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Zöllner C. [Preoperative evaluation of adult patients before elective, non-cardiothoracic surgery : A joint recommendation of the German Society for Anesthesiology and Intensive Care Medicine, the German Society for Surgery and the German Society for Internal Medicine]. DIE ANAESTHESIOLOGIE 2024; 73:294-323. [PMID: 38700730 PMCID: PMC11076399 DOI: 10.1007/s00101-024-01408-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/26/2024] [Indexed: 05/09/2024]
Abstract
The 70 recommendations summarize the current status of preoperative risk evaluation of adult patients prior to elective non-cardiothoracic surgery. Based on the joint publications of the German scientific societies for anesthesiology and intensive care medicine (DGAI), surgery (DGCH), and internal medicine (DGIM), which were first published in 2010 and updated in 2017, as well as the European guideline on preoperative cardiac risk evaluation published in 2022, a comprehensive re-evaluation of the recommendation takes place, taking into account new findings, the current literature, and current guidelines of international professional societies. The revised multidisciplinary recommendation is intended to facilitate a structured and common approach to the preoperative evaluation of patients. The aim is to ensure individualized preparation for the patient prior to surgery and thus to increase patient safety. Taking into account intervention- and patient-specific factors, which are indispensable in the preoperative risk evaluation, the perioperative risk for the patient should be minimized and safety increased. The recommendations for action are summarized under "General Principles (A)," "Advanced Diagnostics (B)," and the "Preoperative Management of Continuous Medication (C)." For the first time, a rating of the individual measures with regard to their clinical relevance has been given in the present recommendation. A joint and transparent agreement is intended to ensure a high level of patient orientation while avoiding unnecessary preliminary examinations, to shorten preoperative examination procedures, and ultimately to save costs. The joint recommendation of DGAI, DGCH and DGIM reflects the current state of knowledge as well as the opinion of experts. The recommendation does not replace the individualized decision between patient and physician about the best preoperative strategy and treatment.
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Affiliation(s)
- Christian Zöllner
- Universitätsklinikum Hamburg-Eppendorf, Klinik und Poliklinik für Anästhesiologie, Zentrum für Anästhesiologie und Intensivmedizin, Martinistr. 52, 20246, Hamburg, Deutschland.
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2
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Kirk JK, Gonzales CF. Preoperative considerations for patients with diabetes. Expert Rev Endocrinol Metab 2023; 18:503-512. [PMID: 37937905 DOI: 10.1080/17446651.2023.2272865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 10/16/2023] [Indexed: 11/09/2023]
Abstract
INTRODUCTION Patients undergoing surgery require a thorough assessment preoperatively. Hyperglycemia is associated with poor outcomes, and stability of glucose levels is an important factor in preoperative management. Diabetes presents a particular challenge since patients are often on multiple medications encompassing glycemic management and cardiovascular therapies. AREAS COVERED A PubMed search of published data and reviews on preoperative approaches in diabetes was conducted. Consensus opinion drives most of the guidelines and recommendations for management of diabetes in surgical patients. Pathophysiology is often complex with varying levels of glucose and surgical stress. Establishing well-controlled diabetes prior to surgical intervention should be standard practice in non-emergent procedures. We review the best practices for implementing preoperative assessment, with diabetes with a focus on diabetes medications. EXPERT OPINION The management of a patient preoperatively varies by region and country. Institutions differ in approaches to preoperative evaluation and the establishment of consistent approaches would provide a platform for monitoring patient outcomes. Multidisciplinary teams and pre-assessment clinics for preoperative evaluation can enhance patient care for those undergoing surgery.
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Affiliation(s)
- Julienne K Kirk
- Department of Family and Community Medicine, Medical Center Boulevard, Atrium Health Wake Forest Baptist, Wake Forest University School of Medicine, Winston Salem, North Carolina, USA
| | - Clifford F Gonzales
- Academic Nursing, Wake Forest University School of Medicine, Winston Salem, North Carolina
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Sandhu S, Virani A, Salmonson H, Damji K, Mathura P, Al-Agha R. Implementing a Diabetic Algorithm for Ophthalmology Surgery Patients: A Quality Improvement Initiative. GLOBAL JOURNAL ON QUALITY AND SAFETY IN HEALTHCARE 2022; 5:93-99. [PMID: 37260931 PMCID: PMC10229036 DOI: 10.36401/jqsh-21-18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 07/18/2022] [Accepted: 08/30/2022] [Indexed: 06/02/2023]
Abstract
Introduction The objective of this quality improvement, interventional study regarding patients with diabetes undergoing diabetic ophthalmology outpatient surgery aimed to develop, implement, and evaluate a new diabetic algorithm to improve safety, operating room efficiency, and decrease supply cost. Methods A multidisciplinary study team was assembled, including ophthalmologists, endocrinologists, anesthesiologists, management, and nurses to review the current diabetic protocol. From August 2016 to July 2017, 13 patient safety concerns or incident reports were reviewed that identified two serious cases of hypoglycemia. Using the concerns data, frontline perspectives, and reviewing best practice guidelines, a new diabetic algorithm was developed and trialed for 24 months. The new algorithm limited the use of an existing preoperative insulin protocol and reduced the number of nurses required. The number of adverse events, nursing setup process steps, setup time, and preoperative insulin infusion protocols used were collected. An evaluation of the supply costs was performed. Results After implementing the new diabetic algorithm, zero safety incidents were reported, and a 97.5% reduction in the use of preoperative insulin protocol resulted. Nursing staff perceived that the new diabetic algorithm was easier to configure, 23 minutes faster to set up, and required one nursing staff member. Supply cost was reduced by $30.63 (Canadian Dollars, CAD) per patient. Conclusion Perioperative glucose irregularities may threaten patient safety and surgical outcomes. Healthcare professionals must improve patient safety, decrease healthcare expenditure, and prevent unnecessary delays. Multidisciplinary frontline staff experiential knowledge aided in the recognition of potential problems and comprehensive solutions to optimize patient care.
