Update on a Quality Initiative to Standardize Perioperative Care for Continuous Subcutaneous Insulin Infusion Therapy

Perioperative diabetes care

People with diabetes occupy approximately 18% of all acute inpatient hospital beds in the UK, compared with 6.5% of the general population. For those undergoing surgery, having diabetes is known to be associated with increased harms, however harm is defined. For those undergoing elective surgery, there is a defined patient journey, starting with referral from primary care to surgical outpatients, then onto preoperative assessment clinic before being admitted for surgery, and then from recovery through to discharge home. Because of the multiple causes for possible harm, communication between members of the healthcare team at each stage of this journey and with the person with diabetes is essential.Recently, the National Confidential Enquiry into Patient Outcomes and Death has shown that the care of people with diabetes undergoing surgery needs to be improved, and they have made several recommendations that trusts should adopt to minimise the harms in this vulnerable population.

Continuous subcutaneous insulin infusion reduces the risk of postoperative infection

BACKGROUND

Perioperative hyperglycemia was associated with postoperative infection, and proper management of perioperative glucose has become critical in improving the prognosis of patients.

METHODS

A total of 1015 diabetic patients who underwent surgery and received insulin treatment for their hyperglycemia in our hospital were retrospectively reviewed. According to propensity matching, we obtained 253 pairs of patients from the group which received continuous subcutaneous insulin infusion (CSII) therapy (CSII group) and the group which received insulin injection therapy (non-CSII group). Perioperative glucose levels and corresponding outcomes were compared between the two groups.

RESULTS

Compared with the non-CSII group, the CSII group had lower fasting and mean glucose levels, lower incidence of fever (operation day: 18.6% vs 10.2%; P = .014; first postoperative day: 55.1% vs 34.7%; P < .001), a positive rate of postoperative secretion culture (6.3% vs 1.2%; P = .004), and a shorter time of antibiotics use (total antibiotics use: P = .002; postoperative antibiotics use: P < .001) and hospital stays (P < .001). However, there was no difference in the total medical expenditure between the two groups (P = .499). Further analysis showed that CSII therapy was superior to multiple daily insulin injection (MDI) therapy in its effect on infection and other postoperative outcomes when 64 pairs of patients from the CSII group and MDI group were compared.

CONCLUSIONS

CSII therapy provides better perioperative glucose control and a lower risk of postoperative infection without increasing the total medical expenditure.

[Anesthesiological perspectives on perioperative management in continuous subcutaneous insulin infusion (CSII): stop or continue?]

OBJECTIVE

Perioperative handling of insulin pumps (CSII) is inconsistent. The aims of this study were a literature search addressing this clinical question, analysis of data found and a proposal for perioperative management recommendations for clinical practice.

METHODS

A systematic search was conducted in PubMed and Clinical Research Network.

RESULTS AND DISCUSSION

A total of 11 publications on CSII in perioperative medicine were identified. According to the evidence CSII guarantees perioperative glycemic stability under certain clinical situations. The use of CSII could be continued in patients undergoing elective non-cardiac minor surgery with fasting for up to one meal only. International guidelines on surgery in diabetes do not address the use of perioperative CSII. There is no nationwide register data for CSII, the use of which could be around 18%. Based on the search results, a hospital internal protocol for perioperative management with CSII and patient information material were designed.

CONCLUSION

Growing evidence for improved patient outcome with perioperative CSII usage warrants interdisciplinary transfer of knowledge and experiences on intensified insulin therapy and patient empowerment.

The impact of glycaemic variability on the surgical patient

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.

Management of hyperglycemia in the neurosurgery patient

Hyperglycemia is associated with adverse outcomes in patients who are candidates for or underwent neurosurgical procedures. Specific concerns and settings that relate to these patients are preoperative glycemic control, intraoperative control, management in the neurological intensive care unit (NICU), and postoperative control. In each of these settings, physicians have to ensure appropriate glycemic control to prevent or minimize adverse events. The glycemic control is usually managed by a neurohospitalist in co-management with the neurosurgery team pre- and post-operatively, and by the neurocritical care team in the setting of NICU. In this review article, we outline current standards of care for neurosurgery patients with diabetes mellitus and/or and hyperglycemia and discuss results of most recent clinical trials. We highlight specific concerns with regards to glycemic controls in these patients including enteral tube feeding and parenteral nutrition, the issues of the transition to the outpatient care, and management of steroid-induced hyperglycemia. We also note lack of evidence in some important areas, and the need for more research addressing these gaps. Where possible, we provide suggestions how to manage these patients when there is no underlying guideline.

Perioperative Management of Patients with Diabetes and Hyperglycemia Undergoing Elective Surgery

Diabetes mellitus (DM) and hyperglycemia are associated with increased surgical morbidity and mortality. Hyperglycemia is a determinant of risk of surgical complications and should be addressed across the continuum of surgical care. While data support the need to address hyperglycemia in patients with DM in the ambulatory setting prior to surgery and in the inpatient setting, data are less certain about hyperglycemia occurring during the perioperative period-that part of the process occurring on the day of surgery itself. The definition of "perioperative" varies in the literature. This paper proposes a standardized definition for the perioperative period as spanning the time of patient admission to the preoperative area through discharge from the recovery area. Available information about the impact of perioperative hyperglycemia on surgical outcomes within the framework of that definition is summarized, and the authors' approach to standardizing perioperative care for patients with DM is outlined, including the special case of patients receiving insulin pump therapy. The discussion is limited to adult ambulatory non-obstetric patients undergoing elective surgical procedures under general anesthesia.