Investigating glycemic control in patients undergoing lower extremity bypass within an enhanced recovery pathway at a single institution.

BACKGROUND: Enhanced recovery pathways (ERPs) aim to lower perioperative stress to facilitate recovery. Limited fasting combined with carbohydrate loading is a common ERP element. The effect of limited fasting has not been elucidated in patients with diabetes. Given the known deleterious effects of poor glycemic control in the perioperative period, such as increased rates of surgical site infection, the associations of preoperative limited fasting with perioperative glycemic control and early outcomes after lower extremity bypass (LEB) were investigated. METHODS: A single institutional retrospective review of patients who underwent infrainguinal LEB from 2016 to 2022 was performed. The ERP was initiated in May 2018. Patients were stratified by diabetes diagnosis and preoperative hemoglobin A1C (HbA1C) levels. Perioperative glycemic control was compared between the limited fasting and traditional fasting patients (nil per os at midnight). Limited fasting was defined as a clear liquid diet until 2 hours before surgery with recommended carbohydrate loading consisting of 400 cc of a clear sports drink (approximately 30 g of carbohydrates). All limited fasting patients were within the ERP. Early perioperative hyperglycemia (EPH) was defined as blood glucose of >180 mg/dL within the first 24 hours of surgery. Perioperative outcomes such as surgical site infection, readmission, reinterventions, and complications were also compared. RESULTS: A total of 393 patients were included (limited fasting patients N = 135; traditional fasting patients N = 258). A trend toward EPH was seen in all limited fasting groups. Evaluating limited fasting within diabetic patients revealed that 74.5% of limited fasting-diabetic patients had EPH compared with 49.6% of traditional fasting-diabetic patients (P = .001). When stratified by the HbA1C level, a significantly higher rate of EPH was seen in the HbA1c >8.0% groups, with 90.5% in the limited fasting patients compared with 67.9% in traditional fasting patients (P = .05). Limited fasting-diabetic patients experience a longer postoperative length of stay at 5.0 days (interquartile range: 3, 9) vs 4.0 days (2, 6) in nondiabetic patients (P = .016). CONCLUSIONS: ERP limited fasting was associated with early perioperative hyperglycemia after LEB, particularly in patients with HbA1C >8.0%. Due to the high prevalence of diabetic patients undergoing LEB under ERP, the role of limited fasting and common glycemic elements of ERP may need to be re-evaluated in this subpopulation.

Effect of intensive insulin therapy on inflammatory response after cardiac surgery using bedside artificial pancreas: A propensity score-matched analysis.

BACKGROUND: Perioperative hyperglycemia leads to poor postoperative clinical outcomes, including compromised immune function, cardiovascular events, and mortality. The optimal perioperative blood glucose levels during cardiac surgery remain unclear. A closed-loop glycemic control system (artificial pancreas, target blood glucose range:120-150 mg/dl) prevents postoperative inflammatory response more effectively than conventional insulin therapy (<200 mg/dl). However, the clinical effects of intensive insulin therapy with strict glycemic control (80-110 mg/dl) are controversial. This study aimed to determine whether intensive insulin therapy would further suppress postoperative inflammatory reactions. METHODS: This study analyzed 262 patients who underwent cardiovascular surgery with cardiopulmonary bypass. The patients were divided into two groups according to their target blood glucose range: 80-110 mg/dl and 120-150 mg/dl. The primary outcome was the difference in the C-reactive protein levels between the two groups. RESULTS: Propensity score matching resulted in 95 patients in each group based on their covariates. There was no difference in the postoperative maximum C-reactive protein levels between the two groups (14.81 ± 5.93 mg/dl vs. 14.34 ± 5.52 mg/dl; p = 0.571) following propensity score matching. Hypoglycemia did not occur during intensive insulin therapy. CONCLUSIONS: Intensive insulin therapy following cardiac surgery with cardiopulmonary bypass did not demonstrate significant advantages in the suppression of postoperative inflammatory reactions compared to that with mild glycemic control. However, intensive insulin therapy using an artificial pancreas was found to be safe, with no hypoglycemic events.

Strategies for intraoperative glucose management: a scoping review.

