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Gianotti L, Sandini M, Biffi R, Marrelli D, Vignali A, Begg SKS, Bernasconi DP. Determinants, time trends and dynamic consequences of postoperative hyperglycemia in nondiabetic patients undergoing major elective abdominal surgery: A prospective, longitudinal, observational evaluation. Clin Nutr 2019; 38:1765-1772. [PMID: 30121142 DOI: 10.1016/j.clnu.2018.07.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 07/05/2018] [Accepted: 07/24/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND & AIMS In retrospective studies an indisputable causal relationship between hyperglycemia and postoperative infections cannot be entirely disclaimed. We aimed investigate whether the time trends of blood glucose levels in the perioperative period could be a determinant of surgery-related infections. METHODS Adult patients without diabetes who were candidates for elective major abdominal operation were prospectively enrolled in a longitudinal, observational multicenter study. The blood glucose level was measured every 6 h for 3 days. We calculated the association between blood glucose (BG) levels and the risk of occurrence of surgery-related infections using a joint regression modeling for longitudinal and time-to-event outcomes which accounts for the effect of other risk factors. RESULTS Between January 2016 and November 2017, we obtained 6078 BG measures distributed on different time-points in 452 patients. There was a nearly 3-fold increased risk of having hyperglycemia, defined as BG ≥ 125 mg/dL, if the BG level at admission was >100 mg/dL (OR = 2.986, P < 0.001).The hazard of infection for each 10 mg/dL increase of BG levels over time was marginal (HR = 1.065, P = 0.045). The calculated risk of having an infection was 9.6% for BG going from 110 mg/dL during surgery to 84 mg/dL at the end of day 3, 10.5% for BG decreasing from 140 to 114, 11.8% for BG decreasing from 180 to 154 and 24.5% for BG increasing from 80 to 145, 24.7% for BG increasing from 110 to 175, and 25.4% for BG increasing from 140 to 205. CONCLUSIONS The time trends of BG - as opposed to the absolute concentration -are major determinants of the risk of postoperative infections.
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Affiliation(s)
- Luca Gianotti
- School of Medicine and Surgery, Milano-Bicocca University, Department of Surgery, San Gerardo Hospital, Monza, Italy.
| | - Marta Sandini
- School of Medicine and Surgery, Milano-Bicocca University, Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Roberto Biffi
- Department of Gastrointestinal Surgery, European Institute of Oncology, Milan, Italy
| | - Daniele Marrelli
- Department of Medicine, Surgery and Neurosciences, Unit of Surgical Oncology, University of Siena, Siena, Italy
| | - Andrea Vignali
- Department of Gastrointestinal Surgery, San Raffaele Scientific Institute, Vita e Salute University, Milan, Italy
| | - Sebastian K S Begg
- Pancreatic Biology Laboratory, Department of Surgery, Massachusetts General Hospital, Boston, MA, United States
| | - Davide P Bernasconi
- Centre of Biostatistics for Clinical Epidemiology, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
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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: 4.0] [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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Postoperative hyperglycemia in patients undergoing cytoreductive surgery and HIPEC: A cohort study. Int J Surg 2019; 64:5-9. [DOI: 10.1016/j.ijsu.2019.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 12/27/2018] [Accepted: 02/06/2019] [Indexed: 01/22/2023]
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Meister KM, Hufford T, Tu C, Khorgami Z, Schauer PR, Brethauer SA, Aminian A. Clinical significance of perioperative hyperglycemia in bariatric surgery: evidence for better perioperative glucose management. Surg Obes Relat Dis 2018; 14:1725-1731. [DOI: 10.1016/j.soard.2018.07.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 06/05/2018] [Accepted: 07/22/2018] [Indexed: 01/04/2023]
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Haase GM. Embracing early recovery after surgery (ERAS) protocols: Is it time for otolaryngology to join the parade? Am J Otolaryngol 2018; 39:652-653. [PMID: 29937105 DOI: 10.1016/j.amjoto.2018.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 06/12/2018] [Indexed: 01/30/2023]
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Karimian N, Niculiseanu P, Amar-Zifkin A, Carli F, Feldman LS. Association of Elevated Pre-operative Hemoglobin A1c and Post-operative Complications in Non-diabetic Patients: A Systematic Review. World J Surg 2018; 42:61-72. [PMID: 28717914 DOI: 10.1007/s00268-017-4106-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
IMPORTANCE Pre-operative hyperglycemia is associated with post-operative adverse outcomes in diabetic and non-diabetic patients. Current pre-operative screening includes random plasma glucose, yet plasma glycated hemoglobin (HbA1c) is a better measure of long-term glycemic control. It is not clear whether pre-operative HbA1c can identify non-diabetic patients at risk of post-operative complications. OBJECTIVE The systematic review summarizes the evidence pertaining to the association of suboptimal pre-operative HbA1c on post-operative outcomes in adult surgical patients with no history of diabetes mellitus. EVIDENCE REVIEW A detailed search strategy was developed by a librarian to identify all the relevant studies to date from the major online databases. FINDINGS Six observational studies met all the eligibility criteria and were included in the review. Four studies reported a significant association between pre-operative HbA1c levels and post-operative complications in non-diabetic patients. Two studies reported increased post-operative infection rates, and two reported no difference. Of four studies assessing the length of stay, three did not observe any association with HbA1c level and only one study observed a significant impact. Only one study found higher mortality rates in patients with suboptimal HbA1c. CONCLUSIONS AND RELEVANCE Based on the limited available evidence, suboptimal pre-operative HbA1c levels in patients with no prior history of diabetes predict post-operative complications and represent a potentially modifiable risk factor.
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Affiliation(s)
- Negar Karimian
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Division of Experimental Surgery, McGill University, Montreal, QC, Canada
| | - Petru Niculiseanu
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | | | - Francesco Carli
- Department of Anesthesia, McGill University, Montreal, QC, Canada
| | - Liane S Feldman
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada. .,Division of Experimental Surgery, McGill University, Montreal, QC, Canada. .,Department of Surgery, McGill University, Montreal, QC, Canada. .,Montreal General Hospital, 1650 Cedar Ave, L9-404, Montreal, QC, H3G 1A4, Canada.
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Outcomes associated with hyperglycemia after abdominal aortic aneurysm repair. J Vasc Surg 2018; 69:763-773.e3. [PMID: 30154015 DOI: 10.1016/j.jvs.2018.05.240] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 05/14/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We evaluated the association between postoperative hyperglycemia and outcomes after abdominal aortic aneurysm (AAA) repair. METHODS We used diagnosis and procedure codes (International Classification of Diseases, Ninth Revision, Clinical Modification) to identify patients who underwent open or endovascular repair of a nonruptured AAA from September 2008 to March 2014 from the Cerner Health Facts database (Cerner Corporation, North Kansas City, Mo). We evaluated the association between postoperative hyperglycemia (glucose concentration >180 mg/dL) and infections, in-hospital mortality, readmission, patients' characteristics, length of hospital stay, and medications. Multivariable logistic models examined the association of postoperative hyperglycemia with in-hospital infection and mortality. RESULTS Of 2478 patients, 2071 (83.5%) had good postoperative glucose control (80-180 mg/dL), and 407 (16.5%) had suboptimal control (hyperglycemia). Patients who had postoperative hyperglycemia experienced longer hospital stays (9.5 vs 4.7 days; P < .0001), higher infection rates (18% vs 8%; P < .0001), higher in-hospital mortality (8.4 vs 1.2%; P <.0001), and more acute complications (ie, acute renal failure, fluid and electrolyte disorders, respiratory complications). After adjusting for patients' characteristics and medications, multivariable logistic regression models demonstrated that patients receiving postoperative insulin had nearly 1.6 times the odds of having an infectious complication (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.12-2.2; P = .007) than those who did not. Hyperglycemic patients had 3.5 times the odds of in-hospital mortality (OR, 3.48; 95% CI, 1.78-6.80 [P = .0003]; 2.3% vs 1.2%; P < .001). When stratified by procedure type, patients with hyperglycemia who underwent endovascular repair had nearly 2 times the odds of an infectious complication (OR, 1.85; 95% CI, 0.98-3.51; P = .05) and 7.5 times the odds of in-hospital mortality (OR, 7.54; 95% CI, 1.95-29.1; P = .003). Patients who underwent an open AAA repair and who had hyperglycemia had three times the odds of dying in the hospital (OR, 3.05; 95% CI, 1.29-7.21; P = .01). CONCLUSIONS Among patients undergoing elective AAA repair, approximately one in six had postoperative hyperglycemia. After AAA repair in patients with and without diabetes, postoperative hyperglycemia was associated with adverse events, including in-hospital mortality and infections. Compared with those who had open surgery, patients undergoing endovascular repair who had postoperative hyperglycemia had greater risk of infection and death. After controlling for insulin administration and postoperative hyperglycemia, a diabetes diagnosis was associated with lower odds of both infection and in-hospital mortality. Our study suggests that hyperglycemia may be used as a clinical marker as it was found to be significantly associated with inferior outcomes after elective AAA repair. This retrospective study, however, cannot imply causation; further study using prospective methods is needed to elucidate the relationship between postoperative hyperglycemia and patient outcomes.
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Hoang SC, Klipfel AA, Roth LA, Vrees M, Schechter S, Shah N. Colon and rectal surgery surgical site infection reduction bundle: To improve is to change. Am J Surg 2018; 217:40-45. [PMID: 30025846 DOI: 10.1016/j.amjsurg.2018.07.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 05/16/2018] [Accepted: 07/06/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Despite the introduction of the Surgical Care Improvement Project, surgical site infections remain a source of morbidity. The aim of this study was to determine the value of implementing a colorectal bundle on SSI rates. METHODS Between 2011 and 2016 a total of 1351 patients underwent colorectal operations. Patients were grouped into pre-implementation (Group A, January 1, 2011-December 31, 2012), implementation (Group B, January 1, 2013-December 31, 2014) and post-implementation (Group C, January 1, 2015-December 31, 2016). Primary endpoints were superficial SSI, deep SSI, wound separation and total SSI. RESULTS After the bundle was implemented, there was a significant reduction in superficial (6.6%-4%, p < 0.05), deep (3.7%-1.1%, p < 0.05), and total SSI rates (10.9%-4.7%, p < 0.05). Comparing Group A to Group C there was a decrease in total SSI (9.4%-4.7%, p < 0.05). CONCLUSION Implementation of the bundle resulted in a reduction in overall SSI rates particularly as compliance increased. This study offers evidence that small changes can lead to significant decreases in surgical site infections.