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Affiliation(s)
- Simrenjeet Sandhu
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, AB, Canada
| | | | - Hilary Salmonson
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, AB, Canada
| | - Karim Damji
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, AB, Canada
- Department of Ophthalmology and Visual Sciences, Aga Khan University, Karachi, Pakistan
| | - Pamela Mathura
- Department of Ophthalmology and Visual Sciences, Aga Khan University, Karachi, Pakistan
| | - Rany Al-Agha
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
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Rupprecht B, Stöckl A, Stöckl S, Dietrich C. [Treatment of diabetes mellitus in perioperative medicine-an update]. Anaesthesist 2021; 70:451-465. [PMID: 33141238 DOI: 10.1007/s00101-020-00875-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2020] [Indexed: 12/15/2022]
Abstract
Patients with diabetes who undergo a surgical intervention have an increased risk of metabolic derailment, anesthesiological complications, postoperative infections and cardiovascular events. The treatment of diabetes mellitus is subject to a continuous further development due to pharmaceutical and technical innovations. This article presents the implications of the current concepts of diabetes treatment for perioperative medicine, particularly the changes due to new oral antidiabetic agents and insulin pump treatment. Some of the currently available guidelines are discussed with respect to the care of diabetes patients in childhood and adulthood in connection with an operation. Finally, possible perspectives in the field of monitoring and treatment of diabetes patients are discussed.
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Affiliation(s)
- B Rupprecht
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
| | - A Stöckl
- Gemeinschaftspraxis Diedorf, Zertifiziertes Diabeteszentrum DDG Dres. Huß, Baur, Ziesing und Kollegen, Bei den Zäunen 2, 86420, Diedorf, Deutschland
| | - S Stöckl
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland
| | - C Dietrich
- Pädiatrische Anästhesiologie, Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum St. Marien Amberg, Mariahilfbergweg 7, 92224, Amberg, Deutschland
- Pädiatrische Anästhesiologie, Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum Weiden - Kliniken Nordoberpfalz AG, Söllnerstr. 16, 92637, Weiden, Deutschland
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5
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Perioperative Management of Systemic Diabetes Mellitus. Int Ophthalmol Clin 2020; 60:31-39. [PMID: 32576721 DOI: 10.1097/iio.0000000000000313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mate S, Bürkle T, Kapsner LA, Toddenroth D, Kampf MO, Sedlmayr M, Castellanos I, Prokosch HU, Kraus S. A method for the graphical modeling of relative temporal constraints. J Biomed Inform 2019; 100:103314. [PMID: 31629921 DOI: 10.1016/j.jbi.2019.103314] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 08/13/2019] [Accepted: 10/14/2019] [Indexed: 02/06/2023]
Abstract
Searching for patient cohorts in electronic patient data often requires the definition of temporal constraints between the selection criteria. However, beyond a certain degree of temporal complexity, the non-graphical, form-based approaches implemented in current translational research platforms may be limited when modeling such constraints. In our opinion, there is a need for an easily accessible and implementable, fully graphical method for creating temporal queries. We aim to respond to this challenge with a new graphical notation. Based on Allen's time interval algebra, it allows for modeling temporal queries by arranging simple horizontal bars depicting symbolic time intervals. To make our approach applicable to complex temporal patterns, we apply two extensions: with duration intervals, we enable the inference about relative temporal distances between patient events, and with time interval modifiers, we support counting and excluding patient events, as well as constraining numeric values. We describe how to generate database queries from this notation. We provide a prototypical implementation, consisting of a temporal query modeling frontend and an experimental backend that connects to an i2b2 system. We evaluate our modeling approach on the MIMIC-III database to demonstrate that it can be used for modeling typical temporal phenotyping queries.
