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Rajan N, Duggan EW, Abdelmalak BB, Butz S, Rodriguez LV, Vann MA, Joshi GP. Society for Ambulatory Anesthesia Updated Consensus Statement on Perioperative Blood Glucose Management in Adult Patients With Diabetes Mellitus Undergoing Ambulatory Surgery. Anesth Analg 2024; 139:459-477. [PMID: 38517760 DOI: 10.1213/ane.0000000000006791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Abstract
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.
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Affiliation(s)
- Niraja Rajan
- From the Department of Anesthesiology and Perioperative Medicine, Penn State Health, Hershey Outpatient Surgery Center, Hershey, Pennsylvania
| | - Elizabeth W Duggan
- Department of Anesthesiology and Perioperative Medicine, University of Alabama Birmingham, Birmingham, Alabama
| | - Basem B Abdelmalak
- Departments of General Anesthesiology and Outcomes Research, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Anesthesia for Bronchoscopic Surgery, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Steven Butz
- Department of Anesthesiology, Division of Pediatric Anesthesiology, Medical College of Wisconsin, Children's Wisconsin Surgicenter, Milwaukee, Wisconsin
| | - Leopoldo V Rodriguez
- Department of Anesthesiology and Perioperative Medicine, Boulder Valley Anesthesiology PLLC, UCHealth Longs Peak Hospital and Surgery Center, Boulder Community Health, Foothills Hospital, Boulder, Colorado
| | - Mary Ann Vann
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical School, Dallas, Texas
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Griffee MJ, Leis AM, Pace NL, Shah N, Kumar SS, Mentz GB, Riegger LQ. Intraoperative hypoglycemia among adults with intraoperative glucose measurements: a cross-sectional multicentre retrospective cohort study. Can J Anaesth 2024:10.1007/s12630-024-02816-z. [PMID: 39138798 DOI: 10.1007/s12630-024-02816-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 04/27/2024] [Accepted: 05/21/2024] [Indexed: 08/15/2024] Open
Abstract
PURPOSE Intraoperative hypoglycemia is presumed to be rare, but generalizable multicentre incidence and risk factor data for adult patients are lacking. We used a multicentre registry to characterize adults with intraoperative hypoglycemia and hypothesized that intraoperative insulin administration would be associated with hypoglycemia. METHODS We conducted a cross-sectional retrospective multicentre cohort study. We searched the Multicenter Perioperative Outcomes Group registry to identify adult patients with intraoperative hypoglycemia (glucose < 3.3 mmol·L-1 [< 60 mg·dL-1]) from 1 January 2015 to 31 December 2019. We evaluated characteristics of patients with intraoperative glucose measurements and with intraoperative hypoglycemia. RESULTS Of 516,045 patients with intraoperative glucose measurements, 3,900 (0.76%) had intraoperative hypoglycemia. Diabetes mellitus and chronic kidney disease were more common in the cohort with intraoperative hypoglycemia. The odds of intraoperative hypoglycemia were higher for the youngest age category (18-30 yr) compared with the odds for every age category above 40 yr (odds ratio [OR], 1.57-3.18; P < 0.001), and were higher for underweight or normal weight patients compared with patients with obesity (OR, 1.48-2.53; P < 0.001). Parenteral nutrition was associated with lower odds of hypoglycemia (OR, 0.23; 95% confidence interval [CI], 0.11 to 0.47; P < 0.001). Intraoperative insulin use was not associated with hypoglycemia (OR, 0.996; 95% CI, 0.91 to 1.09; P = 0.93). CONCLUSION In this large cross-sectional retrospective multicentre cohort study, intraoperative hypoglycemia was a rare event. Intraoperative insulin use was not associated with hypoglycemia.
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Affiliation(s)
- Matthew J Griffee
- Department of Anesthesiology, School of Medicine, University of Utah, Salt Lake City, UT, USA.
