Digital Decision Support for Perioperative Care of Patients With Type 2 Diabetes: A Call to Action

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Type 2 diabetes mellitus affects over 500 million people globally, with 10%-20% requiring surgery. Patients with diabetes are at increased risk for perioperative complications, including prolonged hospital stays and higher mortality, primarily due to perioperative hyperglycemia. Managing blood glucose during the perioperative period is challenging, and conventional monitoring is often inadequate to detect rapid fluctuations. Clinical decision support systems (CDSS) are emerging tools to improve perioperative diabetes management by providing real-time glucose data and medication recommendations. This viewpoint examines the role of CDSS in perioperative diabetes care, highlighting their benefits and limitations. CDSS can help manage blood glucose more effectively, preventing both hyperglycemia and hypoglycemia. However, technical and integration challenges, along with clinician acceptance, remain significant barriers.

Accuracy of Freestyle Libre continuous glucose monitoring system in critically ill patients after cardiac surgery

BACKGROUND

Hyperglycemia is an independent risk factor for perioperative complications and mortality after cardiac surgery. Freestyle Libre Continuous glucose monitor (CGM) is an interstitial glucose monitoring system, which has been proven to be stable and accurate in various disease.

MATERIALS AND METHODS

86 patients with hyperglycemia after cardiac surgery between October 2021 and October 2022 in the cardiovascular ICU, were enrolled in this study. We evaluated systematic errors and numerical accuracy in blood glucose (BG) between two groups using Bland-Altman analysis and mean absolute relative difference (MARD). The clinical accuracy was assessed by consensus and Clarke error grid.

RESULTS

435 paired sensor-reference values were enrolled between the Freestyle and venous BG. The MARD was 18.2% with the Bland-Altman standard bias of 31.87 mg/dL. 1851 paired values were enrolled between the Freestyle and arterial BG. The MARD was 21.5%, and the Bland-Altman standard bias was 41.45 mg/dL. 432 paired values were enrolled between the arterial and venous BG. The MARD was 8.4%, and the Bland-Altman standard bias was - 9.95 mg/dL.

CONCLUSIONS

Our study demonstrated the relatively low accuracy of Freestyle Libre CGM for critical patients after cardiac surgery. The arterial blood gas glucose analysis acts as an effective tool to improve BG management.

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

This consensus statement is a comprehensive update of the 2010 Society for Ambulatory Anesthesia (SAMBA) Consensus Statement on perioperative blood glucose management in patients with diabetes mellitus (DM) undergoing ambulatory surgery. Since the original consensus guidelines in 2010, several novel therapeutic interventions have been introduced to treat DM, including new hypoglycemic agents and increasing prevalence of insulin pumps and continuous glucose monitors. The updated recommendations were developed by an expert task force under the provision of SAMBA and are based on a comprehensive review of the literature from 1980 to 2022. The task force included SAMBA members with expertise on this topic and those contributing to the primary literature regarding the management of DM in the perioperative period. The recommendations encompass preoperative evaluation of patients with DM presenting for ambulatory surgery, management of preoperative oral hypoglycemic agents and home insulins, intraoperative testing and treatment modalities, and blood glucose management in the postanesthesia care unit and transition to home after surgery. High-quality evidence pertaining to perioperative blood glucose management in patients with DM undergoing ambulatory surgery remains sparse. Recommendations are therefore based on recent guidelines and available literature, including general glucose management in patients with DM, data from inpatient surgical populations, drug pharmacology, and emerging treatment data. Areas in need of further research are also identified. Importantly, the benefits and risks of interventions and clinical practice information were considered to ensure that the recommendations maintain patient safety and are clinically valid and useful in the ambulatory setting. What Other Guidelines Are Available on This Topic? Since the publication of the SAMBA Consensus Statement for perioperative blood glucose management in the ambulatory setting in 2010, several recent guidelines have been issued by the American Diabetes Association (ADA), the American Association of Clinical Endocrinologists (AACE), the Endocrine Society, the Centre for Perioperative Care (CPOC), and the Association of Anaesthetists of Great Britain and Ireland (AAGBI) on DM care in hospitalized patients; however, none are specific to ambulatory surgery. How Does This Guideline Differ From the Previous Guidelines? Previously posed clinical questions that were outdated were revised to reflect current clinical practice. Additional questions were developed relating to the perioperative management of patients with DM to include the newer therapeutic interventions.

Myocardial protection in cardiac surgery: a comprehensive review of current therapies and future cardioprotective strategies

Cardiac surgery with cardiopulmonary bypass results in global myocardial ischemia-reperfusion injury, leading to significant postoperative morbidity and mortality. Although cardioplegia is the cornerstone of intraoperative cardioprotection, a number of additional strategies have been identified. The concept of preconditioning and postconditioning, despite its limited direct clinical application, provided an essential contribution to the understanding of myocardial injury and organ protection. Therefore, physicians can use different tools to limit perioperative myocardial injury. These include the choice of anesthetic agents, remote ischemic preconditioning, tight glycemic control, optimization of respiratory parameters during the aortic unclamping phase to limit reperfusion injury, appropriate choice of monitoring to optimize hemodynamic parameters and limit perioperative use of catecholamines, and early reintroduction of cardioprotective agents in the postoperative period. Appropriate management before, during, and after cardiopulmonary bypass will help to decrease myocardial damage. This review aimed to highlight the current advancements in cardioprotection and their potential applications during cardiac surgery.

Perioperative Glycemic Management in Cardiac Surgery: A Narrative Review

Diabetes and hyperglycemic events in cardiac surgical patients are associated with postoperative morbidity and mortality. The causes of dysglycemia, the abnormal fluctuations in blood glucose concentrations, in the perioperative period include surgical stress, surgical techniques, medications administered perioperatively, and patient factors. Both hyperglycemia and hypoglycemia lead to poor outcomes after cardiac surgery. While trying to control blood glucose concentration tightly for better postoperative outcomes, hypoglycemia is the main adverse event. Currently, there is no definite consensus on the optimum perioperative blood glucose concentration to be maintained in cardiac surgical patients. This review provides an overview of perioperative glucose homeostasis, the pathophysiology of dysglycemia, factors that affect glycemic control in cardiac surgery, and current practices for glycemic control in cardiac surgery.

Short-Term Outcome of Robotic versus Laparoscopic Hysterectomy for Endometrial Cancer in Women with Diabetes: Analysis of the US Nationwide Inpatient Sample

This study investigated short-term outcomes of robotic versus laparoscopic hysterectomy for endometrial cancer (EC) in women with diabetes. We extracted the data of hospitalized females aged ≥18 years who were diagnosed with EC and diabetes and underwent robotic or laparoscopic hysterectomy from the US Nationwide Inpatient Sample (NIS) 2005-2018. Associations between study variables and in-hospital outcomes, including complications, unfavorable discharge, length of stay (LOS), and hospital costs, were examined using logistic regression. A total of 5745 women (representing 28,176 women in the US) were included. Multivariable analysis revealed that robotic surgery was significantly associated with a decreased risk of unfavorable discharge (adjusted odds ratio [aOR] = 0.63, 95% confidence interval [CI]: 0.46, 0.85) than pure laparoscopic surgery. Women who underwent robotic surgery had a significantly shorter LOS (0.46 fewer days, 95% CI: -0.57, -0.35) but higher total hospital costs (6129.93 greater USD; 95% CI: 4448.74, 7811.12). Compared with pure laparoscopic surgery, robotic hysterectomy was associated with less unfavorable discharge among women aged ≥60 years (aOR = 0.60, 95% CI: 0.44, 0.80). For US women with EC and diabetes, robotic hysterectomy is associated with shorter LOS, decreased risk of unfavorable discharge, especially among older patients, and higher total costs than laparoscopic surgery.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Feasibility of intraoperative continuous glucose monitoring: An observational study in general surgery patients

BACKGROUND

Perioperative hyperglycemia is associated with adverse outcomes in surgical patients, and major societies recommend intraoperative monitoring and treatment targeting glucose <180-200 mg/dL. However, compliance with these recommendations is poor, in part due to fear of unrecognized hypoglycemia. Continuous Glucose Monitors (CGMs) measure interstitial glucose with a subcutaneous electrode and can display the results on a receiver or smartphone. Historically CGMs have not been utilized for surgical patients. We investigated the use of CGM in the perioperative setting compared to current standard practices.