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Affiliation(s)
- Sebastian Mate
- Medical Centre for Information and Communication Technology, Universitätsklinikum Erlangen, Erlangen, Germany.
| | - Thomas Bürkle
- Bern University of Applied Sciences, Biel, Switzerland
| | - Lorenz A Kapsner
- Medical Centre for Information and Communication Technology, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Dennis Toddenroth
- Chair of Medical Informatics, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Marvin O Kampf
- Medical Centre for Information and Communication Technology, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Martin Sedlmayr
- Institute for Medical Informatics and Biometry, Carl Gustav Carus Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Ixchel Castellanos
- Department of Anesthesiology, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Hans-Ulrich Prokosch
- Medical Centre for Information and Communication Technology, Universitätsklinikum Erlangen, Erlangen, Germany; Chair of Medical Informatics, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Stefan Kraus
- Chair of Medical Informatics, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
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Macones GA, Caughey AB, Wood SL, Wrench IJ, Huang J, Norman M, Pettersson K, Fawcett WJ, Shalabi MM, Metcalfe A, Gramlich L, Nelson G, Wilson RD. Guidelines for postoperative care in cesarean delivery: Enhanced Recovery After Surgery (ERAS) Society recommendations (part 3). Am J Obstet Gynecol 2019; 221:247.e1-247.e9. [PMID: 30995461 DOI: 10.1016/j.ajog.2019.04.012] [Citation(s) in RCA: 156] [Impact Index Per Article: 31.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 04/02/2019] [Accepted: 04/09/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND This Enhanced Recovery After Surgery Guideline for postoperative care in cesarean delivery will provide best practice, evidenced-based recommendations for postoperative care with primarily a maternal focus. OBJECTIVE The pathway process for scheduled and unscheduled cesarean delivery for this Enhanced Recovery After Surgery cesarean delivery guideline will consider time from completion of cesarean delivery until maternal hospital discharge. STUDY DESIGN The literature search (1966-2017) used Embase and PubMed to search medical subject headings that included "Cesarean Section," "Cesarean Delivery," "Cesarean Section Delivery," and all postoperative Enhanced Recovery After Surgery items. Study selection allowed titles and abstracts to be screened by individual reviewers to identify potentially relevant articles. Metaanalyses, systematic reviews, randomized controlled studies, nonrandomized controlled studies, reviews, and case series were considered for each individual topic. Quality assessment and data analyses evaluated the quality of evidence, and recommendations were evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation system as used and described in previous Enhanced Recovery After Surgery Guidelines. RESULTS The Enhanced Recovery After Surgery cesarean delivery guideline/pathway has created a pathway for postoperative care. Specifics include sham feeding, nausea and vomiting prevention, postoperative analgesia, nutritional care, glucose control, thromboembolism prophylaxis, early mobilization, urinary drainage, and discharge counseling. A number of elements of postoperative care of women who undergo cesarean delivery are recommended, based on the evidence. CONCLUSION As the Enhanced Recovery After Surgery cesarean delivery pathway (elements/processes) are studied, implemented, audited, evaluated, and optimized by the maternity care teams, there will be an opportunity for focused and optimized areas of care and recommendations to be further enhanced.
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Affiliation(s)
- George A Macones
- Department of Obstetrics & Gynecology, Washington University in St Louis, St. Louis, MO.
| | - Aaron B Caughey
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR
| | - Stephen L Wood
- Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ian J Wrench
- Sheffield Teaching Hospitals Trust, Royal Hallamshire Hospital, Glossop Road, Sheffield, United Kingdom
| | | | - Mikael Norman
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Karin Pettersson
- Division of Obstetrics, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - William J Fawcett
- Department of Anaesthesia, Royal Surrey County Hospital, Egerton Road, Guildford, United Kingdom
| | - Medhat M Shalabi
- Departments of Anesthesiology and Intensive Care, Alzahra Hospital, Dubai, United Arab Emirates
| | - Amy Metcalfe
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR
| | - Leah Gramlich
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Gregg Nelson
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR
| | - R Douglas Wilson
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR
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Kim H, Han J, Jung SM, Park SJ, Kwon NK. Comparison of sevoflurane and propofol anesthesia on the incidence of hyperglycemia in patients with type 2 diabetes undergoing lung surgery. Yeungnam Univ J Med 2018; 35:54-62. [PMID: 31620571 PMCID: PMC6784668 DOI: 10.12701/yujm.2018.35.1.54] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/10/2018] [Accepted: 05/15/2018] [Indexed: 12/13/2022] Open
Abstract
Background The type and regimen of anesthesia may affect perioperative hyperglycemia following major surgical stress. This study compared the effects of sevoflurane and propofol on the incidence of hyperglycemia and clinical outcomes in diabetic patients undergoing lung surgery. Methods This retrospective study included 176 patients with type 2 diabetes mellitus who had undergone lung surgery. Blood glucose levels and clinical outcomes from the preoperative period to the first 2 post-operative days (PODs) were retrospectively examined in patients who received sevoflurane (group S, n= 87) and propofol (group P, n=89) for maintenance of general anesthesia. The primary endpoint was the incidence of persistent hyperglycemia (2 consecutive blood glucose levels >180 mg/dL [10.0 mmol/L]) during the perioperative period. The secondary composite endpoint was the incidence of major postoperative complications and 30-day mortality rate after surgery. Results Blood glucose levels similarly increased from the preoperative period to the second POD in both groups (p=0.857). Although blood glucose levels at 2 hours after surgery were significantly lower in group P than in group S (p=0.022; 95% confidence interval for mean difference, -27.154 to -2.090), there was no difference in the incidence of persistent hyperglycemia during the perioperative period (group S, 70%; group P, 69%; p=0.816). The composite of major postoperative complications and all-cause in-hospital and 30-day mortality rates were also comparable between the two groups. Conclusion Sevoflurane and propofol were associated with a comparable incidence of perioperative hyperglycemia and clinical outcomes in diabetic patients undergoing lung surgery.
