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Crowley K, Scanaill PÓ, Hermanides J, Buggy DJ. Current practice in the perioperative management of patients with diabetes mellitus: a narrative review. Br J Anaesth 2023:S0007-0912(23)00128-9. [PMID: 37061429 PMCID: PMC10375498 DOI: 10.1016/j.bja.2023.02.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/08/2023] [Accepted: 02/23/2023] [Indexed: 04/17/2023] Open
Abstract
The prevalence of diabetes is increasing, and patients with diabetes mellitus have both an increased likelihood of requiring surgery and of developing postoperative complications when they do. We summarise available evidence underpinning current guidelines on preoperative assessment and optimisation, perioperative management of prescribed insulin and oral hypoglycaemic medication, intraoperative glycaemic control, and postoperative patient care.
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Affiliation(s)
- Kieran Crowley
- Department of Anaesthesiology & Perioperative Medicine, Mater University Hospital, School of Medicine, University College Dublin, Dublin, Ireland.
| | - Pádraig Ó Scanaill
- Department of Anaesthesiology & Perioperative Medicine, Mater University Hospital, School of Medicine, University College Dublin, Dublin, Ireland
| | | | - Donal J Buggy
- Department of Anaesthesiology & Perioperative Medicine, Mater University Hospital, School of Medicine, University College Dublin, Dublin, Ireland; Outcomes Research Cleveland Clinic, Cleveland, OH, USA.
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Dong M, Liu W, Luo Y, Li J, Huang B, Zou Y, Liu F, Zhang G, Chen J, Jiang J, Duan L, Xiong D, Fu H, Yu K. Glycemic Variability Is Independently Associated With Poor Prognosis in Five Pediatric ICU Centers in Southwest China. Front Nutr 2022; 9:757982. [PMID: 35284444 PMCID: PMC8905539 DOI: 10.3389/fnut.2022.757982] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 01/17/2022] [Indexed: 12/15/2022] Open
Abstract
Background Glucose variability (GV) is a common complication of dysglycemia in critically ill patients. However, there are few studies on the role of GV in the prognosis of pediatric patients, and there is no consensus on the appropriate method for GV measurement. The objective of this study was to determine the “optimal” index of GV in non-diabetic critically ill children in a prospective multicenter cohort observational study. Also, we aimed to confirm the potential association between GV and unfavorable outcomes and whether this association persists after controlling for hypoglycemia or hyperglycemia. Materials and Methods Blood glucose values were recorded for the first 72 h and were used to calculate the GV for each participant. Four different metrics [SD, glycemic lability index (GLI), mean absolute glucose (MAG), and absolute change of percentage (ACACP)] were considered and compared to identify the “best” GV index associated with poor prognosis in non-diabetic critically ill children. Among the four metrics, the SD was most commonly used in previous studies, while GLI- and MAG-integrated temporal information, that is the rate and magnitude of change and the time interval between glucose measurements. The fourth metric, the average consecutive ACACP, was introduced in our study, which can be used in real-time clinical decisions. The primary outcome of this study was the 28-day mortality. The receiver operating characteristic (ROC) curve analysis was conducted to compare the predictive power of different metrics of GV for the primary outcome. The GV index with the largest area under ROC curve (AUC) was chosen for subsequent multivariate analyses. Multivariate Cox regression analysis was performed to identify the potential predictors of the outcome. To compare the contribution in 28-day mortality prognosis between glycemic variability and hyper- or hypoglycemia, performance metrics were calculated, which included AUC, net reclassification improvement (NRI), and integrated discrimination improvement (IDI). Results Among 780 participants, 12.4% (n = 97) died within 28 days after admission to the pediatric intensive care unit (PICU). Statistically significant differences were found between survivors and non-survivors in terms of four GV metrics (SD, GLI, MAG, and ACACP), in which MAG (AUC: 0.762, 95% CI: 0.705–0.819, p < 0.001) achieved the largest AUC and showed a strong independent association with ICU mortality. Subsequent addition of MAG to the multivariate Cox model for hyperglycemia resulted in further quantitative evolution of the model statistics (AUC = 0.651–0.681, p = 0.001; IDI: 0.017, p = 0.044; NRI: 0.224, p = 0.186). The impact of hyperglycemia (adjusted hazard ratio [aHR]: 1.419, 95% CI: 0.815–2.471, p = 0.216) on outcome was attenuated and no longer statistically relevant after adjustment for MAG (aHR: 2.455, 95% CI: 1.411–4.270, p = 0.001). Conclusions GV is strongly associated with poor prognosis independent of mean glucose level, demonstrating more predictive power compared with hypoglycemia and hyperglycemia after adjusting for confounding factors. GV metrics that contain information, such as time and rate of change, are the focus of future research; thus, the MAG may be a good choice. The findings of this study emphasize the crucial role of GVs in children in the PICU. Clinicians should pay more attention to GV for clinical glucose management.
