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Habermann A, Widaeus M, Soltani N, Myles PS, Hallqvist L, Bell M. Days at home alive after major surgery in patients with and without diabetes: an observational cohort study. Perioper Med (Lond) 2024; 13:4. [PMID: 38254223 PMCID: PMC10802053 DOI: 10.1186/s13741-023-00357-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 12/29/2023] [Indexed: 01/24/2024] Open
Abstract
OBJECTIVE We hypothesized that days at home alive up to 30 days after surgery (DAH30), a novel patient-centered outcome metric, as well as long-term mortality, would be impaired in patients with type 1 or 2 diabetes mellitus (DM) undergoing major surgery. METHODS This cohort study investigated patients > 18 years with and without DM presenting for major non-cardiovascular, non-ambulatory surgical procedures at 23 hospitals in Sweden between 2007 and 2014. We identified 290,306 patients. Data were matched with various quality registers. The primary outcome was the composite score, DAH30. The secondary outcome was mortality from 31 to 365 days. Using multivariable logistic regression, significant independent risk factors influencing the primary and secondary outcomes were identified, and their adjusted odds ratios were calculated. RESULTS Patients with DM type 1 and 2 had significantly lower DAH30 as compared to non-diabetics. Patients with DM were older, had higher co-morbid burden, and needed more emergency surgery. After adjustment for illness severity and age, the odds of having a DAH30 less than 15, indicating death and/or complications, were significantly increased for both type 1 and type 2 diabetes. In the year after surgery, DM patients had a higher mortality as compared to those without diabetes. CONCLUSIONS The results of this large cohort study are likely broadly generalizable. To optimize patient and societal outcomes, specific perioperative care pathways for patients with diabetes should be evaluated.
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Affiliation(s)
- Amanda Habermann
- Department of Anaesthesia and Intensive Care Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Matilda Widaeus
- Department of Anaesthesia and Intensive Care Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Navid Soltani
- Department of Anaesthesia and Intensive Care Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, VIC, Australia
| | - Linn Hallqvist
- Department of Anaesthesia and Intensive Care Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Max Bell
- Department of Anaesthesia and Intensive Care Medicine, Karolinska University Hospital, Stockholm, Sweden.
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden.
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Tan G, Li Y, Zhou G. The connotation between perioperative glycemic control approach and sternal wound infection in individuals with diabetes mellitus experiencing cardiac surgery: A meta-analysis. Int Wound J 2023; 20:3324-3330. [PMID: 37190865 PMCID: PMC10502249 DOI: 10.1111/iwj.14213] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 03/27/2023] [Accepted: 04/14/2023] [Indexed: 05/17/2023] Open
Abstract
A meta-analysis investigation to measure the connotation between perioperative glycemic control (GC) approach and sternal wound infection (SWI) in individuals with diabetes mellitus (DM) experiencing cardiac surgery (CS). A comprehensive literature inspection till February 2023 was applied and 2654 interrelated investigations were reviewed. The 12 chosen investigations enclosed 1564 individuals with DM and CS in the chosen investigations' starting point, 790 of them were using strict GC, and 774 were using moderate GC. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to compute the value of the Connotation between the perioperative GC approach and SWI in individuals with DM experiencing CS by the dichotomous and continuous approaches and a fixed or random model. Strict GC had significantly lower SWI (OR, 0.33; 95% CI, -0.22-0.50, P < .001) compared with those with moderate GC in individuals with DM and CS. Strict GC had significantly lower SWI compared with those with moderate GC in individuals with DM and CS. However, caused of the small sample sizes of several chosen investigations for this meta-analysis, care must be exercised when dealing with its values.
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Affiliation(s)
- Gang Tan
- Department of Cardiovascular MedicineSichuan Academy of Medical Sciences & Sichuan Provincial People's HospitalSichuanChina
| | - Yongfang Li
- Department of EndoscopySichuan Academy of Medical Sciences & Sichuan Provincial People's HospitalSichuanChina
| | - Guangpeng Zhou
- Department of EndocrinologySichuan Academy of Medical Sciences & Sichuan Provincial People's HospitalSichuanChina
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Bellon F, Solà I, Gimenez-Perez G, Hernández M, Metzendorf MI, Rubinat E, Mauricio D. Perioperative glycaemic control for people with diabetes undergoing surgery. Cochrane Database Syst Rev 2023; 8:CD007315. [PMID: 37526194 PMCID: PMC10392034 DOI: 10.1002/14651858.cd007315.pub3] [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] [Indexed: 08/02/2023]
Abstract
BACKGROUND People with diabetes mellitus are at increased risk of postoperative complications. Data from randomised clinical trials and meta-analyses point to a potential benefit of intensive glycaemic control, targeting near-normal blood glucose, in people with hyperglycaemia (with and without diabetes mellitus) being submitted for surgical procedures. However, there is limited evidence concerning this question in people with diabetes mellitus undergoing surgery. OBJECTIVES To assess the effects of perioperative glycaemic control for people with diabetes undergoing surgery. SEARCH METHODS For this update, we searched the databases CENTRAL, MEDLINE, LILACS, WHO ICTRP and ClinicalTrials.gov. The date of last search for all databases was 25 July 2022. We applied no language restrictions. SELECTION CRITERIA We included randomised controlled clinical trials (RCTs) that prespecified different targets of perioperative glycaemic control for participants with diabetes (intensive versus conventional or standard care). DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed the risk of bias. Our primary outcomes were all-cause mortality, hypoglycaemic events and infectious complications. Secondary outcomes were cardiovascular events, renal failure, length of hospital and intensive care unit (ICU) stay, health-related quality of life, socioeconomic effects, weight gain and mean blood glucose during the intervention. We summarised studies using meta-analysis with a random-effects model and calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes, using a 95% confidence interval (CI), or summarised outcomes with descriptive methods. We used the GRADE approach to evaluate the certainty of the evidence (CoE). MAIN RESULTS A total of eight additional studies were added to the 12 included studies in the previous review leading to 20 RCTs included in this update. A total of 2670 participants were randomised, of which 1320 were allocated to the intensive treatment group and 1350 to the comparison group. The duration of the intervention varied from during surgery to five days postoperative. No included trial had an overall low risk of bias. Intensive glycaemic control resulted in little or no difference in all-cause mortality compared to conventional glycaemic control (130/1263 (10.3%) and 117/1288 (9.1%) events, RR 1.08, 95% CI 0.88 to 1.33; I2 = 0%; 2551 participants, 18 studies; high CoE). Hypoglycaemic events, both severe and non-severe, were mainly experienced in the intensive glycaemic control group. Intensive glycaemic control may slightly increase hypoglycaemic events compared to conventional glycaemic control (141/1184 (11.9%) and 41/1226 (3.3%) events, RR 3.36, 95% CI 1.69 to 6.67; I2 = 64%; 2410 participants, 17 studies; low CoE), as well as those considered severe events (37/927 (4.0%) and 6/969 (0.6%), RR 4.73, 95% CI 2.12 to 10.55; I2 = 0%; 1896 participants, 11 studies; low CoE). Intensive glycaemic control, compared to conventional glycaemic control, may result in little to no difference in the rate of infectious complications (160/1228 (13.0%) versus 224/1225 (18.2%) events, RR 0.75, 95% CI 0.55 to 1.04; P = 0.09; I2 = 55%; 2453 participants, 18 studies; low CoE). Analysis of the predefined secondary outcomes revealed that intensive glycaemic control may result in a decrease in cardiovascular events compared to conventional glycaemic control (107/955 (11.2%) versus 125/978 (12.7%) events, RR 0.73, 95% CI 0.55 to 0.97; P = 0.03; I2 = 44%; 1454 participants, 12 studies; low CoE). Further, intensive glycaemic control resulted in little or no difference in renal failure events compared to conventional glycaemic control (137/1029 (13.3%) and 158/1057 (14.9%), RR 0.92, 95% CI 0.69 to 1.22; P = 0.56; I2 = 38%; 2086 participants, 14 studies; low CoE). We found little to no difference between intensive glycaemic control and conventional glycaemic control in length of ICU stay (MD -0.10 days, 95% CI -0.57 to 0.38; P = 0.69; I2 = 69%; 1687 participants, 11 studies; low CoE), and length of hospital stay (MD -0.79 days, 95% CI -1.79 to 0.21; P = 0.12; I2 = 77%; 1520 participants, 12 studies; very low CoE). Due to the differences within included studies, we did not pool data for the reduction of mean blood glucose. Intensive glycaemic control resulted in a mean lowering of blood glucose, ranging from 13.42 mg/dL to 91.30 mg/dL. One trial assessed health-related quality of life in 12/37 participants in the intensive glycaemic control group, and 13/44 participants in the conventional glycaemic control group; no important difference was shown in the measured physical health composite score of the short-form 12-item health survey (SF-12). One substudy reported a cost analysis of the population of an included study showing a higher total hospital cost in the conventional glycaemic control group, USD 42,052 (32,858 to 56,421) compared to the intensive glycaemic control group, USD 40,884 (31.216 to 49,992). It is important to point out that there is relevant heterogeneity between studies for several outcomes. We identified two ongoing trials. The results of these studies could add new information in future updates on this topic. AUTHORS' CONCLUSIONS High-certainty evidence indicates that perioperative intensive glycaemic control in people with diabetes undergoing surgery does not reduce all-cause mortality compared to conventional glycaemic control. There is low-certainty evidence that intensive glycaemic control may reduce the risk of cardiovascular events, but cause little to no difference to the risk of infectious complications after the intervention, while it may increase the risk of hypoglycaemia. There are no clear differences between the groups for the other outcomes. There are uncertainties among the intensive and conventional groups regarding the optimal glycaemic algorithm and target blood glucose concentrations. In addition, we found poor data on health-related quality of life, socio-economic effects and weight gain. It is also relevant to underline the heterogeneity among studies regarding clinical outcomes and methodological approaches. More studies are needed that consider these factors and provide a higher quality of evidence, especially for outcomes such as hypoglycaemia and infectious complications.
