Immediate preoperative hyperglycemia correlates with complications in non-cardiac surgical cases

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.

Do preoperative glucose levels predict risk of complications in orthopaedic surgery?

PURPOSE

Post-operative hyperglycemia is a known risk factor for post-surgical complications. The predictive value of pre-operative blood glucose levels, however, is less understood. This study aimed to determine if pre-operative screening blood glucose levels affect the rate of post-operative infection or wound complications. We also investigated if case urgency or anatomic location alters this relationship.

METHODS

A single-institution retrospective chart review was performed to evaluate patients treated between 2018 and 2021. Subjects ≥ 18 years with closed, non-infected orthopaedic diagnoses requiring surgery were included. Case urgency, demographics, comorbidities, blood glucose level within twelve h prior to surgery, and hemoglobin A1c level within 3 months of surgery, were collected. Infections and wound complications were recorded as outcomes.

RESULTS

A total of 775 subjects with a mean age of 61 (range 18-96) were identified, including 543 elective and 232 trauma patients, with a mean pre-operative fasting glucose value of 127.7 mg/dL (range, 49-388 mg/dL) and average HbA1c of 6.9%. The odds of infectious complications were increased by a factor of 1.01 for every 1-point increase in blood glucose (95% CI 1.01-1.02; p < 0.01).

CONCLUSIONS

Pre-operative blood glucose levels greater than 137 mg/dL were associated with an increase in wound complications, but not deep infections. Infection rates stratified by anatomic site and case urgency were not impacted by pre-operative glucose levels. The increased risk of poor wound healing in patients with pre-operative hyperglycemia demonstrates that day of surgery point-of-care blood glucose screening can be a useful risk stratification tool.

Preoperative Glucose Predicts Postoperative Complications After Complex Abdominal Wall Reconstruction

BACKGROUND

Despite advances in surgical methods, complication rates after complex abdominal wall reconstruction (CAWR) remain high. Identification of preoperative risk factors can assist surgeons with risk stratification and patient counseling. The deleterious effects of hyperglycemia on wound healing are well established. With the increasing prevalence of diabetes (diabetes mellitus) and prediabetes, a greater proportion of patients are likely to have increased blood glucose levels that may contribute to poor surgical outcomes. The primary aim of this study was to determine whether preoperative hyperglycemia predicted surgical outcome. The secondary aim was to establish glucose thresholds to assist with surgical risk stratification.

METHODS

All patients who underwent CAWR by the senior author at a single institution from 2002 to 2021 were retrospectively reviewed. Patients were stratified into 4 groups based on preoperative blood glucose: <100 mg/dL (n = 184), 100-140 mg/dL (n = 207), 140-180 mg/dL (n = 41), and >180 mg/dL (n = 16). Patient demographics, risk factors, surgical techniques, complications, and outcomes were recorded and compared.

RESULTS

The study cohort comprised of 478 patients. Mean age was 53.9 ± 12.3 years. Mean body mass index was 32.1 ± 7.8 kg/m2. Higher age (P = 0.0085), higher body mass index (P = 0.0005), the presence of diabetes (P < 0.0001), and hypertension (P = 0.0004) were significantly associated with higher glucose. Overall complication rates ranged from 26% (glucose <100 mg/dL) to 94% (glucose >180 mg/dL), whereas recurrence rates ranged from 10% (glucose <100 mg/dL) to 37% (glucose 140-180 mg/dL). Multivariate logistic regression analysis revealed preoperative glucose to have a significant, independent effect on overall complication rate (P < 0.0001), major complication rate (P < 0.0001), and recurrence rate (P < 0.0031).

CONCLUSIONS

Preoperative hyperglycemia is an important predictor of postoperative complications and recurrence after CAWR. Point-of-care glucose levels are routinely gathered before surgery and may help to establish thresholds for which elective CAWR might be deferred. Strategies to lower preoperative glucose should be part of an optimization protocol for improving outcomes.

A New Nomogram-Based Prediction Model for Postoperative Outcome after Sigmoid Resection for Diverticular Disease

Background and Objectives: Sigmoid resection still bears a considerable risk of complications. The primary aim was to evaluate and incorporate influencing factors of adverse perioperative outcomes following sigmoid resection into a nomogram-based prediction model. Materials and Methods: Patients from a prospectively maintained database (2004-2022) who underwent either elective or emergency sigmoidectomy for diverticular disease were enrolled. A multivariate logistic regression model was constructed to identify patient-specific, disease-related, or surgical factors and preoperative laboratory results that may predict postoperative outcome. Results: Overall morbidity and mortality rates were 41.3% and 3.55%, respectively, in 282 included patients. Logistic regression analysis revealed preoperative hemoglobin levels (p = 0.042), ASA classification (p = 0.040), type of surgical access (p = 0.014), and operative time (p = 0.049) as significant predictors of an eventful postoperative course and enabled the establishment of a dynamic nomogram. Postoperative length of hospital stay was influenced by low preoperative hemoglobin (p = 0.018), ASA class 4 (p = 0.002), immunosuppression (p = 0.010), emergency intervention (p = 0.024), and operative time (p = 0.010). Conclusions: A nomogram-based scoring tool will help stratify risk and reduce preventable complications.