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Affiliation(s)
- Hyuckgoo Kim
- Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Jisoo Han
- Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Sung Mee Jung
- Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Sang-Jin Park
- Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Nyeong Keon Kwon
- Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu, Korea
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9
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Brown R, Paul J. Metformin for the management of peri-operative hyperglycaemia. Diabetes Obes Metab 2018; 20:753-754. [PMID: 29119660 DOI: 10.1111/dom.13154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 11/02/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Russell Brown
- Faculty of Health Sciences, Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - James Paul
- Faculty of Health Sciences, Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
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Pontes JPJ, Mendes FF, Vasconcelos MM, Batista NR. [Evaluation and perioperative management of patients with diabetes mellitus. A challenge for the anesthesiologist]. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2018; 68:75-86. [PMID: 28571661 PMCID: PMC9391782 DOI: 10.1016/j.bjan.2017.04.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 01/04/2017] [Accepted: 04/12/2017] [Indexed: 11/27/2022]
Abstract
Diabetes mellitus (DM) is characterized by alteration in carbohydrate metabolism, leading to hyperglycemia and increased perioperative morbidity and mortality. It evolves with diverse and progressive physiological changes, and the anesthetic management requires attention regarding this disease interference in multiple organ systems and their respective complications. Patient's history, physical examination, and complementary exams are important in the preoperative management, particularly glycosylated hemoglobin (HbA1c), which has a strong predictive value for complications associated with diabetes. The goal of surgical planning is to reduce the fasting time and maintain the patient's routine. Patients with Type 1 DM must receive insulin (even during the preoperative fast) to meet the basal physiological demands and avoid ketoacidosis. Whereas patients with Type 2 DM treated with multiple injectable and/or oral drugs are susceptible to develop a hyperglycemic hyperosmolar state (HHS). Therefore, the management of hypoglycemic agents and different types of insulin is fundamental, as well as determining the surgical schedule and, consequently, the number of lost meals for dose adjustment and drug suspension. Current evidence suggests the safe target to maintain glycemic control in surgical patients, but does not conclude whether it should be obtained with either moderate or severe glycemic control.
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11
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Evaluation and perioperative management of patients with diabetes mellitus. A challenge for the anesthesiologist. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2018. [PMID: 28571661 PMCID: PMC9391782 DOI: 10.1016/j.bjane.2017.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Diabetes mellitus (DM) is characterized by alteration in carbohydrate metabolism, leading to hyperglycemia and increased perioperative morbidity and mortality. It evolves with diverse and progressive physiological changes, and the anesthetic management requires attention regarding this disease interference in multiple organ systems and their respective complications. Patient's history, physical examination, and complementary exams are important in the preoperative management, particularly glycosylated hemoglobin (HbA1c), which has a strong predictive value for complications associated with diabetes. The goal of surgical planning is to reduce the fasting time and maintain the patient's routine. Patients with Type 1 DM must receive insulin (even during the preoperative fast) to meet the basal physiological demands and avoid ketoacidosis. Whereas patients with Type 2 DM treated with multiple injectable and/or oral drugs are susceptible to develop a hyperglycemic hyperosmolar state (HHS). Therefore, the management of hypoglycemic agents and different types of insulin is fundamental, as well as determining the surgical schedule and, consequently, the number of lost meals for dose adjustment and drug suspension. Current evidence suggests the safe target to maintain glycemic control in surgical patients, but does not conclude whether it should be obtained with either moderate or severe glycemic control.
