Intraoperative hyperglycemia is independently associated with infectious complications after non-cardiac surgery

Effects of Perioperative Glycemic Management Protocol on Glycemic Outcomes of Type 2 Diabetic Patients Undergoing Major Abdominal Surgery: A Prospective Cohort Study

PURPOSE

This study aimed to reveal the effects of a glycemic control protocol directed by nurses during the perioperative period on glycemic outcomes in diabetic patients undergoing major abdominal surgery.

DESIGN

This was a prospective cohort study METHODS: The study was conducted at the Department of General Surgery of a research and training hospital in Turkey. The study included 47 patients with type 2 diabetes mellitus who underwent elective major abdominal surgery between September 2017 and December 2018. The number of patients in the intervention and the control groups was 22 and 25, respectively. Routine clinical glycemic control was implemented in the control group, whereas a glycemic management protocol developed by a multidisciplinary team was implemented in the intervention group. We collected data on the control group first, followed by the introduction of the glycemic management protocol to clinical staff and glycemia data collection using the new protocol. Blood glucose (BG) levels in patients and the factors that may affect BG were measured in the preoperative, intraoperative, and postoperative periods. Data on glycemic control was also collected. Furthermore, we measured the satisfaction of the nurses implementing the glycemic management protocol.

FINDINGS

The rate of hyperglycemia in intensive care unit was 21% in the intervention group and 59% in the control group (P < .05). Time spent in the target BG range during insulin infusion was 76% in the intervention group and 35% in the control group (P < .05). The time required to achieve target BG range during insulin infusion was 6 hours for the intervention group and 15 hours for the control group, indicating that less time was required to achieve the target BG range in the intervention group (P < .05). Moreover, the insulin consumption rate in the intensive care unit was lower in the intervention group (P < .05). The satisfaction levels of the nurses that used the glycemic management protocol was 92.61 ± 7.93%.

CONCLUSIONS

Results of this study showed that the implementation of a glycemic management protocol by nurses for patients undergoing major abdominal surgery decreases the rate of hyperglycemia, insulin consumption rate, and the time required to achieve the targeted BG range during the perioperative period. Therefore, it is recommended to use a glycemia management protocol to control glycemia in patients during the surgical process.

Society for Ambulatory Anesthesia Updated Consensus Statement on Perioperative Blood Glucose Management in Adult Patients With Diabetes Mellitus Undergoing Ambulatory Surgery

WHAT OTHER GUIDELINES ARE AVAILABLE ON THIS TOPIC

Since the publication of the SAMBA Consensus Statement for perioperative blood glucose management in the ambulatory setting in 2010, several recent guidelines have been issued by the American Diabetes Association (ADA), the American Association of Clinical Endocrinologists (AACE), the Endocrine Society, the Centre for Perioperative Care (CPOC), and the Association of Anaesthetists of Great Britain and Ireland (AAGBI) on DM care in hospitalized patients; however, none are specific to ambulatory surgery.

HOW DOES THIS GUIDELINE DIFFER FROM THE PREVIOUS GUIDELINES

Previously posed clinical questions that were outdated were revised to reflect current clinical practice. Additional questions were developed relating to the perioperative management of patients with DM to include the newer therapeutic interventions.

The relationship between admission hyperglycaemia and urinary tract infections in geriatric patients with hip fractures

PURPOSE

This study investigated the association of admission hyperglycaemia with catheter-associated urinary tract infections (CAUTIs) and catheter-unassociated urinary tract infections (CUUTIs) in elderly patients with hip fractures.

METHODS

In an observational cohort study of elderly patients with hip fractures, glucose values were collected within 24 h of admission. Urinary tract infections were classified as CAUTIs and CUUTIs. Multivariate logistic regression analysis and propensity score matching obtained adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for urinary tract infections. Subgroup analyses were further explored to investigate the relationship between admission hyperglycemia and urinary tract infections.

RESULTS

The study included 1279 elderly patients with hip fractures, 298 (23.3%) of whom had urinary tract infections upon hospitalization (including 182 CAUTIs and 116 CUUTIs). Propensity score matching indicated that patients with glucose levels exceeding 10.00 mmol/L had significantly higher odds of developing CAUTIs (OR 3.10, 95% CI 1.65-5.82) than those with glucose levels between 4.00-6.09 mmol/L. It is worth noting that patients with blood glucose levels greater than 10.00 mmol/L have a higher susceptibility for CUUTIs (OR 4.42, 95% CI 2.09-9.33) than CAUTIs. The subgroup analyses observed significant interactions between diabetes and CAUTIs (p for interaction = 0.01) and between bedridden time and CUUTIs (p for interaction = 0.04).

