A cost-effective screening method for preoperative hyperglycemia

The prevalence of hyperglycemia and its association with perioperative outcomes in gynecologic surgery: a retrospective cohort study

BACKGROUND

Preoperative hyperglycemia has been associated with perioperative morbidity in general surgery patients. Additionally, preoperative hyperglycemia may indicate underlying impaired glucose metabolism. Thus, identification of preoperative hyperglycemia may provide an opportunity to mitigate both short-term surgical and long-term health risk. We aimed to study this phenomenon specifically in the gynecologic surgery population. Specifically, we aimed to evaluate the association between preoperative hyperglycemia and perioperative complications in gynecologic surgery patients and to characterize adherence to diabetes screening guidelines.

METHODS

This retrospective cohort study included 913 women undergoing major gynecologic surgery on an enhanced recovery pathway from January 2018 to July 2019. The main exposure was day of surgery glucose ≥ 140 g/dL. Multivariate regression identified risk factors for hyperglycemia and composite and wound-specific complications.

RESULTS

Sixty-seven (7.3%) patients were hyperglycemic. Diabetes (aOR 24.0, 95% CI 12.3-46.9, P < .001) and malignancy (aOR 2.3, 95% CI 1.2-4.5, P = .01) were associated with hyperglycemia. Hyperglycemia was not associated with increased odds of composite perioperative (aOR 1.3, 95% CI 0.7-2.4, P = 0.49) or wound-specific complications (aOR 1.1, 95% CI 0.7-1.5, P = 0.76). Of nondiabetic patients, 391/779 (50%) met the USPSTF criteria for diabetes screening; 117 (30%) had documented screening in the preceding 3 years. Of the 274 unscreened patients, 94 (34%) had day of surgery glucose levels suggestive of impaired glucose metabolism (glucose ≥ 100 g/dL).

CONCLUSION

In our study cohort, the prevalence of hyperglycemia was low and was not associated with higher risk of composite or wound-specific complications. However, adherence to diabetes screening guidelines was poor. Future studies should aim to develop a preoperative blood glucose testing strategy that balances the low utility of universal glucose screening with the benefit of diagnosing impaired glucose metabolism in at-risk individuals.

Blood glucose measurement in the intensive care unit: what is the best method?

Abnormal glucose measurements are common among intensive care unit (ICU) patients for numerous reasons and hypoglycemia is especially dangerous because these patients are often sedated and unable to relate the associated symptoms. Additionally, wide swings in blood glucose have been closely tied to increased mortality. Therefore, accurate and timely glucose measurement in this population is critical. Clinicians have several choices available to assess blood glucose values in the ICU, including central laboratory devices, blood gas analyzers, and point-of-care meters. In this review, the method of glucose measurement will be reviewed for each device, and the important characteristics, including accuracy, cost, speed of result, and sample volume, will be reviewed, specifically as these are used in the ICU environment. Following evaluation of the individual measurement devices and after considering the many features of each, recommendations are made for optimal ICU glucose determination.

Preoperative "NPO" as an opportunity for diabetes screening

BACKGROUND

Novel preventive care opportunities, such as in hospitalized patients, may merit further investigation in an Accountable Care Organization (ACO) model. As 40% of patients with diabetes are undiagnosed, diabetes screening is an urgent public health need. Screening fasting preoperative patients may present an effective means to identify patients who might otherwise remain undiagnosed.

OBJECTIVE

To pilot an inpatient preventive care strategy for diabetes screening that would ascertain prevalence of unrecognized inpatient diabetes (DM) and impaired fasting glucose (IFG), determine reproducibility of preoperative fasting blood glucose (FBG), and establish feasibility of inpatient preventive screening.

DESIGN

Prospective observational study.

SETTING

Large Midwestern academic medical center.

PATIENTS

Two hundred seventy-five elective orthopedic patients with a preoperative visit between December 1, 2007 and November 30, 2008. Most patients (96.6%) had seen their primary care provider (PCP) within 12 months, and 100% were insured.

MEASUREMENTS

Medical history was recorded, and hemoglobin A(1C) (Hgb A(1C) ) and FBG were drawn immediately prior to surgery. Patients with preoperative FBG ≥100 mg/dL had FBG drawn 6-8 weeks postoperatively.

RESULTS

Twenty-four percent (67/275) of patients had previously unrecognized DM or IFG by virtue of 2 abnormal values. Sixty-four percent of patients with FBG ≥100 mg/dL preoperatively remained elevated at ambulatory follow-up. No patients with new DM or IFG had point-of-care glucose checks ordered or had dysglycemia mentioned on discharge summary.

CONCLUSIONS

Inpatient undiagnosed DM and IFG is common, even in insured, elective surgery patients with recent primary care visits. Preoperative FBG can be used to screen, but results need to be conveyed to PCPs.