PURPOSE: Perioperative hyperglycemia is associated with adverse outcomes for patients with and without diabetes. Guidelines and published protocols for intraoperative glycemic management have substantial variation in their recommendations. We sought to characterize the current evidence-guiding intraoperative glycemic management in a scoping review. SOURCES: Our search strategy included MEDLINE (Ovid and EBSCO), PubMed, PubMed Central, EMBASE, CINAHL, Cochrane Library, SciVerse Scopus, and Web of Science and a gray literature search of Google, Google Scholar, hand searching of the reference lists of included articles, OAISter, institutional protocols, and ClinicalTrails.gov. PRINCIPAL FINDINGS: We identified 41 articles that met our inclusion criteria, 24 of which were original research studies. Outcomes and exposures were defined heterogeneously across studies, which limited comparison and synthesis. Investigators often created arbitrary and differing categories of glucose values rather than analyzing glucose as a continuous variable, which limited our ability to combine results from different studies. In addition, the study populations and surgery types also varied considerably, with few studies performed during day surgeries and specific surgical disciplines. Study populations often included more than one type of surgery, indication, and urgency that were expected to have varying physiologic and inflammatory responses. Combining low- and high-risk patients in the same study population may obscure the harms or benefits of intraoperative glycemic management for high-risk procedures or patients. CONCLUSION: Future studies examining intraoperative glycemic management should carefully consider the study population, surgical characteristics, and pre- and postoperative management of hyperglycemia.

RéSUMé: OBJECTIF: L'hyperglycémie périopératoire est associée à des effets indésirables chez les patients diabétiques et non diabétiques. Les lignes directrices et les protocoles publiés pour la prise en charge glycémique peropératoire présentent des variations substantielles dans leurs recommandations. Nous avons cherché à caractériser les données probantes actuelles guidant la prise en charge glycémique peropératoire dans une étude de portée. SOURCES: Notre stratégie de recherche a inclus les bases de données MEDLINE (Ovid et EBSCO), PubMed, PubMed Central, EMBASE, CINAHL, Cochrane Library, SciVerse Scopus et Web of Science, ainsi qu'une recherche documentaire grise sur Google, Google Scholar, la recherche manuelle des listes de référence des articles inclus, OAISter, les protocoles institutionnels et ClinicalTrials.gov. CONSTATATIONS PRINCIPALES: Nous avons identifié 41 articles qui répondaient à nos critères d'inclusion, dont 24 étaient des études de recherche originales. Les critères d'évaluation et les expositions étaient définis de manière hétérogène d'une étude à l'autre, ce qui a limité la comparaison et la synthèse. Les chercheurs ont souvent créé des catégories arbitraires et différentes de valeurs glycémiques plutôt que d'analyser la glycémie comme une variable continue, ce qui a limité notre capacité à combiner les résultats de différentes études. En outre, les populations étudiées et les types de chirurgie variaient également considérablement, avec peu d'études réalisées lors de chirurgies ambulatoires et dans certaines disciplines chirurgicales spécifiques. Les populations étudiées comprenaient souvent plus d'un type de chirurgie, d'indication et d'urgence, pour lesquelles des réponses physiologiques et inflammatoires variables étaient attendues. La combinaison de patients à faible et à haut risque dans la même population d'étude a pu masquer les inconvénients ou les avantages d'une prise en charge glycémique peropératoire pour les interventions ou les patients à haut risque. CONCLUSION: Les études futures portant sur la prise en charge glycémique peropératoire devraient examiner attentivement la population étudiée, les caractéristiques chirurgicales et la prise en charge pré- et postopératoire de l'hyperglycémie.

Surgical Site Infections and Inflammatory Reaction After Cardiac Surgery; Bedside Artificial Pancreas Versus Conventional Insulin Therapy: A Propensity Score-Matched Analysis.

