Part II: managing perioperative hyperglycemia in total hip and knee replacement surgeries

Potential Clinical Applications for Continuous Ketone Monitoring in the Hospitalized Patient with Diabetes

PURPOSE OF REVIEW

In this review, the authors discuss potential clinical applications for continuous ketone monitoring (CKM) in a broad continuum of clinical settings from pre-hospital care and the emergency department to acute inpatient management and post-discharge follow-up.

RECENT FINDINGS

Though in its early stages, the concept of a novel continuous ketone sensing technology exerts great potential for use in the detection and hospital management of DKA, namely to overcome diagnostic barriers associated with ketoacidosis in patients with diabetes and obtain real-time BOHB levels, which may be useful in understanding both patients' response to treatment and DKA trajectory. Peri- and intra-operative use of CKM technology can potentially be applied in a number of urgent and elective surgical procedures frequently underwent by patients with diabetes and in the observation of patients during peri-operative fasting. In transitional care management, CKM technology could potentially facilitate patients' safe transition through levels of care, following hospital discharge from a DKA episode. This evaluation of the literature presents the potential advantages of adopting CKM and integrating this technology into the care algorithm of patients at risk for ketoacidosis.

Prevalence and Risk of Infection in Patients with Diabetes following Primary Total Knee Arthroplasty: A Global Systematic Review and Meta-Analysis of 120,754 Knees

Diabetes mellitus (DM) is a known risk factor for infection following total joint arthroplasty. This study looked at the prevalence and risk of infection in diabetic and non-diabetic patients who had primary total knee arthroplasty (TKA). PubMed, Scopus, Google Scholar, Web of Science, and Science Direct electronic databases were searched for studies published up to 21 April 2022. To compare the risk of infection between diabetic and non-diabetic subjects, a pooled prevalence, and a risk ratio (RR) with 95% confidence intervals (CIs) were used. This research has been registered with PROSPERO (CRD42021244391). There were 119,244 participants from 18 studies, with a total of 120,754 knees (25,798 diabetic and 94,956 non-diabetic). We discovered that the risks of infection in diabetic patients were 1.84 times significantly higher than in non-diabetic patients. Infection was more common in diabetic patients (1.9%) than in non-diabetic patients (1.2%). In a subgroup analysis, the risks of developing deep surgical site infection (SSI) were 1.96 times higher in diabetic patients, but no significant difference when compared in superficial SSI. Prevalence of deep SSI was higher in diabetic (1.5%) than in non-diabetic (0.7%), but the prevalence of superficial SSI was lower in diabetic (1.4%) than in non-diabetic (2.1%). Consistent with previous research, we found diabetes is a risk factor for infection following primary TKA. However, the risk is much lower than previously published data, indicating that other factors play a larger role in infection.

The Influence of Diabetes Mellitus on Patients Undergoing Primary Total Lower Extremity Arthroplasty: A Systematic Review and Meta-Analysis

Background

Diabetes mellitus (DM) is a common disease that has an adverse impact on most orthopedic surgeries, and its prevalence has gradually increased in recent years. We aim to investigate the influence of DM on comorbidities and complications of patients undergoing primary total lower extremity arthroplasty.

Methods

PubMed, Embase, Cochrane Library, Medline, and Web of Science were systematically searched for relevant studies published before December 2019. Demographic data, comorbidities, and postoperative complications after primary total hip arthroplasties (THA) or primary total knee arthroplasties (TKA) were assessed between DM and non-DM patients. Meta-analysis was conducted using Review Manager 5.3, and forest plots were drawn for each variable.

Results

A total of 1,560,461 patients (215,916 patients with DM and 1,344,545 patients without DM) from 23 studies were included in this meta-analysis. The incidences of several preoperative comorbidities (hypertension (HTN), kidney disease, cardiac and cerebrovascular disease) were generally higher in patients with DM. Moreover, DM patients had a higher rate of postoperative complications (superficial and deep infection, deep vein thrombosis (DVT), and in-hospital mortality) compared to non-DM patients.

