerca do cuidado bebê após alta hospitalar, reforçando que elas levam o bebê para o domicílio sem estar preparadas para a nova realidade.

Preoperative geriatric assessment: comprehensive, multidisciplinary and proactive

With the changing global demographic pattern, our health care systems increasingly have to deal with a greater number of elderly patients, which consequently also takes its toll on our surgical services. The elderly are not simply older adults. They represent a heterogeneous branch of the population with specific physiological, psychological, functional and social issues that require individualised attention prior to surgery. Increased acknowledgement that chronological age alone is not an exclusion criterion, along with advances in surgical and anaesthetic techniques have today lead to decreased reluctance to deny the elderly surgical treatment. In order to ensure a safe perioperative period, we believe that a comprehensive, multidisciplinary and proactive preoperative assessment will be helpful to detect the multiple risk factors and comorbidities common in older patients, to assess functional status and simultaneously allow room for early preoperative interventions and planning of the intra- and postoperative period. In this review we outline the currently available preoperative geriatric risk assessment tools and provide an insight on how a comprehensive, multidisciplinary and proactive approach can help improve perioperative outcome.

Efficacy and tolerability of self-titrated biphasic insulin aspart 70/30 in patients aged >65 years with type 2 diabetes: an exploratory post hoc subanalysis of the INITIATEplus trial

BACKGROUND

The Initiation of Insulin to reach A1C Target (INITIATEplus) trial studied the effect of self-titrating biphasic insulin aspart 70/30 (BiAsp 30) twice daily during 24 weeks in insulin-naïve patients with type 2 diabetes who were poorly controlled by oral medication, and originally randomized according to frequency of dietary counseling interventions.

OBJECTIVE

The purpose of this study was to compare the efficacy and tolerability of biphasic insulin aspart 70/30 (BIAsp 30, NovoLog Mix 70/30) in INITIATEplus patients ≤65 versus >65 years old, irrespective of dietary counseling frequency, and to test the hypothesis that self-titrating BIAsp 30 in patients >65 years old could be well-tolerated and effective in this age group.

METHODS

An exploratory post hoc subanalysis, using standard statistical methods, was performed on patients stratified according to age. Data collected from 3492 patients in the intent-to-treat population who were ≤65 years old and 716 patients who were >65 years old compared glycosylated hemoglobin (HbA(1c)) and plasma glucose changes from baseline. Hypoglycemia rates and adverse event (AE) incidence were compared for the tolerability population of 4007 patients ≤65 years old and 805 patients >65 years old.

RESULTS

Baseline-adjusted HbA(1c) changes for patients ≤65 versus >65 years old were -2.38% versus -2.73% (P < 0.0001), with final HbA(1c) achieving 7.55% and 7.06%, respectively. Thirty-nine percent of patients ≤65 years old achieved HbA(1c) ≤7% compared with 51% of patients >65 years old. Baseline-adjusted fasting plasma glucose decreases were greater for the >65 year old population (85.2 vs 91.2 mg/dL; P = 0.004; ≤65 vs >65 years old, respectively). Minor hypoglycemia was reported in 9.7% and 7.7% of patients ≤65 versus >65 years old, respectively (0.52 vs 0.41 episodes per patient per year [ppy]; P = 0.01). Major hypoglycemia occurred in 1.5% and 3.1% of patients (0.05 vs 0.14 episodes ppy, ≤65 vs >65 years old, respectively; P < 0.0001). Nocturnal major hypoglycemia was reported for 0.4% and 0.6% of patients (P = 0.0028), whereas nocturnal minor hypoglycemia was reported for 3.8% and 2.6% (P = 0.007) of patients ≤65 and >65 years old, respectively. AEs were reported for 24% and 28% of patients ≤65 and >65 years old, respectively, serious AEs were reported for 4% and 9% of patients, respectively, and AE-related withdrawals were reported for 1.3% and 2% of patients, respectively.

CONCLUSIONS

Self-titrated biphasic insulin aspart 70/30 was found to be well-tolerated and effective in type 2 diabetes patients >65 years old, as well as in patients ≤65 years old. HbA(1c) and fasting plasma glucose decreases were significantly (P < 0.05) higher for patients >65 years old versus patients ≤65 years old. Tolerability was indicated by major and minor hypoglycemia rates at or below <0.5 episodes ppy in both age groups. Overall rates of AE and serious AEs were higher among patients > 65 years; withdrawals related to AEs were 2% compared with 1.3% in the younger age group.