CONCLUSIONS

Elderly hip fracture patients with admission hyperglycaemia have an independent association with CAUTIs and CUUTIs. The association is stronger with CUUTIs and necessitates clinician intervention if blood glucose levels at admission exceed 10 mmol/L.

Impact of total intravenous anesthesia and total inhalation anesthesia as the anesthesia maintenance approaches on blood glucose level and postoperative complications in patients with type 2 diabetes mellitus: a double-blind, randomized controlled trial

BACKGROUND

Diabetes mellitus is a prevalent metabolic disease in the world. Previous studies have shown that anesthetics can affect perioperative blood glucose levels which related to adverse clinical outcomes. Few studies have explored the choice of general anesthetic protocol on perioperative glucose metabolism in diabetes patients. We aimed to compare total intravenous anesthesia (TIVA) with total inhalation anesthesia (TIHA) on blood glucose level and complications in type 2 diabetic patients undergoing general surgery.

METHODS

In this double-blind controlled trial, 116 type 2 diabetic patients scheduled for general surgery were randomly assigned to either the TIVA group or TIHA group (n = 56 and n = 60, respectively). The blood glucose level at different time points were measured and analyzed by the repeated-measures analysis of variance. The serum insulin and cortisol levels were measured and analyzed with t-test. The incidence of complications was followed up and analyzed with chi-square test or Fisher's exact test as appropriate. The risk factors for complications were analyzed using the logistic stepwise regression.

RESULTS

The blood glucose levels were higher in TIHA group than that in TIVA group at the time points of extubation, 1 and 2 h after the operation, 1 and 2 days after the operation, and were significantly higher at 1 day after the operation (10.4 ± 2.8 vs. 8.1 ± 2.1 mmol/L; P < 0.01). The postoperative insulin level was higher in TIVA group than that in TIHA group (8.9 ± 2.9 vs. 7.6 ± 2.4 IU/mL; P = 0.011). The postoperative cortisol level was higher in TIHA group than that in TIVA group (15.3 ± 4.8 vs. 12.2 ± 8.9 ug/dL ; P = 0.031). No significant difference regarding the incidence of complications between the two groups was found based on the current samples. Blood glucose level on postoperative day 1 was a risk factor for postoperative complications (OR: 1.779, 95%CI: 1.009 ~ 3.138).

CONCLUSIONS

TIVA has less impact on perioperative blood glucose level and a better inhibition of cortisol release in type 2 diabetic patients compared to TIHA. A future large trial may be conducted to find the difference of complications between the two groups.

TRIAL REGISTRATION

The protocol registered on the Chinese Clinical Trials Registry on 20/01/2020 (ChiCTR2000029247).

Comparison of spinal versus general anesthesia on the perioperative blood glucose levels in patients undergoing lower abdominal and pelvic surgery: a prospective cohort study, Ethiopia

Surgery is linked with fear and stress that disrupt metabolic and neuroendocrine activities, which impair normal maintained glucose metabolism that leads to stress hyperglycaemia. This study aimed to compare the effect of general and spinal anaesthesia on perioperative blood glucose levels in patients undergoing lower abdominal and pelvic surgery.

Methods

This prospective observational cohort study recruits 70 adult patients who underwent lower abdominal and pelvic surgery under general and spinal anaesthesia; 35 in each group. A systematic random sampling technique was used to select study participants. Capillary blood glucose was measured at four perioperative times. An independent t-test, dependent t-test, and Manny-Whitney U test were used for statistical analysis, as appropriate. P values less than 0.05 were considered statistically significant.

Results

No statistically significant difference was observed in mean blood glucose levels at baseline and 5 min after induction of general anaesthesia and complete blocks of spinal anaesthesia. But at the end of surgery and 60 min after the end of surgery the mean blood glucose levels were statistically significantly higher in the general anaesthesia group compared with the spinal anaesthesia group (P<0.05). And the blood glucose level was significantly increased from baseline compared with the different time intervals in the general anaesthesia group.

Conclusion

The mean blood glucose levels were lower in patients undergoing surgery under spinal anaesthesia compared with general anaesthesia. The authors recommend spinal over general anaesthesia whenever possible for patients undergoing lower abdominal and pelvic surgery.

Strategies for intraoperative glucose management: a scoping review

PURPOSE

Perioperative hyperglycemia is associated with adverse outcomes for patients with and without diabetes. Guidelines and published protocols for intraoperative glycemic management have substantial variation in their recommendations. We sought to characterize the current evidence-guiding intraoperative glycemic management in a scoping review.

SOURCES

Our search strategy included MEDLINE (Ovid and EBSCO), PubMed, PubMed Central, EMBASE, CINAHL, Cochrane Library, SciVerse Scopus, and Web of Science and a gray literature search of Google, Google Scholar, hand searching of the reference lists of included articles, OAISter, institutional protocols, and ClinicalTrails.gov.