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Affiliation(s)
- Filip Bellon
- Healthcare Research Group (GRECS), Institute of Biomedical Research in Lleida (IRBLleida), Lleida, Spain
- GESEC group, Department of Nursing and Physiotherapy, Faculty of Nursing and Physiotherapy, University of Lleida, Lleida, Spain
| | - Ivan Solà
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Gabriel Gimenez-Perez
- Endocrinology Section, Department of Medicine, Hospital General de Granollers, Granollers, Spain
- Department of Medicine, Faculty of Medicine and Health Sciences, Universitat Internacional de Catalunya, Sant Cugat del Vallés, Spain
| | - Marta Hernández
- Department of Endocrinology and Nutrition, Hospital Universitari Arnau de Vilanova, Institut de Recerca Biomèdica de Lleida (IRBLLEIDA), Lleida, Spain
| | - Maria-Inti Metzendorf
- Institute of General Practice, Medical Faculty of the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Esther Rubinat
- Healthcare Research Group (GRECS), Institute of Biomedical Research in Lleida (IRBLleida), Lleida, Spain
- GESEC group, Department of Nursing and Physiotherapy, Faculty of Nursing and Physiotherapy, University of Lleida, Lleida, Spain
- CIBER of Diabetes and Associated Metabolic Disease, Barcelona, Spain
| | - Didac Mauricio
- CIBER of Diabetes and Associated Metabolic Disease, Barcelona, Spain
- Department of Endocrinology and Nutrition, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Department of Medicine, Faculty of Medicine, University of Vic & Central University of Catalonia, Vic, Spain
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Sreedharan R, Khanna S, Shaw A. Perioperative glycemic management in adults presenting for elective cardiac and non-cardiac surgery. Perioper Med (Lond) 2023; 12:13. [PMID: 37120562 PMCID: PMC10149003 DOI: 10.1186/s13741-023-00302-6] [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: 11/30/2021] [Accepted: 04/19/2023] [Indexed: 05/01/2023] Open
Abstract
Perioperative dysglycemia is associated with adverse outcomes in both cardiac and non-cardiac surgical patients. Hyperglycemia in the perioperative period is associated with an increased risk of postoperative infections, length of stay, and mortality. Hypoglycemia can induce neuronal damage, leading to significant cognitive deficits, as well as death. This review endeavors to summarize existing literature on perioperative dysglycemia and provides updates on pharmacotherapy and management of perioperative hyperglycemia and hypoglycemia in surgical patients.
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Affiliation(s)
- Roshni Sreedharan
- Department of Intensive Care & Resuscitation, Cleveland Clinic Foundation, Cleveland, OH, USA
- Department of General Anesthesiology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Sandeep Khanna
- Department of General Anesthesiology, Cleveland Clinic Foundation, Cleveland, OH, USA.
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic Foundation, Cleveland, OH, USA.
- Department of Outcomes Research, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - Andrew Shaw
- Department of Intensive Care & Resuscitation, Cleveland Clinic Foundation, Cleveland, OH, USA
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Surgical Pharmacy for Optimizing Medication Therapy Management Services within Enhanced Recovery after Surgery (ERAS ®) Programs. J Clin Med 2023; 12:jcm12020631. [PMID: 36675560 PMCID: PMC9861533 DOI: 10.3390/jcm12020631] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/16/2022] [Accepted: 01/06/2023] [Indexed: 01/15/2023] Open
Abstract
Drug-related problems (DRPs) are common among surgical patients, especially older patients with polypharmacy and underlying diseases. DRPs can potentially lead to morbidity, mortality, and increased treatment costs. The enhanced recovery after surgery (ERAS) system has shown great advantages in managing surgical patients. Medication therapy management for surgical patients (established as "surgical pharmacy" by Guangdong Province Pharmaceutical Association (GDPA)) is an important part of the ERAS system. Improper medication therapy management can lead to serious consequences and even death. In order to reduce DRPs further, and promote the rapid recovery of surgical patients, the need for pharmacists in the ERAS program is even more pressing. However, the medication therapy management services of surgical pharmacy and how surgical pharmacists should participate in ERAS programs are still unclear worldwide. Therefore, this article reviews the main perioperative medical management strategies and precautions from several aspects, including antimicrobial agents, antithrombotic agents, pain medication, nutritional therapy, blood glucose monitoring, blood pressure treatment, fluid management, treatment of nausea and vomiting, and management of postoperative delirium. Additionally, the way surgical pharmacists participate in perioperative medication management, and the relevant medication pathways are explored for optimizing medication therapy management services within the ERAS programs. This study will greatly assist surgical pharmacists' work, contributing to surgeons accepting that pharmacists have an important role in the multidisciplinary team, benefitting medical workers in treating, counseling, and advocating for their patients, and further improving the effectiveness, safety and economy of medication therapy for patients and promoting patient recovery.
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ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, Collins BS, Hilliard ME, Isaacs D, Johnson EL, Kahan S, Khunti K, Leon J, Lyons SK, Perry ML, Prahalad P, Pratley RE, Seley JJ, Stanton RC, Gabbay RA, on behalf of the American Diabetes Association. 16. Diabetes Care in the Hospital: Standards of Care in Diabetes-2023. Diabetes Care 2023; 46:S267-S278. [PMID: 36507644 PMCID: PMC9810470 DOI: 10.2337/dc23-s016] [Citation(s) in RCA: 68] [Impact Index Per Article: 68.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Abstract
Hintergrund Eine Hyperglykämie bei Menschen mit und ohne Diabetes, die ins Krankenhaus eingeliefert werden, ist mit einem erheblichen Anstieg von Morbidität, Mortalität und Gesundheitskosten verbunden. Während eines Krankenhausaufenthaltes treten Stoffwechseldekompensationen häufig als Folge unterschiedlicher Ereignisse oder Zusatztherapien auf. Aufgrund des erhöhten Risikos für eine Zunahme der Morbidität, verbunden mit längerem Krankenhausaufenthalt sowie höheren Kosten und Mortalität, erscheint eine genaue Betrachtung der Bedeutung von Glukosewerten und der Therapieformen im Krankenhaus sinnvoll und angebracht. Material und Methode Aktuelle Befunde, Übersichtsarbeiten und Grundlagendaten wurden analysiert und in einer kurzen Übersicht zusammengefasst und diskutiert. Fazit Eine persistierende Hyperglykämie im Krankenhaus ist häufig und oft mit unzureichenden Ergebnissen des Krankenhausaufenthaltes verbunden. Die kontinuierliche Insulininfusion bleibt die Therapie der Wahl während hyperglykämischer Krisen und kritischen Erkrankungen. Auch bei nicht kritisch kranken Menschen mit ausgeprägter Hyperglykämie, schon ambulant bekannten hohen Insulindosen, mit Typ-1-Diabetes oder mit steroidinduzierter Hyperglykämie bleibt Insulin das Mittel der Wahl.
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Affiliation(s)
- Michael Jecht
- Diabetesschwerpunktpraxis, Rodensteinstr. 32, 13593 Berlin, Deutschland
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8
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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9
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Coleman B, Ramakrishnan K. Surgical Problems of the Digestive System. Fam Med 2022. [DOI: 10.1007/978-3-030-54441-6_100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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10
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Wang Y, Han H, Abdulrahman Salim Mzee S, Wang D, Chen J, Fan X. Feasibility of ERAS in Patients With Gastric Cancer Complicated by Diabetes Mellitus. Technol Cancer Res Treat 2022; 21:15330338221118211. [PMID: 35979622 PMCID: PMC9393351 DOI: 10.1177/15330338221118211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Enhanced Recovery After Surgery (ERAS) is the integration of multiple
perioperative evidence-based medical practices into a single pathway aimed at
eliminating surgical liabilities and improving treatment accuracy to enhance
patients' postoperative outcomes. The ERAS Society has been developing
guidelines that are widely applicable in the surgical field. ERAS pathways in
selective and noncomplicated cases are extensively practiced. However, the ERAS
literature excludes patients with comorbidities, such as gastric cancer
complicated with diabetes mellitus (DM). Current ERAS guidelines exclude
patients with DM in enhanced recovery programs because of insufficient
evidence-based medicine on the molecular physiology of the patients in response
to surgical insult. Therefore, it is important to implement accelerated
rehabilitation surgery for patients with gastric cancer and DM. This review
discusses the feasibility and necessity of applying ERAS guidelines to patients
with gastric cancer complicated by DM. In addition, we documented the need to
lay a logical foundation for enhanced recovery after surgery in patients with
gastric cancer complicated by DM.
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Affiliation(s)
- Ying Wang
- 191612Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - He Han
- 191612Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | | | | | - Jixiang Chen
- 191612Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Xin Fan
- 191612Affiliated Hospital of Jiangsu University, Zhenjiang, China
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Incalzi RA. Surgery in older patients with diabetes. JOURNAL OF GERONTOLOGY AND GERIATRICS 2021. [DOI: 10.36150/2499-6564-n464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Ruzycki SM, Harrison TG, Enns E, McKeen J, Helmle K, Cameron A. Quality gaps in screening and monitoring for postoperative hyperglycemia in a Canadian hospital: a retrospective cohort study. BMJ Open Diabetes Res Care 2021; 9:e002445. [PMID: 34711544 PMCID: PMC8557293 DOI: 10.1136/bmjdrc-2021-002445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/18/2021] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Evidence-based preoperative, intraoperative and postoperative glycemic management may reduce poor surgical outcomes. Previous studies suggest that quality gaps in perioperative glycemic management may be common. RESEARCH DESIGN AND METHODS This retrospective cohort study used administrative health and laboratory data from a single center to estimate quality gaps in perioperative glycemic management in patients with and without diabetes between April 2019 and March 2020. We examined the proportion of patients with preoperative hemoglobin A1c (HbA1c) measurement, postoperative point-of-care testing (POCT) for glucose, hyperglycemia, and basal bolus insulin regimens. We compared the median length of stay (LOS) in patients with and without postoperative hyperglycemia, adjusted for age and sex. RESULTS There were 6576 patients in our cohort; 1165 (17.8%) had diabetes. Most patients with diabetes had an HbA1c measured prior to surgery (n=697, 59.8%). Postoperatively, 16.9% of patients with diabetes had no POCT monitoring (n=197) and 65.7% had hyperglycemia (n=636). Only 35.9% of patients who received insulin had a basal bolus insulin regimen (n=229). Patients with diabetes who had postoperative hyperglycemia had a longer median LOS compared with those who did not have postoperative hyperglycemia (8.4 days (95% CI 7.5 to 9.4) and 6.7 days (95% CI 6.3 to 7.1), respectively). In patients without diabetes, median LOS was 7.4 days (95% CI 4.4 to 10.4) for those with hyperglycemia and 5.2 days (95% CI 5.1 to 5.4) for those with in-target glucose. CONCLUSIONS Quality gaps in perioperative glycemic management include measurement of blood glucose after surgery and treatment of postoperative hyperglycemia. These gaps may contribute to longer LOS.