OBJECTIVES: Perioperative hyperglycemia is associated with poor postoperative recovery, including compromised immune function and increased risk of infection. A closed-loop glycemic control system (artificial pancreas) has demonstrated strict safe perioperative glycemic control without hypoglycemia risk. The authors hypothesized that the artificial pancreas would reduce surgical site infections (SSIs) and postoperative inflammatory reactions. This study aimed to assess the effect of the artificial pancreas on SSIs and C-reactive protein (CRP) levels after cardiac surgery. DESIGN: A single-center retrospective, propensity score-matched analysis. SETTING: A university hospital. PARTICIPANTS: In total, 295 patients who underwent cardiovascular surgery with cardiopulmonary bypass were included. INTERVENTIONS: Patients were divided into two groups: artificial pancreas (target blood glucose: 120-150 mg/dL) and intravenous insulin infusion (conventional insulin therapy, target blood glucose: <200 mg/dL). MEASUREMENTS AND MAIN RESULTS: The differences in the incidence of SSIs and CRP levels between the two groups were assessed. After 1:1 propensity score matching based on their covariates, 101 matched patients were selected from each group. The incidence of SSIs was reduced by 3%, 5% (conventional insulin therapy), and 2% (artificial pancreas), but the reduction was not statistically significant (p = 0.45). The postoperative maximum CRP level was significantly lower in the artificial pancreas group than in the conventional insulin therapy group, mean (standard deviation)14.53 (5.64) mg/dL v 16.57 (5.58) mg/dL; p = 0.01. CONCLUSIONS: The artificial pancreas did not demonstrate a significant reduction in the incidence of SSIs. However, the artificial pancreas was safe and suppressed postoperative inflammation compared with conventional insulin therapy.

Perioperative hyperglycemia: an unmet need within a surgical site infection bundle.

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.

Implementation of perioperative blood glucose monitoring and insulin infusion protocol can decrease postoperative infection rate in diabetic patients undergoing elective craniotomy: An observational study.

BACKGROUND: Severe perioperative hyperglycemia (SH) is a proven risk factor for postoperative complications after craniotomy. To reduce this risk, it has been proposed to implement the standardized clinical protocol for scheduled perioperative blood glucose concentration (BGC) monitoring. This would be followed by intravenous (IV) insulin infusion to keep BGC below 180 mg/dl in the perioperative period. The aim of this prospective observational study was to assess the impact of this type of protocol on the postoperative infection rate in patients undergoing elective craniotomy. METHODS: A total of 42 patients were prospectively enrolled in the study. Protocol included scheduled BGC monitoring in the perioperative period and rapid-acting insulin IV infusion when intraoperative SH was detected. The diagnosis of infection (wound, pulmonary, blood stream, urinary tract infection or central nervous system infection) was established according to CDC criteria within the first postoperative week. A previously enrolled group of patients with sporadic BGC monitoring and subcutaneous insulin injections for SH management was used as a control group. RESULTS: An infectious complication (i.e., pneumonia) was diagnosed only in one patient (2 %) in the prospective group. In comparison with the control group, a decrease in the risk of postoperative infection was statistically significant with OR = 0.08 [0.009 - 0.72] (p = 0.02). Implementation of the perioperative BGC monitoring and the correction protocol prevented both severe hyperglycemia and hypoglycemia with BGC < 70 mg/dl. CONCLUSION: Scheduled BGC monitoring and the use of low-dose insulin infusion protocol can decrease the postoperative infection rate in patients undergoing elective craniotomy. Future studies are needed to prove the causality of the implementation of such a protocol with an improved outcome.

Perioperative glycemic management in adults presenting for elective cardiac and non-cardiac surgery.

Perioperative dysglycemia is associated with adverse outcomes in both cardiac and non-cardiac surgical patients. Hyperglycemia in the perioperative period is associated with an increased risk of postoperative infections, length of stay, and mortality. Hypoglycemia can induce neuronal damage, leading to significant cognitive deficits, as well as death. This review endeavors to summarize existing literature on perioperative dysglycemia and provides updates on pharmacotherapy and management of perioperative hyperglycemia and hypoglycemia in surgical patients.

The diabetes patient for ambulatory surgery.