PRINCIPAL FINDINGS

We identified 41 articles that met our inclusion criteria, 24 of which were original research studies. Outcomes and exposures were defined heterogeneously across studies, which limited comparison and synthesis. Investigators often created arbitrary and differing categories of glucose values rather than analyzing glucose as a continuous variable, which limited our ability to combine results from different studies. In addition, the study populations and surgery types also varied considerably, with few studies performed during day surgeries and specific surgical disciplines. Study populations often included more than one type of surgery, indication, and urgency that were expected to have varying physiologic and inflammatory responses. Combining low- and high-risk patients in the same study population may obscure the harms or benefits of intraoperative glycemic management for high-risk procedures or patients.

CONCLUSION

Future studies examining intraoperative glycemic management should carefully consider the study population, surgical characteristics, and pre- and postoperative management of hyperglycemia.

The relationship between inpatient hyperglycaemia and mortality is modified by baseline glycaemic status

AIMS

There is a well-established association between inpatient hyperglycaemia and mortality. However, evidence is inconsistent regarding whether this association is differential among those with and without type 2 diabetes mellitus (T2DM). Most studies are based on convenience samples or are unable to adjust for comorbidities. We examined whether the association between hyperglycaemia and 30-day mortality was modified by baseline glycaemic status.

MATERIALS AND METHODS

This was a retrospective cohort study of 174,671 eligible hospitalized individuals between 2012 and 2015. Thirty-day mortality was assessed during the first inpatient stay up to 30 days post discharge. The adjusted association between hyperglycaemia and mortality was assessed with logistic regression models. Then, four interaction terms were entered into the model to assess if the association between hyperglycaemia and mortality differed by baseline glycaemic status.

RESULTS

The multivariate model demonstrated a 2.18-fold risk of mortality associated with hyperglycaemia (odds ratio [OR] [95%CI]: 2.19 [2.08-2.31]). Adding the interaction terms between hyperglycaemia and baseline glycaemic status the ORs of 30-day mortality were 1.41 (1.25-1.60) in non-T2DM status, 1.32 (1.16-1.51) in pre-diabetes status and 1.30 (1.04-1.62) in unscreened status, as compared to T2DM status with hyperglycaemia.

CONCLUSIONS

Hyperglycaemia is positively associated with mortality and both those without and with controlled T2DM are at highest risk. These findings may help medical staff identify potential increased risk of mortality upon hospital entry and discharge, and direct further research to assess how hyperglycaemia control and proactive deterioration prevention throughout the entire inpatient stay may prevent adverse outcomes.

Perioperative ADministration of Dexamethasone And blood Glucose concentrations in patients undergoing elective non-cardiac surgery - the randomised controlled PADDAG trial

BACKGROUND

The hyperglycaemic effect of dexamethasone in diabetic and nondiabetic patients in the peri-operative period is unknown.

OBJECTIVE

To assess the effect of a single dose of intra-operative dexamethasone on peri-operative blood glucose.

DESIGN

Multicentre, stratified, randomised trial.

SETTING

University hospitals in Australia and Hong Kong.

PATIENTS

A total of 302 adults scheduled for elective, noncardiac and nonobstetric surgical procedures under general anaesthesia, stratified by diabetes mellitus status, were randomised to receive placebo, 4 or 8 mg dexamethasone administered intravenously after induction of anaesthesia.

MAIN OUTCOME MEASURES

Maximum blood glucose within 24 h of surgery, and the interaction between glycated haemoglobin (HbA1c) and dexamethasone were the primary and secondary outcomes.

RESULTS

The median [IQR] baseline blood glucose in the nondiabetes stratum in the placebo (n=81), 4 mg (n=81) and 8 mg dexamethasone (n=77) trial arms were respectively 5.3 [4.6 to 5.8], 5.0 [4.7 to 5.4] and 5.0 [4.2 to 5.9] mmol l-1. In the diabetes stratum these values were 6.6 [6.0 to 8.3]; (n=22), 6.1 [5.5 to 10.4]; (n=22) and 6.7 [5.6 to 8.3]; (n=19) mmol l-1. The median [IQR] maximum peri-operative blood glucose values in the nondiabetes stratum were 6.0 [5.3 to 6.8], 6.3 [5.5 to 7.3] and 6.3 [5.8 to 7.4] mmol l-1 in the control, dexamethasone 4 mg and dexamethasone 8 mg arms, respectively. In the diabetes stratum these values were 10.3 [8.1 to 12.4], 12.6 [10.3 to 18.3] and 13.6 [11.2 to 20.1] mmol l-1. There was a significant interaction between pre-operative HbA1c value and 8 mg dexamethasone: every 1% increment in HbA1c produced a 4.0 mmol l-1 elevation in maximal peri-operative glucose concentration.