- Department of Anesthesiology, University of Utah School of Medicine, 5050 30 North Mario Capecchi Drive, Salt Lake City, UT, 84112, USA.
| | - Aleda M Leis
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Nathan L Pace
- Department of Anesthesiology, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Nirav Shah
- Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Sathish S Kumar
- Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Graciela B Mentz
- Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Lori Q Riegger
- Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
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Jang J, Colletti AA, Ricklefs C, Snyder HJ, Kardonsky K, Duggan EW, Umpierrez GE, O'Reilly-Shah VN. Implementation of App-Based Diabetes Medication Management: Outpatient and Perioperative Clinical Decision Support. Curr Diab Rep 2021; 21:50. [PMID: 34902056 PMCID: PMC8713442 DOI: 10.1007/s11892-021-01421-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/13/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Outpatient and perioperative therapeutic decision making for patients with diabetes involves increasingly complex medical-decision making due to rapid advances in knowledge and treatment modalities. We sought to review mobile decision support tools available to clinicians for this essential and increasingly difficult task, and to highlight the development and implementation of novel mobile applications for these purposes. RECENT FINDINGS We found 211 mobile applications related to diabetes from the search, but only five were found to provide clinical decision support for outpatient diabetes management and none for perioperative decision support. We found a dearth of tools for clinicians to navigate these tasks. We highlight key aspects for effective development of future diabetes decision support. These include just-in-time availability, respect for the five rights of clinical decision support, and integration with clinical workflows including the electronic medical record.
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Affiliation(s)
- Jeehoon Jang
- Department of Clinical Informatics, University of Washington School of Medicine, Seattle, WA, USA
| | - Ashley A Colletti
- Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine, RR450, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Colbey Ricklefs
- Department of Family Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Holly J Snyder
- Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine, RR450, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Kimberly Kardonsky
- Department of Family Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Elizabeth W Duggan
- Department of Anesthesiology and Perioperative Medicine, University of Alabama Birmingham School of Medicine, Birmingham, AL, USA
| | - Guillermo E Umpierrez
- Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, GA, USA
| | - Vikas N O'Reilly-Shah
- Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine, RR450, 1959 NE Pacific St, Seattle, WA, 98195, USA.
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Syyrilä T, Vehviläinen-Julkunen K, Manias E, Bucknall T, Härkänen M. Communication related to medication incidents-A concept analysis and literature review. Scand J Caring Sci 2021; 36:297-319. [PMID: 34779022 DOI: 10.1111/scs.13044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 09/26/2021] [Accepted: 10/10/2021] [Indexed: 11/29/2022]
Abstract
AIMS (1) To identify and analyse the conceptual framework and operationalise the concept of communication issues related to medication incidents in hospital to facilitate the development of a future tool for measuring frequencies of the communication issues. (2) To determine how the concept is distinct from related concepts. DESIGN Concept analysis. DATA SOURCES Twenty-three articles from seven scientific databases covering the years 2010-2020 and two official documents. METHODS Walker and Avant's concept analysis method was used. That was started by a systematised literature review on 2 November 2020 using specified criteria. Two authors evaluated articles' quality by Joanna Brigg's Institute's criteria. Literature review results were analysed deductive-inductively; conceptual framework was developed and concept defined presenting case scenarios. EQUATOR's standards were used in study reporting. RESULTS A conceptual framework and the concept of 'communication related to medication incidents in hospitals' were defined, comprising six main attribute categories: (1) communication dyads involved in communication, (2) patients' or professionals' individual issues, (3) institutional, (4) contextual and process issues, (5) communication concerning medication prescriptions and (6) qualitative characteristics of communication. The categories consisted of 128 quantitatively measurable and 10 qualitative attributes describing communication issues. The concept is distinct from related concepts by collating fragmented communication issues into the same concept. CONCLUSION The 128-item conceptual framework and the concept of communication related to medication incidents in hospitals were defined, as there was not one. The concept assembled parts of previous theories and fragmented information to one entity. The concept needs further condensing and validation to develop a tool for measuring communication issues. IMPACT ON MEDICATION SAFETY The conceptual framework can be used in practice and education as indicative rationale for reflection of current communication issues. The concept contributes to research by providing necessary grounding for tool development for measuring communication factors relating medication incidents.