METHOD

This study evaluated the use of Abbott Freestyle Libre 2.0 and/or Dexcom G6 CGMs in a prospective cohort of 94 participants with diabetes mellitus undergoing surgery of ≥3 h duration. CGMs were placed preoperatively and compared to point of care (POC) BG checks obtained by capillary samples analyzed with a NOVA glucometer. Frequency of intraoperative blood glucose measurement was at the discretion of the anesthesia care team, with a recommendation of once per hour targeting BG of 140-180 mg/dL. Of those consented, 18 were excluded due to lost sensor data, surgery cancellation, or rescheduling to a satellite campus resulting in 76 enrolled subjects. There were zero occurrences of failure with sensor application. Paired POC BG and contemporaneous CGM readings were compared with Pearson product-moment correlation coefficients, and Bland-Altman plots.

RESULTS

Data for use of CGM in perioperative period was analyzed for 50 participants with Freestyle Libre 2.0, 20 participants with Dexcom G6, and 6 participants with both devices worn simultaneously. Lost sensor data occurred in 3 participants (15%) wearing Dexcom G6, 10 participants wearing Freestyle Libre 2.0 (20%) and 2 of the participants wearing both devices simultaneously. The overall agreement of the two CGM's utilized had a Pearson correlation coefficient of 0.731 in combined groups with 0.573 in Dexcom arm evaluating 84 matched pairs and 0.771 in Libre arm with 239 matched pairs. Modified Bland-Altman plot of the difference of CGM and POC BG indicated for the overall dataset a bias of -18.27 (SD 32.10).

CONCLUSIONS

Both Dexcom G6 and Freestyle Libre 2.0 CGMs were able to be utilized and functioned well if no sensor error occurred at time of initial warmup. CGM provided more glycemic data and further characterized glycemic trends more than individual BG readings. Required time of CGM warm up was a barrier for intraoperative use as well as unexplained sensor failure. CGMs had a fixed warm of time, 1 h for Libre 2.0 and 2 h for Dexcom G6 CGM, before glycemic data obtainable. Sensor application issues did not occur. It is anticipated that this technology could be used to improve glycemic control in the perioperative setting. Additional studies are needed to evaluate use intraoperatively and assess further if any interference from electrocautery or grounding devices may contribute to initial sensor failure. It may be beneficial in future studies to place CGM during preoperative clinic evaluation the week prior to surgery. Use of CGMs in these settings is feasible and warrants further evaluation of this technology on perioperative glycemic management.

The efficacy of intraoperatie continuous glucose monitoring in patients undergoing liver transplantation: a study protocol for a prospective randomized controlled superiority trial

BACKGROUND

The high incidence of intraoperative glucose dysregulations in liver transplantation (LT) is related to the lack of highly orchestrated control of intraoperative blood glucose. Glucose monitoring based on a single arterial blood gas test can only provide a simple glucose profile and is insufficient in monitoring intraoperative glycemic variability (GV), which is not conducive to controlling GV and may have a lag in the management of hyper/hypoglycemia. Continuous glucose monitor (CGM), which has been successfully applied in the management of chronic disease in diabetes, provides more detailed blood glucose records and reflect GV parameters such as coefficient of variation (CV%). However, its effectiveness and accuracy for guiding blood glucose management in major surgeries remains unclear.

METHODS

This is a single-center, randomized, controlled, superiority trial. One hundred and eighty patients scheduled for orthotopic LT will be recruited and randomized into two groups. All patients are monitored for intraoperative glucose using CGM combined with arterial blood gas (ABG). In the intervention group (group CG), ABG will be performed when CGM value is < 6.1 mmol/L or > 10.0 mmol/L, or the rate of change of CGM value > 1.67 mmol/(L·min). In the control group (group G), intraoperative ABG tests will be performed every 2 h, and the frequency of ABG tests will be adjusted based on the previous arterial glucose result. Patients in both groups will have their blood glucose adjusted according to arterial glucose values and a uniform protocol. Surgical and other anesthetic management is completed according to standard LT practices.

DISCUSSION

This study intends to investigate the effectiveness of CGM-based intraoperative glucose management and its impact on the prognosis of LT patients by comparing the GV, mean glucose values, and the incidence of hypo/hypoglycemic events guided by the above two glucose monitoring methods.

TRIAL REGISTRATION

This study is registered at www.chictr.org.cn on January 4, 2022, under the registration number ChiCTR2200055236.

Hidden blood loss of minimally invasive hybrid lumbar interbody fusion: an analysis of influencing factors

BACKGROUND

Lumbar interbody fusion(LIF) is the leading way to treat Lumbar Degenerative Diseases(LDD). At present, there is a lack of research on the influencing factors of hidden blood loss in minimally invasive hybrid lumbar interbody fusion. This study comprehensively explores the definite factors affecting the hidden blood loss in minimally invasive hybrid lumbar interbody fusion.

MATERIALS AND METHODS

One hundred patients with Lumbar degenerative diseases who underwent minimally invasive hybrid lumbar interbody fusion in our center were included. Demographics, laboratory data, surgical data, and radiographic data were collected. The Gross equation and Sehat equation were used to calculate the estimated value of hidden blood loss. Multi-factor linear regression analysis was used to determine the influencing factors of hidden blood loss.

RESULT

We reviewed and collected 100 patients who underwent minimally invasive hybrid approach, mean age 65 ± 10 years, male: female 37:63; 17 patients of diabetes and 83 patients of non-diabetes; Total blood loss was 645.59 ± 376.37 ml, hidden blood loss was 421.39 ± 337.45 ml, the hidden blood loss percentage was 57 ± 26%. Results from the multi-factorial linear regression model: Diabetes (p < 0.05), hypertension (p < 0.05), psoas thickness (p < 0.05) and dorsal extensor group thickness (p < 0.05) were potential risk factors for postoperative hidden blood loss.

CONCLUSION

Although minimally invasive hybrid approach is minimally invasive surgery, there is still a significant amount of hidden blood loss. There is a greater risk of blood loss in diabetes, hypertension and preoperative MRI assessment of thickness of the psoas, thickness of the dorsal extensor group.

The effect of pre-operative carbohydrate loading in femur fracture: a randomized controlled trial

BACKGROUND

Femur fracture is a major burden among elderly people, leading patients to be bedridden for a long time in the hospital. The body is more likely to be in a catabolic state as a result of the prolonged fasting period required for surgery, leading to an increase in insulin resistance. Pre-operative carbohydrate loading has been shown to improve postoperative outcomes in several countries. The study aimed to evaluate the effect of pre-operative carbohydrate loading in femur fracture surgery.