CONCLUSION

Dexamethasone 4 mg or 8 mg did not induce greater hyperglycaemia compared with placebo for nondiabetic and well controlled diabetic patients. Maximal peri-operative blood glucose concentrations in patients with diabetes were related to baseline HbA1c values in a concentration-dependent fashion after 8 mg of dexamethasone.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Registry (ACTRN12614001145695): URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=367272.

Outcome of Organ Dysfunction in the Perioperative Period

While intraoperative mortality has diminished greatly over the last several decades, the risk of death within 30 days of surgery remains stubbornly high and is ultimately related to perioperative organ failure. Perioperative strokes, while rare (<2% in noncardiac surgery), are associated with a more than 10-fold increase in mortality. Rapid identification and treatment are key to maximizing long-term outcomes. Postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) are separate but related perioperative neurological disorders, both of which are associated with poor long-term outcomes. To date, there are few known interventions that can ameliorate the risk of perioperative central nervous system dysfunction. Major adverse cardiac events (MACE) are a major contributor to adverse clinical outcomes following surgical procedures. Recently, advances in diagnostic strategies (eg, high-sensitivity cardiac troponin [hs-cTn] assays) have improved our understanding of MACE. Recently, the dabigatran in patients with myocardial injury after noncardiac surgery (MINS; Management of myocardial injury After NoncArdiac surGEry) trial demonstrated that a direct thrombin inhibitor could improve outcomes following MINS. While the risk of acute respiratory distress syndrome (ARDS) after surgery is approximately 0.2%, other less severe complications (eg, pneumonia, reintubation) are closer to 2%. While intensive care unit (ICU) concepts related to ARDS have migrated into the operating room, whether or not adverse pulmonary outcomes impact long-term outcomes in surgical patients remains a matter of debate. The standardization of acute kidney injury (AKI) definition has improved the ability of clinicians to measure and study the incidence of this important source of perioperative morbidity. AKI is associated with increased mortality as well as nonrenal morbidity (eg, myocardial infarction) after major surgery. Gastrointestinal complications after surgery range from ileus (common in abdominal procedures and associated with an increased length of stay) to less common complications such as mesenteric ischemia and gastrointestinal bleeding, both of which are associated with very high mortality. Outside of cardiothoracic surgery, the incidence of perioperative hepatic injury is not well described but, in this population, is associated with worsened long-term outcomes. Hyperglycemia is a common perioperative complication and occurs in patients undergoing both cardiac and noncardiac surgery. Both hyper- and hypoglycemia are associated with worsened long-term outcomes in cardiac and noncardiac surgery. Better diagnosis and increased understanding of perioperative organ injury has led to an increased appreciation for the specific role that particular organ systems play in poor long-term outcomes and has set the stage for targeted therapeutic interventions.

The effect of dexmedetomidine on intraoperative blood glucose homeostasis: secondary analysis of a randomized controlled trial

Purpose

To investigate the effect of dexmedetomidine on intraoperative blood glucose hemostasis in elderly patients undergoing non-cardiac major surgery.

Methods

This was secondary analysis of a randomized controlled trial. Patients in dexmedetomidine group received a loading dose dexmedetomidine (0.6 μg/kg in 10 min before anaesthesia induction) followed by a continuous infusion (0.5 μg/kg/hr) till 1 h before the end of surgery. Patients in control group received volume-matched normal saline at the same time interval. Primary outcome was the incidence of intraoperative hyperglycemia (blood glucose higher than 10 mmol/L).

Results

303 patients in dexmedetomidine group and 306 patients in control group were analysed. The incidence of intraoperative hyperglycemia showed no statistical significance between dexmedetomidine group and control group (27.4% vs. 22.5%, RR = 1.22, 95%CI 0.92–1.60, P = 0.167). Median value of glycemic variation in dexmedetomidine group (2.5, IQR 1.4–3.7, mmol) was slightly lower than that in control group (2.6, IQR 1.5–4.0, mmol), P = 0.034. In multivariable logistic analysis, history of diabetes (OR 3.007, 95%CI 1.826–4.950, P < 0.001), higher baseline blood glucose (OR 1.353, 95%CI 1.174–1.560, P < 0.001) and prolonged surgery time (OR 1.197, 95%CI 1.083–1.324, P < 0.001) were independent risk factors of hyperglycaemia.

Conclusions

Dexmedetomidine presented no effect on intraoperative hyperglycemia in elderly patients undergoing major non-cardiac surgery.

Trial registration

Present study was registered at Chinese Clinical Trial Registry on December 1, 2015 (www.chictr.org.cn, registration number ChiCTR-IPR-15007654).