Perioperative management of blood glucose is vital to the recovery and return to normal life for patients with diabetes undergoing ambulatory surgery. Important aspects of the preoperative assessment include the evaluation of the patient's usual level of control and self-management skills and the occurrence of hypoglycemia. There are disputes on the perioperative administration of diabetes medications, insulin, and certain other drugs. This article will provide information on current recommendations for ambulatory surgery and anesthesia for diabetic patients. It will address controversies and reemphasize important points of optimal care. New drugs and technologies for diabetes patients that may impact the perioperative period will be described.

Barriers to High-quality Postoperative Glycemic Management by Surgical Teams: A Theory-informed Qualitative Analysis.

OBJECTIVE: Our aim in this study was to identify the barriers to following recommendations for postoperative glycemic management among surgical team members. METHODS: We conducted semistructured interviews with surgical team members guided by 2 theoretical frameworks for understanding the barriers and drivers of health-care behaviours: the Theoretical Domains Framework and the Consolidated Framework for Implementation Research. Interview data were coded deductively by 2 study team members. RESULTS: Sixteen surgical team members from 7 surgical disciplines at a single hospital participated in this investigation. The most important barriers to management of postoperative hyperglycemia were knowledge of glycemic targets, belief about consequences of hyper- and hypoglycemia, available resources to manage hyperglycemia, adaptability of usual insulin regimens to complex postoperative patients, and skills to initiate insulin. CONCLUSIONS: Interventions to reduce postoperative hyperglycemia are unlikely to be effective unless they use implementation science to address local barriers to high-quality management among surgical team members, including setting and systems-level barriers.

Perioperative Management of Hyperglycemia and Diabetes in Cardiac Surgery Patients.

Perioperative hyperglycemia is common after cardiac surgery, reported in 60% to 90% of patients with diabetes and in approximately 60% of patients without history of diabetes. Many observational and prospective randomized trials in critically-ill cardiac surgery patients support a strong association between hyperglycemia and poor clinical outcome. Despite ongoing debate about the optimal glucose target, there is strong agreement that improved glycemic control reduces perioperative complications.

Management of diabetes medications for patients undergoing ambulatory surgery.

A stress-free actively managed perioperative experience is crucial to successful ambulatory surgery for diabetes patients. Practitioners who integrate diabetes treatment regimens into their perioperative management can facilitate a good outcome, smooth recovery, and rapid return to normal life. Hypoglycemia, hyperglycemia, and glucose variability must be avoided and patients should be maintained near their usual blood glucose.

Efeito da hiperglicemia sobre a incidência de infecção de sítio cirúrgico em cirurgias abdominais: estudo de coorte / Effect of hyperglycemia on the incidence of surgical site infection in abdominal surgeries: a cohort study