METHODS

This study was single-center, hospital-based, open-label, parallel-group randomized controlled trial conducted between August 2020 and November 2021. A total of 66 participants, aged 50 years and above having femur fractures planned for surgery were included in this study and assigned to the control (n = 33) and study (n = 33) groups through computer-generated random numbers. The control group was kept fasting from midnight to the next morning as in existence while the study group was intervened with carbohydrate loading according to the Enhanced Recovery After Surgery (ERAS) protocol. The pre-operative nutritional status was identified and the postoperative outcomes were measured using the Visual Analogue Score (VAS), Cumulative Ambulatory Score (CAS), and Modified Barthel Index (MBI) scoring systems. Statistical analyses were performed using the Chi-square test and the Student's two-sample t-test to compare the outcomes between the two groups.

RESULTS

All the participants completed the study. There was a significant reduction in the average postoperative pain in the carbohydrate loading group (VAS: 4.8 (SD ± 1.8), 95% CI: 4.7-5.4) as compared to the control group (VAS: 6.1 (SD ± 2.1), 95% CI: 5.3-6.8). The average CAS showed a significant improvement in regaining the mobility function of participants in the study group (CAS: 8.1 (SD ± 2.8), 95% CI: 7.1-9.1) than that of the control group (CAS: 6.8 (SD ± 2.8), 95% CI: 5.8-7.8). The mean MBI score of the participants at the time of discharge from the hospital was higher in the study group (MBI:13.1 (SD ± 2.3), 95% CI: 12.2-13.9) compared to the control group (MBI: 11.8 (SD ± 3.1), 95% CI:10.6-12.9). Similarly, the length of hospital stay after surgery had decreased in the study group than in the control group.

CONCLUSIONS

The uptake of carbohydrate loading showed reduced post-operative pain, enhanced functional mobility, and decreased length of hospital stay. This study warrants larger trials to show the effect of pre-operative carbohydrate loading in a clinical setting.

TRIAL REGISTRATION

NCT04838366, first registered on 09/042021 ( https://clinicaltrials.gov/ct2/show/NCT04838366 ).

Establishing a recommended duration of blood glucose monitoring in nondiabetic patients following orthopaedic surgery

Previous studies have demonstrated that blood glucose (BG) levels should be monitored for at least 1 week after orthopaedic surgery in diabetic patients, but no study has determined how long nondiabetic patients should be monitored. As postoperative elevations in BG have deleterious effects, determining a duration for monitoring the BG of nondiabetic patients after major orthopaedic surgery is needed to detect hyperglycemic events, create comprehensive protocols for nondiabetic orthopaedic patients, and reduce adverse outcomes. A retrospective study was conducted including consecutive patients who underwent a major orthopaedic surgery at a community hospital. A BG level of 150 mg/dl was the cutoff used to define hyperglycemia according to our institutional guidelines. A χ² , analysis of variance, and subgroup analysis were performed separately. Greater than 67% of nondiabetic patients experienced a high BG level (>150 mg/dl) after surgery. We found that nondiabetic patients reached their postoperative maximum BG level at 20 h, which was sooner compared to diabetic patients. We discovered more than 92% of nondiabetic patients reached a maximum BG levels within the first 72 h of hospitalization, while the BG levels after this period were found to be within normal limits in greater than 87% of cases. We propose that BG management be instituted in nondiabetics from the preoperative period to 72 h after surgery, including patients who are same-day discharges. There may not be a need to continue inpatient BG monitoring beyond the first 72 h for nondiabetic hospitalized patients with extended hospitalizations.

Guidelines on enhanced recovery after cardiac surgery under cardiopulmonary bypass or off-pump

OBJECTIVE

To provide recommendations for enhanced recovery after cardiac surgery (ERACS) based on a multimodal perioperative medicine approach in adult cardiac surgery patients with the aim of improving patient satisfaction, reducing postoperative mortality and morbidity, and reducing the length of hospital stay.

DESIGN

A consensus committee of 20 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société française d'anesthésie et de réanimation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Société française de chirurgie thoracique et cardio-vasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide the assessment of the quality of evidence.

METHODS

Six fields were defined: (1) selection of the patient pathway and its information; (2) preoperative management and rehabilitation; (3) anaesthesia and analgesia for cardiac surgery; (4) surgical strategy for cardiac surgery and bypass management; (5) patient blood management; and (6) postoperative enhanced recovery. For each field, the objective of the recommendations was to answer questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). Based on these questions, an extensive bibliographic search was carried out and analyses were performed using the GRADE approach. The recommendations were formulated according to the GRADE methodology and then voted on by all the experts according to the GRADE grid method.

RESULTS

The SFAR/SFCTCV guideline panel provided 33 recommendations on the management of patients undergoing cardiac surgery under cardiopulmonary bypass or off-pump. After three rounds of voting and several amendments, a strong agreement was reached for the 33 recommendations. Of these recommendations, 10 have a high level of evidence (7 GRADE 1+ and 3 GRADE 1-); 19 have a moderate level of evidence (15 GRADE 2+ and 4 GRADE 2-); and 4 are expert opinions. Finally, no recommendations were provided for 3 questions.

CONCLUSIONS

Strong agreement existed among the experts to provide recommendations to optimise the complete perioperative management of patients undergoing cardiac surgery.

Development and validation of a prediction model of perioperative hypoglycemia risk in patients with type 2 diabetes undergoing elective surgery

AIM

To develop and validate a prediction model to evaluate the perioperative hypoglycemia risk in hospitalized type 2 diabetes mellitus (T2DM) patients undergoing elective surgery.

METHODS

We retrospectively analyzed the electronic medical records of 1410 T2DM patients who had been hospitalized and undergone elective surgery. Regression analysis was used to develop a predictive model for perioperative hypoglycemia risk. The receiver operating characteristic (ROC) curve and the Hosmer-Lemeshow test were used to verify the model.

RESULTS

Our study showed an incidence of 10.7% for level 1 hypoglycemia and 1.8% for level 2 severe hypoglycemia during the perioperative period. A perioperative hypoglycemic risk prediction model was developed that was mainly composed of four predictors: duration of diabetes ≥ 10 year, body mass index (BMI) < 18.5 kg/m², standard deviation of blood glucose (SDBG) ≥ 3.0 mmol/L, and preoperative hypoglycemic regimen of insulin subcutaneous. Based on this model, patients were categorized into three groups: low, medium, and high risk. Internal validation of the prediction model showed high discrimination (ROC statistic = 0.715) and good calibration (no significant differences between predicted and observed risk: Pearson χ² goodness-of-fit P = 0.765).

CONCLUSIONS

The perioperative hypoglycemic risk prediction model categorizes the risk of hypoglycemia using only four predictors and shows good reliability and validity. The model serves as a favorable tool for clinicians to predict hypoglycemic risk and guide future interventions to reduce hypoglycemia risk.

Chinese clinical practice guidelines for perioperative blood glucose management

With the increased incidence of diabetes, the number of diabetic patients who require surgical treatment is also increasing. Unfortunately, practices in this area lack standardisation. The purpose of this multidisciplinary, evidence-based guidelines for perioperative blood glucose management is to provide a comprehensive set of recommendations for clinicians treating diabetes with different types of surgery. The intended audience comprises Chinese endocrinologists, surgeons, anaesthetists, clinical pharmacists, nurses and professionals involved in perioperative blood glucose management. The guidelines were formulated as follows. First, a multidisciplinary expert group was established to identify and formulate key research questions on topics of priority according to the Population, Intervention, Comparator and Outcomes (PICO) process. We conducted a meta-analysis of available studies using Review Manager version 5.3, as appropriate. We pooled crude estimates as odds ratios with 95% confidence intervals using a random-effects model, and used the Grading of Recommendations Assessment, Development, and Evaluation methods to assess the quality of the retrieved evidence. Finally, 32 recommendations were gathered that covered 11 fields-management and coordination, endocrinologists' consultation, diabetes diagnosis, surgery timing and anaesthesia method, blood glucose target values and monitoring frequency, hypoglycaemia treatment, oral administration of blood glucose lowering drugs, use of insulin, enteral and parenteral nutritional, postoperative treatment and medication and education and training. Twenty-five systematic reviews and meta-analyses were conducted for these guidelines to address the PICO questions. These guidelines are intended to improve perioperative blood glucose management and help doctors in specifying medical diagnosis and treatment, and will be implemented / disseminated extensively in China.