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Affiliation(s)
- Tiina Syyrilä
- Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland (UEF), Kuopio, Finland.,Abdominal Center, Helsinki University Hospital (HUS), University of Helsinki, Helsinki, Finland
| | - Katri Vehviläinen-Julkunen
- Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland (UEF), Kuopio, Finland.,Kuopio University Hospital (KUH), Kuopio, Finland
| | - Elizabeth Manias
- School of Nursing & Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, Burwood, Vic., Australia
| | - Tracey Bucknall
- School of Nursing & Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, Burwood, Vic., Australia
| | - Marja Härkänen
- Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland (UEF), Kuopio, Finland
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Duggan E, Chen Y. Glycemic Management in the Operating Room: Screening, Monitoring, Oral Hypoglycemics, and Insulin Therapy. Curr Diab Rep 2019; 19:134. [PMID: 31749027 DOI: 10.1007/s11892-019-1277-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW This review provides a literature update and practical outline for the management of diabetes and stress hyperglycemia for adult surgical patients in the pre- and intraoperative settings. RECENT FINDINGS Hyperglycemia in surgical patients has been associated with increased risk of complication in both diabetic and non-diabetic patients in the perioperative setting. While current recommended perioperative blood glucose target is < 180 mg/dL (10 mmol/L), optimal outcomes may require different treatment targets for diabetic versus non-diabetic patients. Hemoglobin A1C level is associated with elevated risk of hyperglycemia and adverse outcomes, but there is insufficient evidence to recommend routine preoperative testing or optimal values in elective surgical patients. Day of surgery blood glucose testing and treatment are recommended in the perioperative period, and anesthetic management includes appropriate patient selection for use of subcutaneous insulin, intravenous insulin infusions, and insulin pumps. Additionally, administration of both intravenous and perineural dexamethasone is associated with increased blood glucose levels and clinicians should consider the risk benefit ratio in surgical patients. For enhanced recovery after surgery protocols, further evidence is needed to support routine use of carbohydrate loading in diabetic patients. Optimal perioperative care includes screening at-risk patients, use of preoperative oral hypoglycemics and home insulin, anesthetic type and medication selection, blood glucose testing, and treatment for hyperglycemia in the operating room. Partnerships with surgery and endocrinology teams aid optimal postoperative management and discharge planning.
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Affiliation(s)
- Elizabeth Duggan
- Department of Anesthesiology, Emory University School of Medicine, 1364 Clifton Road, Atlanta, GA, 30322, USA.
| | - York Chen
- Department of Anesthesiology, Emory University School of Medicine, 1364 Clifton Road, Atlanta, GA, 30322, USA
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Epstein RH, Dexter F. Database Quality and Access Issues Relevant to Research Using Anesthesia Information Management System Data. Anesth Analg 2018; 127:105-114. [DOI: 10.1213/ane.0000000000003324] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
An association between perioperative hyperglycemia and adverse outcomes has been established in surgical patients, 1 -3 with morbidity being reduced in those treated with insulin.5 -6 A practical treatment algorithm and literature summary is provided for surgical patients with diabetes and hyperglycemia.
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Affiliation(s)
- Elizabeth W Duggan
- From the Departments of Anesthesiology (E.W.D., K.C.) and Medicine (G.E.U.), Emory University School of Medicine, Atlanta, Georgia
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Duggan EW, Klopman MA, Berry AJ, Umpierrez G. The Emory University Perioperative Algorithm for the Management of Hyperglycemia and Diabetes in Non-cardiac Surgery Patients. Curr Diab Rep 2016; 16:34. [PMID: 26971119 DOI: 10.1007/s11892-016-0720-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Hyperglycemia is a frequent manifestation of critical and surgical illness, resulting from the acute metabolic and hormonal changes associated with the response to injury and stress (Umpierrez and Kitabchi, Curr Opin Endocrinol. 11:75-81, 2004; McCowen et al., Crit Care Clin. 17(1):107-24, 2001). The exact prevalence of hospital hyperglycemia is not known, but observational studies have reported a prevalence of hyperglycemia ranging from 32 to 60 % in community hospitals (Umpierrez et al., J Clin Endocrinol Metab. 87(3):978-82, 2002; Cook et al., J Hosp Med. 4(9):E7-14, 2009; Farrokhi et al., Best Pract Res Clin Endocrinol Metab. 25(5):813-24, 2011), and 80 % of patients after cardiac surgery (Schmeltz et al., Diabetes Care 30(4):823-8, 2007; van den Berghe et al., N Engl J Med. 345(19):1359-67, 2001). Retrospective and randomized controlled trials in surgical populations have reported that hyperglycemia and diabetes are associated with increased length of stay, hospital complications, resource utilization, and mortality (Frisch et al., Diabetes Care 33(8):1783-8, 2010; Kwon et al., Ann Surg. 257(1):8-14, 2013; Bower et al., Surgery 147(5):670-5, 2010; Noordzij et al., Eur J Endocrinol. 156(1):137-42, 2007; Mraovic et al., J Arthroplasty 25(1):64-70, 2010). Substantial evidence indicates that correction of hyperglycemia reduces complications in critically ill, as well as in general surgery patients (Umpierrez et al., J Clin Endocrinol Metab. 87(3):978-82, 2002; Clement et al., Diabetes Care 27(2):553-97, 2004; Pomposelli et al., JPEN J Parented Enteral Nutr. 22(2):77-81, 1998). This manuscript reviews the pathophysiology of stress hyperglycemia during anesthesia and the perioperative period. We provide a practical outline for the diagnosis and management of preoperative, intraoperative, and postoperative care of patients with diabetes and hyperglycemia.