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Affiliation(s)
- Sook C Hoang
- Division of Colon and Rectal Surgery, Department of Surgery, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA.
| | - Adam A Klipfel
- Division of Colon and Rectal Surgery, Department of Surgery, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA
| | - Leslie A Roth
- Division of Colon and Rectal Surgery, Department of Surgery, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA
| | - Mathew Vrees
- Division of Colon and Rectal Surgery, Department of Surgery, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA
| | - Steven Schechter
- Division of Colon and Rectal Surgery, Department of Surgery, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA
| | - Nishit Shah
- Division of Colon and Rectal Surgery, Department of Surgery, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA
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Rudy MD, Ahuja NK, Aaronson AJ. Diabetes and Hyperglycemia in Lower-Extremity Total Joint Arthroplasty. JBJS Rev 2018; 6:e10. [DOI: 10.2106/jbjs.rvw.17.00146] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Gianotti L, Biffi R, Sandini M, Marrelli D, Vignali A, Caccialanza R, Viganò J, Sabbatini A, Di Mare G, Alessiani M, Antomarchi F, Valsecchi MG, Bernasconi DP. Preoperative Oral Carbohydrate Load Versus Placebo in Major Elective Abdominal Surgery (PROCY): A Randomized, Placebo-controlled, Multicenter, Phase III Trial. Ann Surg 2018; 267:623-630. [PMID: 28582271 DOI: 10.1097/sla.0000000000002325] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To explore whether preoperative oral carbohydrate (CHO) loading could achieve a reduction in the occurrence of postoperative infections. BACKGROUND Hyperglycemia may increase the risk of infection. Preoperative CHO loading can achieve postoperative glycemic control. METHODS This was a randomized, controlled, multicenter, open-label trial. Nondiabetic adult patients who were candidates for elective major abdominal operation were randomized (1:1) to a CHO (preoperative oral intake of 800 mL of water containing 100 g of CHO) or placebo group (intake of 800 mL of water). The blood glucose level was measured every 4 hours for 4 days. Insulin was administered when the blood glucose level was >180 mg/dL. The primary endpoint was the occurrence of postoperative infection. The secondary endpoint was the number of patients needing insulin. RESULTS From January 2011 through December 2015, 880 patients were randomly allocated to the CHO (n = 438) or placebo (n = 442) group. From each group, 331 patients were available for the analysis. Postoperative infection occurred in 16.3% (54/331) of CHO group patients and 16.0% (53/331) of placebo group patients (relative risk 1.019, 95% confidence interval 0.720-1.442, P = 1.00). Insulin was needed in 8 (2.4%) CHO group patients and 53 (16.0%) placebo group patients (relative risk 0.15, 95% confidence interval 0.07-0.31, P < 0.001). CONCLUSIONS Oral preoperative CHO load is effective for avoiding a blood glucose level >180 mg/dL, but without affecting the risk of postoperative infectious complication.
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Affiliation(s)
- Luca Gianotti
- School of Medicine and Surgery, Milano-Bicocca University, San Gerardo Hospital, Monza, Italy
| | - Roberto Biffi
- Department of Gastrointestinal Surgery, European Institute of Oncology, Milan, Italy
| | - Marta Sandini
- School of Medicine and Surgery, Milano-Bicocca University, San Gerardo Hospital, Monza, Italy
| | - Daniele Marrelli
- Department of Medicine, Surgery and Neurosciences, Unit of Surgical Oncology, University of Siena, Siena, Italy
| | - Andrea Vignali
- Department of Gastrointestinal Surgery, San Raffaele Scientific Institute, Vita e Salute University, Milan, Italy
| | - Riccardo Caccialanza
- Nutrition and Dietetics Service, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Jacopo Viganò
- Department of Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Annarita Sabbatini
- Department of Gastrointestinal Surgery, European Institute of Oncology, Milan, Italy
| | - Giulio Di Mare
- Department of Medicine, Surgery and Neurosciences, Unit of Surgical Oncology, University of Siena, Siena, Italy
| | - Mario Alessiani
- Department of Surgery, ASST Pavia and Department of Clinical and Surgical Sciences, University of Pavia, Pavia, Italy
| | | | - Maria Grazia Valsecchi
- Centre of Biostatistics for Clinical Epidemiology, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Davide P Bernasconi
- Centre of Biostatistics for Clinical Epidemiology, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
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Short HL, Taylor N, Piper K, Raval MV. Appropriateness of a pediatric-specific enhanced recovery protocol using a modified Delphi process and multidisciplinary expert panel. J Pediatr Surg 2018; 53:592-598. [PMID: 29017725 DOI: 10.1016/j.jpedsurg.2017.09.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 08/11/2017] [Accepted: 09/16/2017] [Indexed: 12/23/2022]
Abstract
PURPOSE Despite Enhanced Recovery After Surgery (ERAS) protocols demonstrating improved outcomes in a wide variety of adult surgical populations, these protocols are infrequently and inconsistently being used in pediatric surgery. Our purpose was to develop a pediatric-specific ERAS protocol for use in adolescents undergoing elective intestinal procedures. METHODS A modified Delphi process including extensive literature review, iterative rounds of surveys, and expert panel discussions was used to establish ERAS elements that would be appropriate for children. The 16-member multidisciplinary expert panel included surgeons, gastroenterologists, anesthesiologists, nursing, and patient/family representatives. RESULTS Building upon a national survey of surgeons in which 14 of 21 adult ERAS elements were considered acceptable for use in children, the 7 more contentious elements were investigated using the modified Delphi process. In final ranking, 5 of the 7 controversial elements were deemed appropriate for inclusion in a pediatric ERAS protocol. Routine use of insulin to treat hyperglycemia and avoidance of mechanical bowel preparation were not included in the final recommendations. CONCLUSIONS Using a modified Delphi process, we have defined an appropriate ERAS protocol comprised of 19 elements for use in adolescents undergoing elective intestinal surgery. Prospective validation studies of ERAS protocols in children are needed. LEVEL OF EVIDENCE Level V, Expert opinion.
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Affiliation(s)
- Heather L Short
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Natalie Taylor
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Kaitlin Piper
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA.
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Perioperative hyperglycemia: an unmet need within a surgical site infection bundle. Tech Coloproctol 2018; 22:201-207. [PMID: 29512047 DOI: 10.1007/s10151-018-1769-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Accepted: 01/21/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND The aim of this study was to determine whether perioperative stress hyperglycemia is correlated with surgical site infection (SSI) rates in non-diabetes mellitus (DM) patients undergoing elective colorectal resections within an SSI bundle. METHODS American College of Surgeons National Surgical Quality Improvement Program data of patients treated at a single institution in 2006-2012 were supplemented by institutional review board-approved chart review. A multifactorial SSI bundle was implemented in 2009 without changing the preoperative 8-h nil per os, and in the absence of either a carbohydrate loading strategy or hyperglycemic management protocol. Hyperglycemia was defined as blood glucose level > 140 mg/dL. The primary endpoint was SSI defined by the Centers for Disease Control National Nosocomial Infections Surveillance. RESULTS Of 690 patients included, 112 (16.2%) had pre-existing DM. Overall SSI rates were significantly higher in DM patients as compared to non-DM patients (28.7 vs. 22.3%, p = 0.042). Postoperative hyperglycemia was more frequently seen in non-DM patients (46 vs. 42.9%). The SSI bundle reduced SSI rates (17 vs. 29.3%, p < 0.001), but the rate of hyperglycemia remained unchanged for DM or non-DM patients (pre-bundle 59%; post-bundle 62%, p = 0.527). Organ/space SSI rates were higher in patients with pre- and postoperative hyperglycemia (12.6%) (p = 0.017). Overall SSI rates were higher in DM patients with hyperglycemia as compared to non-DM patients with hyperglycemia (35.6 vs. 20.8%, p = 0.002). At multivariate analysis DM, chronic steroid use, chemotherapy and SSI bundle were predictive factors for SSI. CONCLUSIONS This study showed that non-DM patients have a postoperative hyperglycemia rate as high as 46% in spite of the SSI bundle. A positive correlation was found between stress hyperglycemia and organ/space SSI rates regardless of the DM status. These data support the need for a strategy to prevent stress hyperglycemia in non-DM patients undergoing colorectal resections.
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Bollig CA, Spradling CS, Dooley LM, Galloway TL, Jorgensen JB. Impact of perioperative hyperglycemia in patients undergoing microvascular reconstruction. Head Neck 2018; 40:1196-1206. [PMID: 29498137 DOI: 10.1002/hed.25097] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 10/07/2017] [Accepted: 01/10/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The effects of perioperative hyperglycemia on complications and outcomes in microvascular reconstruction have not been reported in the literature. METHODS A retrospective cohort of 203 patients undergoing microvascular reconstruction was generated. Perioperative glucose levels and clinical factors were tested for associations with complications using simple and multivariate analyses. RESULTS Hyperglycemia (blood glucose ≥ 180 mg/dL) occurred in 91 patients (44.8%) perioperatively, and was associated with increased rates of surgical complications, medical complications, surgical site infections, fistulas, and wound dehiscence. On univariate analysis, a more strict definition of hyperglycemia (blood glucose ≥ 165 mg/dL) was significantly associated with greater rates of venous thrombosis, although this lost statistical significance on multivariate analysis. CONCLUSION Perioperative hyperglycemia occurs commonly in patients undergoing microvascular reconstruction and is associated with higher rates of complications, independent of a preexisting diagnosis of diabetes mellitus. Further research is needed to define the ideal glycemic target in this population.