Improvement in Hyperglycemia Prevents Surgical Site Infection Irrespective of Insulin Therapy in Non-diabetic Patients Undergoing Gastrointestinal Surgery

BACKGROUND

Intensive glycemic control is recommended to prevent surgical site infections (SSI). Our aim was to evaluate retrospectively the effect of improvement in hyperglycemia irrespective of insulin use on the incidence of SSI in non-diabetic patients.

METHODS

The highest blood glucose (BG) concentration within 12 h (early peak BG) and the final BG from 12 to 24 h after surgery were evaluated in patients who underwent gastrointestinal surgery. Patients with an early peak BG of ≥150 mg/dL were divided into those with persistent (final BG of ≥150 mg/dL) and improved hyperglycemia (final BG of <150 mg/dL). Patients without hyperglycemia and those with late-onset hyperglycemia were also assessed for SSI risk.

RESULTS

Overall, 1612 patients were studied (diabetes, n = 293). Although hyperglycemia increased the SSI rates in non-diabetic patients, no correlation was demonstrated in patients with diabetes at any cutoff final BG defining htperglycemia except for 180 mg/dL. Hyperglycemia improved without insulin therapy in 283 of 512 non-diabetic patients who had early hyperglycemia. The adjusted standardized residual for those with SSI and persistent hyperglycemia was 5.2 (P < 0.05). In contrast, the absence of hyperglycemia was a significant preventive factor for SSI. In the multivariate analyses, persistent hyperglycemia was an independent risk factor for SSI (odds ratio 1.54; 95% confidence interval 1.03-2.31).

CONCLUSIONS

Remission of hyperglycemia within 24 h after surgery prevented SSI in non-diabetic patients. Considering that hyperglycemia improved in approximately half of patients without insulin therapy, commencement of insulin dosing after two consecutive BGs of ≥150 mg/dL might be reasonable, especially in general wards.

Transoperative glycemia in pets: validating old ones, and presenting lip mucosa as new sampling site

The aim of our study was to investigate the viability and validity of blood sampling from the upper lip mucosa in healthy dogs and cats for monitoring transoperative glycemia and compare the results with those obtained from samples taken from previously described blood sampling sites for determination of glycemia using a glucose meter. Blood glucose (BG) levels were determined in samples taken from the upper lip mucosa of 24 dogs and 31 cats undergoing neutering or spaying surgeries. These values were compared to those of samples obtained from other sites previously described for capillary blood glucose monitoring (marginal ear vein, carpal pad in dogs, metacarpal pad in cats) using a glucose meter. Additionally, BG from peripheral venous blood was determined using a glucose meter, and the gold standard enzymatic colorimetric assay. The clinical reliability of BG values taken from lip mucosa and from all the other BG values measured by the glucose meter was evaluated using the error grid analysis modified by Parkes et al (2000). The upper lip mucosa was an easily accessible site for the obtainment of appropriate blood samples, and glucose levels read in these samples correlated positively with glycemic values read in blood samples from all other sites in dogs and cats. All BG made using glucose meters taken from all sites were within the clinically acceptable range when compared with enzymatic colorimetric assay (gold standard), and were analytically accurate according to the error grid (zones A and B). All blood sampling sites described in this work can be used to assess transoperative glycemia. The upper lip mucosa is a viable blood sampling site for precise monitoring of transoperative glycemia in healthy dogs and cats and shows promise for alternative blood glucose monitoring.

Intra-operative anaesthetic management of older patients undergoing liver surgery

Older patients represent a growing proportion of the general surgical caseload. This includes those undergoing liver resection, with figures rising faster than the rate of population ageing. The physiology of ageing leads to changes in all body systems which may render the provision of safe anaesthesia more challenging than in younger patients. Anaesthesia for liver surgery has specific principles, largely aimed at reducing venous bleeding from the liver, and those related to complex major surgery. This review explores the principles of anaesthesia for liver resection and describes how they may require modification in the older patient. The traditional approach of low central venous pressure anaesthesia in order to reduce bleeding may need to be altered in the presence of a cardiovascular system less able to tolerate hypotension and hypoperfusion. These changes in physiology should also lower the threshold for invasive monitoring. The provision of effective analgesia perioperatively should be tailored to minimise the surgical stress response and opiate use. Careful consideration of general principles of intra-operative care for older patients, such as positioning, drug dosing, avoidance of excessively deep anaesthesia, and maintenance of normothermia are also important given the prolonged, complex nature of liver surgery. This individualised approach, with careful attention to changes in physiology allows liver resections to be undertaken in older patients without increases in mortality.