Evaluating perioperative glycemic status after different types of pancreatic surgeries via continuous glucose monitoring system: a pilot study

BACKGROUND

Perioperative glycemic status after pancreatic surgery has never been described. However, it's essential for optimal perioperative glucose management and understanding the pathogenesis of new-onset diabetes mellitus (NODM) after pancreatectomy. Continuous glucose monitoring (CGM) system provides us a helpful tool for closely monitoring and studying perioperative glucose change. This study tried to describe and compare perioperative glucose level and glycemic variability between different types of pancreatic surgeries via CGM device.

METHODS

This study was designed as a prospective observational study. Eighteen patients were enrolled and were grouped by different types of surgery received: control group (CTRL), pancreaticoduodenectomy (PD), distal pancreatectomy (DP), and total pancreatectomy (TP). CGM devices were implanted and initiated right after the surgery. Mean glucose value (MGV), coefficient of variation (CV), mean of daily difference (MODD), continuous overall net glycemic action (CONGA), and time above range (TAR)/time below range (TBR) was compared between groups to assess glucose level and glycemic variability.

RESULTS

TP showed the highest MGV and CV among all groups (P<0.001), while CTRL showed the lowest (P<0.001). PD and DP had similar MGV and CV lower than TP but higher than CTRL (P<0.001). TP had the highest MODD and CONGA, CTRL had the lowest, but no significant differences were found between groups. TP had the highest TAR (24.29%) and the lowest TBR (1.28%), while the control group showed the opposite. The differences in TAR/TBR between groups were all significant (P<0.05).

CONCLUSIONS

TP had the highest mean glucose level and the greatest glycemic variability. PD and DP had similar results: a higher mean glucose level than control but lower than TP. For glycemic variability, PD and DP seemed to have a near-normal result resembling the control group. CGM is useful for glucose monitoring in the perioperative management of pancreatic surgery.

Perioperative Glycemia Management in Patients Undergoing Craniotomy for Brain Tumor Resection: A Global Survey of Neuroanesthesiologists' Perceptions and Practices

OBJECTIVE

There is a paucity of clinical evidence that guides perioperative glycemia management in patients undergoing craniotomy for brain tumor resection. The purpose of this study was to better understand global perceptions and practices related to glycemia management in these patients.

METHODS

Neuroanesthesiologists throughout North America, South America, Europe, and Asia filled out a brief online questionnaire related to their perceptions and practices regarding glycemia management in patients undergoing craniotomy for brain tumor resection.

RESULTS

Over 4 weeks, 435 participants practicing in 34 countries across 6 continents participated in this survey. Although responders in North America were found to perceive a higher risk hyperglycemia compared with those practicing in European (P = 0.024) and South Asian (P = 0.007) countries, responders practicing in South Asian countries (P = 0.030), Middle Eastern countries (P = 0.029), and South American (P = 0.005) countries were more likely than those from North America to remeasure glucose after an initial normal glucose measurement at incision. Responders from North America reported that a higher blood glucose threshold was necessary for them to delay or cancel the surgery compared with responders in Slavic (P < 0.001), European (P = 0.002), South American (P = 0.002), and Asian and Pacific (P < 0.001) countries. Responders from North America were more likely to report that they would delay or cancel the surgery because of a higher blood glucose threshold.

CONCLUSIONS

Our survey results suggest that perceptions and practices related to blood glucose management in patients undergoing brain tumor resection are variable. This study highlights the need for stronger clinical evidence and guidelines to help guide decisions for when and how to manage blood glucose derangements in these patients.

Postoperative extremity gangrene in a patient with type 2 diabetes taking SGLT2 inhibitors: A case report

RATIONALE

Sodium-glucose cotransporter 2 (SGLT2) inhibitors have been approved and marketed since March 2013. The proportion of patients with type 2 diabetes (T2D) taking SGLT2 inhibitors is increasing. The perioperative adverse effects of SGLT2 inhibitors, especially euglycemic diabetic ketoacidosis (euDKA), should be taken into consideration in perioperative patient evaluation in both elective and emergency surgeries.

PATIENT CONCERNS

A 57-year-old woman taking SGLT2 inhibitors for T2D developed euDKA after undergoing an emergency orthopedic surgery; the euDKA diagnosis was delayed, thereby causing extremity gangrene.

DIAGNOSES

EuDKA was diagnosed based on the presence of strongly positive ketonuria, elevated blood beta-hydroxybutyrate level, and severe metabolic acidosis.

INTERVENTION

EuDKA was treated with insulin infusion with dextrose solution and intravenous fluid resuscitation.

OUTCOME

Due to a delayed diagnosis of euDKA, the patient received a high-dose vasopressor, which led to limb gangrene and amputation 6 months later.

LESSONS

EuDKA is often misdiagnosed due to the absence of hyperglycemia. Serum beta-hydroxybutyrate levels or urinalysis could be used as screening tools for euDKA in patients scheduled for emergency surgery, in order to preoperatively administer rapid fluid resuscitation and insulin infusion with dextrose solution, which should continue postoperatively along with serum beta-hydroxybutyrate monitoring.

Hysterectomy Complications Relative to HbA1c Levels: Identifying a Threshold for Surgical Planning

STUDY OBJECTIVE

To evaluate whether diabetes diagnosis and level of diabetes control as reflected by higher preoperative glycosylated hemoglobin (HbA_1c) levels are associated with increased complication rates after hysterectomy and to identify a threshold of preoperative HbA_1c level past which we should consider delaying surgery owing to increased risk of complications.

DESIGN

Retrospective cohort study.

SETTING

Hospitals in the Michigan Surgical Quality Collaborative between June 4, 2012, and October 17, 2017.

PATIENTS

Women with and without a diabetes diagnosis.

INTERVENTIONS

Hysterectomy.

MEASUREMENTS AND MAIN RESULTS

Data on demographics, preoperative HbA_1c values, surgical approach, composite postoperative complications, readmissions, emergency department visits, and reoperations were abstracted. The risk of a postoperative complication when diabetes was stratified by preoperative HbA_1c level was evaluated in a sensitivity analysis, and independent associations were identified in a mixed, multivariate logistic regression model. We identified 41 286 hysterectomies performed at 70 hospitals to be included for analysis. The sensitivity analysis identified 4 groups of risk for postoperative complications: group 1: no diabetes diagnosis and no HbA_1c value; group 2: no diabetes diagnosis, with HbA_1c levels between 4% and 6.5%; group 3: diabetes diagnosis and no HbA_1c value or HbA_1c levels <9%; and group 4: diabetes diagnosis with HbA_1c levels ≥9%. In the adjusted model, there were significant 32% and 34% increased odds of postoperative complications for groups 2 and 3, respectively, compared with group 1. There were more than 2-fold increased odds of complications for women with diabetes and a preoperative HbA_1c level ≥9% (group 4) compared with the women in group 1. Diabetes diagnosis with preoperative HbA_1c levels ≥9% had increased odds of complications compared with diabetes diagnosis with preoperative HbA_1c levels <9%. Patients with well-controlled diabetes seemed to have increased odds of complications with laparoscopic surgery.