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Affiliation(s)
- Craig A Bollig
- Department of Otolaryngology - Head and Neck Surgery, University of Missouri School of Medicine, Columbia, Missouri
| | | | - Laura M Dooley
- Department of Otolaryngology - Head and Neck Surgery, University of Missouri School of Medicine, Columbia, Missouri
| | - Tabitha L Galloway
- Department of Otolaryngology - Head and Neck Surgery, University of Missouri School of Medicine, Columbia, Missouri
| | - Jeffrey B Jorgensen
- Department of Otolaryngology - Head and Neck Surgery, University of Missouri School of Medicine, Columbia, Missouri
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Offodile AC, Chou HY, Lin JAJ, Loh CYY, Chang KP, Aycart MA, Kao HK. Hyperglycemia and risk of adverse outcomes following microvascular reconstruction of oncologic head and neck defects. Oral Oncol 2018; 79:15-19. [PMID: 29598945 DOI: 10.1016/j.oraloncology.2018.02.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 02/04/2018] [Accepted: 02/10/2018] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Our aim is to examine the correlation between perioperative hyperglycemia and post-operative outcomes following microvascular reconstruction of head and neck defects. PATIENTS AND METHODS Retrospective review of a prospectively collected database of 350 consecutive patients who underwent microvascular reconstruction of malignant head and neck defects over a 2 year period. The relationship between perioperative hyperglycemia (≥ 180 mg/dL) and the incidence of the following complications was evaluated: flap loss, flap-related complications and surgical site infections (SSI). Sub-group analysis based on timing of hyperglycemia was also performed. RESULTS We identified 313 patients (89.4%) in the normoglycemic group and 37 patients (10.6%) in the hyperglycemic group. Baseline demographics, tumor stage, operative variable were comparable. There were no significant differences in flap-related complications and overall mortality. SSI were significantly higher in the hyperglycemic cohort (48% vs. 28%, p = 0.01). On multivariate analysis, hyperglycemia [OR 2.07; 95% CI, 1.87-4.89], perioperative insulin administration [OR 4.805; 95% CI, 2.18-10.60], prolonged operative time [OR 1.003; 95% CI, 1.002-1.025] and higher Charlson co-morbidity indices [II: OR 2.286 & III: OR 2.284] were independent predictors of SSI. On sub-group analysis, only patients with early (POD 1) post-operative hyperglycemia had a significant OR for SSI (OR 1.88; 95% CI, 1.07-3.29). CONCLUSION Our findings suggest that perioperative hyperglycemia, specifically during the first 24 h post-operatively, is associated with SSI in microvascular head and neck reconstruction. This association highlights the need for strict screening of head and neck patients for hyperglycemia especially in the immediate post-operative period.
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Affiliation(s)
- Anaeze C Offodile
- Department of Plastic and Reconstructive Surgery, MD Anderson Cancer Center, Houston, TX 77030, United States
| | - Hsuan-Yu Chou
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Jennifer An-Jou Lin
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Charles Yuen Yung Loh
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Kai-Ping Chang
- Department of Otolaryngology-Head & Neck Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Mario A Aycart
- Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, United States
| | - Huang-Kai Kao
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.
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Abstract
PURPOSE OF REVIEW Diabetes is the most prevalent long-term metabolic condition and its incidence continues to increase unabated. Patients with diabetes are overrepresented in the surgical population. It has been well recognized that poor perioperative diabetes control is associated with poor surgical outcomes. The outcomes are worst for those people who were not recognized as having hyperglycaemia. RECENT FINDINGS Recent work has shown that preoperative recognition of diabetes and good communication between the clinical teams at all stages of the patient pathway help to minimize the potential for errors, and improve glycaemic control. The stages of the patient journey start in primary care and end when the patient goes home. The early involvement of the diabetes specialist team is important if the glycated haemoglobin is more than 8.5%, and advice sought if the preoperative assessment team is not familiar with the drug regimens. To date the glycaemic targets for the perioperative period have remained uncertain, but recently a consensus is being reached to ensure glucose levels remain between 108 and180 mg/dl (6.0 and 10.0 mmol/l). There have been a number of ways to achieve these - primarily by manipulating the patients' usual diabetes medications, to also allow day of surgery admission. SUMMARY glycaemic control remains an important consideration in the surgical patient.
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Comparison of cortisol and inflammatory response between aged and middle-aged patients undergoing total hip arthroplasty: a prospective observational study. BMC Musculoskelet Disord 2017; 18:541. [PMID: 29258488 PMCID: PMC5738105 DOI: 10.1186/s12891-017-1900-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 12/08/2017] [Indexed: 02/08/2023] Open
Abstract
Background To investigate the differences in the perioperative serum cortisol, C-reactive protein (CRP) and interleukin-6 (IL-6) levels between aged and middle-aged patients undergoing total hip arthroplasty (THA). Methods Sixty patients (30 aged and 30 middle-aged) undergoing THA for osteoarthritis between August 2016 and January 2017 participated in this study. Blood samples were collected preoperatively and at 6 hours, 24 hours and 3 days after surgery to measure the cortisol, CRP and IL-6 concentrations. The clinical outcomes were assessed using the visual analogue scale (VAS) pain score and Harris hip score (HHS). Results No significant differences were found between the two groups before the operation in the cortisol, IL-6 and CRP levels; the VAS score; or the HHS. Cortisol was significantly lower at 6 hours after surgery in the aged group than in the middle-aged group (P < 0.05). IL-6 at 6 and 24 hours after surgery, CRP at 3 days after surgery and the VAS score at 6 and 24 hours after surgery in the aged group were significantly higher than those in the middle-aged group (P < 0.05). In the aged group, weak correlations were found between the cortisol concentration 6 hours after THA and the IL-6 level 24 hours after THA (r = −0.37, P = 0.04) and between the IL-6 level 6 hours after THA and the VAS score 24 hours after THA (r = 0.42, P = 0.02). Conclusion Aged patients showed lower cortisol levels at 6 hours after surgery and higher IL-6 levels at 6 and 24 hours after surgery than middle-aged patients undergoing THA.
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Grass F, Schäfer M, Demartines N, Hübner M. Normal Diet within Two Postoperative Days-Realistic or Too Ambitious? Nutrients 2017; 9:nu9121336. [PMID: 29292741 PMCID: PMC5748786 DOI: 10.3390/nu9121336] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 11/30/2017] [Accepted: 12/05/2017] [Indexed: 12/13/2022] Open
Abstract
Enhanced Recovery After Surgery (ERAS) protocols advocate early postoperative resumption of normal diet to decrease surgical stress and prevent excessive catabolism. The aim of the present study was to identify reasons for delayed tolerance of normal postoperative diet. This was a retrospective analysis including all consecutive colorectal surgical procedures since May 2011 until May 2017. Data was prospectively recorded by an institutional data manager in a dedicated database. Uni- and multivariate risk factors associated with delayed diet (beyond POD 2) were identified by multiple logistic regression among demographic, surgery- and modifiable pre- and intraoperative ERAS-related items. In a second step, univariate analysis was performed to compare surgical outcomes for patients with early vs. delayed oral intake. The study cohort consisted of 1301 consecutive colorectal ERAS patients. Herein, 691 patients (53%) were able to resume normal diet within two days of surgery according to ERAS protocol, while in 610 patients (47%), a delay in tolerance of normal diet was observed. Male gender was independently correlated to early tolerance (Odds Ratio (OR) 0.66; 95% Confidence Interval (CI) 0.46–0.84, p = 0.002), while ASA score ≥ 3 (OR 1.60; 95% CI 1.12–2.28, p = 0.010), abdominal drains (OR 1.80; 95% CI 1.10–2.49, p = 0.020), right colectomy (OR 1.64; 95% CI 1.08–2.49, p = 0.020) and Hartmann reversal (OR 2.61; 95% CI 1.32–5.18, p = 0.006) constituted risk factors for delayed tolerance of normal diet. Patients with delayed resumption of normal diet experienced more overall (Clavien grade I–V) (47% vs. 21%, p < 0.001) and major (Clavien grade IIIb–V) (11% vs. 4%, p < 0.001) complications and had a longer length of stay (9 ± 5 vs. 5 ± 4 days, p < 0.001). Over half of patients could not tolerate early enteral realimentation and were at higher risk for postoperative complications. Prophylactic drain placement was the only independent modifiable risk factor for delayed oral intake.
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Affiliation(s)
- Fabian Grass
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne 1011, Switzerland.
| | - Markus Schäfer
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne 1011, Switzerland.
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne 1011, Switzerland.
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne 1011, Switzerland.
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Jones CE, Graham LA, Morris MS, Richman JS, Hollis RH, Wahl TS, Copeland LA, Burns EA, Itani KMF, Hawn MT. Association Between Preoperative Hemoglobin A1c Levels, Postoperative Hyperglycemia, and Readmissions Following Gastrointestinal Surgery. JAMA Surg 2017; 152:1031-1038. [PMID: 28746706 DOI: 10.1001/jamasurg.2017.2350] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Preoperative hyperglycemia is associated with adverse postoperative outcomes among patients who undergo surgery. Whether preoperative hemoglobin A1c (HbA1c) or postoperative glucose levels are more useful in predicting adverse events following surgery is uncertain in the current literature. Objective To examine the use of preoperative HbA1c and early postoperative glucose levels for predicting postoperative complications and readmission. Design, Setting, and Participants In this observational cohort study, inpatient gastrointestinal surgical procedures performed at 117 Veterans Affairs hospitals from 2007 to 2014 were identified, and cases of known infection within 3 days before surgery were excluded. Preoperative HbA1c levels were examined as a continuous and categorical variable (<5.7%, 5.7%-6.5%, and >6.5%). A logistic regression modeled postoperative complications and readmissions with the closest preoperative HbA1c within 90 days and the highest postoperative glucose levels within 48 hours of undergoing surgery. Main Outcomes and Measures Postoperative complications and 30-day unplanned readmission following discharge. Results Of 21 541 participants, 1193 (5.5%) were women, and the mean (SD) age was 63.7 (10.6) years. The cohort included 23 094 operations with measurements of preoperative HbA1c levels and postoperative glucose levels. The complication and 30-day readmission rates were 27.2% and 14.7%, respectively. In logistic regression models adjusting for HbA1c, postoperative glucose levels, postoperative insulin use, diabetes, body mass index (calculated as weight in kilograms divided by height in meters squared), and other patient and procedural factors, peak postoperative glucose levels of more than 250 mg/dL were associated with increased 30-day readmissions (odds ratio, 1.18; 95% CI, 0.99-1.41; P = .07). By contrast, a preoperative HbA1c of more than 6.5% was associated with decreased 30-day readmissions (odds ratio, 0.85; 95% CI, 0.74-0.96; P = .01). As preoperative HbA1c increased, the frequency of 48-hour postoperative glucose checks increased (4.92, 6.89, and 9.71 for an HbA1c <5.7%, 5.7%-6.4%, and >6.5%, respectively; P < .001). Patients with a preoperative HbA1c of more than 6.5% had lower thresholds for postoperative insulin use. Conclusions and Relevance Early postoperative hyperglycemia was associated with increased readmission, but elevated preoperative HbA1c was not. A higher preoperative HbA1c was associated with increased postoperative glucose level checks and insulin use, suggesting that heightened postoperative vigilance and a lower threshold to treat hyperglycemia may explain this finding.