Effects of intravenous and inhalation anesthesia on blood glucose and complications in patients with type 2 diabetes mellitus: study protocol for a randomized controlled trial

Background

Diabetes mellitus (DM) is a metabolic disorder syndrome caused by relative or absolute lack of insulin and varying degrees of insulin resistance. The type and regimen of anesthesia may affect perioperative hyperglycemia following major surgical stress. The effect of perioperative anesthetics on the blood glucose level of diabetic patients will play an essential role in the postoperative recovery of patients. However, there is no rigorously-designed randomized controlled trial to compare the effects of total intravenous anesthesia (TIVA) and total inhalation anesthesia (TIHA) on blood glucose and complications in type 2 diabetes. Hence, we design this clinical trial to compare the effects of TIVA and TIHA of hyperglycemia and clinical outcomes in type 2 diabetes undergoing surgery.

Methods

This is a randomized, double-blind, parallel controlled trial. One hundred twelve patients with type 2 DM who meet the qualification criteria will be randomly divided into two groups: TIVA group and TIHA group. The levels of serum insulin and cortisol will be measured before and after the operation, and the levels of blood glucose at different setting time will be monitored. All patients will be followed up by blinded evaluators at baseline and 1, 3, 7, and 30 days after the intervention. The follow-up included postoperative complications [such as myocardial infarction (MI), stroke, renal failure, anastomotic fistula, stress ulcer, incision infection, lung infection] and adverse events.

Discussion

The routinely used clinical anesthesia schemes are TIVA, TIHA and intravenous-inhalation combined anesthesia. We expect that the results of this trial will provide high-quality clinical evidence for the choice of anesthesia options for patients with type 2 DM.

Trial registration

Chinese Clinical Trial Registry: ChiCTR2000029247, registration date: 20 January 2020.

Association of intraoperative hyperglycemia and postoperative outcomes in patients undergoing non-cardiac surgery: a multicenter retrospective study

BACKGROUND

While pre and postoperative hyperglycemia is associated with increased risk of surgical site infection, myocardial infarction, stroke and risk of death, there are no multicenter data regarding the association of intraoperative blood glucose levels and outcomes for the non-cardiac surgical population.

METHODS

We conducted a retrospective cohort study from the Michigan Surgical Quality Collaborative, a network of 64 hospitals that prospectively collects validated data on surgical patients for the purpose of quality improvement. We included data for adult general, vascular, endocrine, hepatobiliary, and gastrointestinal operations between 2013 and 2015. We assessed the risk-adjusted, independent relationship between intraoperative hyperglycemia (glucose > 180) and the primary outcome of 30-day morbidity/mortality and secondary outcome of infectious complications using multivariable logistic regression modelling. Post hoc sensitivity analysis to assess the association between blood glucose values ≥250 mg/dL and outcomes was also performed.

RESULTS

Ninety-two thousand seven hundred fifty-one patients underwent surgery between 2013 and 2015 and 5014 (5.4%) had glucose testing intra-operatively. Of these patients, 1647 patients (32.9%) experienced the primary outcome, and 909 (18.1%) the secondary outcome. After controlling for patient comorbidities and surgical factors, peak intraoperative glucose > 180 mg/dL was not an independent predictor of 30-day mortality/morbidity (adjusted OR 1.05, 95%CI:0.86 to 1.28; p-value 0.623; model c-statistic of 0.720) or 30-day infectious complications (adjusted OR 0.93, 95%CI:0.74,1.16; p 0.502; model c-statistic of 0.709). Subgroup analysis for patients with or without diabetes yielded similar results. Sensitivity analysis demonstrated blood glucose of 250 mg/dL was a predictor of 30-day mortality/morbidity (adjusted OR: 1.59, 95% CI: 1.24, 2.05; p < 0.001).

CONCLUSIONS

Among more than 5000 patients across 64 hospitals who had glucose measurements during surgery, there was no difference in postoperative outcomes between patients who had intraoperative glucose > 180 mg/ dL compared to patients with glucose values ≤180 mg/ dL.

Dextrose-Containing Carrier Solution for Hyperthermic Intraperitoneal Chemotherapy: Increased Intraoperative Hyperglycemia and Postoperative Complications

PURPOSE

Intraoperative hyperglycemia is associated with infectious complications in general surgery patients. This study aimed to determine if the use of lactated Ringer's (LR) carrier solution during hyperthermic intraperitoneal chemotherapy (HIPEC) would lower the incidence of intraoperative hyperglycemia and improve postoperative outcomes when compared with a standard 1.5% dextrose peritoneal dialysate carrier solution.

PATIENTS AND METHODS

This is a retrospective cohort study of 134 patients who underwent HIPEC at the University of Colorado. Perioperative glucose levels and outcomes were compared between patients who were perfused with 1.5% dextrose peritoneal dialysate carrier solution (n = 68) versus LR carrier solution (n = 66).