CONCLUSION

Diabetes diagnosis and measurement of preoperative HbA_1c levels provide risk stratification for postoperative complications after hysterectomy, with the highest observed effect among patients with diabetes with a preoperative HbA_1c level ≥9%.

Preoperative Carbohydrate Drinks Do Not Decrease Postoperative Nausea and Vomiting in Type 2 Diabetic Patients Undergoing Total Knee Arthroplasty-A Randomized Controlled Trial

INTRODUCTION

We evaluated whether preoperative carbohydrate drink would be able to decrease postoperative nausea and vomiting (PONV) and improve the quality of recovery (QoR) in diabetic patients undergoing total knee arthroplasty (TKA).

METHODS

Eighty-two patients were randomized to either the intravenous (IV) Dextrose group (n = 41) or Oral carbohydrate (CHO) group (n = 41). The IV Dextrose group received dextrose solution mixed with insulin while fasting, and the Oral CHO group received carbohydrate drinks preoperatively. PONV was assessed up to postoperative 36 hours, and QoR was assessed before surgery and on postoperative day (POD) 1. Blood glucose was measured from the morning of surgery until POD 1.

RESULTS

PONV scores were not different between the groups. Postoperative QoR scores were significantly higher in the Oral CHO group (median [interquartile range]; 160 [153 to 167]) than the IV Dextrose group (155 [147 to 159]) (P = 0.009), but the difference did not meet the minimal clinically important difference. Blood glucose was comparable between the groups.

DISCUSSION

Preoperative CHO drink did not reduce PONV in diabetic patients after total knee arthroplasty. A statistically significant but clinically questionable improvement in the QoR was seen in the Oral CHO group. However, preoperative CHO drink did not increase hyperglycemia, which suggests that it may be a safe component of perioperative care in diabetic patients.

Perioperative care of the adult diabetic patient

The prevalence of diabetes mellitus is rapidly increasing in the UK, presenting greater complexity in its management when in the presence of other comorbidities. In the care of the adult perioperative patient with diabetes mellitus not only can symptoms can be difficult to attribute to one specific cause but also the onset of complications can be rapid. This article discusses the aetiology and key concerns during the perioperative pathway of care for successful management of the adult diabetic patient.

Association Between Preoperative Benzodiazepine Use and Postoperative Opioid Use and Health Care Costs

Importance

The association between preoperative benzodiazepine use and long-term postoperative outcomes is not well understood.

Objective

To characterize the association between preoperative benzodiazepine use and postoperative opioid use and health care costs.

Design, Setting, and Participants

In this cohort study, retrospective analysis of private health insurance claims data on 946 561 opioid-naive patients (no opioid prescriptions filled in the year before surgery) throughout the US was conducted. Patients underwent 1 of 11 common surgical procedures between January 1, 2004, and December 31, 2016; data analysis was performed January 9, 2020.

Exposures

Benzodiazepine use, defined as long term (≥10 prescriptions filled or ≥120 days supplied in the year before surgery) or intermittent (any use not meeting the criteria for long term).

Main Outcomes and Measures

The primary outcome was opioid use 91 to 365 days after surgery. Secondary outcomes included opioid use 0 to 90 days after surgery and health care costs 0 to 30 days after surgery.

Results

In this sample of 946 561 patients, the mean age was 59.8 years (range, 18-89 years); 615 065 were women (65.0%). Of these, 23 484 patients (2.5%) met the criteria for long-term preoperative benzodiazepine use and 47 669 patients (5.0%) met the criteria for intermittent use. After adjusting for confounders, long-term (odds ratio [OR], 1.59; 95% CI, 1.54-1.65; P < .001) and intermittent (OR, 1.47; 95% CI, 1.44-1.51; P < .001) benzodiazepine use were associated with an increased probability of any opioid use during postoperative days 91 to 365. For patients who used opioids in postoperative days 91 to 365, long-term benzodiazepine use was associated with a 44% increase in opioid dose (additional 0.6 mean daily morphine milligram equivalents [MMEs]; 95% CI, 0.3-0.8 MMEs; P < .001), although intermittent benzodiazepine use was not significantly different (0.0 average daily MMEs; 95% CI, -0.2 to 0.2 MMEs; P = .65). Preoperative benzodiazepine use was also associated with increased opioid use in postoperative days 0 to 90 for both long-term (32% increase, additional 1.9 average daily MMEs; 95% CI, 1.6-2.1 MMEs; P < .001) and intermittent (9% increase, additional 0.5 average daily MMEs; 95% CI, 0.4-0.6 MMEs; P < .001) users. Intermittent benzodiazepine use was associated with an increase in 30-day health care costs ($1155; 95% CI, $938-$1372; P < .001), while no significant difference was observed for long-term benzodiazepine use.

Conclusions and Relevance

The findings of this study suggest that, among opioid-naive patients, preoperative benzodiazepine use may be associated with an increased risk of developing long-term opioid use and increased opioid dosages postoperatively, and also may be associated with increased health care costs.

General treatment principles for fracture-related infection: recommendations from an international expert group

Fracture-related infection (FRI) remains a challenging complication that creates a heavy burden for orthopaedic trauma patients, their families and treating physicians, as well as for healthcare systems. Standardization of the diagnosis of FRI has been poor, which made the undertaking and comparison of studies difficult. Recently, a consensus definition based on diagnostic criteria for FRI was published. As a well-established diagnosis is the first step in the treatment process of FRI, such a definition should not only improve the quality of published reports but also daily clinical practice. The FRI consensus group recently developed guidelines to standardize treatment pathways and outcome measures. At the center of these recommendations was the implementation of a multidisciplinary team (MDT) approach. If such a team is not available, it is recommended to refer complex cases to specialized centers where a MDT is available and physicians are experienced with the treatment of FRI. This should lead to appropriate use of antimicrobials and standardization of surgical strategies. Furthermore, an MDT could play an important role in host optimization. Overall two main surgical concepts are considered, based on the fact that fracture fixation devices primarily target fracture consolidation and can be removed after healing, in contrast to periprosthetic joint infection were the implant is permanent. The first concept consists of implant retention and the second consists of implant removal (healed fracture) or implant exchange (unhealed fracture). In both cases, deep tissue sampling for microbiological examination is mandatory. Key aspects of the surgical management of FRI are a thorough debridement, irrigation with normal saline, fracture stability, dead space management and adequate soft tissue coverage. The use of local antimicrobials needs to be strongly considered. In case of FRI, empiric broad-spectrum antibiotic therapy should be started after tissue sampling. Thereafter, this needs to be adapted according to culture results as soon as possible. Finally, a minimum follow-up of 12 months after cessation of therapy is recommended. Standardized patient outcome measures purely focusing on FRI are currently not available but the patient-reported outcomes measurement information system (PROMIS) seems to be the preferred tool to assess the patients' short and long-term outcome. This review summarizes the current general principles which should be considered during the whole treatment process of patients with FRI based on recommendations from the FRI Consensus Group.Level of evidence: Level V.

Does Perioperative Hemoglobin A1c Level Affect the Incidence, Pattern and Mortality of Lower Extremity Amputation?

BACKGROUND

We hypothesized that perioperative HbA1c influenced the pattern and outcomes of Lower Extremity Amputation (LEA).