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Affiliation(s)
- Caroline E Jones
- University of Alabama-Birmingham, Department of Surgery; Birmingham Veterans Administration Hospital, Birmingham
| | - Laura A Graham
- University of Alabama-Birmingham, Department of Surgery; Birmingham Veterans Administration Hospital, Birmingham
| | - Melanie S Morris
- University of Alabama-Birmingham, Department of Surgery; Birmingham Veterans Administration Hospital, Birmingham
| | - Joshua S Richman
- University of Alabama-Birmingham, Department of Surgery; Birmingham Veterans Administration Hospital, Birmingham
| | - Robert H Hollis
- University of Alabama-Birmingham, Department of Surgery; Birmingham Veterans Administration Hospital, Birmingham
| | - Tyler S Wahl
- University of Alabama-Birmingham, Department of Surgery; Birmingham Veterans Administration Hospital, Birmingham
| | | | - Edith A Burns
- Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | - Kamal M F Itani
- Veteran Affairs Boston Health Care System and Tufts University School of Medicine, Department of Surgery, Boston, Massachusetts
| | - Mary T Hawn
- Stanford University, Department of Surgery; Veteran Affairs Palo Alto Health Care System, Palo Alto, California
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Wang ZK, Chen RJ, Wang SL, Li GW, Zhu ZZ, Huang Q, Chen ZL, Chen FC, Deng L, Lan XP, Hu T. Clinical application of a novel diagnostic scheme including pancreatic β‑cell dysfunction for traumatic multiple organ dysfunction syndrome. Mol Med Rep 2017; 17:683-693. [PMID: 29115473 DOI: 10.3892/mmr.2017.7898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 08/22/2017] [Indexed: 11/06/2022] Open
Abstract
A novel diagnostic scheme that includes pancreatic β‑cell dysfunction analysis for the diagnosis of traumatic multiple organ dysfunction syndrome (MODS) was investigated to assist in the early diagnosis and detection of MODS. Early intervention and treatment of MODS has been associated with a reduced mortality rate. A total of 2,876 trauma patients (including patients post‑major surgery) were admitted to the intensive care unit of the authors' hospital between December 2010 and December 2015 and enrolled in the present study. There were 205 cases where the patient succumbed to their injuries. In addition to the conventional diagnostic scheme for traumatic MODS, indexes of pancreatic β‑cell dysfunction [fasting blood‑glucose (FBG), homeostatic model assessment‑β and (blood insulin concentration 30 min following glucose loading‑fasting insulin concentration)/(blood glucose concentration 30 min following glucose loading‑FBG concentration)] were included to establish an improved diagnostic scheme for traumatic MODS. The novel scheme was subsequently used in clinical practice alongside the conventional scheme and its effect was evaluated. The novel scheme had a significantly higher positive number of MODS diagnoses for all trauma patients compared with the conventional scheme (12.48 vs. 8.87%; P<0.01). No significant difference was identified in the final percentage of positive of MODS diagnoses for trauma‑associated mortality patients between the novel (88.30%) and the conventional scheme (86.34%). The novel scheme had a significantly higher positive number of MODS diagnoses for trauma‑associated mortality patients 3 days prior to patients succumbing to MODS compared with the conventional scheme (80.98 vs. 64.39%; P<0.01). The consensus of the MODS diagnosis of all trauma patients between the novel scheme and the conventional scheme was 100%; however, out of the patients diagnosed as positive by novel scheme 71.03% were positive by the conventional scheme. The consensus between the final MODS diagnosis and the MODS diagnosis 3 days prior to patients succumbing to their injuries between the novel scheme and the conventional scheme was 100%; however, out of the patients diagnosed as positive by novel scheme 97.79 were positive by the conventional scheme of the 205 patients who succumbed to MODS and out of the patients diagnosed as positive for MODS by novel scheme 3 days prior to succumbing, 79.52% were positive by the conventional scheme. The results of the present study demonstrated that the novel diagnostic scheme using the relevant indexes of pancreatic β‑cell dysfunction for diagnosis of traumatic MODS, was able to diagnose MODS early without excessively extending the diagnostic scope. Its clinical application should be promoted.
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Affiliation(s)
- Zhan-Ke Wang
- Department of Clinical Laboratory, The 94th Hospital of People's Liberation Army, Nanchang, Jiangxi 330002, P.R. China
| | - Rong-Jian Chen
- Department of General Surgery, The 94th Hospital of People's Liberation Army, Nanchang, Jiangxi 330002, P.R. China
| | - Shi-Liang Wang
- Department of Burns, Third Military Medical University, Chongqing 400038, P.R. China
| | - Guang-Wei Li
- Department of Endocrinology, China‑Japan Friendship Hospital, Beijing 100029, P.R. China
| | - Zhong-Zhen Zhu
- Department of Clinical Laboratory, The 94th Hospital of People's Liberation Army, Nanchang, Jiangxi 330002, P.R. China
| | - Qiang Huang
- Trauma Emergency Center, The 94th Hospital of People's Liberation Army, Nanchang, Jiangxi 330002, P.R. China
| | - Zi-Li Chen
- Department of Intensive Medicine, The 94th Hospital of People's Liberation Army, Nanchang, Jiangxi 330002, P.R. China
| | - Fan-Chang Chen
- Department of General Surgery, The 94th Hospital of People's Liberation Army, Nanchang, Jiangxi 330002, P.R. China
| | - Lei Deng
- Department of Neurosurgery, The 94th Hospital of People's Liberation Army, Nanchang, Jiangxi 330002, P.R. China
| | - Xiao-Peng Lan
- Department of Clinical Laboratory, Fuzhou General Hospital of Nanjing Military Region, Fuzhou, Fujian 350025, P.R. China
| | - Tian Hu
- Department of Wound Healing and Cell Biology Laboratory, Institute of Basic Medical Science, Trauma Centre of Postgraduate Medical School, Chinese People's Liberation Army General Hospital, Beijing 100853 P.R. China
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Leissner KB, Shanahan JL, Bekker PL, Amirfarzan H. Enhanced Recovery After Surgery in Laparoscopic Surgery. J Laparoendosc Adv Surg Tech A 2017; 27:883-891. [PMID: 28829221 DOI: 10.1089/lap.2017.0239] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND As part of an effort to maximize value in the perioperative setting, a paradigm shift is underway in the way that patients are cared for preoperatively, on the day of surgery, and postoperatively-a setting collectively known as the perioperative care. Enhanced Recovery After Surgery (ERAS®) is an evidence-based, patient-centered team approach to delivering high-quality perioperative care to surgical patients. METHODS This review focuses on anesthesiologists, with their unique purview of perioperative setting, who are important drivers of change in the delivery of valuable perioperative care. ERAS care pathways begin in the preoperative setting by both preparing the patient for the psychological stress of surgery and optimizing the patient's medical and physiologic status so the body is ready for the physical demands of surgery. RESULTS Minimization of perioperative fasting is important to maintain volume status-decreasing reliance on intravenous fluid administration, and to reduce protein catabolism around the time of surgery. Intraoperative management in ERAS pathways relies on goal-directed fluid therapy and opioid-sparing multimodal analgesia. Postoperatively, early feeding and ambulation, as well as discontinuation of extraneous lines and catheters facilitate patients' functional recovery. CONCLUSION The laparoscopic approach to surgery, when possible, compliments ERAS techniques by reducing abdominal wall trauma and the resultant milieu of inflammatory, neurohumoral, and pain responses. Anesthesiologists driving change in the perioperative setting, in collaboration with surgeons and other disciplines, can improve value in healthcare and provide optimal outcomes that matter most to patients and healthcare providers alike.