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Affiliation(s)
- Shannon M Ruzycki
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Tyrone G Harrison
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Edwin Enns
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Julie McKeen
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Karmon Helmle
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Anna Cameron
- Department of Obstetrics and Gynecology, Cumming School of Medicine, Calgary, Alberta, Canada
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Todd LA, Vigersky RA. Evaluating Perioperative Glycemic Control of Non-cardiac Surgical Patients with Diabetes. Mil Med 2021; 186:e867-e872. [PMID: 33196796 DOI: 10.1093/milmed/usaa467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/18/2020] [Accepted: 10/21/2020] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Hyperglycemia during the perioperative period has generally been accepted as a contributor of poor outcomes in patients with diabetes mellitus undergoing surgery. Although an optimal glycemic range has not been clearly established in the literature, a consensus among national medical organizations generally recommends serum glucose levels to be maintained less than 180 mg/dL during the perioperative period. MATERIALS AND METHODS The primary purpose of this evidence-based project was to identify the range of blood glucose values obtained from adult patients with diabetes mellitus undergoing non-cardiac surgery at a large military medical facility. The secondary purpose of this project was to assess the need for change in future practice. A retrospective review of the electronic medical record was conducted to identify adult surgical patients with diabetes scheduled for non-cardiac surgery. Preoperative and postoperative blood glucose values were obtained from the electronic medical record. The frequency of blood glucose values maintained within the recommended range of 140-180 mg/dL was recorded. Additional demographic data were collected to include age, height, weight, body mass index, length of surgery, and insulin/oral glycemic medications. RESULTS Of the 9,449 surgeries performed between January 1, 2013, and December 31, 2013, there were 762 (8%) adult non-cardiac surgical patients identified with either a diagnosis of diabetes or a blood glucose value reported during the perioperative period. The recommended blood glucose range of 140-180 mg/dL was achieved in 31.3% (179 of 572) of patients before surgery and 28.6% (71 of 248) after surgery. A blood glucose value was not recorded before or after surgery in 24.9% (190 of 762) of patients identified as having pre-diabetes or diabetes. CONCLUSION Diabetes is a frequent finding in surgical patients. Monitoring blood glucose values during the perioperative period may allow for early treatment and prevent complications related to poor glycemic control. The results of this project revealed 2 potential areas of improvement in the care of non-cardiac surgical patients with diabetes: (1) improving compliance with obtaining blood glucose values before and after surgery and (2) reducing the incidence of postoperative hyperglycemia (>180 mg/dL) which potentially could prevent avoidable complications related to poor glycemic control.
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Affiliation(s)
- L Alan Todd
- Daniel K. Inouye Graduate School of Nursing, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Robert A Vigersky
- Endocrinology and Diabetes Service, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
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Sadhu AR, Patham B, Vadhariya A, Chikermane SG, Johnson ML. Outcomes of "Real-World" Insulin Strategies in the Management of Hospital Hyperglycemia. J Endocr Soc 2021; 5:bvab101. [PMID: 34235360 PMCID: PMC8252645 DOI: 10.1210/jendso/bvab101] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Indexed: 11/28/2022] Open
Abstract
Context Guidelines recommend scheduled long-acting basal and short-acting bolus insulin several times daily to manage inpatient hyperglycemia. In the “real world,” insulin therapy is complicated, with limited data on the comparative effectiveness of different insulin strategies. Objective This work aimed to evaluate the association of different insulin strategies with glucose control and hospital outcomes after adjustment for patient and physician factors that influence choice of therapy. Methods This retrospective, observational study took place at an academic hospital. Participants included noncritically ill hospitalized medical/surgical patients (n = 4558) receiving subcutaneous insulin for 75% or longer during admission. Insulin therapy was grouped into 3 strategies within the first 48 hours: basal bolus (BB: scheduled long and short/rapid n = 2358), sliding scale (SS: short/rapid acting n = 1855), or basal only (BO: long only: n = 345). Main outcome measures included glucose control: hypoglycemic days, hyperglycemic days, euglycemic days, mean glucose; and hospitalization: in-hospital mortality, length of stay (LOS), and readmissions. Results Initial therapy with BB was associated with more hypoglycemic (2.40; CI, 2.04 to 2.82) (P < .001) and fewer euglycemic days (0.90; CI, 0.85 to 0.97) (P = .003) than SS, whereas BO was associated with fewer hyperglycemic days (0.70; CI, 0.62 to 0.79) (P < .001), lower mean glucose (–18.03; CI, –22.46 to –12.61) (P < .001), and more euglycemic days (1.22; CI, 1.09 to 1.37) (P < .001) compared to SS. No difference in mortality, LOS, and readmissions was found. However, decreased LOS was observed in the BB subgroup with a medical diagnostic related group (0.93; CI, 0.89 to 0.97) (P < .001). Conclusion BO had a more favorable hyperglycemia profile than SS. BB, on the other hand, showed worse glycemic control as compared to SS. In the real-world hospital, BO may be a simpler and more effective insulin strategy.
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Affiliation(s)
| | | | - Aisha Vadhariya
- University of Houston, College of Pharmacy, Houston, Texas 77204, USA
| | | | - Michael L Johnson
- University of Houston, College of Pharmacy, Houston, Texas 77204, USA
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Gonzales HM, Taber DJ, Nadig S, Patel N, Lin A, Baliga PK, Rohan VS. The impact of race on metabolic, graft, and patient outcomes after pancreas transplantation. Am J Surg 2021; 223:812-816. [PMID: 34158161 DOI: 10.1016/j.amjsurg.2021.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 05/11/2021] [Accepted: 06/12/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Racial disparities following pancreas transplantation (PTX) are poorly defined. METHODS This was a large-scale, single-center, longitudinal cohort study including adult PTX recipients. Patients were grouped by race to allow for comparisons. RESULTS 287 PTX recipients were included; 125 (43.5%) were African American (AA). At baseline, AAs had a significantly higher proportion of T2DM (19.4% vs. 5.7%, p = 0.001), were younger, and more likely to be female. AAs experienced significantly higher rates of pancreatic leaks and post-operative bleeding. PTX rejection was comparable, however, kidney rejection tended to be higher among AA SPKs. Long-term mean HgbA1C levels were significantly higher among AAs (6.9% vs. 6.3%, p = 0.039). Patient and graft survival was comparable between groups, but early patient survival tended to be lower in AAs. CONCLUSIONS This study demonstrated significant perioperative health disparities among AA PTX recipients, including poorer glycemic control and more early deaths, despite similar long-term patient and graft survival.
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Affiliation(s)
- Haley M Gonzales
- Department of Surgery, The Medical University of South Carolina, Charleston, SC, USA.
| | - David J Taber
- Department of Surgery, The Medical University of South Carolina, Charleston, SC, USA
| | - Satish Nadig
- Department of Surgery, The Medical University of South Carolina, Charleston, SC, USA
| | - Neha Patel
- Department of Pharmacy, The Medical University of South Carolina, Charleston, SC, USA
| | - Angello Lin
- Department of Surgery, The Medical University of South Carolina, Charleston, SC, USA
| | - Prabhakar K Baliga
- Department of Surgery, The Medical University of South Carolina, Charleston, SC, USA
| | - Vinayak S Rohan
- Department of Surgery, The Medical University of South Carolina, Charleston, SC, USA
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16
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Ponticelli C, Favi E, Ferraresso M. New-Onset Diabetes after Kidney Transplantation. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:250. [PMID: 33800138 PMCID: PMC7998982 DOI: 10.3390/medicina57030250] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 02/25/2021] [Accepted: 03/05/2021] [Indexed: 02/07/2023]
Abstract
New-onset diabetes mellitus after transplantation (NODAT) is a frequent complication in kidney allograft recipients. It may be caused by modifiable and non-modifiable factors. The non-modifiable factors are the same that may lead to the development of type 2 diabetes in the general population, whilst the modifiable factors include peri-operative stress, hepatitis C or cytomegalovirus infection, vitamin D deficiency, hypomagnesemia, and immunosuppressive medications such as glucocorticoids, calcineurin inhibitors (tacrolimus more than cyclosporine), and mTOR inhibitors. The most worrying complication of NODAT are major adverse cardiovascular events which represent a leading cause of morbidity and mortality in transplanted patients. However, NODAT may also result in progressive diabetic kidney disease and is frequently associated with microvascular complications, eventually determining blindness or amputation. Preventive measures for NODAT include a careful assessment of glucose tolerance before transplantation, loss of over-weight, lifestyle modification, reduced caloric intake, and physical exercise. Concomitant measures include aggressive control of systemic blood pressure and lipids levels to reduce the risk of cardiovascular events. Hypomagnesemia and low levels of vitamin D should be corrected. Immunosuppressive strategies limiting the use of diabetogenic drugs are encouraged. Many hypoglycemic drugs are available and may be used in combination with metformin in difficult cases. In patients requiring insulin treatment, the dose and type of insulin should be decided on an individual basis as insulin requirements depend on the patient's diet, amount of exercise, and renal function.