RESULTS

The study population consisted of patients undergoing HIPEC for appendiceal (50%), colorectal (34%), mesothelioma (8%), and ovarian cancer (5%). Intraoperative severe hyperglycemia (glucose ≥ 180 mg/dL) was significantly more common among patients perfused with a dextrose-containing carrier solution versus those perfused with LR (88% vs. 21%; p < 0.001). Patients in the dextrose cohort had significantly more severe complications (39% vs. 12%; p = 0.034), infectious complications (35% vs. 15%; p = 0.011), and organ space infections (18% vs. 5%: p = 0.026) than the LR cohort. On multivariable analysis, dextrose-containing carrier solution was significantly associated with an increased risk of postoperative infectious complications (HR 5.16; p = 0.006).

CONCLUSIONS

Intraoperative hyperglycemia is common when dextrose-containing carrier solution is used during HIPEC, and severe intraoperative hyperglycemia is strongly associated with an increased risk for infectious of complications following HIPEC. LR carrier solution should be routinely used to reduce intraoperative hyperglycemia and its associated risks.

Intraoperative hyperglycemia increases the incidence of postoperative delirium

BACKGROUND

Hyperglycemia frequently occurs during major surgery and is associated with adverse postoperative outcomes. This study aimed to investigate the influence of intraoperative hyperglycemia on incidences of postoperative delirium (POD) and postoperative cognitive dysfunction (POCD).

METHODS

Eighty-seven patients aged ≥65 years undergoing elective surgery were included in this prospective observational subproject of the BioCog study. Blood glucose (BG) levels were measured every 20 minutes intraoperatively. Hyperglycemia was defined as BG levels ≥150 mg·dL-1. Patients were assessed for POD twice daily until postoperative day 7. The occurrence of POCD was determined three months after surgery. Multivariable logistic regression was used to identify associations between hyperglycemia and POD as well as POCD. Secondary endpoints comprised duration of hyperglycemia, maximum glucose level (Glucosemax) and differences between diabetic and non-diabetic patients.

RESULTS

POD occurred in 41 (47.1%), POCD in five (15.2%) patients. In two separate multivariable logistic regression models, hyperglycemia was significantly associated with POD (OR 3.86 [CI 95% 1.13, 39.49], P=0.044) but not POCD (3.59 [NaN, NaN], P=0.157). Relative duration of hyperglycemia was higher in POD patients compared to patients without POD (20 [0; 71] % versus 0 [0; 55] %, P=0.075), whereas the maximum glucose levels during surgery were similar between the two groups. Considering only non-diabetic patients, relative duration of hyperglycemia (P=0.003) and Glucosemax (P=0.015) were significantly higher in patients with POD.

CONCLUSIONS

Intraoperative hyperglycemia was independently associated with POD but not POCD. Relative duration of hyperglycemia appeared thereby to also play a role. Especially hyperglycemic non-diabetic patients might be at high risk for POD.

Association of postoperative glycemic control with outcomes after carotid procedures

Objective

There are limited data evaluating the impact of postoperative hyperglycemia in patients undergoing vascular procedures. This study evaluated the relationship between suboptimal glucose control and adverse outcomes after carotid artery stenting and carotid endarterectomy.

Methods

Patients admitted for elective carotid procedures were selected from the Cerner Health Facts® (2008–2015) database using ICD-9-CM diagnosis and procedure codes. We examined the relationship between patient characteristics, postoperative hyperglycemia (any value > 180 mg/dL), and complications with chi-square analysis. A multivariable model examined the association between patient characteristics, procedure type, and glucose control with infection, renal failure, stroke, respiratory and cardiac complications, and length of stay over 10 days.

Results

Of the 4287 patients admitted for an asymptomatic carotid procedure, 788 (18%) underwent carotid artery stenting and 3499 (82%) underwent carotid endarterectomy. Most patients (87%) had optimal postoperative glucose control (80–180 mg/dL); 13% had suboptimal glucose control. On average, patients with suboptimal glucose control experienced: higher stroke rates (6.2% vs. 2.7%; p <  0.001); more cardiac complications (5.1% vs. 2.0%; p <  0.001); longer hospital stays (3.1 vs. 1.8 days; p < .001); higher rates of post-procedure infection (4.0% vs. 1.8%; p = .001); and more complications than patients with optimal glucose control. Multivariable logistic regression demonstrated that patients with suboptimal glucose control had higher odds of having an infectious (pneumonia, cellulitis, surgical site, etc.) complication (OR 1.91, 95% CI 1.10–3.34), renal failure (OR 3.36, 95% CI 1.95–5.78), respiratory complications (OR 1.81, 95% CI 1.21–2.71), stroke (OR 1.82, 95% CI 1.15–2.88), or length of stay > 10 days (OR 4.07, 95% CI 2.02–8.20).