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Affiliation(s)
- Kay B Leissner
- Department of Anesthesiology, Critical Care and Pain Management, VA Boston Healthcare System, Harvard Medical School , West Roxbury, Massachusetts
| | - Jessica L Shanahan
- Department of Anesthesiology, Critical Care and Pain Management, VA Boston Healthcare System, Harvard Medical School , West Roxbury, Massachusetts
| | - Peter L Bekker
- Department of Anesthesiology, Critical Care and Pain Management, VA Boston Healthcare System, Harvard Medical School , West Roxbury, Massachusetts
| | - Houman Amirfarzan
- Department of Anesthesiology, Critical Care and Pain Management, VA Boston Healthcare System, Harvard Medical School , West Roxbury, Massachusetts
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Sudlow A, O'Connor HM, Narwani V, Swafe L, Dhatariya K. Assessing the prevalence of dexamethasone use in patients undergoing surgery, and subsequent glucose measurements: a retrospective cohort study. PRACTICAL DIABETES 2017. [DOI: 10.1002/pdi.2098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Alexis Sudlow
- Department of Medicine; Norfolk and Norwich University Hospitals NHS Foundation Trust; Norwich UK
| | - Henry M O'Connor
- Department of Medicine; Norfolk and Norwich University Hospitals NHS Foundation Trust; Norwich UK
| | - Vishal Narwani
- Department of Medicine; Norfolk and Norwich University Hospitals NHS Foundation Trust; Norwich UK
| | - Leyla Swafe
- Department of Medicine; Norfolk and Norwich University Hospitals NHS Foundation Trust; Norwich UK
| | - Ketan Dhatariya
- Department of Medicine; Norfolk and Norwich University Hospitals NHS Foundation Trust; Norwich UK
- Elsie Bertram Diabetes Centre; Norfolk and Norwich University Hospitals NHS Foundation Trust; Norwich UK
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Postoperative hyperglycemia in nondiabetic patients after gastric surgery for cancer: perioperative outcomes. Gastric Cancer 2017; 20:536-542. [PMID: 27339152 DOI: 10.1007/s10120-016-0621-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 06/02/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hyperglycemia (HG) is widely known to be associated with increased postoperative complications after colorectal surgery. Very few data on the effects of HG on patients after gastric surgery for cancer are reported in literature. The aim of this study was to evaluate the effects of postoperative HG in non-diabetic patients undergoing gastrectomy for cancer. METHODS One hundred and ninety-three consecutive gastrectomies for cancer performed between January 2010 and December 2015 were considered. Diabetic patients, and those undergoing pancreatic resections were excluded. Postoperative blood glucose levels were monitored in the first 72 h after surgery. Postoperative complications, mortality, and postoperative course were analyzed in patients who experienced postoperative HG (blood glucose level; BGL > 125 mg/dl) compared with euglycemic patients (BGL ≤ 125 mg/dl). Differences between mild HG (BGL between 125 and 200 mg/dl) and severe HG (BGL ≥ 200 mg/dl) were also analyzed. RESULTS Ninety-six patients (55.5 %) experienced postoperative HG. In 11 patients (6.4 %), a severe postoperative HG was found. Postoperative BGL > 200 mg/dl was related to worse outcomes than those experienced by euglycemic patients (and even than patients who experienced mild postoperative HG). The postoperative complications rate was 24.8 % (43 patients out of 173), but significantly higher in patients with postoperative severe HG compared to mild HG and normoglycemic patients (63.6, 30.6, and 13 %, respectively, p < 0.001). CONCLUSION Poor postoperative glycemic control seems to be related to worse postoperative outcomes even in patients undergoing elective gastric surgery for cancer.
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Takesue Y, Tsuchida T. Strict glycemic control to prevent surgical site infections in gastroenterological surgery. Ann Gastroenterol Surg 2017; 1:52-59. [PMID: 29863158 PMCID: PMC5881357 DOI: 10.1002/ags3.12006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 03/18/2017] [Indexed: 12/21/2022] Open
Abstract
Perioperative hyperglycemia is a risk factor for surgical site infections (SSI). Although the recommended target blood glucose level (BG) is 140–180 mg/dL for critically ill patients, recent studies conducted in patients undergoing surgery showed a significant benefit of intensive insulin therapy for the management of perioperative hyperglycemia. The aim of the present review is to evaluate the benefits of strict glycemic control for reducing SSI in gastroenterological surgery. We carried out a post‐hoc analysis of the previously published data from research on the risk factors for SSI. The highest BG within 24 hours after surgery was evaluated. A total of 1555 patients were enrolled in the study. In multivariate analysis, a dose–response relationship between the level of hyperglycemia and the odds of SSI was demonstrated when compared with the reference group (≤150 mg/dL) (odds ratio [OR] = 1.68, 95% confidence interval [CI] 1.14–2.49 for 150–200 mg/dL; and OR = 2.15, 95% CI 1.40–3.29 for >200 mg/dL). Unexpectedly, hyperglycemia was not a significant risk factor for SSI among diabetes patients. By contrast, non‐diabetes patients with a BG of >150 mg/dL were found to have increased odds of SSI. In conclusion, a target BG of ≤150 mg/dL is recommended in patients without diabetes who undergo gastroenterological surgery. Additional study is required to determine an optimal target BG in diabetes patients. Because of the risk of hypoglycemia, a conventional protocol is indicated for patients admitted to the general ward where frequent glucose measurement is not assured.
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Affiliation(s)
- Yoshio Takesue
- Department of Infection Prevention and Control Hyogo College of Medicine Hyogo Japan
| | - Toshie Tsuchida
- Department of Nursing Hyogo University of Health Sciences Hyogo Japan
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Abstract
Abstract
Background
Glucocorticoids are increasingly used perioperatively, principally to prevent nausea and vomiting. Safety concerns focus on the potential for hyperglycemia and increased infection. The authors hypothesized that glucocorticoids predispose to such adverse outcomes in a dose-dependent fashion after elective noncardiac surgery.
Methods
The authors conducted a systematic literature search of the major medical databases from their inception to April 2016. Randomized glucocorticoid trials in adults specifically reporting on a safety outcome were included and meta-analyzed with Peto odds ratio method or the quality effects model. Subanalyses were performed according to a dexamethasone dose equivalent of low (less than 8 mg), medium (8 to 16 mg), and high (more than 16 mg). The primary endpoints of any wound infection and peak perioperative glucose concentrations were subject to meta-regression.
Results
Fifty-six trials from 18 countries were identified, predominantly assessing dexamethasone. Glucocorticoids did not impact on any wound infection (odds ratio, 0.8; 95% CI, 0.6 to 1.2) but did result in a clinically unimportant increase in peak perioperative glucose concentration (weighted mean difference, 20.0 mg/dl; CI, 11.4 to 28.6; P < 0.001 or 1.1 mM; CI, 0.6 to 1.6). Glucocorticoids reduced peak postoperative C-reactive protein concentrations (weighted mean difference, −22.1 mg/l; CI, −31.7 to −12.5; P < 0.001), but other adverse outcomes and length of stay were unchanged. No dose–effect relationships were apparent.
Conclusions
The evidence at present does not highlight any safety concerns with respect to the use of perioperative glucocorticoids and subsequent infection, hyperglycemia, or other adverse outcomes. Nevertheless, collated trials lacked sufficient surveillance and power to detect clinically important differences in complications such as wound infection.
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van Rooijen S, Carli F, Dalton SO, Johansen C, Dieleman J, Roumen R, Slooter G. Preoperative modifiable risk factors in colorectal surgery: an observational cohort study identifying the possible value of prehabilitation. Acta Oncol 2017; 56:329-334. [PMID: 28067102 DOI: 10.1080/0284186x.2016.1267872] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Colorectal cancer (CRC) is the second most prevalent type of cancer in the world. Surgery is the most common therapeutic intervention, and associated with 20-40% reduction in physiological and functional capacity. Postoperative complications occur in up to 50% of patients resulting in higher mortality rates and greater hospital costs. The number and severity of complications is closely related to patients' preoperative performance status. The aim of this study was to identify the most important preoperative modifiable risk factors that could be part of a multimodal prehabilitation program. METHODS Prospectively collected data of a consecutive series of Dutch CRC patients undergoing colorectal surgery were analyzed. Modifiable risk factors were correlated to the Comprehensive Complication Index (CCI) and compared within two groups: none or mild complications (CCI <20), and severe complications (CCI ≥20). Multivariate logistic regression analysis was done to explore the combined effect of individual risk factors. RESULTS In this 139 patient cohort, smoking, malnutrition, alcohol consumption, neoadjuvant therapy, higher age, and male sex, were seen more frequently in the severe complications group (CCI ≥20). Patients with severe complications had significantly longer hospital stay (16 vs. 6 days, p < 0.001). The risk for severe complications was increased in patients with ASA score III [adjusted odds ratio (OR) 4.4, 95% CI 1.04-18.6], and hemoglobin level <7 mmol/l (adjusted OR 3.3, 95% CI 1.3-8.2). Compared to having no risk factors, more than one risk factor increased OR of severe complications (crude OR 5.2, 95% CI 1.8-15). CONCLUSION This study revealed that the risk of getting severe complications increases with the number of risk factors present preoperatively. Several preoperative patient-related risk factors are modifiable. Multimodal prehabilitation may improve patients' preoperative status and should be tested in a multicenter randomized controlled trial. With an international consortium (Copenhagen, Montreal, Paris, Eindhoven) we initiated a randomized controlled trial (NTR5947).
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Affiliation(s)
| | - Francesco Carli
- Department of Anesthesiology, The Montreal General Hospital, McGill University, Montreal, Canada
| | | | - Christoffer Johansen
- Danish Cancer Society Research Center, Copenhagen, Denmark
- Department of Surgery, Rigshospitalet, University of Copenhagen, Denmark
| | | | - Rudi Roumen
- Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands
| | - Gerrit Slooter
- Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands
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Shi HJ, Jin C, Fu DL. Impact of postoperative glycemic control and nutritional status on clinical outcomes after total pancreatectomy. World J Gastroenterol 2017; 23:265-274. [PMID: 28127200 PMCID: PMC5236506 DOI: 10.3748/wjg.v23.i2.265] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 11/26/2016] [Accepted: 12/08/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the impact of glycemic control and nutritional status after total pancreatectomy (TP) on complications, tumor recurrence and overall survival. METHODS Retrospective records of 52 patients with pancreatic tumors who underwent TP were collected from 2007 to 2015. A series of clinical parameters collected before and after surgery, and during the follow-up were evaluated. The associations of glycemic control and nutritional status with complications, tumor recurrence and long-term survival were determined. Risk factors for postoperative glycemic control and nutritional status were identified. RESULTS High early postoperative fasting blood glucose (FBG) levels (OR = 4.074, 95%CI: 1.188-13.965, P = 0.025) and low early postoperative prealbumin levels (OR = 3.816, 95%CI: 1.110-13.122, P = 0.034) were significantly associated with complications after TP. Postoperative HbA1c levels over 7% (HR = 2.655, 95%CI: 1.299-5.425, P = 0.007) were identified as one of the independent risk factors for tumor recurrence. Patients with postoperative HbA1c levels over 7% had much poorer overall survival than those with HbA1c levels less than 7% (9.3 mo vs 27.6 mo, HR = 3.212, 95%CI: 1.147-8.999, P = 0.026). Patients with long-term diabetes mellitus (HR = 15.019, 95%CI: 1.278-176.211, P = 0.031) and alcohol history (B = 1.985, SE = 0.860, P = 0.025) tended to have poor glycemic control and lower body mass index levels after TP, respectively. CONCLUSION At least 3 mo are required after TP to adapt to diabetes and recover nutritional status. Glycemic control appears to have more influence over nutritional status on long-term outcomes after TP. Improvement in glycemic control and nutritional status after TP is important to prevent early complications and tumor recurrence, and improve survival.
