Immediate preoperative hyperglycemia correlates with complications in non-cardiac surgical cases.

STUDY OBJECTIVE: Assess for a relationship between immediate preoperative glucose concentrations and postoperative complications. DESIGN: Retrospective cohort study. SETTING: Single large, tertiary care academic medical center. PATIENTS: A five-year registry of all patients at our hospital who had a glucose concentration (plasma, serum, or venous/capillary/arterial whole blood) measured up to 6 h prior to a non-emergent surgery. INTERVENTIONS: The glucose registry was cross-referenced with a database from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). We applied an outcomes review to the subset of patients for whom we had data from both registries (n = 1774). MEASUREMENTS: Preoperative glucose concentration in the full population as well as the subgroups of patients with or without diabetes were correlated with adverse postsurgical outcomes using 1) univariable analysis and 2) full multivariable analysis correcting for 27 clinical factors available from the ACS NSQIP database. Logistic regression analysis was performed using glucose level either as a continuous variable or as a categorical variable according to the following classifications: mild (≥140 mg/dL; ≥7.8 mmol/L), moderate (≥180 mg/dL; ≥10 mmol/L), or severe (≥250 mg/dL; ≥13.9 mmol/L) hyperglycemia. A third analysis was performed correcting for 7 clinically important factors (age, BMI, predicted duration of procedure, sex, CKD stage, hypoalbuminemia, and diabetic status) identified by anesthesiologists and surgeons as immediately available and important for decision making. MAIN RESULTS: Univariable analysis of all patients and the subgroups of patients without diabetes or with diabetes showed that immediate preoperative mild or moderate hyperglycemia correlates with postoperative complications. Statistical significance was lost in most groups using full multivariable analysis, but not when correcting for the 7 factors available immediately preoperatively. However, for all patients with diabetes, moderate hyperglycemia (≥180 mg/dL; ≥10 mmol/L) continued to significantly correlate with complications even in the full multivariable analysis [odds ratio (OR) 1.79; 95% Confidence Intervals (CI) 1.10, 2.92], and with readmission/reoperation within 30 days [OR 1.93; 95% CI 1.18, 3.13]. CONCLUSIONS: Preoperative hyperglycemia within 6 h of surgery is a marker of adverse postoperative outcomes. Among patients with diabetes in our study, a preoperative glucose level ≥ 180 mg/dL (≥10 mmol/L) independently correlates with risk of postoperative complications and readmission/reoperation. These results should encourage future work to determine whether addressing immediate preoperative hyperglycemia can improve complication rates, or simply serves as a marker of higher risk.

Effects of patient-level noise abatement orders on sound levels experienced by critically ill subarachnoid hemorrhage patients: an observational study.

BACKGROUND/OBJECTIVE: Patients with aneurysmal subarachnoid hemorrhage (aSAH) may be at risk for complications related to excessive environmental noise. Our ICU utilizes a variety of universal interventions to minimize ambient noise levels, but patients with aSAH additionally have specific orders intended to further minimize physiologic stress and noise exposure. It is unknown whether such orders can have a supplementary reductive effect on noise exposure. METHODS: Sound levels were measured for at least three consecutive days in the rooms of 17 patients with aSAH and implemented 'subarachnoid precautions' orders. Sound levels were similarly recorded in the rooms of 11 geographically-proximate, critically-ill control patients without aSAH. RESULTS: Linear mixed models were used to assess the difference in measurements between groups. Observations were combined into fifteen-minute windows, then group means and their differences were calculated and plotted to help identify what times of the day had significant differences. aSAH patients consistently experienced lower sound levels than control patients, with a statistically significant difference (p < 0.05) in mean sound levels at 62 of 96 intervals throughout the day. Overall, the mean sound level for aSAH patients was always between 62-63dBA, while the mean sound level experienced by control patients ranged between 64-66dBA. CONCLUSIONS: Implementation of patient-specific orders can have a supplementary reductive effect on noise exposure for aSAH patients in an intensive care unit that already utilizes universal noise abatement interventions.

Acute spinal cord injury.

Acute spinal cord injury (SCI) is a devastating event with high mortality and, among survivors, a high degree of morbidity due to both motor and sensory deficits. The damage that occurs with a SCI is recognized to be pathophysiologically biphasic: the initial insult to neural tissue can be followed by a secondary process of progressive ischemia that may worsen the severity of dysfunction. The extent of this secondary insult is potentially modifiable, and a variety of interventions have been studied in an attempt to improve motor and sensory outcomes. What follows is a brief review of some such procedural and pharmacologic interventions, including early decompressive surgery, use of methylprednisolone, and blood pressure and respiratory management, which have been proposed to improve outcomes after SCI.