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Affiliation(s)
- Claudio Ponticelli
- Nephrology, Dialysis and Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Evaldo Favi
- Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
- Department of Clinical Sciences and Community Health, Università Degli Studi di Milano, 20122 Milan, Italy
| | - Mariano Ferraresso
- Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
- Department of Clinical Sciences and Community Health, Università Degli Studi di Milano, 20122 Milan, Italy
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Himes CP, Ganesh R, Wight EC, Simha V, Liebow M. Perioperative Evaluation and Management of Endocrine Disorders. Mayo Clin Proc 2020; 95:2760-2774. [PMID: 33168157 DOI: 10.1016/j.mayocp.2020.05.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 05/02/2020] [Accepted: 05/12/2020] [Indexed: 12/25/2022]
Abstract
Evaluation of endocrine issues is a sometimes overlooked yet important component of the preoperative medical evaluation. Patients with diabetes, thyroid disease, and hypothalamic-pituitary-adrenal axis suppression are commonly encountered in the surgical setting and require unique consideration to optimize perioperative risk. For patients with diabetes, perioperative glycemic control has the strongest association with postsurgical outcomes. The preoperative evaluation should include recommendations for adjustment of insulin and noninsulin diabetic medications before surgery. Recommendations differ based on the type of diabetes, the type of insulin, and the patient's predisposition to hyperglycemia or hypoglycemia. Generally, patients with thyroid dysfunction can safely undergo operations unless they have untreated hyperthyroidism or severe hypothyroidism. Patients with known primary or secondary adrenal insufficiency require supplemental glucocorticoids to prevent adrenal crisis in the perioperative setting. Evidence supporting the use of high-dose supplemental corticosteroids for patients undergoing long-term glucocorticoid therapy is sparse. We discuss an approach to these patients based on the dose and duration of ongoing or recent corticosteroid therapy. As with other components of the preoperative medical evaluation, the primary objective is identification and assessment of the severity of endocrine issues before surgery so that the surgeons, anesthesiologists, and internal medicine professionals can optimize management accordingly.
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Affiliation(s)
- Carina P Himes
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN.
| | - Ravindra Ganesh
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | | | - Vinaya Simha
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Mark Liebow
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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20
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Jin X, Wang J, Ma Y, Li X, An P, Wang J, Mao W, Mu Y, Chen Y, Chen K. Association Between Perioperative Glycemic Control Strategy and Mortality in Patients With Diabetes Undergoing Cardiac Surgery: A Systematic Review and Meta-Analysis. Front Endocrinol (Lausanne) 2020; 11:513073. [PMID: 33391180 PMCID: PMC7774648 DOI: 10.3389/fendo.2020.513073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 11/11/2020] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To analyze association between different perioperative glycemic control strategies and postoperative outcomes in patients with diabetes undergoing cardiac surgery. METHODS MEDLINE, Cochrane Library, Web of Science, EMBASE, Wanfang Data, China National Knowledge Infrastructure (CNKI) and China Biology Medicine (CBM) databases were searched from inception to January 31, 2019. Two researchers independently screened the literature, extracted data, and evaluated the risk of bias of included studies, and consensus was reached by discussion with a third researcher. RESULTS Six RCTs were included in the meta-analysis. We analyzed the effect of liberal (>180 mg/dl or 10.0 mmol/L), moderate (140-180 mg/dl or 7.8-10.0 mmol/L) and strict (<140 mg/dl or 7.8 mmol/L) glycemic control strategies in patients with diabetes undergoing cardiac surgery. The pooled results showed that strict glycemic control strategy was associated with a significant reduction in the risk of atrial fibrillation [OR = 0.48, 95%CI (0.32, 0.72), P < 0.001] and sternal wound infection [OR = 0.28, 95%CI (0.14, 0.54), P < 0.001], while there was no significant differences in postoperative mortality, stroke, and hypoglycemic episodes when compared with moderate control. In addition, there is no significant difference between moderate and liberal glycemic control strategies in postoperative mortality. However, moderate control was beneficial in reducing atrial fibrillation [OR = 0.28, 95%CI (0.13, 0.60), P = 0.001] compared with the liberal glycemic control strategy. CONCLUSIONS This meta-analysis showed when compared with moderate glycemic control strategy in patients with diabetes undergoing cardiac surgery, maintained strict glycemic control was associated with lower risk of atrial fibrillation and sternal wound infection. No benefit was found with liberal glycemic control strategy, so it could be a poor glycemic control strategy.
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Affiliation(s)
- Xinye Jin
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
- Department of Endocrinology and Nephrology, Hainan Hospital of Chinese PLA General Hospital, Sanya, China
- Hainan Academician Team Innovation Center, Sanya, China
| | - Jinjing Wang
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
- Department of Endocrinology, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yanfang Ma
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- WHO Collaborating Center for Guideline Implementation and Knowledge Translation, Lanzhou, China
- Chinese GRADE Center, Lanzhou, China
| | - Xueqiong Li
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
- Department of Gerontology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Ping An
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
| | - Jie Wang
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
- School of Medicine, Nankai University, Tianjin, China
| | - Wenfeng Mao
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
- School of Medicine, Nankai University, Tianjin, China
| | - Yiming Mu
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
- *Correspondence: Yiming Mu, ; Yaolong Chen, ; Kang Chen,
| | - Yaolong Chen
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- WHO Collaborating Center for Guideline Implementation and Knowledge Translation, Lanzhou, China
- Chinese GRADE Center, Lanzhou, China
- *Correspondence: Yiming Mu, ; Yaolong Chen, ; Kang Chen,
| | - Kang Chen
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
- *Correspondence: Yiming Mu, ; Yaolong Chen, ; Kang Chen,
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21
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Surgical Problems of the Digestive System. Fam Med 2020. [DOI: 10.1007/978-1-4939-0779-3_100-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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22
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Corcoran TB, Myles PS, Forbes AB, O'Loughlin E, Leslie K, Story D, Short TG, Chan MT, Coutts P, Sidhu J, Cheng AC, Bach LA, Ho KM. The perioperative administration of dexamethasone and infection (PADDI) trial protocol: rationale and design of a pragmatic multicentre non-inferiority study. BMJ Open 2019; 9:e030402. [PMID: 31494615 PMCID: PMC6731833 DOI: 10.1136/bmjopen-2019-030402] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION The intraoperative administration of dexamethasone for prophylaxis against postoperative nausea and vomiting is a common and recommended practice. The safety of the administration of this immunosuppressive agent at a time of significant immunological disruption has not been rigorously evaluated in terms of infective complications. METHODS/ANALYSIS This is a pragmatic, multicentre, randomised, controlled, non-inferiority trial. A total of 8880 patients undergoing elective major surgery will be enrolled. Participants will be randomly allocated to receive either dexamethasone 8 mg or placebo intravenously following the induction of anaesthesia in a 1:1 ratio, stratified by centre and diabetes status. Patient enrolment into the trial is ongoing. The primary outcome is surgical site infection at 30 days following surgery, defined according to the Centre for Disease Control criteria. ETHICS/DISSEMINATION The PADDI trial has been approved by the ethics committees of over 45 participating sites in Australia, New Zealand, Hong Kong, South Africa and the Netherlands. The trial has been endorsed by the Australia and New Zealand College of Anaesthetists Clinical Trials Network and the Australian Society for Infectious Diseases Clinical Research Network. Participant recruitment began in March 2016 and is expected to be complete in mid-2019. Publication of the results of the PADDI trial is anticipated to occur in early 2020. TRIAL REGISTRATION NUMBER ACTRN12614001226695.
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Affiliation(s)
- Tomás B Corcoran
- Royal Perth Hospital, Perth, Western Australia, Australia
- University of Western Australia, Perth, Western Australia, Australia
- Monash University, Melbourne, Victoria, Australia
| | - Paul S Myles
- Monash University, Melbourne, Victoria, Australia
- Alfred Hospital, Melbourne, Victoria, Australia
| | | | - Ed O'Loughlin
- University of Western Australia, Perth, Western Australia, Australia
- Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Kate Leslie
- Monash University, Melbourne, Victoria, Australia
- Royal Melbourne Hospital, Melbourne, Victoria, Australia
- The University of Melbourne, Melbourne, Victoria, Australia
| | - David Story
- Royal Melbourne Hospital, Melbourne, Victoria, Australia
- The University of Melbourne, Melbourne, Victoria, Australia
| | | | | | - Pauline Coutts
- Royal Perth Hospital, Perth, Western Australia, Australia
| | | | - Allen C Cheng
- Monash University, Melbourne, Victoria, Australia
- Alfred Hospital, Melbourne, Victoria, Australia
| | - Leon A Bach
- Monash University, Melbourne, Victoria, Australia
- Alfred Hospital, Melbourne, Victoria, Australia
| | - Kwok M Ho
- Royal Perth Hospital, Perth, Western Australia, Australia
- University of Western Australia, Perth, Western Australia, Australia
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Sheikh A, Anolik J, Maurer AH. Update on Serum Glucose and Metabolic Management of Clinical Nuclear Medicine Studies: Current Status and Proposed Future Directions. Semin Nucl Med 2019; 49:411-421. [PMID: 31470934 DOI: 10.1053/j.semnuclmed.2019.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Management of a patient's blood glucose or metabolism in nuclear medicine studies has become an integral aspect of daily work primarily due to the increasing use of F-18 flurodeoxyglucose (FDG) positron emission tomography (PET). Newer tracers such as F-18 Fluciclovine and C-11 Choline, are in theory subject to metabolic shifts and changes based on patients' insulin levels, and also require attention to achieving optimum patient preparation. Metabolic derangements can also affect other studies, such as gastric emptying (GE), the results of which are dependent upon the patient's blood glucose level during the time of imaging. The growing variety of diabetic medications has increased the complexity of the instructions which need to be given to patients. Current guidelines for patient preparation were developed in the past and have only slowly evolved with the introduction of newer oral medications. In addition to older insulin formulations newer formulations with different profiles of onset, duration, and consistency of action are being used. The wide spectrum of newer drugs now in use for treating diabetes has not been accompanied by any updated consensus on how to manage these drugs for imaging studies which require blood glucose level management. In this article we review these newer diabetes medications primarily to raise awareness of the changing landscape. Our focus will be on suggestions to optimize patient preparation and management for these studies. For each scenario, our suggestions will be given as summary proposals for best patient management. Our hope is that this discussion will stimulate multicenter studies to provide data to support new practice guidelines for metabolically dependent nuclear medicine procedures.