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Concepts in Physiology and Pathophysiology of Enhanced Recovery after Surgery. Int Anesthesiol Clin 2017; 55:38-50. [DOI: 10.1097/aia.0000000000000166] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Hellspong G, Gunnarsson U, Dahlstrand U, Sandblom G. Diabetes as a risk factor in patients undergoing groin hernia surgery. Langenbecks Arch Surg 2016; 402:219-225. [PMID: 27928640 DOI: 10.1007/s00423-016-1519-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 10/02/2016] [Indexed: 01/27/2023]
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Küçükdurmaz F, Parvizi J. The Prevention of Periprosthetic Joint Infections. Open Orthop J 2016; 10:589-599. [PMID: 28144372 PMCID: PMC5226971 DOI: 10.2174/1874325001610010589] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 06/12/2016] [Accepted: 07/15/2016] [Indexed: 12/14/2022] Open
Abstract
Periprosthetic joint infection (PJI) following total joint arthroplasty (TJA) adversely affects patient quality of life and health status, and places a huge financial burden on the health care. The first step in combating this complication is prevention, which may include implementation of strategies during the preoperative, intraoperative, or postoperative period. Optimization of the patient with appreciation of the modifiable and non-modifiable factors is crucial. Preoperative optimization involves medical optimization of patients with comorbidities such as diabetes, anemia, malnutrition and other conditions that may predispose the patient to PJI. Among the intraoperative strategies, administration of appropriate and timely antibiotics, blood conservation, gentle soft tissue handling, and expeditious surgery in an ultra clean operating room are among the most effective strategies. During the postoperative period, all efforts should be made to minimize ingress or proliferation of bacteria at the site of the index arthroplasty from draining the wound and hematoma formation. Although the important role of some preventative measures is known, further research is needed to evaluate the role of unproven measures that are currently employed and to devise further strategies for prevention of this feared complication.
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Affiliation(s)
- Fatih Küçükdurmaz
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Javad Parvizi
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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81
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American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. J Am Coll Surg 2016; 224:59-74. [PMID: 27915053 DOI: 10.1016/j.jamcollsurg.2016.10.029] [Citation(s) in RCA: 640] [Impact Index Per Article: 71.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 10/05/2016] [Indexed: 02/08/2023]
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82
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de Vries FEE, Gans SL, Solomkin JS, Allegranzi B, Egger M, Dellinger EP, Boermeester MA. Meta-analysis of lower perioperative blood glucose target levels for reduction of surgical-site infection. Br J Surg 2016; 104:e95-e105. [DOI: 10.1002/bjs.10424] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 07/26/2016] [Accepted: 10/05/2016] [Indexed: 01/04/2023]
Abstract
Abstract
Background
There is a clear association between hyperglycaemia and surgical-site infection (SSI). Intensive glucose control may involve a risk of hypoglycaemia, which in turn results in potentially severe complications. A systematic review was undertaken of studies comparing intensive versus conventional glucose control protocols in relation to reduction of SSI and other outcomes, including hypoglycaemia, mortality and stroke.
Methods
PubMed, Embase, CENTRAL, CINAHL and WHO databases from 1 January 1990 to 1 August 2015 were searched. Inclusion criteria were RCTs comparing intensive with conventional glucose control protocols, and reporting on the incidence of SSI. Meta-analyses were performed with a random-effects model, and meta-regression was subsequently undertaken. Targeted blood glucose levels, achieved blood glucose levels, and important adverse events were summarized.
Results
Fifteen RCTs were included. The summary estimate showed a significant benefit for an intensive compared with a conventional glucose control protocol in reducing SSI (odds ratio (OR) 0·43, 95 per cent c.i. 0·29 to 0·64; P < 0·001). A significantly higher risk of hypoglycaemic events was found for the intensive group compared with the conventional group (OR 5·55, 2·58 to 11·96), with no increased risk of death (OR 0·74, 0·45 to 1·23) or stroke (OR 1·37, 0·26 to 7·20). These results were consistent both in patients with and those without diabetes, and in studies with moderately strict and very strict glucose control.
Conclusion
Stricter and lower blood glucose target levels of less than 150 mg/dl (8·3 mmol/l), using an intensive protocol in the perioperative period, reduce SSI with an inherent risk of hypoglycaemic events but without a significant increase in serious adverse events.
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Affiliation(s)
- F E E de Vries
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - S L Gans
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
- Department of Surgery, Tergooi Hospital, Hilversum, The Netherlands
| | - J S Solomkin
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - B Allegranzi
- Infection Prevention and Control Global Unit, Service Delivery and Safety, World Health Organization, Geneva, Switzerland
| | - M Egger
- Institute of Social and Preventive Medicine, University of Berne, Berne, Berne, Switzerland
| | - E P Dellinger
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - M A Boermeester
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
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83
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van Rooijen SJ, Huisman D, Stuijvenberg M, Stens J, Roumen RMH, Daams F, Slooter GD. Intraoperative modifiable risk factors of colorectal anastomotic leakage: Why surgeons and anesthesiologists should act together. Int J Surg 2016; 36:183-200. [PMID: 27756644 DOI: 10.1016/j.ijsu.2016.09.098] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 09/12/2016] [Accepted: 09/26/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Colorectal anastomotic leakage (CAL) is a major surgical complication in intestinal surgery. Despite many optimizations in patient care, the incidence of CAL is stable (3-19%) [1]. Previous research mainly focused on determining patient and surgery related risk factors. Intraoperative non-surgery related risk factors for anastomotic healing also contribute to surgical outcome. This review offers an overview of potential modifiable risk factors that may play a role during the operation. METHODS Two independent literature searches were performed using EMBASE, Pubmed and Cochrane databases. Both clinical and experimental studies published in English from 1985 to August 2015 were included. The main outcome measure was the risk of anastomotic leakage and other postoperative complications during colorectal surgery. Determined risk factors of CAL were stated as strong evidence (level I and II high quality studies), and potential risk factors as either moderate evidence (experimental studies level III), or weak evidence (level IV or V studies). RESULTS The final analysis included 117 articles. Independent factors of CAL are diabetes mellitus, hyperglycemia and a high HbA1c, anemia, blood loss, blood transfusions, prolonged operating time, intraoperative events and contamination and a lack of antibiotics. Unequivocal are data on blood pressure, the use of inotropes/vasopressors, oxygen suppletion, type of analgesia and goal directed fluid therapy. No studies could be found identifying the impact of body core temperature or mean arterial pressure on CAL. Subjective factors such as the surgeons' own assessment of local perfusion and visibility of the operating field have not been the subject of relevant studies for occurrence in patients with CAL. CONCLUSION Both surgery related and non-surgery related risk factors that can be modified must be identified to improve colorectal care. Surgeons and anesthesiologists should cooperate on these items in their continuous effort to reduce the number of CAL. A registration study determining individual intraoperative risk factors of CAL is currently performed as a multicenter cohort study in the Netherlands.
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Affiliation(s)
- S J van Rooijen
- Máxima Medical Center, Department of Surgery, Veldhoven, The Netherlands.
| | - D Huisman
- VU Medical Center, Department of Surgery, Amsterdam, The Netherlands
| | - M Stuijvenberg
- Máxima Medical Center, Department of Surgery, Veldhoven, The Netherlands
| | - J Stens
- VU Medical Center, Department of Surgery, Amsterdam, The Netherlands
| | - R M H Roumen
- Máxima Medical Center, Department of Surgery, Veldhoven, The Netherlands
| | - F Daams
- VU Medical Center, Department of Surgery, Amsterdam, The Netherlands
| | - G D Slooter
- Máxima Medical Center, Department of Surgery, Veldhoven, The Netherlands
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84
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Hu Q, Ren J, Li G, Wu X, Wang G, Gu G, Li J. Clinical Significance of Post-Operative Hyperglycemia in Nondiabetic Patients Undergoing Definitive Surgery for Gastrointestinal Fistula. Surg Infect (Larchmt) 2016; 17:491-7. [PMID: 27183504 DOI: 10.1089/sur.2016.050] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Qiongyuan Hu
- Department of Surgery, Jinling Hospital, Medical School of Southeast University, Nanjing, China
| | - Jianan Ren
- Department of Surgery, Jinling Hospital, Medical School of Southeast University, Nanjing, China
- Medical School of Nanjing University, Nanjing, China
| | - Guanwei Li
- Department of Surgery, Jinling Hospital, Medical School of Southeast University, Nanjing, China
- Medical School of Nanjing University, Nanjing, China
| | - Xiuwen Wu
- Department of Surgery, Jinling Hospital, Medical School of Southeast University, Nanjing, China
| | - Gefei Wang
- Department of Surgery, Jinling Hospital, Medical School of Southeast University, Nanjing, China
- Medical School of Nanjing University, Nanjing, China
| | - Guosheng Gu
- Department of Surgery, Jinling Hospital, Medical School of Southeast University, Nanjing, China
| | - Jieshou Li
- Department of Surgery, Jinling Hospital, Medical School of Southeast University, Nanjing, China
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85
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Raevuori A, Lukkariniemi L, Suokas JT, Gissler M, Suvisaari JM, Haukka J. Increased use of antimicrobial medication in bulimia nervosa and binge-eating disorder prior to the eating disorder treatment. Int J Eat Disord 2016; 49:542-52. [PMID: 26875554 DOI: 10.1002/eat.22497] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 11/23/2015] [Accepted: 11/30/2015] [Indexed: 01/31/2023]
Abstract
OBJECTIVE We examined the use of antimicrobial medication as a proxy for infections in large patient cohort treated for binge-eating disorder (BED), bulimia nervosa (BN), and anorexia nervosa (AN) over the five-year period preceding eating disorder treatment. METHOD Patients (N = 1592) at the Eating Disorder Unit of Helsinki University Central Hospital between 2000 and 2010 were compared with matched general population controls (N = 6368). The study population was linked to the prescription data of antibacterial, antifungal and antiviral medication from the Register on Reimbursed Prescription Medicine. Data were analyzed using regression models. RESULTS Individuals with BN and BED had received more often antimicrobial medication prescriptions compared to their controls (OR: 1.7, 95% CI: 1.3-2.1; OR: 2.6, 95% CI: 1.4-4.6, respectively), while no significant difference emerged in AN (OR: 0.9, 95% CI: 0.7-1.0, p = 0.10). Of the main drug categories, the respective pattern was seen in antibacterial and antifungal medication, while increased use for antivirals appeared only in BN (OR: 1.6, 95% CI: 1.1-2.3). Measured with the mean number of prescriptions or mean Defined Daily Doses per individual, patients with BN, BED and males with AN had also higher total antimicrobial medication use. DISCUSSION Indicating increased infections, we found elevated use of antimicrobial medication in BN, BED and in males with AN. Infections may be consequence of hyperglycemia, weight gain, or dysregulation of intestinal microbiota associated with core eating disorder behaviors. Or the other way round; changes in intestinal microbiota due to infections, inflammation, or antibacterial medications might contribute to eating disorders in multiple ways. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:542-552).