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12
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Yoshida N, Midorikawa Y, Higaki T, Nakayama H, Tsuji S, Matsuoka S, Ishihara H, Moriyama M, Takayama T. Diabetes mellitus not an unfavorable factor on the prognosis of hepatitis C virus-related hepatocellular carcinoma. Hepatol Res 2018; 48:28-35. [PMID: 28258663 DOI: 10.1111/hepr.12888] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 02/27/2017] [Accepted: 02/28/2017] [Indexed: 02/08/2023]
Abstract
AIM Diabetes mellitus (DM) is a potential risk factor for hepatocarcinogenesis, especially in patients with hepatitis C virus (HCV) infection. We aimed to elucidate whether DM influences the surgical outcomes of patients with hepatocellular carcinoma (HCC). METHODS Our patients were routinely controlled to keep urinary glucose excretion to less than 3.0 g/day before surgery, and the serum glucose level under 200 mg/dL after surgery. The surgical outcomes and postoperative complications of 112 patients with HCV-related HCC with DM (DM group) were compared to those of 112 propensity-matched patients without DM (non-DM group). RESULTS After a median follow-up of 3.2 years (range, 0.2-11.3 years), the median overall (5.2 years; 95% confidence interval, 3.8-6.5 years) and recurrence-free survival (2.2 years; 1.7-2.9 years) in the DM group were not significantly different from those (6.3 years; 5.4-7.1 years, P = 0.337; and 2.2 years; 1.7-3.6 years, P = 0.613) in the non-DM group. The independent factors related to overall survival were the background liver (hazard ratio, 2.06; 95% confidence interval, 1.27-3.39, P = 0.014) and tumor differentiation grade (2.07; 1.14-4.05, P = 0.015). Thirty-two patients (28.5%) in the DM group and 32 patients (28.5%) in the non-DM group had morbidities after operation, with no significant difference between the groups (P = 1.000). Furthermore, postoperative control status of DM did not affect the prognostic outcome. CONCLUSION Diabetes mellitus does not affect the surgical outcomes of patients with HCV-related HCC, and it is not an unfavorable factor when selecting candidates for liver resection of HCC.
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Affiliation(s)
- Naoki Yoshida
- Departments of Digestive Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Yutaka Midorikawa
- Departments of Digestive Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Tokio Higaki
- Departments of Digestive Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Hisashi Nakayama
- Departments of Digestive Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Shingo Tsuji
- Genome Science Division, Research Center for Advanced Science and Technologies, The University of Tokyo, Tokyo, Japan
| | - Shunichi Matsuoka
- Gastroenterology and Hepatology, Nihon University School of Medicine, Tokyo, Japan
| | - Hisamitsu Ishihara
- Diabetes and Metabolic Diseases, Nihon University School of Medicine, Tokyo, Japan
| | - Mitsuhiko Moriyama
- Gastroenterology and Hepatology, Nihon University School of Medicine, Tokyo, Japan
| | - Tadatoshi Takayama
- Departments of Digestive Surgery, Nihon University School of Medicine, Tokyo, Japan
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Leung V, Ragbir-Toolsie K. Perioperative Management of Patients with Diabetes. Health Serv Insights 2017; 10:1178632917735075. [PMID: 29162977 PMCID: PMC5692120 DOI: 10.1177/1178632917735075] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Accepted: 08/30/2017] [Indexed: 12/18/2022] Open
Abstract
Hyperglycemia has long been recognized to have detrimental effects on postoperative outcomes in patients undergoing surgery. The manifestations of uncontrolled diabetes are manifold and can include risk of hyperglycemic crises, postoperative infection, poor wound healing, and increased mortality. There is substantial literature supporting the role of diligent glucose control in the prevention of adverse surgical outcomes, but considerable debate remains as to the optimal glucose targets. Hence, most organizations advocate the avoidance of hypoglycemia while striving for adequate glucose control in the perioperative period. These objectives can be accomplished with careful preoperative evaluation, clear patient instructions the day of surgery, frequent blood glucose monitoring during the perioperative period, and use of effective strategies for insulin initiation and titration. This article highlights the major issues concerning patients with diabetes undergoing surgery and reviews the management recommendations put forth by general consensus guidelines and expert opinion.
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Affiliation(s)
- Vivien Leung
- Division of Endocrinology, Bronx-Lebanon Hospital Center, Bronx, NY, USA.,Department of Medicine, Mount Sinai School of Medicine, New York, NY, USA
| | - Kristal Ragbir-Toolsie
- Division of Geriatric Medicine, North Shore University Hospital/Long Island Jewish Medical Center, Manhasset, NY, USA
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14
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Zwissler B. Preoperative evaluation of adult patients before elective, noncardiothoracic surgery. Anaesthesist 2017; 68:25-39. [DOI: 10.1007/s00101-017-0376-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Cornelius BW. Patients With Type 2 Diabetes: Anesthetic Management in the Ambulatory Setting. Part 1: Pathophysiology and Associated Disease States. Anesth Prog 2017; 63:208-215. [PMID: 27973934 DOI: 10.2344/0003-3006-63.4.208] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
The increasing prevalence of diabetes mellitus in the general population has many implications for the ambulatory anesthesia provider. Complications, particularly associated with poor glycemic control, can affect multiple organ systems and jeopardize the safety of any planned anesthetic. It is essential that anesthesiologists and sedation providers have in-depth knowledge of the pathophysiology of diabetes mellitus and the comorbid conditions that commonly accompany it. Anesthesiologists and sedation providers must also understand certain surgical and anesthetic considerations when planning an effective and safe anesthetic for diabetic patients. This is a 2-part series concerning perioperative glycemic control for patients with diabetes mellitus. Part 1 will focus on the physiology of diabetes and its associated disease states. Part 2 will address the pharmacology associated with the wide variety of medications used to treat the disorder and the most recent guidelines for blood glucose management in ambulatory surgical patients.