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Affiliation(s)
- Arif Sheikh
- Division of Nuclear Medicine; Department of Diagnostic, Molecular and Interventional Radiology, Mount Sinai Hospital, Icahn School of Medicine, New York, NY.
| | - Jonathan Anolik
- Section of Endocrinology, Department of Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, PA
| | - Alan H Maurer
- Section of Nuclear Medicine, Department of Radiology, Temple University Lewis Katz School of Medicine, Philadelphia, PA
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Franco T, Rupp S, Williams B, Blackmore C. Effectiveness of standardised preoperative assessment and patient instructions on admission blood glucose for patients with diabetes undergoing orthopaedic surgery at a tertiary referral hospital. BMJ Open Qual 2019; 8:e000455. [PMID: 31206054 PMCID: PMC6542547 DOI: 10.1136/bmjoq-2018-000455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 11/13/2018] [Accepted: 11/17/2018] [Indexed: 11/04/2022] Open
Abstract
Diabetes and hyperglycaemia affect a significant number of people and are associated with a variety of untoward effects, especially under physiological stress such as surgery. Due, in large part to limited evidence, clinical practice in monitoring blood glucose and treating hyperglycaemic conditions in the perioperative period is variable. We used Lean methodologies to implement a standardised approach to preoperative management of patients undergoing elective surgery in an effort to improve glycaemic control. Overall, we saw an appropriate increase in monitoring and a decrease in the rate of hyperglycaemia on presentation to the operating room. This approach may be useful in other care settings or patient populations, potentially contributing to improved glycaemic control and subsequent decrease in associated complications.
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Affiliation(s)
- Thérèse Franco
- Section of Hospital Medicine, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Stephen Rupp
- Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Barbara Williams
- The Center for Healthcare Improvement Science, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Craig Blackmore
- The Center for Healthcare Improvement Science, Virginia Mason Medical Center, Seattle, Washington, USA
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Long CA, Fang ZB, Hu FY, Arya S, Brewster LP, Duggan E, Duwayri Y. Poor glycemic control is a strong predictor of postoperative morbidity and mortality in patients undergoing vascular surgery. J Vasc Surg 2019; 69:1219-1226. [DOI: 10.1016/j.jvs.2018.06.212] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 06/04/2018] [Indexed: 12/31/2022]
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Polderman JAW, Farhang‐Razi V, Dieren S, Kranke P, DeVries JH, Hollmann MW, Preckel B, Hermanides J. Adverse side‐effects of dexamethasone in surgical patients – an abridged Cochrane systematic review. Anaesthesia 2019; 74:929-939. [DOI: 10.1111/anae.14610] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2019] [Indexed: 01/18/2023]
Affiliation(s)
- J. A. W. Polderman
- Department of Anaesthesiology Amsterdam University Medical Centre Amsterdamthe Netherlands
| | - V. Farhang‐Razi
- Department of Anaesthesiology Amsterdam University Medical Centre Amsterdamthe Netherlands
| | - S. Dieren
- Department of Surgery Amsterdam University Medical Centre Amsterdamthe Netherlands
| | - P. Kranke
- Department of Anaesthesia and Critical Care University Hospitals of Wuerzburg Germany
| | - J. H. DeVries
- Department of Endocrinology Amsterdam University Medical Centre Amsterdamthe Netherlands
| | - M. W. Hollmann
- Department of Anaesthesiology and Laboratory of Experimental Intensive Care and Anaesthesiology (L.E.I.C.A.) Amsterdam University Medical Centre Amsterdam the Netherlands
| | - B. Preckel
- Department of Anaesthesiology and Laboratory of Experimental Intensive Care and Anaesthesiology (L.E.I.C.A.) Amsterdam University Medical Centre Amsterdam the Netherlands
| | - J. Hermanides
- Department of Anaesthesiology Amsterdam University Medical Centre Amsterdamthe Netherlands
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Polderman JAW, Farhang‐Razi V, Van Dieren S, Kranke P, DeVries JH, Hollmann MW, Preckel B, Hermanides J. Adverse side effects of dexamethasone in surgical patients. Cochrane Database Syst Rev 2018; 11:CD011940. [PMID: 30480776 PMCID: PMC6426282 DOI: 10.1002/14651858.cd011940.pub3] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND In the perioperative period, dexamethasone is widely and effectively used for prophylaxis of postoperative nausea and vomiting (PONV), for pain management, and to facilitate early discharge after ambulatory surgery.Long-term treatment with steroids has many side effects, such as adrenal insufficiency, increased infection risk, hyperglycaemia, high blood pressure, osteoporosis, and development of diabetes mellitus. However, whether a single steroid load during surgery has negative effects during the postoperative period has not yet been studied. OBJECTIVES To assess the effects of a steroid load of dexamethasone on postoperative systemic or wound infection, delayed wound healing, and blood glucose change in adult surgical patients (with planned subgroup analysis of patients with and without diabetes). SEARCH METHODS We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library, and the Web of Science for relevant articles on 29 January 2018. We searched without language or date restriction two clinical trial registries to identify ongoing studies, and we handsearched the reference lists of relevant publications to identify all eligible trials. SELECTION CRITERIA We searched for randomized controlled trials comparing an incidental steroid load of dexamethasone versus a control intervention for adult patients undergoing surgery. We required that studies include a follow-up of 30 days for proper assessment of the number of postoperative infections, delayed wound healing, and the glycaemic response. DATA COLLECTION AND ANALYSIS Two review authors independently screened studies for eligibility, extracted data from relevant studies, and assessed all included studies for bias. We resolved differences by discussion and pooled included studies in a meta-analysis. We calculated Peto odds ratios (ORs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes. Our primary outcomes were postoperative systemic or wound infection, delayed wound healing, and glycaemic response within 24 hours. We created a funnel plot for the primary outcome postoperative (wound or systemic) infection. We used GRADE to assess the quality of evidence for each outcome. MAIN RESULTS We included in the meta-analysis 37 studies that included adults undergoing a large variety of surgical procedures (i.e. abdominal surgery, cardiac surgery, neurosurgery, and orthopaedic surgery). We excluded one previously included study, as this study was recently retracted. Age range of participants was 18 to 80 years. There is probably little or no difference in the risk of postoperative (wound or systemic) infection with dexamethasone compared with no treatment, placebo, or active control (ramosetron, ondansetron, or tropisetron) (Peto OR 1.01, 95% confidence interval (CI) 0.80 to 1.27; 4603 participants, 26 studies; I² = 32%; moderate-quality evidence). The effects of dexamethasone on delayed wound healing are unclear because the wide confidence interval includes both meaningful benefit and harm (Peto OR 0.99, 95% CI 0.28 to 3.43; 1072 participants, eight studies; I² = 0%; low-quality evidence). Dexamethasone may produce a mild increase in glucose levels among participants without diabetes during the first 12 hours after surgery (MD 13 mg/dL, 95% CI 6 to 21; 10 studies; 595 participants; I² = 50%; low-quality evidence). We identified two studies reporting on glycaemic response after dexamethasone in participants with diabetes within 24 hours after surgery (MD 32 mg/dL, 95% CI 15 to 49; 74 participants; I² = 0%; very low-quality evidence). AUTHORS' CONCLUSIONS A single dose of dexamethasone probably does not increase the risk for postoperative infection. It is uncertain whether dexamethasone has an effect on delayed wound healing in the general surgical population owing to imprecision in trial results. Participants with increased risk for delayed wound healing (e.g. participants with diabetes, those taking immunosuppressive drugs) were not included in the randomized studies reporting on delayed wound healing included in this meta-analysis; therefore our findings should be extrapolated to the clinical setting with caution. Furthermore, one has to keep in mind that dexamethasone induces a mild increase in glucose. For patients with diabetes, very limited evidence suggests a more pronounced increase in glucose. Whether this influences wound healing in a clinically relevant way remains to be established. Once assessed, the two studies awaiting classification and three that are ongoing may alter the conclusions of this review.
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Affiliation(s)
- Jorinde AW Polderman
- Academic Medical Center (AMC) University of AmsterdamDepartment of AnaesthesiologyMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Violet Farhang‐Razi
- Academic Medical Center (AMC) University of AmsterdamDepartment of AnaesthesiologyMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Susan Van Dieren
- Academic Medical Center (AMC) University of AmsterdamDepartment of AnaesthesiologyMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Peter Kranke
- University of WürzburgDepartment of Anaesthesia and Critical CareOberdürrbacher Str. 6WürzburgGermany97080
| | - J Hans DeVries
- Academic Medical CentreDepartment of Internal MedicinePO Box 22700AmsterdamNetherlands1100 DE
| | - Markus W Hollmann
- Academic Medical Center (AMC) University of AmsterdamDepartment of AnaesthesiologyMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Benedikt Preckel
- Academic Medical Center (AMC) University of AmsterdamDepartment of AnaesthesiologyMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Jeroen Hermanides
- Academic Medical Center (AMC) University of AmsterdamDepartment of AnaesthesiologyMeibergdreef 9AmsterdamNetherlands1105 AZ
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Kheniser KG, Kashyap SR. Diabetes management before, during, and after bariatric and metabolic surgery. J Diabetes Complications 2018; 32:870-875. [PMID: 30042058 DOI: 10.1016/j.jdiacomp.2018.06.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 06/06/2018] [Accepted: 06/07/2018] [Indexed: 12/20/2022]
Abstract
Metabolic surgery is unrivaled by other therapeutic modalities due to its ability to foster diabetes remission. Metabolic surgery is an integral therapeutic modality in obese and morbidly obese populations because pharmacological and behavioral therapy often fail to effectively manage type II diabetes. However, given the invasiveness of the metabolic surgery relative to behavioral therapy and the need to conform to preparatory and discharge guidelines, patients must adhere to strict nutritional and diabetes management protocols. Also, the pharmacological regimen that is instituted upon discharge is distinct from the preoperative regimen. Oftentimes, the dose for insulin and oral medications are significantly decreased or withdrawn. As time elapses and depending on several factors (e.g., exercise adherence), diabetes control becomes tenuous in a small portion of the patients because there is weight regain and on-going beta cell failure. At this time interval, intensification of diabetes therapy becomes prudent. Indeed, pharmacotherapy from the preoperative to the postoperative phase is labile and may be complex. Therefore, by discussing pharmacology options during the preoperative, perioperative, and postoperative period, the goal is to guide clinician-driven care.
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Affiliation(s)
- Karim G Kheniser
- Department of Endocrinology and Metabolism, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America.
| | - Sangeeta R Kashyap
- Department of Endocrinology and Metabolism, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America.