[Position statement: surgery and diabetes mellitus (Update 2023)]

This position statement reflects the perspective of the Austrian Diabetes Association concerning the perioperative management of people with diabetes mellitus based on the available scientific evidence. The paper covers necessary preoperative examinations from an internal/diabetological point of view as well as the perioperative metabolic control by means of oral antihyperglycemic and/or insulin therapy.

[Malnutrition management of hospitalized patients with diabetes/hyperglycemia un the perioperative setting]

Introduction

People with diabetes are at high risk of requiring surgical intervention throughout their lives, and of perioperative complications in case of poor metabolic control. Hospitalization represents a stressful event that, together with other factors associated with diagnostic and therapeutic procedures, leads to a deterioration in the nutritional status of the patients. An association between poor nutritional status and adverse outcomes in surgical patients has been observed. This article describes the results of the expert consensus and the responses of the panelists on the nutritional management in routine clinical practice of patients with diabetes/hyperglycemia hospitalized (non-critically ill) in the perioperative setting.

Management of Hyperglycemia in Hospitalized Adult Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline

BACKGROUND

Adult patients with diabetes or newly recognized hyperglycemia account for over 30% of noncritically ill hospitalized patients. These patients are at increased risk for adverse clinical outcomes in the absence of defined approaches to glycemic management.

OBJECTIVE

To review and update the 2012 Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline and to address emerging areas specific to the target population of noncritically ill hospitalized patients with diabetes or newly recognized or stress-induced hyperglycemia.

METHODS

A multidisciplinary panel of clinician experts, together with a patient representative and experts in systematic reviews and guideline development, identified and prioritized 10 clinical questions related to inpatient management of patients with diabetes and/or hyperglycemia. The systematic reviews queried electronic databases for studies relevant to the selected questions. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make recommendations.

RESULTS

The panel agreed on 10 frequently encountered areas specific to glycemic management in the hospital for which 15 recommendations were made. The guideline includes conditional recommendations for hospital use of emerging diabetes technologies including continuous glucose monitoring and insulin pump therapy; insulin regimens for prandial insulin dosing, glucocorticoid, and enteral nutrition-associated hyperglycemia; and use of noninsulin therapies. Recommendations were also made for issues relating to preoperative glycemic measures, appropriate use of correctional insulin, and diabetes self-management education in the hospital. A conditional recommendation was made against preoperative use of caloric beverages in patients with diabetes.

CONCLUSION

The recommendations are based on the consideration of important outcomes, practicality, feasibility, and patient values and preferences. These recommendations can be used to inform system improvement and clinical practice for this frequently encountered inpatient population.

A Systematic Review Supporting the Endocrine Society Clinical Practice Guideline for the Management of Hyperglycemia in Adults Hospitalized for Noncritical Illness or Undergoing Elective Surgical Procedures

CONTEXT

Individuals with diabetes or newly recognized hyperglycemia account for over 30% of noncritically ill hospitalized patients. Management of hyperglycemia in these patients is challenging.

OBJECTIVE

To support development of the Endocrine Society Clinical Practice Guideline for management of hyperglycemia in adults hospitalized for noncritical illness or undergoing elective surgical procedures.

METHODS

We searched several databases for studies addressing 10 questions provided by a guideline panel from the Endocrine Society. Meta-analysis was conducted when feasible. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess certainty of evidence.

RESULTS

We included 94 studies reporting on 135 553 patients. Compared with capillary blood glucose, continuous glucose monitoring increased the number of patients identified with hypoglycemia and decreased mean daily blood glucose (BG) (very low certainty). Data on continuation of insulin pump therapy in hospitalized adults were sparse. In hospitalized patients receiving glucocorticoids, combination neutral protamine hagedorn (NPH) and basal-bolus insulin was associated with lower mean BG compared to basal-bolus insulin alone (very low certainty). Data on NPH insulin vs basal-bolus insulin in hospitalized adults receiving enteral nutrition were inconclusive. Inpatient diabetes education was associated with lower HbA1c at 3 and 6 months after discharge (moderate certainty) and reduced hospital readmissions (very low certainty). Preoperative HbA1c level < 7% was associated with shorter length of stay, lower postoperative BG and a lower number of neurological complications and infections, but a higher number of reoperations (very low certainty). Treatment with glucagon-like peptide-1 agonists or dipeptidyl peptidase-4 inhibitors in hospitalized patients with type 2 diabetes and mild hyperglycemia was associated with lower frequency of hypoglycemic events than insulin therapy (low certainty). Caloric oral fluids before surgery in adults with diabetes undergoing surgical procedures did not affect outcomes (very low certainty). Counting carbohydrates for prandial insulin dosing did not affect outcomes (very low certainty). Compared with scheduled insulin (basal-bolus or basal insulin + correctional insulin), correctional insulin was associated with higher mean daily BG and fewer hypoglycemic events (low certainty).

CONCLUSION

The certainty of evidence supporting many hyperglycemia management decisions is low, emphasizing importance of shared decision-making and consideration of other decisional factors.