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Affiliation(s)
- Anu Raevuori
- Clinicum, Department of Public Health, University of Helsinki, Finland.,Department of Adolescent Psychiatry, Helsinki University Central Hospital, Helsinki, Finland.,Institute of Clinical Medicine, Child Psychiatry, University of Turku, Finland.,Department of Mental Health and Substance Abuse Services, National Institute for Health and Welfare, Helsinki, Finland
| | | | - Jaana T Suokas
- Department of Mental Health and Substance Abuse Services, National Institute for Health and Welfare, Helsinki, Finland.,Department of Psychiatry, Helsinki University Central Hospital, Finland
| | - Mika Gissler
- Information Services Department, National Institute for Health and Welfare, Helsinki, Finland
| | - Jaana M Suvisaari
- Department of Mental Health and Substance Abuse Services, National Institute for Health and Welfare, Helsinki, Finland.,Department of Social Psychiatry, Tampere School of Public Health, Finland
| | - Jari Haukka
- Clinicum, Department of Public Health, University of Helsinki, Finland.,Department of Mental Health and Substance Abuse Services, National Institute for Health and Welfare, Helsinki, Finland
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86
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Abstract
BACKGROUND Hospital-acquired infections (HAIs) are a persistent concern and include surgical site infections, intravascular line-associated infections, pneumonia, catheter-associated urinary tract infections, and C. difficile infection. METHOD Review of the pertinent English-language literature. RESULTS Hospital-acquired infections result in significant increases in morbidity, mortality rates, and cost and are a focus of efforts at reduction. CONCLUSION I discuss efforts specific to each of the most common infections and a philosophical approach to prevention that strives to achieve zero potentially preventable hospital-acquired infections.
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87
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Risk of Surgical Site Infection Varies Based on Location of Disease and Segment of Colorectal Resection for Cancer. Dis Colon Rectum 2016; 59:493-500. [PMID: 27145305 DOI: 10.1097/dcr.0000000000000577] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Current quality-monitoring initiatives do not accurately evaluate surgical site infections based on type of surgical procedure. OBJECTIVE This study aimed to characterize the effect of the anatomical site resected (right, left, rectal) on wound complications, including superficial, deep, and organ space surgical site infections, in patients who have cancer. SETTINGS Data were retrieved from the American College of Surgeons National Surgical Quality Improvement Program database. DESIGN This study was designed to determine the independent risk associated with the anatomical location of cancer resection for all subtypes of surgical site infection. Statistical methods included the Fisher exact test, the χ test, and univariable and multivariable analyses for each outcome of interest. PATIENTS All colon and rectal resections for colorectal cancer between 2006 and 2012 were selected. Included were 45,956 patients: 17,993 (39.2%) underwent right colectomy, 11,538 (25.1%) underwent left colectomy, and 16,425 (35.7%) underwent rectal resections. RESULTS The overall surgical site infection rate was 12.3%: 3.7% organ space, 1.4% deep, and 7.2% superficial. On multivariable analysis, rectal resection was associated with the greatest odds of overall surgical site infections in comparison with left- or right-sided resections (rectal OR, 1.51; 95% CI, 1.35-1.69 vs left OR, 1.09; 95% CI, 0.97-1.23 vs right OR, 1). Rectal resections were also associated with greater odds of developing a deep surgical site infection than either right (rectal OR, 1.45; 95% CI, 1.06-1.99) or left (OR, 0.89; 95% CI, 0.62-1.27). The likelihood of organ space surgical site infection followed a similar pattern (rectal OR, 1.83; 95% CI 1.49-2.25; left colon, OR, 0.95; 95% CI, 0.75-1.19). Rectal and left resections had increased odds of superficial surgical site infections compared with right resections (rectal OR, 1.31; 95% CI, 1.14-1.51; left OR, 1.19; 95% CI, 1.03-1.37). LIMITATIONS This is a retrospective observational study. CONCLUSIONS Rectal resections for cancer are independently associated with an increased likelihood of superficial, deep, and organ space infections. The policy on surgical site infections as a quality measure currently in place requires modification to adjust for the location of pathology and, hence, the anatomical segment resected when assessing the risk for type of surgical site infection.
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88
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Abstract
Hyperglycemia occurs frequently among patients undergoing colorectal surgery and is associated with increased risk of poor clinical outcomes, especially related to surgical site infections. Treating hyperglycemia has become a target of many enhanced recovery after surgery programs developed for colorectal procedures. There are several unique considerations for patients undergoing colorectal surgery including bowel preparations and alterations in oral intake. Focused protocols for those with diabetes and those at risk of hyperglycemia are needed in order to address the specific needs of those undergoing colorectal procedures.
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Affiliation(s)
- Rachel E Thompson
- Department of Medicine, University of Nebraska Medical Center, 986435 Nebraska Medical Center, Omaha, NE, 68198-6435, USA.
| | - Elizabeth K Broussard
- Department of Medicine, University of Washington, Harborview Medical Center, 325 9th Ave, Seattle, WA, 98104, USA
| | - David R Flum
- Department of Surgery, University of Washington Medical Center, 1959 NE Pacific St, Seattle, WA, 98105, USA
| | - Brent E Wisse
- Department of Medicine, University of Washington, Harborview Medical Center, 325 9th Ave, Seattle, WA, 98104, USA
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89
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Hanazaki K, Munekage M, Kitagawa H, Namikawa T. Tight Glycemic Control Using an Artificial Pancreas Is Useful for Surgical Patients With Uncontrolled Perioperative Hyperglycemia. Ann Surg 2016; 263:e50. [PMID: 25876013 DOI: 10.1097/sla.0000000000001145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Kazuhiro Hanazaki
- Department of Surgery, Kochi Medical School Kochi University Kochi, Japan
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90
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Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations--Part II. Gynecol Oncol 2016; 140:323-32. [PMID: 26757238 PMCID: PMC6038804 DOI: 10.1016/j.ygyno.2015.12.019] [Citation(s) in RCA: 301] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 12/14/2015] [Accepted: 12/21/2015] [Indexed: 12/15/2022]
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91
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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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92
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Park YY, Kim CW, Park SJ, Lee KY, Lee JJ, Lee HO, Lee SH. Influence of Shorter Duration of Prophylactic Antibiotic Use on the Incidence of Surgical Site Infection Following Colorectal Cancer Surgery. Ann Coloproctol 2015; 31:235-242. [PMID: 26817019 PMCID: PMC4724705 DOI: 10.3393/ac.2015.31.6.235] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Accepted: 10/21/2015] [Indexed: 12/14/2022] Open
Abstract
PURPOSE This study aimed to identify the risk factors for surgical site infections (SSIs) in patients undergoing colorectal cancer surgery and to determine whether significantly different SSI rates existed between the short prophylactic antibiotic use group (within 24 hours) and the long prophylactic antibiotic use group (beyond 24 hours). METHODS The medical records of 327 patients who underwent colorectal resection due to colorectal cancer from January 2010 to May 2014 at a single center were retrospectively reviewed, and their characteristics as well as the surgical factors known to be risk factors for SSIs, were identified. RESULTS Among the 327 patients, 45 patients (13.8%) developed SSIs. The patients were divided into two groups according to the duration of antibiotic use: group S (within 24 hours) and group L (beyond 24 hours). Of the 327 patients, 114 (34.9%) were in group S, and 213 (65.1%) were in group L. Twelve patients (10.5%) in group S developed SSIs while 33 patients (15.5%) in group L developed SSIs (P = 0.242). History of diabetes mellitus and lung disease, long operation time, and perioperative transfusion were independent risk factors for SSIs. CONCLUSION This study shows that discontinuation of prophylactic antibiotics within 24 hours after colorectal surgery has no significant influence on the incidence of SSIs. This study also showed that history of diabetes mellitus and lung disease, long operation time, and perioperative transfusion were associated with increased SSI rates.
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Affiliation(s)
- Youn Young Park
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Chang Woo Kim
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Sun Jin Park
- Department of Surgery, Kyung Hee University Medical Center, Kyung Hee University School of Medicine, Seoul, Korea
| | - Kil Yeon Lee
- Department of Surgery, Kyung Hee University Medical Center, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jung Joo Lee
- Nutrition Team, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Hye Ok Lee
- Nutrition Team, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Suk-Hwan Lee
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
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93
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Postoperative hyperglycemia and adverse outcomes in patients undergoing colorectal surgery: results from the Michigan surgical quality collaborative database. Int J Colorectal Dis 2015. [PMID: 26198996 DOI: 10.1007/s00384-015-2322-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Our objective was to assess the relationship between high blood glucose levels (BG) in the early postoperative period and the incidence of surgical site infections (SSIs), sepsis, and death following colorectal operations. METHODS The Michigan Surgical Quality Collaborative database was queried for colorectal operations from July 2012 to December 2013. Normoglycemic (BG < 180 mg/dL) and hyperglycemic (BG ≥ 180 mg/dL) groups were defined by using the highest BG within the first 72 h postoperatively. Outcomes of interest included the incidence of superficial, deep, and organ/space SSIs, sepsis, and death within 30 days. Initial unadjusted analysis was followed by propensity score matching and multiple logistic regression modeling after adjusting for significant predictors. Separate analyses were performed for previously diagnosed diabetic and non-diabetic patients. RESULTS A total of 5145 cases met inclusion criteria, of which 1072 were diabetic. For diabetic patients, there was a marginally significant association between high BG and superficial SSI in the unadjusted analysis (OR = 1.75, p = 0.056), but not in the adjusted analysis (OR = 1.35, p = 0.39). There was no significant relationship between elevated BG and deep SSI, organ/space SSI, sepsis, or death among diabetic patients. For non-diabetic patients, there was a significant association between high BG and superficial SSI (OR = 1.53, p = 0.03), sepsis (OR = 1.61, p < 0.01), and death (OR = 2.26, p < 0.01), but not deep or organ/space SSI. CONCLUSIONS Following colorectal operations, superficial SSI, sepsis, and death are associated with postoperative serum hyperglycemia in patients without diabetes, but not those with diabetes. Vigilant postoperative BG monitoring is critical for all patients undergoing colorectal surgery.