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Polderman JAW, Farhang‐Razi V, Van Dieren S, Kranke P, DeVries JH, Hollmann MW, Preckel B, Hermanides J. Adverse side effects of dexamethasone in surgical patients. Cochrane Database Syst Rev 2018; 8:CD011940. [PMID: 30152137 PMCID: PMC6513495 DOI: 10.1002/14651858.cd011940.pub2] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND In the perioperative period, dexamethasone is widely and effectively used for prophylaxis of postoperative nausea and vomiting (PONV), for pain management, and to facilitate early discharge after ambulatory surgery.Long-term treatment with steroids has many side effects, such as adrenal insufficiency, increased infection risk, hyperglycaemia, high blood pressure, osteoporosis, and development of diabetes mellitus. However, whether a single steroid load during surgery has negative effects during the postoperative period has not yet been studied. OBJECTIVES To assess the effects of a steroid load of dexamethasone on postoperative systemic or wound infection, delayed wound healing, and blood glucose change in adult surgical patients (with planned subgroup analysis of patients with and without diabetes). SEARCH METHODS We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library, and the Web of Science for relevant articles on 29 January 2018. We searched without language or date restriction two clinical trial registries to identify ongoing studies, and we handsearched the reference lists of relevant publications to identify all eligible trials. SELECTION CRITERIA We searched for randomized controlled trials comparing an incidental steroid load of dexamethasone versus a control intervention for adult patients undergoing surgery. We required that studies include a follow-up of 30 days for proper assessment of the number of postoperative infections, delayed wound healing, and the glycaemic response. DATA COLLECTION AND ANALYSIS Two review authors independently screened studies for eligibility, extracted data from relevant studies, and assessed all included studies for bias. We resolved differences by discussion and pooled included studies in a meta-analysis. We calculated Peto odds ratios (ORs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes. Our primary outcomes were postoperative systemic or wound infection, delayed wound healing, and glycaemic response within 24 hours. We created a funnel plot for the primary outcome postoperative (wound or systemic) infection. We used GRADE to assess the quality of evidence for each outcome. MAIN RESULTS We included in the meta-analysis 38 studies that included adults undergoing a large variety of surgical procedures (i.e. abdominal surgery, cardiac surgery, neurosurgery, and orthopaedic surgery). Age range of participants was 18 to 80 years. There is probably little or no difference in the risk of postoperative (wound or systemic) infection with dexamethasone compared with no treatment, placebo, or active control (ramosetron, ondansetron, or tropisetron) (Peto OR 1.01, 95% confidence interval (CI) 0.80 to 1.27; 4931 participants, 27 studies; I² = 27%; moderate-quality evidence). The effects of dexamethasone on delayed wound healing are unclear because the wide confidence interval includes both meaningful benefit and harm (Peto OR 0.99, 95% CI 0.28 to 3.43; 1072 participants, eight studies; I² = 0%; low-quality evidence). Dexamethasone may produce a mild increase in glucose levels among participants without diabetes during the first 12 hours after surgery (MD 13 mg/dL, 95% CI 6 to 21; 10 studies; 595 participants; I² = 50%; low-quality evidence). We identified two studies reporting on glycaemic response after dexamethasone in participants with diabetes within 24 hours after surgery (MD 32 mg/dL, 95% CI 15 to 49; 74 participants; I² = 0%; very low-quality evidence). AUTHORS' CONCLUSIONS A single dose of dexamethasone probably does not increase the risk for postoperative infection. It is uncertain whether dexamethasone has an effect on delayed wound healing in the general surgical population owing to imprecision in trial results. Participants with increased risk for delayed wound healing (e.g. participants with diabetes, those taking immunosuppressive drugs) were not included in the randomized studies reporting on delayed wound healing included in this meta-analysis; therefore our findings should be extrapolated to the clinical setting with caution. Furthermore, one has to keep in mind that dexamethasone induces a mild increase in glucose. For patients with diabetes, very limited evidence suggests a more pronounced increase in glucose. Whether this influences wound healing in a clinically relevant way remains to be established. Once assessed, the three studies awaiting classification and two that are ongoing may alter the conclusions of this review.
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Affiliation(s)
- Jorinde AW Polderman
- Academic Medical Center (AMC) University of AmsterdamDepartment of AnaesthesiologyMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Violet Farhang‐Razi
- Academic Medical Center (AMC) University of AmsterdamDepartment of AnaesthesiologyMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Susan Van Dieren
- Academic Medical Center (AMC) University of AmsterdamDepartment of AnaesthesiologyMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Peter Kranke
- University of WürzburgDepartment of Anaesthesia and Critical CareOberdürrbacher Str. 6WürzburgGermany97080
| | - J Hans DeVries
- Academic Medical CentreDepartment of Internal MedicinePO Box 22700AmsterdamNetherlands1100 DE
| | - Markus W Hollmann
- Academic Medical Center (AMC) University of AmsterdamDepartment of AnaesthesiologyMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Benedikt Preckel
- Academic Medical Center (AMC) University of AmsterdamDepartment of AnaesthesiologyMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Jeroen Hermanides
- Academic Medical Center (AMC) University of AmsterdamDepartment of AnaesthesiologyMeibergdreef 9AmsterdamNetherlands1105 AZ
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Effects of peri-operative administration of steroids on the blood glucose levels of patients with and without diabetes undergoing laparoscopic cholecystectomy. JOURNAL OF SURGERY AND MEDICINE 2018. [DOI: 10.28982/josam.424450] [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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Albalawi Z, Laffin M, Gramlich L, Senior P, McAlister FA. Enhanced Recovery After Surgery (ERAS ®) in Individuals with Diabetes: A Systematic Review. World J Surg 2018; 41:1927-1934. [PMID: 28321553 DOI: 10.1007/s00268-017-3982-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Prevalence of diabetes in surgical patients is 10-40%. It is well recognized that they have higher rates of complications, and longer stays in hospital compared to patients without diabetes. Enhanced recovery after surgery (ERAS) is an evidence-based multimodal surgical care pathway that improves postoperative complications and length of stay in patients without diabetes. This review evaluates the evidence on whether individuals with diabetes would benefit from ERAS implementation. METHODS MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL) and EMBASE searched with no language restrictions applied. Conference proceedings and bibliographies were reviewed. Experts in the field were contacted, and www.clinicaltrials.gov searched for ongoing trials. SELECTION CRITERIA Randomized controlled trials (RCT) looking at individuals with diabetes undergoing surgery randomized to ERAS® or conventional care. Non-randomized controlled trials, controlled before-after studies, interrupted time series, and cohort studies with concurrent controls were also considered. Two authors independently screened studies. RESULTS The electronic search yielded 437 references. After removing duplicates, 376 were screened for eligibility. Conference proceedings and bibliographies identified additional references. Searching www.clinicaltrials.gov yielded 59 references. Contacting experts in the field identified no further studies. Fourteen full articles were assessed and subsequently excluded for the following reasons: used an intervention other than ERAS®, did not include patients with diabetes, or used an uncontrolled observational design. CONCLUSIONS To date, the effects of ERAS® on patients with diabetes have not been rigorously evaluated. This review highlights the lack of evidence in this area and provides guidance on design for future studies.
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Affiliation(s)
- Zaina Albalawi
- Department of Medicine, University of Alberta, Edmonton, Canada. .,Endocrinology and Metabolism, Alberta Health Services, Edmonton, Canada.
| | - Michael Laffin
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - Leah Gramlich
- Department of Medicine, University of Alberta, Edmonton, Canada.,Gastroenterology, University of Alberta, Edmonton, Canada
| | - Peter Senior
- Department of Medicine, University of Alberta, Edmonton, Canada.,Endocrinology and Metabolism, University of Alberta, Edmonton, Canada
| | - Finlay A McAlister
- Department of Medicine, University of Alberta, Edmonton, Canada.,General Internal Medicine, University of Alberta, Edmonton, Canada
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Morley N. Operating department practitioners care of the patient with diabetes in the perioperative period. J Perioper Pract 2018; 27:71-76. [PMID: 29328746 DOI: 10.1177/175045891702700402] [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: 03/08/2015] [Accepted: 07/29/2016] [Indexed: 11/16/2022]
Abstract
Diabetes mellitus (DM) is a of group metabolic diseases which are defined by hyperglycaemia affecting multiple organs. The condition is found in people of all ages and ethnicities. Diabetes mellitus affects 180 million people worldwide and increasing numbers of patients are presenting with diabetic complications and the need for surgical intervention. This article describes the pathophysiology of DM and the management of the condition, particularly type I and type 2, in the perioperative phase of the surgical patient journey.
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Lopez LF, Reaven PD, Harman SM. Review: The relationship of hemoglobin A1c to postoperative surgical risk with an emphasis on joint replacement surgery. J Diabetes Complications 2017; 31:1710-1718. [PMID: 29029935 DOI: 10.1016/j.jdiacomp.2017.08.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 08/06/2017] [Accepted: 08/31/2017] [Indexed: 12/12/2022]
Abstract
Patients with diabetes mellitus are known to have a high risk of postoperative complications, including infections, impaired wound healing, cardiovascular events, venous thromboembolism, and mortality. Because hyperglycemia has been thought to mediate this risk, there is a clinical propensity for improving glycemic control, as assessed by hemoglobin A1c (HbA1c) level, prior to proceeding with elective surgery, particularly joint replacement surgery. However, it is not established whether chronic poor glycemic control, indicated by elevated HbA1c levels, predicts increased risk of postoperative complications. The benefit of improving glycemic control must be weighed against risks of delaying necessary elective surgery, such as joint replacement surgery, which risks may include negative impact on long-term glycemic control. Thus, we review the current evidence to determine the relationship between HbA1c and postoperative surgical risk, especially on joint replacement surgery.
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Affiliation(s)
- Lizette F Lopez
- Endocrinology Division, Phoenix VA Health Care System, 650 E. Indian School Road, Phoenix, AZ 85012, USA.
| | - Peter D Reaven
- Endocrinology Division, Phoenix VA Health Care System, 650 E. Indian School Road, Phoenix, AZ 85012, USA; University of Arizona College of Medicine-Phoenix, 550 E. Van Buren St., Phoenix, AZ 85004, USA.
| | - Sherman M Harman
- Endocrinology Division, Phoenix VA Health Care System, 650 E. Indian School Road, Phoenix, AZ 85012, USA; University of Arizona College of Medicine-Phoenix, 550 E. Van Buren St., Phoenix, AZ 85004, USA.