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Affiliation(s)
| | - Matthew A Klopman
- Department of Anesthesiology, Emory University Hospital, Atlanta, USA
| | - Arnold J Berry
- Department of Anesthesiology, Emory University Hospital, Atlanta, USA
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Wade T. The anaesthetic practitioner and type 1 diabetes mellitus. J Perioper Pract 2015; 25:19-23. [PMID: 26016260 DOI: 10.1177/1750458915025001-204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Type 1 diabetes mellitus (T1DM) is a serious lifelong condition affecting many people in the UK. With the increasing prevalence of T1DM, it is inevitable that more patients will present for anaesthesia and surgery. This article will inform anaesthetic practitioners about the condition, the challenges involved with glycaemic control, complications such as hyperglycaemia and hypoglycaemia, and the importance of maintaining good glycaemic control. It will offer advice about what anaesthetic practitioners can do to help manage and care for their patients.
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Cobaugh DJ, Maynard G, Cooper L, Kienle PC, Vigersky R, Childers D, Weber R, Carson SL, Mabrey ME, Roderman N, Blum F, Burkholder R, Dortch M, Grunberger G, Hays D, Henderson R, Ketz J, Lemke T, Varma SK, Cohen M. Enhancing insulin-use safety in hospitals: Practical recommendations from an ASHP Foundation expert consensus panel. Am J Health Syst Pharm 2014; 70:1404-13. [PMID: 23903479 DOI: 10.2146/ajhp130169] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Consensus recommendations to help ensure safe insulin use in hospitalized patients are presented. SUMMARY Insulin products are frequently involved in medication errors in hospitals, and insulin is classified as a high-alert medication when used in inpatient settings. In an initiative to promote safer insulin use, the American Society of Health-System Pharmacists (ASHP) Research and Education Foundation convened a 21-member panel representing the fields of pharmacy, medicine, and nursing and consumer advocacy groups for a three-stage consensus-building initiative. The panel's consensus recommendations include the following: development of protocol-driven insulin order sets, elimination of the routine use of correction/sliding-scale insulin doses for management of hyperglycemia, restrictions on the types of insulin products stored in patient care areas, and policies to restrict the preparation of insulin bolus doses and i.v. infusions to the pharmacy department. In addition, the panelists recommended that hospitals better coordinate insulin use with meal intake and glucose testing, prospectively monitor the coordination of insulin delivery and rates of hypoglycemia and hyperglycemia, and provide standardized education and competency assessment for all hospital-based health care professionals responsible for insulin use. CONCLUSION A 21-member expert panel convened by the ASHP Foundation identified 10 recommendations for enhancing insulin-use safety across the medication-use process in hospitals. Professional organizations, accrediting bodies, and consumer groups can play a critical role in the translation of these recommendations into practice. Rigorous research studies and program evaluations are needed to study the impact of implementation of these recommendations.
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Affiliation(s)
- Daniel J Cobaugh
- American Society of Health-System Pharmacists Research and Education Foundation, Bethesda, MD 20814, USA.
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