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94
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Scott MJ, Baldini G, Fearon KCH, Feldheiser A, Feldman LS, Gan TJ, Ljungqvist O, Lobo DN, Rockall TA, Schricker T, Carli F. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 1: pathophysiological considerations. Acta Anaesthesiol Scand 2015; 59:1212-31. [PMID: 26346577 PMCID: PMC5049676 DOI: 10.1111/aas.12601] [Citation(s) in RCA: 256] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 06/18/2015] [Accepted: 07/23/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND The present article has been written to convey concepts of anaesthetic care within the context of an Enhanced Recovery After Surgery (ERAS) programme, thus aligning the practice of anaesthesia with the care delivered by the surgical team before, during and after surgery. METHODS The physiological principles supporting the implementation of the ERAS programmes in patients undergoing major abdominal procedures are reviewed using an updated literature search and discussed by a multidisciplinary group composed of anaesthesiologists and surgeons with the aim to improve perioperative care. RESULTS The pathophysiology of some key perioperative elements disturbing the homoeostatic mechanisms such as insulin resistance, ileus and pain is here discussed. CONCLUSIONS Evidence-based strategies aimed at controlling the disruption of homoeostasis need to be evaluated in the context of ERAS programmes. Anaesthesiologists could, therefore, play a crucial role in facilitating the recovery process.
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Affiliation(s)
- M. J. Scott
- Royal Surrey County Hospital NHS Foundation Trust University of Surrey Guildford UK
| | - G. Baldini
- Department of Anesthesia McGill University Health Centre Montreal General Hospital Montreal QC Canada
| | - K. C. H. Fearon
- University of Edinburgh The Royal Infirmary Clinical Surgery Edinburgh UK
| | - A. Feldheiser
- Department of Anesthesiology and Intensive Care Medicine Campus Charit Mitte and Campus Virchow‐Klinikum Charit University Medicine Berlin Germany
| | - L. S. Feldman
- Department of Surgery McGill University Health Centre Montreal General Hospital Montreal QC Canada
| | - T. J. Gan
- Department of Anesthesiology Duke University Medical Center Durham NY USA
| | - O. Ljungqvist
- Department of Surgery Faculty of Medicine and Health Orebro University Orebro Sweden
| | - D. N. Lobo
- Division of Gastrointestinal Surgery Nottingham Digestive Diseases Centre National Institute for Health Research Biomedical Research Unit Nottingham University Hospitals Queen's Medical Centre Nottingham UK
| | - T. A. Rockall
- Royal Surrey County Hospital NHS Foundation Trust University of Surrey Guildford UK
| | - T. Schricker
- Department of Anesthesia McGill University Health Centre Royal Victoria Hospital Montreal QC Canada
| | - F. Carli
- Department of Anesthesia McGill University Health Centre Montreal General Hospital Montreal QC Canada
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95
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Perioperative hyperglycemia and risk of adverse events among patients with and without diabetes. Ann Surg 2015; 261:97-103. [PMID: 25133932 DOI: 10.1097/sla.0000000000000688] [Citation(s) in RCA: 292] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To study the association between diabetes status, perioperative hyperglycemia, and adverse events in a statewide surgical cohort. BACKGROUND Perioperative hyperglycemia may increase the risk of adverse events more significantly in patients without diabetes (NDM) than in those with diabetes (DM). METHODS Using data from the Surgical Care and Outcomes Assessment Program, a cohort study (2010-2012) evaluated diabetes status, perioperative hyperglycemia, and composite adverse events in abdominal, vascular, and spine surgery at 53 hospitals in Washington State. RESULTS Among 40,836 patients (mean age, 54 years; 53.6% women), 19% had diabetes; 47% underwent a perioperative blood glucose (BG) test, and of those, 18% had BG ≥180 mg/dL. DM patients had a higher rate of adverse events (12% vs 9%, P < 0.001) than NDM patients. After adjustment, among NDM patients, those with hyperglycemia had an increased risk of adverse events compared with those with normal BG. Among NDM patients, there was a dose-response relationship between the level of BG and composite adverse events [odds ratio (OR), 1.3 for BG 125-180 (95% confidence interval (CI), 1.1-1.5); OR, 1.6 for BG ≥180 (95% CI, 1.3-2.1)]. Conversely, hyperglycemic DM patients did not have an increased risk of adverse events, including those with a BG 180 or more (OR, 0.8; 95% CI, 0.6-1.0). NDM patients were less likely to receive insulin at each BG level. CONCLUSIONS For NDM patients, but not DM patients, the risk of adverse events was linked to hyperglycemia. Underlying this paradoxical effect may be the underuse of insulin, but also that hyperglycemia indicates higher levels of stress in NDM patients than in DM patients.
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96
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Li Y, Zuo L, Zhu W, Gong J, Zhang W, Gu L, Guo Z, Li N, Li J. The impact of bacterial DNA translocation on early postoperative outcomes in Crohn's patients undergoing abdominal surgery. J Crohns Colitis 2015; 9:259-265. [PMID: 25555386 DOI: 10.1093/ecco-jcc/jju029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Bacterial DNA (bactDNA) translocation occurs frequently in patients with Crohn's disease and can be present in patients with a negative blood microbiological culture. We aimed to determine the effects of bactDNA translocation on postoperative outcomes in Crohn's disease patients undergoing abdominal surgery. METHODS Patients with Crohn's disease who underwent abdominal surgery between January 2012 and March 2014 were identified. General and postoperative outcome-related information was retrieved from a database, and the data were compared between patients with and without bactDNA translocation. Multivariate analysis was used to determine the independent effect of bactDNA translocation on postoperative morbidity. RESULTS One hundred and seven patients who underwent abdominal surgery were included in our study. The presence of bactDNA in blood samples was identified in 29 patients (27.1%). There was a total of 55 complications in 28 patients (26.2%). Patients with bactDNA in their blood had a mean postoperative hospital stay of 12.7±4.2 days and patients without DNA translocation had a mean postoperative hospital stay of 10.1±4.8 days (p = 0.009). The readmission rate was increased in patients with bactDNA translocation (p = 0.032). A low preoperative level of serum albumin (p = 0.024), preoperative immunosuppressive agent use (p = 0.046), and the presence of bactDNA in blood (p = 0.005) were independently associated with increased postoperative adverse outcomes. CONCLUSIONS Preoperative bactDNA translocation into the blood increases the incidence of postoperative adverse outcomes in patients with Crohn's disease who undergo abdominal surgery.
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Affiliation(s)
- Yi Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, PR China
| | - Lugen Zuo
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, PR China
| | - Weiming Zhu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, PR China
| | - Jianfeng Gong
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, PR China
| | - Wei Zhang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, PR China
| | - Lili Gu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, PR China
| | - Zhen Guo
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, PR China
| | - Ning Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, PR China
| | - Jieshou Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, PR China
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97
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Page AJ, Ejaz A, Spolverato G, Zavadsky T, Grant MC, Galante DJ, Wick EC, Weiss M, Makary MA, Wu CL, Pawlik TM. Enhanced recovery after surgery protocols for open hepatectomy--physiology, immunomodulation, and implementation. J Gastrointest Surg 2015; 19:387-99. [PMID: 25472030 DOI: 10.1007/s11605-014-2712-0] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 11/19/2014] [Indexed: 01/31/2023]
Abstract
There has been recent interest in enhanced-recovery after surgery (ERAS®) or "fast-track" perioperative protocols in the surgical community. The subspecialty field of colorectal surgery has been the leading adopter of ERAS protocols, with less data available regarding its adoption in hepato-pancreato-biliary surgery. This review focuses on available data pertaining to the application of ERAS to open hepatectomy. We focus on four fundamental variables that impact normal physiology and exacerbate perioperative inflammation: (1) the stress of laparotomy, (2) the use of opioids, (3) blood loss and blood product transfusions, and (4) perioperative fasting. The attenuation of these inflammatory stressors is largely responsible for the improvements in perioperative outcomes due to the implementation of ERAS-based pathways. Collectively, the data suggest that the implementation of ERAS principles should be strongly considered in all patients undergoing hepatectomy.
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Affiliation(s)
- Andrew J Page
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
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98
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Reply to Letter: "The Clinical Significance of an Elevated Postoperative Glucose Value in Nondiabetic Patients After Colorectal Surgery: Evidence for the Need for Tight Glucose Control?". Ann Surg 2014; 263:e51. [PMID: 24979601 DOI: 10.1097/sla.0000000000000801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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99
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Janket SJ. Scaling and Root-planing (SRP) May Improve Glycemic Control and Lipid Profile in Patients With Chronic Periodontitis (CP) and Type 2 Diabetes (DM2) in a Specific Subgroup: A Meta-analysis of Randomized Clinical Trials. J Evid Based Dent Pract 2014; 14:31-3. [DOI: 10.1016/j.jebdp.2014.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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100
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Abstract
The aging of the U.S. population is leading to an increasing number of surgical procedures performed on older adults. At the same time, the quality of medical care is being more closely scrutinized. Surgical site infection is a widely-assessed outcome. Evidence suggests that strict perioperative serum glucose control among patients with or without diabetes can lower the risk of these infections, but it is unclear whether this control should be applied to older surgical patients. In this clinical review, we discuss current research on perioperative serum glucose management for cardiothoracic, orthopedic, and general/colorectal surgery. In addition, we summarize clinical recommendations and quality-of-care process indicators provided by surgical, diabetes, and geriatric medical organizations.
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