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Affiliation(s)
- Bryant W Cornelius
- Assistant Professor, Department of Dental Anesthesiology, University of Pittsburgh School of Dental Medicine, Pittsburgh, Pennsylvania
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Zwissler B. Präoperative Evaluation erwachsener Patienten vor elektiven, nicht Herz-Thorax-chirurgischen Eingriffen. Anaesthesist 2017; 66:442-458. [DOI: 10.1007/s00101-017-0321-5] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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17
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Goh SNS, Yeoh E, Tan KY. Impact of perioperative hypoglycaemia in subjects with diabetes undergoing colorectal surgery. Int J Colorectal Dis 2017; 32:209-214. [PMID: 27864588 DOI: 10.1007/s00384-016-2680-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/11/2016] [Indexed: 02/04/2023]
Abstract
INTRODUCTION This study explores the association between perioperative hypoglycaemia and surgical outcomes in subjects with diabetes, undergoing colorectal surgery. METHODS A retrospective review of 149 subjects with Type 2 Diabetes Mellitus (DM) who underwent colorectal surgery between 2010 and 2015 was performed. Perioperative glucose levels, glycated haemoglobin (HbA1c) measurements within 3 months of surgery and surgical complications based on Clavien-Dindo classification were analysed. RESULTS The mean age was 67 years (67 ± 11.2). Perioperative hypoglycaemia was found in 7.4% of subjects. The mean HbA1c of subjects with Clavien 2 and above surgical complications were higher than patients with Clavien 1 or no complications, Hba1c 7.6% (7.6 ± 2.5%) and 7.0% (7.0 ± 1.1%, p = 0.008), respectively. Similar findings in subjects with Clavien 3 and above complications, HbA1c of 8.2% (8.2 ± 3.9%) as compared to those with Clavien 2 and below complications, 7.2% (7.2 ± 1.5%, p = 0.001). Adjusted multivariate analysis showed that hypoglycaemia was significantly associated with Clavien 2 and above surgical complications, OR of 19.0 (CI 2.23-162, p = 0.007). Preoperative hypoglycaemia was associated with Clavien 2 and above surgical complications, OR 10.7 (CI 1.22-94.1, p = 0.032). Suboptimal glycaemic control (Hba1c >8.0%) was significantly associated with Clavien 2 and above complications, OR 2.48 (CI 1.04-5.91, p = 0.04), but not with Clavien 3 and above complications, OR 1.50 (CI 0.450-4.98, p = 0.511). CONCLUSION Perioperative hypoglycaemia is associated with adverse surgical outcomes in diabetic patients undergoing colorectal surgery. Prevention of hypoglycaemia may improve surgical outcomes. HbA1c is an independent predictor for adverse surgical outcomes.
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Affiliation(s)
- Si Ning Serene Goh
- Department of General Surgery, Khoo Teck Puat Hospital, Singapore, Singapore.
| | - Ester Yeoh
- Diabetes Centre, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Kok Yang Tan
- Department of General Surgery, Khoo Teck Puat Hospital, Singapore, Singapore
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Cornelius BW. Patients With Type 2 Diabetes: Anesthetic Management in the Ambulatory Setting: Part 2: Pharmacology and Guidelines for Perioperative Management. Anesth Prog 2017; 64:39-44. [PMID: 28128657 PMCID: PMC5278535 DOI: 10.2344/anpr-64-01-02] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 11/28/2016] [Indexed: 01/05/2023] Open
Abstract
Type 2 diabetes is a disease of metabolism in which the afflicted patient cannot properly utilize carbohydrates, fats, and proteins. Because the prevalence of type 2 diabetes is rapidly increasing throughout the general population, anesthesia providers must realize that a significant percentage of their patients will present with the disease. Anesthesia providers should have an intimate knowledge of the comorbidities and complications that are associated with type 2 diabetes and know the specific pharmacokinetics and pharmacodynamics of the drugs used to treat the disease. Part 1 of this series on the anesthetic management of type 2 diabetes in the ambulatory theater addressed the pathology of diabetes and its comorbid disease states. Part 2 of the series now focuses on the pharmacology associated with the many medications used to treat the disorder and the most recent guidelines for blood glucose management recommended for patients in an ambulatory surgery setting.