Conclusions

Suboptimal glucose control was associated with adverse events after carotid artery stenting and carotid endarterectomy, independent of a diabetes diagnosis. Several adverse outcomes were associated with hyperglycemia, including stroke. Given the singular role of carotid procedures in preventing stroke, we suggest that incorporating rigorous post-operative glucose control into best medical treatment of carotid disease should be considered as a standard practice.

Challenges in the management of people with diabetes and cancer

Although micro- and macrovascular complications of diabetes are the most important cause of mortality and morbidity in people with diabetes, it is increasingly recognized that diabetes increases the risk of developing cancer. Diabetes and cancer commonly co-exist, and outcomes in people with both conditions are poorer than in those who have cancer but no diabetes. There is no randomized trial evidence that treating hyperglycaemia in people with cancer improves outcomes, but therapeutic nihilism should be avoided, and a personalized approach to managing hyperglycaemia in people with cancer is needed. This review aims to outline the link between diabetes therapies and cancer, and discuss the reasons why glucose should be actively managed people with both. In addition, we discuss clinical challenges in the management of hyperglycaemia in cancer, specifically in relation to glucocorticoids, enteral feeding and end-of-life care.

Spinal Cord Stimulation Infection Rate and Incremental Annual Expenditures: Results From a United States Payer Database

OBJECTIVES

Surgical site infections (SSIs) result in significant negative clinical and economic outcomes. The objective of this study is to estimate annual health expenditures associated with spinal cord stimulation (SCS)-related infections.

MATERIALS AND METHODS

Data from the Truven MarketScan® databases were used to identify patients with an SCS implant (2009-2014) and a continuous health plan enrollment for at least 12-months before and after implant (index date). Annual expenditures were estimated for patients with a device-related infection vs. those without infection since index date. A generalized linear model estimated annual expenditures attributable to device-related infection. Multivariable expenditure models were conducted separately for patients in initial and replacement groups, controlling for demographics, comorbidities, and clinical characteristics.

RESULTS

The study included 6615 patients. Multivariable expenditure models revealed that patients with infection have higher annual expenditures than patients without infection. Estimated incremental annual healthcare expenditures for patients with an infection were $59,716 (95% CI: $48,965-$69,480) for initial implanted patients and $64,833 (95% CI: $37,377-$86,519) for replacement patients. Only 26% of patients who were explanted for infection underwent a reimplant.

CONCLUSIONS

These results show the substantial expenditure burden associated with an SCS-related infection. Management of SCS-related infection is important from both clinical and economic standpoints. The economic and clinical data presented here reinforce the need for additional research and strategies for healthcare providers to minimize SCS infections. Future economic research is needed to further define the specific economic cost drivers associated with the extensive expenditure burden.

Risk Factors of Intraoperative Dysglycemia in Elderly Surgical Patients

BACKGROUNDː Dysglycemia is associated with adverse outcome including increased morbidity and mortality in surgical patients. Acute insulin resistance due to the surgical stress response is seen as a major cause of so-called stress hyperglycemia. However, understanding of factors determining blood glucose (BG) during surgery is limited. Therefore, we investigated risk factors contributing to intraoperative dysglycemia. METHODSː In this subgroup investigation of the BIOCOG study, we analyzed 87 patients of ≥ 65 years with tight intraoperative BG measurement every 20 min during elective surgery. Dysglycemia was defined as at least one intraoperative BG measurement outside the recommended target range of 80-150 mg/dL. Additionally, all postoperative BG measurements in the ICU were obtained. Multivariable logistic regression analysis adjusted for age, sex, American Society of Anesthesiologists (ASA) status, diabetes, type and duration of surgery, minimum Hemoglobin (Hb) and mean intraoperative norepinephrine use was performed to identify risk factors of intraoperative dysglycemia. RESULTSː 46 (52.9%) out of 87 patients developed intraoperative dysglycemia. 31.8% of all intraoperative BG measurements were detected outside the target range. Diabetes [OR 9.263 (95% CI 2.492, 34.433); p=0.001] and duration of surgery [OR 1.005 (1.000, 1.010); p=0.036] were independently associated with the development of intraoperative dysglycemia. Patients who experienced intraoperative dysglycemia had significantly elevated postoperative mean (p<0.001) and maximum BG levels (p=0.001). Length of ICU (p=0.007) as well as hospital stay (p=0.012) were longer in patients with dysglycemia. CONCLUSIONSː Diabetes and duration of surgery were confirmed as independent risk factors for intraoperative dysglycemia, which was associated with adverse outcome. These patients, therefore, might require intensified glycemic control. Increased awareness and management of intraoperative dysglycemia is warranted.