METHODS

A retrospective analysis was conducted for all patients who underwent LEA between 2000 and 2013. Patients were categorized into 5 groups according to their perioperative HbA1c values [Group 1 (<6.5%), Group 2 (6.5-7.4%), Group 3 (7.5-8.4%), Group 4 (8.5-9.4%) and Group 5 (≥9.5%)]. We identified 848 patients with LEA; perioperative HbA1c levels were available in 547 cases (Group 1: 18.8%, Group 2: 17.7%, Group 3: 15.0%, Group 4: 13.5% and Group 5: 34.9%). Major amputation was performed in 35%, 32%, 22%, 10.8% and 13.6%, respectively.

RESULTS

The overall mortality was 36.5%; of that one quarter occurred during the index hospitalization. Mortality was higher in Group 1 (57.4%) compared with Groups 2-5 (46.9%, 38.3%, 36.1% and 31.2%, respectively, p=0.001). Cox regression analysis showed that poor glycemic control (Group 4 and 5) had lower risk of mortality post-LEA [hazard ratio 0.57 (95% CI 0.35-0.93) and hazard ratio 0.46 (95% CI 0.31-0.69)]; this mortality risk persisted even after adjustment for age and sex but was statistically insignificant. The rate of LEA was greater among poor glycemic control patients; however, the mortality was higher among patients with tight control.

CONCLUSION

The effects of HbA1c on the immediate and long-term LEA outcomes and its therapeutic implications need further investigation.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Optimal Dose of Dexmedetomidine for Perioperative Blood Glucose Regulation in Non-Diabetic Patients Undergoing Gastrointestinal Malignant Tumor Resection: A Randomized Double-Blinded Controlled Trial

PURPOSE

To evaluate the optimal dose of dexmedetomidine for perioperative blood glucose regulation in non-diabetic patients with gastrointestinal malignant tumor.

METHODS

One hundred patients were randomly divided into four groups: control group (group C), dexmedetomidine 1 μg/kg + 0.25 mcg/kg/h (group D₁); + 0.5 mcg/kg/h (group D₂); and + 1 mcg/kg/h (group D₃). Blood glucose concentrations were measured before dexmedetomidine infusion (T₁), 1 h after surgery beginning (T₂), at the end of surgery (T₃), and 1 h in PACU (T₄). Duration of surgery, extubation time, anesthetics doses, adverse reactions, postoperative pulmonary infection, total peritoneal drainage 2 days after surgery and hospital stay were recorded.

RESULTS

Compared with T₁, blood glucose concentrations were higher at T₄ in group C and at T_2-4 in groups D₁, D₂, and D₃ (p < 0.01). Compared with group C, blood glucose concentrations were higher at T₂ and T₃ in groups D₂ and D₃ (p < 0.05), but significantly lower at T₄ in groups D₁, D₂, and D₃ (p < 0.01). Propofol and remifentanil consumption in groups D₁, D₂, and D₃ decreased significantly compared with group C (p < 0.01). In group D₃, doses of ephedrine (p < 0.05) and atropine (p < 0.01) were higher, and extubation time was prolonged (p < 0.01) compared with the other groups. The incidence of bradycardia was higher in group D₃ than that in group C (p < 0.05).

CONCLUSIONS

Dexmedetomidine loading dose of 1 mcg/kg followed by maintenance with 0.25 mcg/kg/h can regulate perioperative blood glucose well in non-diabetic patients undergoing gastrointestinal malignant tumor resection and reduce doses of anesthetics without extending extubation time.

Association Between Perioperative Glycemic Control Strategy and Mortality in Patients With Diabetes Undergoing Cardiac Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

To analyze association between different perioperative glycemic control strategies and postoperative outcomes in patients with diabetes undergoing cardiac surgery.

METHODS

MEDLINE, Cochrane Library, Web of Science, EMBASE, Wanfang Data, China National Knowledge Infrastructure (CNKI) and China Biology Medicine (CBM) databases were searched from inception to January 31, 2019. Two researchers independently screened the literature, extracted data, and evaluated the risk of bias of included studies, and consensus was reached by discussion with a third researcher.

RESULTS

Six RCTs were included in the meta-analysis. We analyzed the effect of liberal (>180 mg/dl or 10.0 mmol/L), moderate (140-180 mg/dl or 7.8-10.0 mmol/L) and strict (<140 mg/dl or 7.8 mmol/L) glycemic control strategies in patients with diabetes undergoing cardiac surgery. The pooled results showed that strict glycemic control strategy was associated with a significant reduction in the risk of atrial fibrillation [OR = 0.48, 95%CI (0.32, 0.72), P < 0.001] and sternal wound infection [OR = 0.28, 95%CI (0.14, 0.54), P < 0.001], while there was no significant differences in postoperative mortality, stroke, and hypoglycemic episodes when compared with moderate control. In addition, there is no significant difference between moderate and liberal glycemic control strategies in postoperative mortality. However, moderate control was beneficial in reducing atrial fibrillation [OR = 0.28, 95%CI (0.13, 0.60), P = 0.001] compared with the liberal glycemic control strategy.

CONCLUSIONS

This meta-analysis showed when compared with moderate glycemic control strategy in patients with diabetes undergoing cardiac surgery, maintained strict glycemic control was associated with lower risk of atrial fibrillation and sternal wound infection. No benefit was found with liberal glycemic control strategy, so it could be a poor glycemic control strategy.

Effects of Preoperative HbA1c Levels on the Postoperative Outcomes of Coronary Artery Disease Surgical Treatment in Patients with Diabetes Mellitus and Nondiabetic Patients: A Systematic Review and Meta-Analysis

AIMS

To investigate the effect of preoperative HbA1c levels on the postoperative outcomes of coronary artery disease surgery in diabetic and nondiabetic patients.

METHODS AND RESULTS

The MEDLINE (via PubMed), Cochrane Library, Web of Science, Embase, Wanfang Data, China National Knowledge Infrastructure (CNKI), and Chinese Biology Medicine (CBM) databases were used to search the effects of different preoperative HbA1c levels on the postoperative outcomes of coronary artery disease surgical treatment in diabetic and nondiabetic patients from inception to December 2018. Two review authors worked in an independent and duplicate manner to select eligible studies, extract data, and assess the risk of bias of the included studies. We used a meta-analysis to synthesize data and analyze subgroups, sensitivity, and publication bias as well as the GRADE methodology if appropriate. The literature search retrieved 886 records initially, and 23 cohort studies were included in the meta-analysis. In this meta-analysis, we found that there was a reduced incidence of surgical site infections (OR = 2.94, 95% CI 2.18-3.98), renal failure events (OR = 1.63, 95% CI 1.13-2.33), and myocardial infarction events (OR = 1.69, 95% CI 1.16-2.47), as well as a shortened hospital stay (MD = 1.08, 95% CI 0.46-1.71), in diabetic patients after coronary artery disease surgical treatment with lower preoperative HbA1c levels. For nondiabetic patients, a higher preoperative HbA1c level resulted in an increase in the incidence of mortality (OR = 2.23, 95% CI 1.01-4.90) and renal failure (OR = 2.33, 95% CI 1.32-4.12). No significant difference was found between higher and lower preoperative HbA1c levels in the incidence of mortality (OR = 1.06, 95% CI 0.88-1.26), stroke (OR = 1.49, 95% CI 0.94-2.37), or atrial fibrillation (OR = 0.94, 95% CI 0.67-1.33); the length of ICU stay (MD = 0.20, 95% CI -0.14-0.55); or sepsis incidence (OR = 2.49, 95% CI 0.99-6.25) for diabetic patients or for myocardial infarction events (OR = 1.32, 95% CI 0.27-6.31) or atrial fibrillation events (OR = 0.99, 95% CI 0.74-1.33) for nondiabetic patients. The certainty of evidence was judged to be moderate or low.