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Affiliation(s)
- Bryant W. Cornelius
- Assistant Professor, Department of Dental Anesthesiology, University of Pittsburgh School of Dental Medicine, Pittsburgh, Pennsylvania
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19
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Yang MH, Jaeger M, Baxter M, VanDenKerkhof E, van Vlymen J. Postoperative dysglycemia in elective non-diabetic surgical patients: a prospective observational study. Can J Anaesth 2016; 63:1319-1334. [DOI: 10.1007/s12630-016-0742-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 06/14/2016] [Accepted: 09/14/2016] [Indexed: 10/20/2022] Open
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20
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Cummins BM, Ligler FS, Walker GM. Point-of-care diagnostics for niche applications. Biotechnol Adv 2016; 34:161-76. [PMID: 26837054 PMCID: PMC4833668 DOI: 10.1016/j.biotechadv.2016.01.005] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 01/28/2016] [Accepted: 01/28/2016] [Indexed: 01/26/2023]
Abstract
Point-of-care or point-of-use diagnostics are analytical devices that provide clinically relevant information without the need for a core clinical laboratory. In this review we define point-of-care diagnostics as portable versions of assays performed in a traditional clinical chemistry laboratory. This review discusses five areas relevant to human and animal health where increased attention could produce significant impact: veterinary medicine, space travel, sports medicine, emergency medicine, and operating room efficiency. For each of these areas, clinical need, available commercial products, and ongoing research into new devices are highlighted.
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Affiliation(s)
- Brian M Cummins
- Joint Department of Biomedical Engineering, University of North Carolina - Chapel Hill and North Carolina State University, Raleigh, NC, 27695, USA
| | - Frances S Ligler
- Joint Department of Biomedical Engineering, University of North Carolina - Chapel Hill and North Carolina State University, Raleigh, NC, 27695, USA
| | - Glenn M Walker
- Joint Department of Biomedical Engineering, University of North Carolina - Chapel Hill and North Carolina State University, Raleigh, NC, 27695, USA.
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21
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Pereira VR, Azuma RA, Gatto BEO, Silva Junior JM, Carmona MJC, Malbouisson LMS. [Hyperglycemia assessment in the post-anesthesia care unit]. Rev Bras Anestesiol 2016; 67:565-570. [PMID: 27005828 DOI: 10.1016/j.bjan.2015.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Accepted: 08/17/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Hyperglycemia in surgical patients may cause serious problems. Analyzing this complication in this scenario contributes to improve the management of these patients. The aim of this study was to evaluate the prevalence of hyperglycemia in the post-anesthetic care unit (PACU) in non-diabetic patients undergoing elective surgery and analyze the possible risk factors associated with this complication. METHODS We evaluated non-diabetic patients undergoing elective surgeries and admitted in the PACU. Data were collected from medical records through precoded questionnaire. Hyperglycemia was considered when blood glucose was>120mg.dL-1. Patients with hyperglycemia were compared to normoglycemic ones to assess factors associated with the problem. We excluded patients with endocrine-metabolic disorders, diabetes, children under 18 years, body mass index (BMI) below 18 or above 35, pregnancy, postpartum or breastfeeding, history of drug use, and emergency surgeries. RESULTS We evaluated 837 patients. The mean age was 47.8±16.1 years. The prevalence of hyperglycemia in the postoperative period was 26.4%. In multivariate analysis, age (OR=1.031, 95% CI 1.017-1.045); BMI (OR=1.052, 95% CI 1.005-1.101); duration of surgery (OR=1.011, 95% CI 1.008-1.014), history of hypertension (OR=1.620, 95% CI 1.053-2.493), and intraoperative use of corticosteroids (OR=5.465, 95% CI 3.421-8.731) were independent risk factors for postoperative hyperglycemia. CONCLUSION The prevalence of hyperglycemia was high in the PACU, and factors such as age, BMI, corticosteroids, blood pressure, and duration of surgery are strongly related to this complication.
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Affiliation(s)
- Vinicius Rodovalho Pereira
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas de São Paulo, São Paulo, SP, Brasil
| | - Rodrigo Akio Azuma
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas de São Paulo, São Paulo, SP, Brasil
| | - Bruno Emanuel Oliva Gatto
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas de São Paulo, São Paulo, SP, Brasil
| | - João Manoel Silva Junior
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas de São Paulo, São Paulo, SP, Brasil.
