SUN-153 Patterns and Predictors of Peri-Operative Glycemic Control in Ambulatory Surgery: An Academic Single Center Experience

Abstract

Introduction: Peri-operative glucose control improves patient outcomes. Most of the evidence for this stems from cardiac surgery where insulin management protocols are well developed. Guidelines for peri-operative insulin management in the ambulatory setting are fraught with significant variation in recommendations. Our study analyzes patterns of peri-operative insulin adjustment at our institution and attempts to identify predictors of hypo- and hyperglycemia. Methods: We identified patients with any form of diabetes on basal insulin, who underwent elective non-cardiac surgery over a 5 months period at our institution. Data regarding demographics, baseline diabetes control, peri-operative insulin changes, fingerstick glucose values on day of surgery and complications were abstracted through a chart review supplemented by a patient phone call. Primary outcome was glycemic control on day of surgery and secondary outcomes was self-reported complications postoperatively. Results:A total of 100 patients were included. Fasting hyperglycemia (Fingerstick glucose >140mg/dL) was noted in 42% of patients on day of surgery. Younger age (p=0.04) and longer duration of surgery (p=0.01) were found to predispose patients to hyperglycemia. Glycemic outcomes were also studied based on timing of basal dose, total daily insulin dose and pre-operative dose adjustment. The majority of patients who took an evening dose made no adjustments (73%) while those with morning dose typically held their dose on the day of surgery (77%). We found no statistically significant difference in risk of hypoglycemia or hyperglycemia attributable to pre-operative insulin adjustment. Severe fasting hyperglycemia (Fingerstick glucose >250mg/dL) was noted in 10% of patients, of which 50% required inpatient admission for glycemic management. The majority of the patients who had severe hyperglycemia had a hemoglobin A1c of more than 8.4%. Fasting hypoglycemia (Fingerstick glucose <70 mg/dL ) was noted in three patients in setting of no dose change and prolonged fasting. Discussion: Although multiple guidelines exist for pre-operative insulin adjustment, there is no unified clinical practice. Our study identified factors such as young age and long duration of surgery that should be considered when developing a peri-operative insulin plan as they could lead to hyperglycemia. Also, patients with hemoglobin A1c >8.4% could benefit from stricter control to minimize risk of severe hyperglycemia. Coordinated team efforts between endocrinology and anesthesiology during pre-surgical evaluations can benefit patients.