CONCLUSION

This meta-analysis showed that higher preoperative HbA1c levels may potentially increase the risk of surgical site infections, renal failure, and myocardial infarction and reduce the length of hospital stay in diabetic subjects after coronary artery disease surgical treatment and increase the risk of mortality and renal failure in nondiabetic patients. However, there was great inconsistency in defining higher preoperative HbA1c levels in the studies included; we still need high-quality RCTs with a sufficiently large sample size to further investigate this issue in the future. This trial is registered with CRD42019121531.

Perioperative tight glycemic control using artificial pancreas decreases infectious complications via suppression of inflammatory cytokines in patients who underwent pancreaticoduodenectomy: A prospective, non-randomized clinical trial

BACKGROUND

We sought to investigate the efficacy of perioperative tight glycemic control (TGC) in reducing of postoperative infectious complications (POICs) and study its impact on early inflammatory mediators in patients who underwent pancreaticoduodenectomy.

METHODS

In this non-randomized trial, the artificial pancreas (AP) group received TGC (target glucose range of 80-110 mg/dL; n = 14), while the control group received conventional glycemic control (range of 80-180 mg/dL; n = 15). The primary endpoint was POICs.

RESULTS

The AP group had a markedly decreased POIC rate (28.6% vs. 73.3%; P = 0.027), mean glycemic variability (13.5 ± 3.5% vs. 16.4 ± 5.9%; P = 0.038), and plasma interleukin-6 level (26.3 ± 33.8 vs 98.3 ± 89.1 pg/ml; P = 0.036) compared to the control group, but insulin dosage (27.0 ± 13.4 vs. 10.2 ± 16.2 U; P = 0.002) and the adiponectin ratio (i.e., postoperative/preoperative adiponectin; 0.8 ± 0.2 vs. 0.6 ± 0.3; P = 0.021) were markedly higher in the AP group.

CONCLUSIONS

Among patients undergoing PD with impaired glucose tolerance, AP facilitated strict glycemic control and resulted in a reduction of anti-inflammatory mediators and POICs.

SUMMARY

Perioperative hyperglycemia increases postoperative infectious complications; however, tight glycemic control using artificial pancreas can reduce them via a dual effect. Artificial pancreas facilitates strict and safe glycemic control while reducing anti-inflammatory mediators, including adiponectin, following pancreaticoduodenectomy.

Level of agreement of point-of-care and laboratory HbA1c measurements in the preoperative outpatient clinic in non-diabetic patients who are overweight or obese

Implementation of point-of-care HbA1c devices in the preoperative outpatient clinic might facilitate the early diagnosis of glycemic disturbances in overweight or obese patients undergoing surgery, but validation studies in this setting do not exist. We determined the level of agreement between a point-of-care and laboratory HbA1c test in non-diabetic patients visiting the outpatient clinic for preoperative risk profiling. Point-of-care HbA1c levels were measured in whole blood obtained by a finger prick (Siemens DCA Vantage HbA1c analyzer) and in hemolysed EDTA blood in the central laboratory (LAB). Bland Altman and Clarke's error grid analysis were used to analyze the agreement between the point-of-care and laboratory measurements. Patients (n = 49) were 55 ± 11 years old, 47% were male with a body mass index (BMI) of 30.6 ± 3.4 kg/m2. The mean HbA1c was 38.1 ± 3.7 mmol/mol or 5.6 ± 0.3%. One patient was diagnosed with a HbA1c indicative for diabetes mellitus (6.7%). Bland Altman analysis revealed a bias of - 0.53 ± 1.81 mmol/mol with limits of agreement of - 4.09 to 3.03 mmol/mol and a bias of - 0.05 ± 0.17% with limits of agreement - 0.39 to 0.28%. The percentage error was 9.2% and 5.9% for HbA1c expressed in mmol/mol and %, respectively. Clarke's error grid analysis showed that 48 out of 49 measurements were located in area A (98%). Point-of-care HbA1c measurements showed a high level of agreement with the laboratory test in the outpatient setting, and may be used for preoperative risk profiling in patients prone to cardiometabolic complications.Trial registration: Netherlands Trial Register NTR3057.

Insulin therapy in organ donation and transplantation

Hyperglycaemia is common in hospitalized individuals, and is often caused by physiological stress associated with critical illness or major surgery. Insulin therapy is an established treatment for hyperglycaemia and acute hyperkalaemia, and has also been used for myocardial dysfunction resistant to inotropic support. Insulin is commonly used in both organ donors and transplant recipients for hyperglycaemia, but the underlying knowledge base supporting its use remains limited. Insulin therapy plays an important yet poorly understood role in both organ donation and transplantation. Tight glycaemic control has been extensively studied in critical care over the past 15 years; however, this has not yet translated into the field of transplantation, where patients are more unwell and where improved outcomes remain an ongoing challenge. Insulin therapy and optimization of glycaemic control represent important areas for future hypothesis-driven research into organ donation and transplantation, such as amelioration of ischaemia-reperfusion injury, rejection and infection.

Enhanced recovery after surgical repair of incisional hernias

AIM

Enhanced recovery programmes (ERPs) were developed to improve the patient's post-operative comfort and reduce post-operative morbidity after several types of major surgery including the incisional hernia repair. The aim of this review was to describe the features of ERPs in the setting for incisional hernia repair.

METHODS

The literature review was conducted until March 2019, but retrieved very few papers (n = 4) on this topic. All studies were retrospective.

RESULTS

Setting and comorbidities of incisional hernia patients are of such importance in many cases that prehabilitation (including tobacco use cessation, management of obesity, diabetes or malnutrition) should play a greater role compared with other specialties. The other peri-operative measures are similar to other specialties but their implementation was very heterogeneous in the published studies.

CONCLUSIONS

Like in other surgeries, ERPs were feasible and probably efficient to improve the post-operative course of incisional hernia patients. But the level of evidence remains low.

[Perioperative handling of antidiabetic drugs]

Diabetes mellitus is the most frequent metabolic disorder in the western world with a prevalence of 3% in adults under 65 years of age and 14.3% in adults over 65 years of age. Due to the increasing age of our population, the number of patients taking oral antidiabetic drugs has increased. Thus, operating physicians must make a risk-adapted decision whether the medication can be continued perioperatively or if certain drugs must be paused, and if so, with what risks. Operative interventions can lead to a number of metabolic shifts, which change the normal glucose metabolism. Hyperglycemia in the perioperative period is a risk factor for postoperative sepsis, dysfunction of the endothelium, cerebral ischemia and poor wound healing. Due to perioperative fasting oral antidiabetic medication can lead to severe hypoglycemia if taken during this period. This leads to an increased morbidity and mortality in the perioperative period and extends the duration of stay in the intensive care unit (ICU) as well as the overall hospital stay. Oral antidiabetic medication should be paused on the day of the operation and restarted in line with the gradual postoperative return to solid food. Especially metformin, the most commonly used medication in the treatment of type 2 diabetes, should be paused perioperatively due to the severe side effect of lactate acidosis.

