Reactive Rather than Proactive Diabetes Management in the Perioperative Period.

As perioperative hyperglycemia is associated with poor postoperative patient outcomes, clinical guidelines provide recommendations for optimal perioperative glucose control. It is unclear to what extent recommended glucose levels are met in daily practice, and little is known about factors that influence these levels. We describe blood glucose levels throughout the hospital care pathway in 375 non-critically ill patients with diabetes who underwent major surgery (abdominal, cardiac, or orthopedic) in 6 hospitals, examine determinants of these levels including adherence to 9 quality indicators for optimal perioperative diabetes care, and perform qualitative interviews to identify barriers for optimal care. Virtually all patients (95%) experienced at least one hyperglycemic value (>10 mmol/l); 9% had at least one value <4 mmol/l. Mean glucose increased from preoperative to postoperative day (POD) 1 (+2.3 mmol/l, 5-95% CI 1.9-2.7), and then gradually decreased on POD 2-14 (+1.8 mmol/l, 5-95% CI 1.4-2.2). Insulin-treated patients (with or without oral agents) had higher glucose levels (+1.7 mmol/l, 5-95% CI 0.5-3.0, and +1.2 mmol/l, -0.1 to -2.5) than patients using oral agents only. Indicator adherence tended to be associated with higher glucose levels. Barriers for optimal care included a lack of formalized agreements on target glucose levels, absence of directly obvious disadvantages of hyperglycemia, and concern about inducing hypoglycemia. Hyperglycemia is common after major surgery, in particular on POD1 and in insulin-treated patients. Our results suggest that perioperative diabetes care is reactive rather than proactive, and that current emphasis of professionals is on treating instead of preventing postoperative hyperglycemia.

[Autonomic dysreflexia in spinal cord injury patients: recognition is vital]. / Autonome dysreflexie bij dwarslaesiepatiënten.

Depending on the level and severity of spinal cord injury (SCI), SCI patients may suffer from loss of autonomic nervous system function besides the well-known motor and sensory function loss. Changes in the autonomic control of the cardiovascular system can lead to the life-threatening phenomenon of autonomic dysreflexia (AD), especially in patients with cervical or high thoracic SCI. AD is defined as a sudden increase in systolic blood pressure of at least 20 mmHg above baseline. It results from an uncontrolled reaction of the sympathetic nervous system to a stimulus below the neurological SCI level. The characteristic symptoms above the neurological level are caused by vasodilation (headache, flushing, sweating, nasal congestion) whereas the symptoms below the neurological level are caused by vasoconstriction (piloerection). Recognition and appropriate management of AD are essential in preventing life-threatening complications of hypertensive crisis as well as identifying underlying disease requiring further treatment.

Perioperative diabetes care: development and validation of quality indicators throughout the entire hospital care pathway.

BACKGROUND: In this study, we aim to develop a set of quality indicators for optimal perioperative diabetes care throughout the hospital care pathway and to gain insight into the feasibility of the indicator set in daily clinical practice by assessing the clinimetric properties of the indicators in a practice test. METHODS: A literature-based modified Delphi method was used to develop a set of quality indicators. To assess clinimetric properties of each indicator (measurability, applicability, reliability, improvement potential and case-mix stability), a practice test was performed in six Dutch hospitals using a sample of 389 major surgery patients with diabetes who underwent abdominal, cardiac or large joint orthopaedic surgery. RESULTS: We developed a set of 36 quality indicators for perioperative diabetes care. The practice test showed that one indicator was inapplicable, and nine indicators were unmeasurable. Interobserver reliability was good (0.61≤k≤0.8) for all indicators except for one with moderate (0.41≤k≤0.6) interobserver reliability. Improvement potential was low (<10%) for five indicators. Twenty-one indicators, including three outcome indicators, nine process indicators and nine structure indicators, could be used to assess the quality of care delivered in our six study hospitals. CONCLUSION: We developed a face and content valid set of quality indicators for optimal perioperative diabetes care throughout the hospital care pathway, using a rigorous and systematic approach. The results from our practice test show that it is essential to subject indicators to a practice test before applying them for quality improvement purposes. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov: NCT01610674.