Planejamento da alta hospitalar do paciente diabético: construção de uma proposta

As complicações agudas e crônicas enfrentadas pelo paciente diabético e sua família após a alta hospitalar podem ser consequência de deficiências no processo educativo ao longo da hospitalização e do preparo formal para alta. O objetivo deste estudo é apresentar uma proposta de planejamento da alta hospitalar do paciente diabético adulto. Foi realizada revisão de literatura sobre alta hospitalar da clientela em questão, selecionando-se artigos publicados de 2004 a fevereiro de 2009. Considerando a literatura, foi desenvolvido um impresso para nortear o planejamento da alta. Este abrange informações a serem colhidas e trabalhadas junto ao cliente, ao longo dos primeiros quatro dias de internação, considerando as necessidades individuais e o Autocontrole ineficaz da saúde. A alta precisa estar inserida no Processo de Enfermagem, uma vez que o enfermeiro tem papel fundamental na identificação das necessidades do paciente e família. O impresso auxilia a identificação das necessidades do cliente e das ações realizadas pela equipe.

Society for Ambulatory Anesthesia consensus statement on perioperative blood glucose management in diabetic patients undergoing ambulatory surgery

Optimal evidence-based perioperative blood glucose control in patients undergoing ambulatory surgical procedures remains controversial. Therefore, the Society for Ambulatory Anesthesia has developed a consensus statement on perioperative glycemic management in patients undergoing ambulatory surgery. A systematic review of the literature was conducted according the protocol recommended by the Cochrane Collaboration. The consensus panel used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system for providing suggestions. It was revealed that there is insufficient evidence to provide strong recommendations for the posed clinical questions. In the absence of high-quality evidence, recommendations were based on general principles of blood glucose control in diabetics, drug pharmacology, and data from inpatient surgical population, as well as clinical experience and judgment. In addition, areas of further research were also identified.

Addressing hyperglycemia from hospital admission to discharge

BACKGROUND

This review examines glycemia management practices in hospitalized patients. Optimal glycemic control remains a challenge among hospitalized patients. Recent studies have questioned the benefit of tight glycemic control and have raised concerns regarding the safety of this approach. As a result, medical societies have updated glycemic targets and have published new consensus guidelines for management of glycemia in hospitalized patients. This review highlights recent inpatient glycemic trials, the new glycemic targets and recommended strategies for management of glycemia in hospitalized patients.

METHODS

Medline and PubMed searches (diabetes, hyperglycemia, hypoglycemia, intensive therapy insulin, tight glycemic control, and hospital patients) were performed for English-language articles on treatment of diabetes, insulin therapy, hyperglycemia or hypoglycemia in hospitalized patients published from 2004 to present. Earlier works cited in these papers were surveyed. Clinical studies, reviews, consensus/guidelines statements, and meta-analyses relevant to the identification and management of diabetes and hyperglycemia in hospitalized patients were included and selected. This is not an exhaustive review of the published literature.

RESULTS

Insulin remains the most appropriate agent for a majority of hospitalized patients. In critically ill patients insulin is given as a continuous intravenous (IV) infusion and in non-critically ill inpatients hyperglycemia is best managed using scheduled subcutaneous (SC) basal-bolus insulin regimens supplemented with correction doses as needed and adjusted daily with the guidance of frequent blood glucose monitoring. Prevention of hypoglycemia is equally as important to patient outcomes and is an equally necessary part of any effective glucose control program. Modern insulin analogs offer advantages over the older human insulins (e.g., regular and neutral protamine Hagedorn [NPH] insulin) because their time-action profiles more closely correspond to physiological basal and prandial insulin requirements, and have a lower propensity for inducing hypoglycemia than human insulin formulations. Long-acting basal insulin analogs (glargine, detemir) are suitable and preferred for the basal component of therapy; rapid-acting insulin analogs (aspart, lispro, glulisine) are recommended for bolus and correction doses. Sliding-scale insulin (SSI) regimens are not effective and should not be used, especially as this excludes a basal insulin component from the therapy.