A infecção do sítio cirúrgico (ISC) é complicação frequente que pode acometer o paciente cirúrgico e acarretar incremento de morbimortalidade, readmissão, prolongamento da permanência no serviço de saúde e custos. A presente investigação teve como objetivos estimar as taxas de incidência (bruta e densidade) de infecção de sítio cirúrgico em pacientes submetidos à cirurgia abdominal, identificar os fatores de risco ou proteção e identificar o efeito independente da hiperglicemia perioperatória sobre a incidência de infecção de sítio cirúrgico. Trata-se de estudo de coorte. A amostra foi composta de 484 pacientes submetidos à cirurgia abdominal, os quais foram acompanhados durante o período de 30 dias após a cirurgia. Para a coleta das informações, utilizou-se instrumento padronizado, pré-codificado e submetido à validação aparente e de conteúdo (cinco juízes). A coleta de dados foi realizada na admissão do paciente, no dia da cirurgia, no primeiro dia de pós-operatório até a alta hospitalar, no 30º dia após a cirurgia e nos casos de reinternação. A hiperglicemia perioperatória foi avaliada em três momentos, a saber: na sala de recepção do centro cirúrgico, ao final da cirurgia e 12 horas após o término da cirurgia. A incidência bruta de ISC foi de 20,25%, a maioria dos pacientes era do sexo feminino (54,34%), classificados na categoria ASA II (58,47%), e mais de 15% com diagnóstico prévio de diabetes mellitus e neoplasia. A duração média da cirurgia foi de 117,62 minutos e da anestesia de 144,15 minutos. Com relação ao potencial de contaminação da ferida, 63,64% foram classificadas em potencialmente contaminadas e 62,81% dos pacientes apresentaram hipotermia (<= 5vezes). Ao final da cirurgia, a média da temperatura da sala de operação foi 23,92ºC e a umidade do ar foi de 54,50kg/m3. A hiperglicemia perioperatória esteve presente em 17,77% dos pacientes ao final da cirurgia e 12 horas após o término do procedimento cirúrgico. Com relação à gravidade da hiperglicemia, 24,38% da amostra apresentou tal condição em uma das aferições e 5,79% duas ou mais vezes. As medidas de associação brutas (modelos univariados) indicaram que pacientes expostos à hiperglicemia têm maior risco de desenvolvimento de ISC (RR >2,5), quando comparados aos não expostos. A fração atribuível indicou que a ISC não ocorreria em mais de 60% dos casos se a hiperglicemia pudesse ser evitada. No modelo multivariado, as variáveis, potencial de contaminação da ferida (cirurgia contaminada), hipotermia e gravidade da hiperglicemia, permaneceram independentemente associadas à ISC. A variável hiperglicemia foi fator de risco independente associada ao desfecho em todos os modelos, exceto na sala de recepção do centro cirúrgico. A temperatura da sala de operação foi associada independentemente ao desfecho, exceto 12 horas após o final da cirurgia (fator protetor). As evidências geradas podem contribuir para a prevenção e controle de ISC, uma vez que o conhecimento pelos profissionais de saúde, sobre os fatores de risco, especialmente, a hiperglicemia perioperatória, pode promover o planejamento e implementação de ações direcionadas para a redução deste tipo de infecção

Surgical site infection (SSI) is a frequent complication that may affect the surgical patient, leading to an increase in morbidity and mortality, readmission, prolonged stay in the health service and costs. This study aimed to estimate the incidence rates (gross and density) of surgical site infection in patients submitted to abdominal surgery, to identify the risk or protection factors and to identify the independent effect of perioperative hyperglycemia on the incidence of infection of surgical site. It is a cohort study; the sample was composed of 484 patients submitted to abdominal surgery, who were followed during the period of 30 days after surgery. For the information collection, a standardized, pre-coded instrument was used and it was submitted to the apparent and content validation (five judges). Data collection was performed at the patient's admission, in the day of surgery, from the first postoperative day to the hospital discharge, on the 30th day after surgery, and in cases of rehospitalization. The perioperative hyperglycemia was evaluated in three moments, as following: in the reception room of the surgical center, at the end of the surgery and 12 hours after the end of the surgery. The gross incidence of SSI was 20.25%, the majority of the patients were female (54.34%), classified as ASA II (58.47%), and more than 15% with previous diagnosis of diabetes mellitus and neoplasia. The average duration of surgery was 117.62 minutes and of anesthesia was 144.15 minutes. Regarding the potential for contamination of the wound, 63.64% of them were classified as potentially contaminated, and 62.81% of the patients presented hypothermia (<= 5 times). At the end of the surgery, the average operating room temperature was 23.92ºC and the air humidity was 54.50kg/m3. Perioperative hyperglycemia was present in 17.77% of the patients at the end of the surgery and 12 hours after the end of the surgery. Regarding the severity of hyperglycemia, 24.38% of the sample presented such condition in one of the measurements and 5.79% in two or more times. Measures of gross association (univariate models) indicated that patients exposed to hyperglycemia had a higher risk of developing SSI (RR>2.5) when compared to those not exposed. The attributable fraction indicated that SSI would not occur in more than 60% of cases if hyperglycemia could be avoided. In the multivariate model, the potential variables of wound contamination (contaminated surgery), hypothermia and severity of hyperglycemia remained independently associated to SSI. The variable hyperglycemia was an independent risk factor associated to the outcome in all models, except in the reception room of the surgical center. The operating room temperature was independently associated to the outcome, except 12 hours after the end of surgery (protective factor). The evidence found may contribute to the prevention, control of SSI, since the knowledge of health professionals about the risk factors, especially perioperative hyperglycemia, may promote the planning, and implementation of actions aimed at reducing this type of infection