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Affiliation(s)
- Milan Dong
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Department of Pediatrics, The People's Hospital of Yubei District of Chongqing City, Chongqing, China
| | - Wenjun Liu
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Yetao Luo
- Department of Clinical Epidemiology and Biostatistics, Children's Institute of Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Jing Li
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- *Correspondence: Jing Li
| | - Bo Huang
- Department of Pediatric Critical Care, The First People's Hospital of Zunyi, Zunyi, China
| | - Yingbo Zou
- Department of Pediatric Critical Care, The First People's Hospital of Zunyi, Zunyi, China
| | - Fuyan Liu
- Department of Pediatric Critical Care, The First People's Hospital of Zunyi, Zunyi, China
| | - Guoying Zhang
- Department of Pediatric Critical Care, Chengdu Women's and Children's Central Hospital, Chengdu, China
| | - Ju Chen
- Department of Pediatric Critical Care, Chengdu Women's and Children's Central Hospital, Chengdu, China
| | - Jianyu Jiang
- Department of Pediatrics, Chongqing Three Gorges Women and Children's Hospital, Chongqing, China
| | - Ling Duan
- Department of Pediatrics, Chongqing Three Gorges Women and Children's Hospital, Chongqing, China
| | - Daoxue Xiong
- Department of Pediatrics, Chongqing Three Gorges Women and Children's Hospital, Chongqing, China
| | - Hongmin Fu
- Department of Pediatric Critical Care, Kunming Children's Hospital, Kunming, China
| | - Kai Yu
- Department of Pediatric Critical Care, Kunming Children's Hospital, Kunming, China
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Derakhshan P, Khatibi A, Faiz SHR, Rahimzadeh P, Nouri N. Comparison of the effect of insulin glargine and regular insulin on perioperative glycemic control in patients with type 2 diabetes mellitus under insulin treatment during vitrectomy surgery under general anesthesia: A randomized clinical trial study. Med J Islam Repub Iran 2021; 35:31. [PMID: 34211933 PMCID: PMC8236081 DOI: 10.47176/mjiri.35.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Indexed: 11/23/2022] Open
Abstract
Background: Perioperative glycemic control is an important factor in the clinical management of a patient with diabetes mellitus under surgery. Poorly controlled long-term hyperglycemia not only predisposes individuals to systemic complications of diabetes mellitus and cardiovascular morbidity but also increases the risk of anesthesia and weakens the outcome of the surgery. Given the importance of the issue and the limited studies on glucose control using insulin glargine during surgery, we aimed to investigate the effects of glargine on glucose control in patients with diabetes mellitus during vitrectomy surgery.
Methods: This randomized, double-blind trial was conducted in two groups of 35 patients with diabetes mellitus under treatment with insulin. In the control group, the patients received regular insulin based on the blood glucose and the sliding scale, and in the intervention group, they received insulin glargine (0.3 unit/kg) before surgery. From the start of the operation up to 3 hours of the surgery blood glucose of the patients was measured every 45 minutes and once 6 hours after the operation, and if needed, the regular insulin was injected. Data were analyzed using SPSS 16. Frequency, percentage, mean, and standard deviation (SD) were used to describe the data. To compare the quantitative variables, the independent t-test or U-Mann-Whitney test was used. For comparison of the qualitative variables, Chi-square test or Fischer's exact test and repeated measure ANOVA was employed. The significance level (P-value) was considered as p<0.05.
Results: Use of insulin glargine was associated with significantly lower blood glucose levels compared to regular insulin at 90-minutes (p=0.004), 135 minutes (p=0.001), and 6 hours after the operation (p=0.005).
Conclusion: Glycemic control using glargine compared to regular insulin has a better performance with less need for surplus insulin dose administration during surgery.
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Affiliation(s)
- Pooya Derakhshan
- Anesthesiology Department, Rasool Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Khatibi
- Anesthesiology Department, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed Hamid Reza Faiz
- Anesthesiology Department, Rasool Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Poupak Rahimzadeh
- Anesthesiology Department, Rasool Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Nasrin Nouri
- Anesthesiology Department, Fatima Plastic And Reconstructive Surgery Hospital, Iran University of Medical Sciences, Tehran, Iran
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