CONCLUSIONS

Optimal glycemic management in the hospital setting requires judicious treatment of hyperglycemia while avoiding hypoglycemia. Insulin is the most appropriate agent for management of hyperglycemia for the majority of hospitalized patients. Intravenous insulin infusion is still preferred during and immediately after surgery, but s.c. basal insulin analogs with prandial or correction doses should be used after the immediate post-operative period, and also should be used in non-critically ill patients. Frequent and effective glucose monitoring is critical for avoiding wide deviations from acceptable glucose levels, which under a recently promulgated consensus guideline currently range between 140 mg/dL and 180 mg/dL. Glucose targets near 140 mg/dL are recommended as being the most appropriate for all hospitalized patients.

Perioperative management of ambulatory surgical patients with diabetes mellitus

PURPOSE OF REVIEW

Patients with diabetes frequently present for ambulatory surgery concomitant with the rise in incidence of the disease. This review will examine recent evidence on glucose control, the harmful effects of hyperglycemia, fluctuations of blood glucose, and hypoglycemia, as well as treatments and medications utilized for type 1 and type 2 diabetes mellitus. Based on this evidence, a strategy for perioperative decision making for the diabetic patient undergoing ambulatory surgery will be presented.

RECENT FINDINGS

New studies question the practice of intensive control of blood glucose in critically ill patients. Also, tight control of HbA1c levels in patients with type 2 diabetes may have associated cardiovascular risks. Glucose fluctuations and hypoglycemia may pose greater risks to patients than elevated glucose itself. New medications and insulin regimens make perioperative blood glucose control easier now than in the past.

SUMMARY

The ambulatory anesthesiologist, with a dedication to low-impact practices and emphasis on rapid recovery, provides an ideal environment of care for the patient with diabetes. This review will examine issues and concerns with management of the patient with diabetes undergoing ambulatory surgery and address them in a step-wise strategy for care, including recommendations for perioperative insulin administration.

Incidence and mortality of hip fractures in the United States

CONTEXT

Understanding the incidence and subsequent mortality following hip fracture is essential to measuring population health and the value of improvements in health care.

OBJECTIVE

To examine trends in hip fracture incidence and resulting mortality over 20 years in the US Medicare population.

DESIGN, SETTING, AND PATIENTS

Observational study using data from a 20% sample of Medicare claims from 1985-2005. In patients 65 years or older, we identified 786,717 hip fractures for analysis. Medication data were obtained from 109,805 respondents to the Medicare Current Beneficiary Survey between 1992 and 2005.

MAIN OUTCOME MEASURES

Age- and sex-specific incidence of hip fracture and age- and risk-adjusted mortality rates.

RESULTS

Between 1986 and 2005, the annual mean number of hip fractures was 957.3 per 100,000 (95% confidence interval [CI], 921.7-992.9) for women and 414.4 per 100,000 (95% CI, 401.6-427.3) for men. The age-adjusted incidence of hip fracture increased from 1986 to 1995 and then steadily declined from 1995 to 2005. In women, incidence increased 9.0%, from 964.2 per 100,000 (95% CI, 958.3-970.1) in 1986 to 1050.9 (95% CI, 1045.2-1056.7) in 1995, with a subsequent decline of 24.5% to 793.5 (95% CI, 788.7-798.3) in 2005. In men, the increase in incidence from 1986 to 1995 was 16.4%, from 392.4 (95% CI, 387.8-397.0) to 456.6 (95% CI, 452.0-461.3), and the subsequent decrease to 2005 was 19.2%, to 369.0 (95% CI, 365.1-372.8). Age- and risk-adjusted mortality in women declined by 11.9%, 14.9%, and 8.8% for 30-, 180-, and 360-day mortality, respectively. For men, age- and risk-adjusted mortality decreased by 21.8%, 25.4%, and 20.0% for 30-, 180-, and 360-day mortality, respectively. Over time, patients with hip fracture have had an increase in all comorbidities recorded except paralysis. The incidence decrease is coincident with increased use of bisphosphonates.

CONCLUSION

In the United States, hip fracture rates and subsequent mortality among persons 65 years and older are declining, and comorbidities among patients with hip fractures have increased.