| | - Maria Jose Carvalho Carmona
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas de São Paulo, São Paulo, SP, Brasil
| | - Luiz Marcelo Sá Malbouisson
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas de São Paulo, São Paulo, SP, Brasil
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22
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Quak EKY, Patil V, Patil A. Perioperative management of diabetic patients: new controversies. Br J Anaesth 2015; 115:639-40. [PMID: 26385679 DOI: 10.1093/bja/aev318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Aldam P, Levy NA, Hall GM. Perioperative management of diabetic patients: new controversies--authors' reply. Br J Anaesth 2015; 115:640-1. [PMID: 26385680 DOI: 10.1093/bja/aev319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Evans MT, Kelliher LJS. Perioperative management of diabetic patients: new controversies. Br J Anaesth 2015; 115:638-9. [PMID: 26385678 DOI: 10.1093/bja/aev316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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El Messaoudi S, Nederlof R, Zuurbier CJ, van Swieten HA, Pickkers P, Noyez L, Dieker HJ, Coenen MJ, Donders ART, Vos A, Rongen GA, Riksen NP. Effect of metformin pretreatment on myocardial injury during coronary artery bypass surgery in patients without diabetes (MetCAB): a double-blind, randomised controlled trial. Lancet Diabetes Endocrinol 2015; 3:615-23. [PMID: 26179504 DOI: 10.1016/s2213-8587(15)00121-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 04/15/2015] [Accepted: 04/17/2015] [Indexed: 12/24/2022]
Abstract
BACKGROUND During coronary artery bypass graft (CABG) surgery, ischaemia and reperfusion damage myocardial tissue, and increased postoperative plasma troponin concentration is associated with a worse outcome. We investigated whether metformin pretreatment limits cardiac injury, assessed by troponin concentrations, during CABG surgery in patients without diabetes. METHODS We did a placebo-controlled, double-blind, single-centre study in an academic hospital in Nijmegen (Netherlands) in adult patients without diabetes undergoing an elective on-pump CABG procedure. We randomly assigned patients (1:1) in blocks of ten via a computer-generated randomisation sequence to either metformin hydrochloride (500 mg three times per day) or placebo (three times per day) for 3 days before surgery. The last dose was given roughly 3 h before surgery. Patients, investigators, trial staff, and the statistician were all masked to treatment allocation. The primary endpoint was the plasma concentration of high-sensitive troponin I at 6, 12, and 24 h postreperfusion after surgery, analysed in the per-protocol population with a mixed-model analysis using all these timepoints. Secondary endpoints included the occurrence of clinically relevant arrhythmias within 24 hours after reperfusion, the need for inotropic support, time to detubation, duration of stay in the intensive-care unit, and postoperative use of insulin. This study is registered with ClinicalTrials.gov, number NCT01438723. FINDINGS Between Nov 8, 2011, and Nov 22, 2013, we randomly assigned 111 patients to treatment (57 to metformin and 54 to placebo). Five patients dropped out from the metformin group, and six from the placebo group. 52 patients in the metformin group and 48 patients in the placebo group were included in the per-protocol analysis. Geometric mean high-sensitivity troponin I increased from 0 μg/L to 3·67 μg/L (95% CI 3·06-4·41) with metformin and to 3·32 μg/L (2·75-4·01) with placebo at 6 h after reperfusion; 2·84 μg/L (2·37-3·41) and 2·45 μg/L (2·02-2·96), respectively, at 12 h; and to 1·77 μg/L (1·47-2·12) and 1·60 μg/L (1·32-1·94) at 24 h. The concentrations did not differ significantly between the groups (difference 12·3% for all timepoints [95% CI -12·4 to 44·1] p=0·35). Occurrence of arrhythmias did not differ between groups (three [5·8%] of 52 patients who received metformin vs three [6·3%] of 48 patients who received placebo; p=1·00). There was no difference between groups in the need for inotropic support, time to detubation, duration of stay in the intensive-care unit, or postoperative use of insulin. No patients died within 30 days after surgery. Occurrence of gastrointestinal discomfort (mostly diarrhoea) was significantly higher with metformin than with placebo (11 [21·2%] of 52 vs two [4·2%] of 48 patients; p=0·01). INTERPRETATION Short-term metformin pretreatment, although safe, does not seem to be an effective strategy to reduce periprocedural myocardial injury in patients without diabetes undergoing CABG surgery. FUNDING Netherlands Organisation for Health Research and Development and Netherlands Heart Foundation.
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Affiliation(s)
- Saloua El Messaoudi
- Department of Pharmacology-Toxicology, Radboud University Medical Center, Nijmegen, Netherlands; Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Rianne Nederlof
- Laboratory of Experimental Intensive Care and Anesthesiology, Department of Anesthesiology, Academic Medical Center, Amsterdam, Netherlands
| | - Coert J Zuurbier
- Laboratory of Experimental Intensive Care and Anesthesiology, Department of Anesthesiology, Academic Medical Center, Amsterdam, Netherlands
| | - Henry A van Swieten
- Department of Cardiothoracic Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Luc Noyez
- Department of Cardiothoracic Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Hendrik-Jan Dieker
- Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Marieke J Coenen
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, Netherlands
| | - A Rogier T Donders
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, Netherlands
| | - Annemieke Vos
- Department of Pharmacology-Toxicology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Gerard A Rongen
- Department of Pharmacology-Toxicology, Radboud University Medical Center, Nijmegen, Netherlands; Department of Internal Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Niels P Riksen
- Department of Pharmacology-Toxicology, Radboud University Medical Center, Nijmegen, Netherlands; Department of Internal Medicine, Radboud University Medical Center, Nijmegen, Netherlands.
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