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Masnaghetti SE, Sarzi Braga S, Vaninetti R, Baiardi P, Pedretti RF. Altered fasting glycemia in cardiac patients during in-hospital rehabilitation. J Cardiovasc Med (Hagerstown) 2017; 18:625-630. [DOI: 10.2459/jcm.0000000000000478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Pournaras DJ, Photi ES, Barnett N, Challand CP, Chatzizacharias NA, Dlamini NP, Doulias T, Foley A, Hernon J, Kumar B, Martin J, Nunney I, Oglesby F, Panagiotopoulou I, Sengupta N, Shivakumar O, Sinclair P, Stather P, Than MM, Wells AC, Xanthis A, Dhatariya K. Assessing the quality of primary care referrals to surgery of patients with diabetes in the East of England: A multi-centre cross-sectional cohort study. Int J Clin Pract 2017; 71. [PMID: 28618177 DOI: 10.1111/ijcp.12971] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 05/10/2017] [Indexed: 01/10/2023] Open
Abstract
AIM Peri-operative hyperglycaemia is associated with an increased incidence of adverse outcomes. Communication between primary and secondary care is paramount to minimise these harms. National guidance in the UK recommends that the glycated haemoglobin (HbA1c) should be measured within 3 months prior to surgery and that the concentration should be less that 69 mmol/mol (8.5%). In addition, national guidance outlines the minimum dataset that should be included in any letter at the time of referral to the surgeons. Currently, it is unclear how well this process is being carried out. This study investigated the quality of information being handed over during the referral from primary care to surgical outpatients within the East of England. METHODS Primary care referrals to nine different NHS hospital Trusts were gathered over a 1-week period. All age groups were included from 11 different surgical specialties. Referral letters were analysed using a standardised data collection tool based on the national guidelines. RESULTS A total of 1919 referrals were received, of whom 169 (8.8%) had previously diagnosed diabetes mellitus (DM). However, of these, 38 made no mention of DM in the referral letter but were on glucose-lowering agents. Only 13 (7.7%) referrals for patients with DM contained a recent HbA1c, and 20 (11.8%) contained no documentation of glucose-lowering medication. CONCLUSION This study has shown that the quality of referral letters to surgical specialties for patients with DM in the East of England remain inadequate. There is a clear need for improving the quality of clinical data contained within referral letters from primary care. In addition, we have shown that the rate of referral for surgery for people with diabetes is almost 50% higher than the background population with diabetes.
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Affiliation(s)
- Dimitri J Pournaras
- Norfolk and Norwich University Hospitals, Norwich, UK
- Addenbrookes Hospital, Cambridge, UK
| | | | - Nicholas Barnett
- Mid Essex Hospital Services NHS Trust, Broomfield Hospital, Essex, UK
| | | | | | | | | | | | - James Hernon
- Norfolk and Norwich University Hospitals, Norwich, UK
| | - Bhaskar Kumar
- Norfolk and Norwich University Hospitals, Norwich, UK
| | - Jack Martin
- Peterborough City Hospital, Peterborough, UK
| | | | | | | | | | | | | | - Phil Stather
- Queen Elizabeth Hospital Kings Lynn, Norwich, UK
| | | | - Antonia C Wells
- Mid Essex Hospital Services NHS Trust, Broomfield Hospital, Essex, UK
| | | | - Ketan Dhatariya
- Norfolk and Norwich University Hospitals, Norwich, UK
- University of East Anglia, Norwich, UK
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38
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Surgical Problems of the Digestive System. Fam Med 2017. [DOI: 10.1007/978-3-319-04414-9_100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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40
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Polderman JAW, de Groot FA, Zamanbin A, Hollmann MW, Holleman F, Preckel B, Hermanides J. An automated reminder for perioperative glucose regulation improves protocol compliance. Diabetes Res Clin Pract 2016; 116:80-2. [PMID: 27321319 DOI: 10.1016/j.diabres.2016.04.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 02/03/2016] [Accepted: 04/15/2016] [Indexed: 11/17/2022]
Abstract
A growing proportion of patients presenting for surgery have diabetes. Unfortunately, perioperative diabetes protocol compliance is low. Using digitalization of the perioperative environment, an automated reminder in the preoperative assessment platform proved to increase compliance and we advocate its use throughout the perioperative process.
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Affiliation(s)
| | - Fleur A de Groot
- Department of Anesthesiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Alaleh Zamanbin
- Department of Anesthesiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Markus W Hollmann
- Department of Anesthesiology and Laboratory of Experimental Intensive Care and Anesthesiology L.E.I.C.A., Academic Medical Centre, Amsterdam, The Netherlands
| | - Frits Holleman
- Department of Internal Medicine, Academic Medical Centre, Amsterdam, The Netherlands
| | - Benedikt Preckel
- Department of Anesthesiology and Laboratory of Experimental Intensive Care and Anesthesiology L.E.I.C.A., Academic Medical Centre, Amsterdam, The Netherlands
| | - Jeroen Hermanides
- Department of Anesthesiology, Academic Medical Centre, Amsterdam, The Netherlands
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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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Khetarpal R, Chatrath V, Kaur J, Bala A, Singh H. Impact of different intravenous fluids on blood glucose levels in nondiabetic patients undergoing elective major noncardiac surgeries. Anesth Essays Res 2016; 10:425-431. [PMID: 27746527 PMCID: PMC5062227 DOI: 10.4103/0259-1162.176411] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background: Intravenous (IV) fluids are an integral part of perioperative management. Intraoperative hyperglycemia is associated with poor clinical outcomes in patients undergoing major surgeries even in nondiabetics. Aim: This study was conducted to observe the effect of different maintenance fluid regimens on intraoperative blood glucose levels in nondiabetic patients undergoing major surgeries under general anesthesia. Settings and Design: Randomized double-blind study. Materials and Methods: One hundred nondiabetic patients of either sex were divided randomly into two Groups I and II of 50 each undergoing elective major surgeries of more than 90 min duration under general anesthesia. Both groups were given calculated dosage of IV fluids accordingly 4-2-1 formula while Group I was given Ringer lactate (RL) and Group II was given 0.45% dextrose normal saline and potassium chloride 20 mmol/L. Changes in vital parameters, % oxygen saturation, and urine output were monitored at regular intervals. Capillary blood glucose (CBG) was measured half-hourly until end of surgery. If CBG level was more than 150 mg%, then calculated dose of human insulin (CBG/100) was given as IV bolus dose. Statistical Analysis: Statistical analysis was done using SPSS 22.0 software (IBM Corporation, Armonk, New York, USA), paired t-test and Chi-square test. Results: A significant increase of CBG level and was observed during intraoperative and immediate postoperative period (P < 0.001) in Group II. Conclusion: RL solution is probably the alternative choice of IV fluid for perioperative maintenance and can be used as replacement fluid in nondiabetic patients undergoing major surgeries.
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Affiliation(s)
- Ranjana Khetarpal
- Department of Anaesthesia and Critical Care, Government Medical College, Amritsar, Punjab, India
| | - Veena Chatrath
- Department of Anaesthesia and Critical Care, Government Medical College, Amritsar, Punjab, India
| | - Jagjit Kaur
- Department of Anaesthesia and Critical Care, Government Medical College, Amritsar, Punjab, India
| | - Anju Bala
- Department of Anaesthesia and Critical Care, Government Medical College, Amritsar, Punjab, India
| | - Harjeet Singh
- Department of Anaesthesia and Critical Care, Government Medical College, Amritsar, Punjab, India
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Abstract
Hyperglycemia and acute kidney injury (AKI) are frequently observed during the perioperative period. Substantial evidence indicates that hyperglycemia increases the prevalence of AKI as a surgical complication. Patients who develop hyperglycemia and AKI during the perioperative period are at significantly elevated risk for poor outcomes such as major adverse cardiac events and all-cause mortality. Early observational and interventional trials demonstrated that the use of intensive insulin therapy to achieve strict glycemic control resulted in remarkable reductions of AKI in surgical populations. However, more recent interventional trials and meta-analyses have produced contradictory evidence questioning the renal benefits of strict glycemic control. Although the exact mechanisms through which hyperglycemia increases the risk of AKI have not been elucidated, multiple pathophysiologic pathways have been proposed. Hypoglycemia and glycemic variability may also play a significant role in the development of AKI. In this literature review, the complex relationship between hyperglycemia and AKI as well as its impact on clinical outcomes during the perioperative period is explored.
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Affiliation(s)
- Carlos E Mendez
- Albany Stratton VA Medical Center, Albany Medical College, 113 Holland Avenue, Albany, NY, 12208, USA.
| | - Paul J Der Mesropian
- Albany Stratton VA Medical Center, Albany Medical College, 113 Holland Avenue, Albany, NY, 12208, USA.
| | - Roy O Mathew
- Albany Stratton VA Medical Center, Albany Medical College, 113 Holland Avenue, Albany, NY, 12208, USA.
| | - Barbara Slawski
- Department of Medicine, Froedtert and Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI, 53226, USA.
