RESUMEN
BACKGROUND: Preoperative hyperglycemia has been associated with perioperative morbidity in general surgery patients. Additionally, preoperative hyperglycemia may indicate underlying impaired glucose metabolism. Thus, identification of preoperative hyperglycemia may provide an opportunity to mitigate both short-term surgical and long-term health risk. We aimed to study this phenomenon specifically in the gynecologic surgery population. Specifically, we aimed to evaluate the association between preoperative hyperglycemia and perioperative complications in gynecologic surgery patients and to characterize adherence to diabetes screening guidelines. METHODS: This retrospective cohort study included 913 women undergoing major gynecologic surgery on an enhanced recovery pathway from January 2018 to July 2019. The main exposure was day of surgery glucose ≥ 140 g/dL. Multivariate regression identified risk factors for hyperglycemia and composite and wound-specific complications. RESULTS: Sixty-seven (7.3%) patients were hyperglycemic. Diabetes (aOR 24.0, 95% CI 12.3-46.9, P < .001) and malignancy (aOR 2.3, 95% CI 1.2-4.5, P = .01) were associated with hyperglycemia. Hyperglycemia was not associated with increased odds of composite perioperative (aOR 1.3, 95% CI 0.7-2.4, P = 0.49) or wound-specific complications (aOR 1.1, 95% CI 0.7-1.5, P = 0.76). Of nondiabetic patients, 391/779 (50%) met the USPSTF criteria for diabetes screening; 117 (30%) had documented screening in the preceding 3 years. Of the 274 unscreened patients, 94 (34%) had day of surgery glucose levels suggestive of impaired glucose metabolism (glucose ≥ 100 g/dL). CONCLUSION: In our study cohort, the prevalence of hyperglycemia was low and was not associated with higher risk of composite or wound-specific complications. However, adherence to diabetes screening guidelines was poor. Future studies should aim to develop a preoperative blood glucose testing strategy that balances the low utility of universal glucose screening with the benefit of diagnosing impaired glucose metabolism in at-risk individuals.
RESUMEN
Noonan syndrome is a relatively common genetic disorder and the second most common cause of congenital heart disease after trisomy 21. The spectrum of cardiac anomalies in Noonan syndrome typically involves pulmonary valve stenosis occasionally in conjunction with hypertrophic cardiomyopathy. Mitral valve involvement is a rare finding in Noonan syndrome and is most commonly associated with either mitral valve prolapse or abnormal valvular insertion causing left ventricular outflow tract obstruction. Patients with Noonan syndrome typically have preserved fertility and, given the success of cardiac surgery and medical management of heart failure in this population, are beginning to present more commonly as parturients in adulthood. Maternal physiologic changes during pregnancy introduce an added complexity to hemodynamic management and anesthetic considerations during labor and delivery. In this article, we present a case of a patient with Noonan syndrome with severe mitral stenosis, pulmonary valve insufficiency, and severe restrictive and obstructive pulmonary disease who presented preterm for delivery due to increased dyspnea at rest. Here we review the pathophysiology behind Noonan syndrome and peripartum management strategies in a patient with severe combined cardiac and pulmonary disease.