Postoperative adverse events in patients with diabetes undergoing orthopedic and general surgery

Factors that may result in the occurrence of adverse clinical events in diabetic patients during the postoperative period are not entirely clear. This study evaluated factors that may cause adverse events following elective orthopedic or general surgery.Patients with diabetes who underwent orthopedic or general surgery between January 2010 and October 2015 were retrospectively selected from the General Hospital of People's Liberation Army database. Factors associated with postoperative adverse events were analyzed using multivariable logistic regression.Among 1525 patients included, mean age was 63.5 ± 10.8 years and mean duration of diabetes was 8.8 ± 6.6 years. Among them, 49.9% underwent orthopedic surgery and 50.1% underwent general surgery. Postoperatively, 118 (7.7%) patients had adverse events, including delayed extubation (n = 43, 36.4%), circulatory disorder (n = 15, 12.7%), respiratory and circulatory abnormalities (n = 23, 19.5%), nonhealing of the incision (n = 11, 9.3%), infections at other sites (n = 15, 12.7%), other complications (n = 8, 6.8%), and death (n = 3, 2.5%). Multivariable regression analysis showed that age >65 years old [odds ratio (OR) = 2.23, 95% confidence interval (CI): 1.25-3.98], male sex (OR = 2.14, 95% CI: 1.24-3.38), postoperative peripheral blood glucose (OR = 1.13, 95% CI: 1.13-1.82), diabetic complications (OR = 2.41, 95% CI: 1.36-4.28), abnormal kidney function (OR = 2.73, 95% CI: 1.13-6.58) and general surgery (OR = 1.48, 95% CI: 1.11-5.26) were associated with the occurrence of postoperative adverse events.In patients with diabetes undergoing intermediate or major elective surgery, older age, male sex, high postoperative peripheral blood glucose, diabetic complications, abnormal kidney function, and general surgery type were associated with the occurrence of postoperative adverse events.

Diabetes Mellitus: Preoperative Concerns and Evaluation

Diabetes is an important cause of morbidity in the adult population resulting in blindness, renal dysfunction, cardiovascular events, and amputation. Such morbidities may have an impact on perioperative anesthetic care and outcomes. In this review, the authors discuss the preoperative considerations in managing patients with diabetes as well as those without diabetes albeit hyperglycemic. They propose a plan for managing preoperative diabetes pharmacotherapy, including the use of a subcutaneous insulin pump to avoid both hypoglycemia and hyperglycemia. The authors also discuss the decision whether to proceed or cancel surgery for a given hemoglobin A1c percentage or blood glucose concentration.

Perioperative Characteristics of the Accuracy of Subcutaneous Continuous Glucose Monitoring: Pilot Study in Neurosurgery and Cardiac Surgery

BACKGROUND

The aim of this study was to elucidate the characteristics of accuracy of subcutaneous continuous glucose monitoring (SCGM) in the perioperative period for neurosurgical and cardiac surgery patients.

METHODS

Forty-five subjects, including healthy volunteers (n = 15), neurosurgical patients (n = 15), and cardiac surgery patients (n = 15), were enrolled. A subcutaneous sensor of the MiniMed™ 620G SCGM system was inserted into the upper arm. On the day after sensor insertion, SCGM data and blood glucose data were collected simultaneously and compared. In cardiac surgery patients, data were continuously collected on postoperative day (POD) 1 and POD 3. Clarke error grid analysis and Bland-Altman analysis were performed to assess the accuracy of SCGM.

RESULTS

Clarke error grid analysis showed clinical acceptance of the SCGM system with 82.7% and 86.8% of the data being within zone A for healthy volunteers and neurosurgical patients, respectively. Mean biases were -2.1 mg/dL in healthy volunteers and -8.3 mg/dL in neurosurgical patients. In cardiac surgery, although Clarke error grid analysis showed clinical acceptance, 65.3% of the data were within zone A and mean bias was -23.5 mg/dL. Changes in accuracy of SCGM in individuals occurred during cardiopulmonary bypass (CPB), and SCGM tended to show a lower glucose level. On POD 1 and POD 3, the accuracy improved, and 85.0% and 86.3% of the data were within zone A.

CONCLUSIONS

Although the accuracy of the SCGM system was clinically acceptable in the perioperative period, sensor accuracy was affected by CPB and showed lower glucose levels.

Association of Elevated Pre-operative Hemoglobin A1c and Post-operative Complications in Non-diabetic Patients: A Systematic Review

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.

[Evaluation and perioperative management of patients with diabetes mellitus. A challenge for the anesthesiologist]

Diabetes mellitus (DM) is characterized by alteration in carbohydrate metabolism, leading to hyperglycemia and increased perioperative morbidity and mortality. It evolves with diverse and progressive physiological changes, and the anesthetic management requires attention regarding this disease interference in multiple organ systems and their respective complications. Patient's history, physical examination, and complementary exams are important in the preoperative management, particularly glycosylated hemoglobin (HbA1c), which has a strong predictive value for complications associated with diabetes. The goal of surgical planning is to reduce the fasting time and maintain the patient's routine. Patients with Type 1 DM must receive insulin (even during the preoperative fast) to meet the basal physiological demands and avoid ketoacidosis. Whereas patients with Type 2 DM treated with multiple injectable and/or oral drugs are susceptible to develop a hyperglycemic hyperosmolar state (HHS). Therefore, the management of hypoglycemic agents and different types of insulin is fundamental, as well as determining the surgical schedule and, consequently, the number of lost meals for dose adjustment and drug suspension. Current evidence suggests the safe target to maintain glycemic control in surgical patients, but does not conclude whether it should be obtained with either moderate or severe glycemic control.

Evaluation and perioperative management of patients with diabetes mellitus. A challenge for the anesthesiologist

Diabetes mellitus (DM) is characterized by alteration in carbohydrate metabolism, leading to hyperglycemia and increased perioperative morbidity and mortality. It evolves with diverse and progressive physiological changes, and the anesthetic management requires attention regarding this disease interference in multiple organ systems and their respective complications. Patient's history, physical examination, and complementary exams are important in the preoperative management, particularly glycosylated hemoglobin (HbA1c), which has a strong predictive value for complications associated with diabetes. The goal of surgical planning is to reduce the fasting time and maintain the patient's routine. Patients with Type 1 DM must receive insulin (even during the preoperative fast) to meet the basal physiological demands and avoid ketoacidosis. Whereas patients with Type 2 DM treated with multiple injectable and/or oral drugs are susceptible to develop a hyperglycemic hyperosmolar state (HHS). Therefore, the management of hypoglycemic agents and different types of insulin is fundamental, as well as determining the surgical schedule and, consequently, the number of lost meals for dose adjustment and drug suspension. Current evidence suggests the safe target to maintain glycemic control in surgical patients, but does not conclude whether it should be obtained with either moderate or severe glycemic control.

Does Site Matter? Comparing Accuracy and Patient Comfort of Blood Glucose Samples Taken From the Finger and Palm of the Perioperative Patient

PURPOSE

This study compared two blood glucose (BG) point of care sampling methods to determine which is least painful yet accurate.

DESIGN

The two-period, two-treatment crossover trial compared the traditional fingertip sampling method to a form of alternative site testing (AST), palm of the hand.

METHODS

Subjects received both methods of BG sampling to compare comfort and accuracy. They were randomly assigned to determine which method was used first. Pain rating (0 to 10) and glucose results for both methods were documented.

FINDING

Results indicated that pain rating was significantly lower with AST (1.65) than with the standard site (2.83) (P < .001). There was no significant difference in mean glucose measurements between standard care (150 mg/dL) and AST (149 mg/dL). The numbers were closely correlated (r = 0.9815).

CONCLUSIONS

Findings support AST via the palm of the hand as an accurate and less painful method of obtaining BG results on diabetic patients.