Conclusions

DM patients were more likely to suffer from comorbidities and had a higher risk of complications in total lower extremity arthroplasty compared to non-DM patients. It is necessary to identify DM and control hyperglycemia in the perioperative period to prevent postoperative complications in patients with DM.

Stress Hyperglycemia and Complications Following Traumatic Injuries in Individuals With/Without Diabetes: The Case of Orthopedic Surgery

PURPOSE

Hyperglycemia in trauma patients may stem from metabolic response to stress, both in the presence and the absence of underlying diabetes. We aimed to test the association of stress hyperglycemia with risks of adverse events subjects undergoing orthopedic surgery.

PATIENTS AND METHODS

In a prospective observational study, we enrolled 202 consecutive patients with hyperglycemia at hospital admission for trauma injuries requiring orthopedic surgery. Based on history, diabetes was present in 183, and 13 more were defined as unknown diabetes on the basis of HbA1c ≥48mmol/mol. Stress hyperglycemia was defined in subjects with/without diabetes by a stress hyperglycemia ratio (SHR) >1.14, calculated as admission glucose/average glucose, estimated from glycosylated hemoglobin. Logistic regression analysis was used to calculate the risk of post-surgery adverse events associated with different states of hyperglycemia, after correction for demographic and clinical confounders.

RESULTS

Stress hyperglycemia was diagnosed, either as superimposed to diabetes (54/196 cases, 27.6%) as well as in the 6 cases without diabetes. At least one complication was recorded in 68 cases (33.7%), the most common being systemic infection (22.8% of cases). In the total cohort, stress hyperglycemia, irrespective of the presence of diabetes, increased the risk of adverse events (any events, odds ratio [OR], 4.43; 95% confidence interval [CI], 2.11-9.30), cardiovascular events (OR, 7.09; 95% CI, 2.47-19.91), systemic infections (OR, 4.21; 95% CI, 1.97-9.03) and other adverse events (OR, 6.30; 95% CI, 1.41-28.03), after adjustment for confounders; hospital stay was much longer. The same was true when the analysis was limited to the diabetes cohort or by comparing pure stress hyperglycemia vs diabetes without stress hyperglycemia.

CONCLUSION

The study highlights the importance of stress hyperglycemia for adverse events in the setting of orthopedic surgery following trauma injuries. This condition requires stricter management, considering the much longer length of hospital stay and higher costs.

Trauma in the Diabetic Limb

Poorly controlled diabetes with comorbid manifestations negatively affects outcomes in lower extremity trauma, increasing the risk of short-term and long-term complications. Management strategies of patients with diabetes that experience lower extremity trauma should also include perioperative management of hyperglycemia to reduce adverse and serious adverse events.

Management of Hyperglycemia and Diabetes in Orthopedic Surgery

An increasing number of orthopedic operations are being carried out in an older population in whom the prevalence of diabetes is dramatically increasing. People having surgery with diabetes and hyperglycemia are at increased risk of post-operative complications. The peri-operative risks have been well demonstrated for cardiac surgery and, more recently, for orthopedic surgery. This paper considers the issues surrounding orthopaedic surgery in patients with diabetes and the significance and management of hyperglycemia in the peri-operative period.

Part I: triggers for an evidence based practice project: managing peri-operative hyperglycemia in total hip and total knee replacement surgeries

A descriptive study of risk factors for surgical site infection (SSI) in patients receiving total knee arthroplasty discovered an infection rate higher than the benchmark. Although no risk factors were significant predictors of SSI in this population, an important finding was that, despite a patient population with comorbid diabetes, a lack of standardized practice related to the identification and management of hyperglycemia was identified. These findings identified and validated an important practice issue and led to the continued commitment to improve glucose management. In this way, a study was a trigger for improved nursing practice using evidence-based practice.