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Polderman JAW, Farhang-Razi V, Van Dieren S, Kranke P, DeVries JH, Hollmann MW, Preckel B, Hermanides J. Adverse side effects of dexamethasone in surgical patients. Hippokratia 2015. [DOI: 10.1002/14651858.cd011940] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Jorinde AW Polderman
- Academic Medical Center (AMC) University of Amsterdam; Department of Anaesthesiology; Meibergdreef 9 Amsterdam Netherlands 1105 AZ
| | - Violet Farhang-Razi
- Academic Medical Center (AMC) University of Amsterdam; Department of Anaesthesiology; Meibergdreef 9 Amsterdam Netherlands 1105 AZ
| | - Susan Van Dieren
- Academic Medical Center (AMC) University of Amsterdam; Department of Anaesthesiology; Meibergdreef 9 Amsterdam Netherlands 1105 AZ
| | - Peter Kranke
- University of Würzburg; Department of Anaesthesia and Critical Care; Oberdürrbacher Str. 6 Würzburg Germany 97080
| | - J Hans DeVries
- Academic Medical Centre; Internal Medicine; PO Box 22700 Amsterdam Netherlands 1100 DE
| | - Markus W Hollmann
- Academic Medical Center (AMC) University of Amsterdam; Department of Anaesthesiology; Meibergdreef 9 Amsterdam Netherlands 1105 AZ
| | - Benedikt Preckel
- Academic Medical Center (AMC) University of Amsterdam; Department of Anaesthesiology; Meibergdreef 9 Amsterdam Netherlands 1105 AZ
| | - Jeroen Hermanides
- Academic Medical Center (AMC) University of Amsterdam; Department of Anaesthesiology; Meibergdreef 9 Amsterdam Netherlands 1105 AZ
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Hommel I, van Gurp PJ, Tack CJ, Wollersheim H, Hulscher ME. Perioperative diabetes care: development and validation of quality indicators throughout the entire hospital care pathway. BMJ Qual Saf 2015; 25:525-34. [PMID: 26384710 DOI: 10.1136/bmjqs-2015-004112] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 09/01/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND In this study, we aim to develop a set of quality indicators for optimal perioperative diabetes care throughout the hospital care pathway and to gain insight into the feasibility of the indicator set in daily clinical practice by assessing the clinimetric properties of the indicators in a practice test. METHODS A literature-based modified Delphi method was used to develop a set of quality indicators. To assess clinimetric properties of each indicator (measurability, applicability, reliability, improvement potential and case-mix stability), a practice test was performed in six Dutch hospitals using a sample of 389 major surgery patients with diabetes who underwent abdominal, cardiac or large joint orthopaedic surgery. RESULTS We developed a set of 36 quality indicators for perioperative diabetes care. The practice test showed that one indicator was inapplicable, and nine indicators were unmeasurable. Interobserver reliability was good (0.61≤k≤0.8) for all indicators except for one with moderate (0.41≤k≤0.6) interobserver reliability. Improvement potential was low (<10%) for five indicators. Twenty-one indicators, including three outcome indicators, nine process indicators and nine structure indicators, could be used to assess the quality of care delivered in our six study hospitals. CONCLUSION We developed a face and content valid set of quality indicators for optimal perioperative diabetes care throughout the hospital care pathway, using a rigorous and systematic approach. The results from our practice test show that it is essential to subject indicators to a practice test before applying them for quality improvement purposes. TRIAL REGISTRATION NUMBER ClinicalTrials.gov: NCT01610674.
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Affiliation(s)
- Inge Hommel
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare, Nijmegen, The Netherlands
| | - Petra J van Gurp
- Department of General Internal Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Cees J Tack
- Department of General Internal Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Hub Wollersheim
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare, Nijmegen, The Netherlands
| | - Marlies Ejl Hulscher
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare, Nijmegen, The Netherlands
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Kroin JS, Buvanendran A, Li J, Moric M, Im HJ, Tuman KJ, Shafikhani SH. Short-term glycemic control is effective in reducing surgical site infection in diabetic rats. Anesth Analg 2015; 120:1289-96. [PMID: 25695673 DOI: 10.1213/ane.0000000000000650] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Patients and animals with diabetes exhibit enhanced vulnerability to bacterial surgical infections. Despite multiple retrospective studies demonstrating the benefits associated with glycemic control in reducing bacterial infection after cardiac surgery, there are fewer guidelines on the use of glycemic control for noncardiac surgeries. In the current study, we investigated whether long-term (begun 2 weeks before surgery) or immediate (just before surgery) glycemic controls, continued postoperatively, can reduce surgical site infection in type 1 diabetic-induced rats. METHODS Rats were injected with streptozotocin to induce type 1 diabetes. Four groups of animals underwent surgery and thigh muscle Staphylococcus aureus bacteria challenge (1 × 10 colony forming units) at the time of surgery. Group 1 diabetic rats received insulin treatment just before surgery and continued until the end of study (short-term glycemic control group). Group 2 diabetic rats received insulin treatment 2 weeks before surgery and continued until the end of study (long-term glycemic control). Group 3 diabetic rats received no insulin treatment (no glycemic control group). Group 4 nondiabetic rats served as a healthy control group. Rats were euthanized at 3 or 6 days after surgery. Blood glucose and muscle bacterial burden were measured at 3 or 6 days after surgery. RESULTS Glycemic control was achieved in both long- and short-term insulin-treated diabetic rats. Compared with untreated diabetic rats, the bacterial burden in muscle was significantly lower in both groups of glycemic controlled diabetic rats at 3 (all P < 0.003) and 6 (all P < 0.0001) days after surgery. CONCLUSIONS A short-term glycemic control regimen, initiated just before surgery and bacterial exposure, was as effective in reducing surgical site infection as a long-term glycemic control in type 1 diabetic rats. These data suggest that immediately implementing glycemic control in type 1 diabetic surgical patients before undergoing noncardiac surgery may decrease the risk of infection.
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Affiliation(s)
- Jeffrey S Kroin
- From the *Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois; †Department of Biochemistry, Rush University Medical Center, Chicago, Illinois; and ‡Department of Immunology/Microbiology, Rush University Medical Center, Chicago, Illinois
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Maitra S, Kirtania J, Pal S, Bhattacharjee S, Layek A, Ray S. Intraoperative blood glucose levels in nondiabetic patients undergoing elective major surgery under general anaesthesia receiving different crystalloid solutions for maintenance fluid. Anesth Essays Res 2015; 7:183-8. [PMID: 25885830 PMCID: PMC4173512 DOI: 10.4103/0259-1162.118953] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
CONTEXT The study was undertaken to observe the effect of different maintenance-fluid regimen on intraoperative blood glucose levels in non-diabetic patients undergoing elective major non-cardiac surgery under general anesthesia. AIMS To know the intraoperative blood glucose levels. SETTINGS AND DESIGN Prospective randomized parallel group study. SUBJECTS AND METHODS Two hundred non-diabetic patients (100 in each group) aged between 18 years and 60 years were enrolled for this prospective randomized parallel group study. Group A patients received Ringer's lactate solution and Group B patients received 0.45% sodium chloride with 5% dextrose and 20 mmol/L potassium chloride as maintenance fluid. Capillary blood glucose (CBG) level was measured immediately before initiation of intravenous fluid therapy and thereafter hourly till the end of surgery. If at any time intraoperative CBG was found to be more than or equal to 150 mg/dL calculated dose of human soluble insulin was given as intravenous bolus equal to the amount of CBG/100 units. STATISTICAL ANALYSIS USED For comparison of normally distributed variables independent sample t test was done. For rest of the data, i.e., CBG_0, CBG_4 and insulin consumption Mann-Whitney U test was employed. RESULTS 63% patients in group B developed at least one episode of hyperglycemia CBG ≥ 150 mg/dL) but only 29% in the Group A did so. Insulin consumption was significantly higher in Group B than in Group A to maintain normoglycemia. The relative risk of becoming hyperglycemic in Group B patients is 2.172 (95% CI 1.544 to 3.057). Number needed to harm, i.e., hyperglycemia, in Group B is 2.941 (95% CI 2 to 5). CONCLUSIONS We conclude that stress induced-hyperglycemic response in patients undergoing major non-cardiac surgery is common in non-diabetic population. Maintenance-fluid therapy by dextrose containing solution as opposed to Ringer's lactate solution increases the incidence of hyperglycemia. To achieve normoglycemia by intravenous bolus dose of human regular insulin, significantly higher doses are required in patients receiving dextrose containing saline as maintenance fluid.
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Affiliation(s)
- Souvik Maitra
- Department of Anaesthesiology, IPGMER Kolkata, India
| | | | - Samaendra Pal
- Department of Anaesthesiology, IPGMER Kolkata, India
| | | | - Amitava Layek
- Department of Anaesthesiology, IPGMER Kolkata, India
| | - Shreyasi Ray
- Department of Anaesthesiology, Medical College, Kolkata, India
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Coleman B, Ramakrishnan K. Surgical Problems of the Digestive System. Fam Med 2015. [DOI: 10.1007/978-1-4939-0779-3_100-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Pasquel FJ, Powell W, Peng L, Johnson TM, Sadeghi-Yarandi S, Newton C, Smiley D, Toyoshima MT, Aram P, Umpierrez GE. A randomized controlled trial comparing treatment with oral agents and basal insulin in elderly patients with type 2 diabetes in long-term care facilities. BMJ Open Diabetes Res Care 2015; 3:e000104. [PMID: 26336609 PMCID: PMC4553905 DOI: 10.1136/bmjdrc-2015-000104] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Revised: 07/20/2015] [Accepted: 07/29/2015] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Managing hyperglycemia and diabetes is challenging in geriatric patients admitted to long-term care (LTC) facilities. METHODS This randomized control trial enrolled patients with type 2 diabetes (T2D) with blood glucose (BG) >180 mg/dL or glycated hemoglobin >7.5% to receive low-dose basal insulin (glargine, starting dose 0.1 U/kg/day) or oral antidiabetic drug (OAD) therapy as per primary care provider discretion for 26 weeks. Both groups received supplemental rapid-acting insulin before meals for BG >200 mg/dL. Primary end point was difference in glycemic control as measured by fasting and mean daily glucose concentration between groups. RESULTS A total of 150 patients (age: 79±8 years, body mass index: 30.1±6.5 kg/m(2), duration of diabetes mellitus: 8.2±5.1 years, randomization BG: 194±97 mg/dL) were randomized to basal insulin (n=75) and OAD therapy (n=75). There were no differences in the mean fasting BG (131±27 mg/dL vs 123±23 mg/dL, p=0.06) between insulin and OAD groups, but patients treated with insulin had greater mean daily BG (163±39 mg/dL vs 138±27 mg/dL, p<0.001) compared to those treated with OADs. There were no differences in the rate of hypoglycemia (<70 mg/dL) between insulin (27%) and OAD (31%) groups, p=0.58. In addition, there were no differences in the number of hospital complications, emergency room visits, and mortality between treatment groups. CONCLUSIONS The results of this randomized study indicate that elderly patients with T2D in LTC facilities exhibited similar glycemic control, hypoglycemic events and complications when treated with either basal insulin or with oral antidiabetic drugs. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Identifier: NCT01131052.
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Affiliation(s)
- Francisco J Pasquel
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Winter Powell
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Limin Peng
- Departments of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Theodore M Johnson
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Christopher Newton
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Dawn Smiley
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marcos T Toyoshima
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Pedram Aram
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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Shaw P, Saleem T, Gahtan V. Correlation of hemoglobin A1C level with surgical outcomes: Can tight perioperative glucose control reduce infection and cardiac events? Semin Vasc Surg 2014; 27:156-61. [DOI: 10.1053/j.semvascsurg.2015.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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