Intraoperative Glucose Research Articles

Intraoperative hypoglycemia among adults with intraoperative glucose measurements: a cross-sectional multicentre retrospective cohort study.

Intraoperative hypoglycemia is presumed to be rare, but generalizable multicentre incidence and risk factor data for adult patients are lacking. We used a multicentre registry to characterize adults with intraoperative hypoglycemia and hypothesized that intraoperative insulin administration would be associated with hypoglycemia. We conducted a cross-sectional retrospective multicentre cohort study. We searched the Multicenter Perioperative Outcomes Group registry to identify adult patients with intraoperative hypoglycemia (glucose < 3.3mmol·L-1 [< 60mg·dL-1]) from 1 January 2015 to 31 December 2019. We evaluated characteristics of patients with intraoperative glucose measurements and with intraoperative hypoglycemia. Of 516,045 patients with intraoperative glucose measurements, 3,900 (0.76%) had intraoperative hypoglycemia. Diabetes mellitus and chronic kidney disease were more common in the cohort with intraoperative hypoglycemia. The odds of intraoperative hypoglycemia were higher for the youngest age category (18-30yr) compared with the odds for every age category above 40yr (odds ratio [OR], 1.57-3.18; P < 0.001), and were higher for underweight or normal weight patients compared with patients with obesity (OR, 1.48-2.53; P < 0.001). Parenteral nutrition was associated with lower odds of hypoglycemia (OR, 0.23; 95% confidence interval [CI], 0.11 to 0.47; P < 0.001). Intraoperative insulin use was not associated with hypoglycemia (OR, 0.996; 95% CI, 0.91 to 1.09; P = 0.93). In this large cross-sectional retrospective multicentre cohort study, intraoperative hypoglycemia was a rare event. Intraoperative insulin use was not associated with hypoglycemia.

Liraglutide effects on epicardial adipose tissue micro-RNAs and intra-operative glucose control

Background and aimEpicardial adipose tissue (EAT) plays a role in coronary artery disease (CAD). EAT has regional distribution throughout the heart and each location may have a different genetic profile and function. Glucagon like peptide-1 receptor analogs (GLP-1RAs) reduce cardiovascular risk. However, the short-term effects of GLP-1RA on microRNA (miRNA) profile of each EAT location is unknown. Objective was to evaluate if EAT miRNAs were different between coronary (CORO-EAT), left atrial EAT (LA-EAT) and subcutaneous fat (SAT), and liraglutide can modulate EAT miRNAs expression. Methods and resultsThis was a 12-week randomized, double-blind, placebo-controlled study in 38 patients with type 2 diabetes (T2DM) and coronary artery disease (CAD) who were started on either liraglutide or placebo for a minimum of 4 up to 12 weeks prior to coronary artery by-pass grafting (CABG). Fat samples were collected during CABG. miR16, miR155 and miR181a were significantly higher in CORO-EAT and in LA-EAT than SAT (p < 0.01 and p < 0.05) in overall patients. miR16 and miR181-a were significantly higher in CORO-EAT than SAT (p < 0.01), and miR155 and miR181a were higher in LA-EAT than SAT (p < 0.05) in the liraglutide group. Liraglutide-treated patients had better intra-op glucose control than placebo (146 ± 21 vs 160 ± 21 mg/dl, p < 0.01). ConclusionsOur study shows that CORO- and LA-miRNAs profiles were significantly different than SAT miRNAs in overall patients and miRNAs were significantly higher in CORO-EAT and LA-EAT than SAT in the liraglutide group. Pre-op liraglutide was also associated with better intra operative glucose control than placebo independently of weight loss.

Intra- and Early Post-Operative Factors Affecting Spinal Cord Ischemia in Patients Undergoing Fenestrated and Branched Endovascular Aortic Repair.

Background: Spinal cord ischemia (SCI) is a severe complication after fenestrated/branched endovascular repair (f/bEVAR). The underlying causes of SCI are still under investigation. This study aimed to evaluate intra- and early post-operative parameters that may affect SCI evolution. Methods: A single-center retrospective analysis was conducted including SCI patients with complete anesthesiologic records (1 January 2011 to 31 December 2023). Values of intra-operative glucose, hemoglobin, lactate, activated clotting time (ACT), and the need for transfusion were collected. The cohort was compared to a matched cohort of non-SCI patients. Results: Fifty-one patients with SCI and complete anesthesiologic records were included (mean age: 69.8 ± 6.2 years; 39.2% male). Intra-operative glucose value < 110 mg/dL (AUC: 0.73; sensitivity 91%, specificity of 83%) and hemoglobin value > 8.5 mg/dL (AUC: 0.61; sensitivity 83%, specificity 78%) were protective for Grade 3 SCI. Twenty-three patients with SCI were matched to 23 patients without SCI. SCI patients presented significantly higher glucose levels intra-operatively (glucose mean value: SCI 150 ± 46 mg/dL vs. non-SCI: 122 ± 30 mg/dL, p = 0.005). ACT (SCI 259 ± 31 svs. non-SCI 288 ± 28 s, p = 0.001), volume input (SCI 4030 ± 1430 mL vs. non-SCI 3020 ± 113 mL, p = 0.009), and need for transfusion (SCI: 52.5% vs. 4.3%, p < 0.001) were related to SCI. Higher glucose levels were detected among patients with SCI, at 24 (SCI: 142 ± 30 mg/dL vs. non-SCI: 118 ± 26 mg/dL, p=0.004) and 48 h (SCI: 140 ± 29 mg/dL vs. non-SCI: 112 ± 20 mg/dL, p < 0.001) post-operatively. Conclusions: SCI is a multifactorial complication after f/bEVAR. Intra-operative and early post-operative glucose levels may be related to SCI evolution. Targeted glucose < 110 mg/dL may be protective for Grade 3 SCI.

Intraoperative Glucose and Kidney Injury After On-Pump Cardiac Surgery: A Retrospective Cohort Study

IntroductionAcute kidney injury (AKI) is a common complication after on-pump cardiac surgery, and previous studies have suggested that blood glucose is associated with postoperative AKI. However, limited evidence is available regarding intraoperative glycemic thresholds in cardiac surgery. The aim of this study was to explore the association between peak intraoperative blood glucose and postoperative AKI, and determine the cut-off values for intraoperative glucose concentration associated with an increased risk of AKI. MethodsThe study was retrospective and single-centered. Adult patients in West China Hospital of Sichuan University who underwent on-pump cardiac surgery (n = 3375) were included. The primary outcome was the incidence of AKI. Multivariable logistic analysis using restricted cubic spline was performed to explore the association between intraoperative blood glucose and postoperative AKI. ResultsThe incidence of AKI in the study population was 18.0% (607 of 3375). Patients who developed AKI had a significantly higher peak intraoperative glucose during the surgery compared to those without AKI. After adjustment for confounders, the incidence of AKI increased with peak intraoperative blood glucose (adjusted odds ratio, 1.08, 95% confidence interval 1.03, 1.12). Furthermore, it was demonstrated that the possibility of AKI was relatively flat till 127.8 mg/dL (7.1 mmol/L) glucose levels which started to rapidly increase afterward. ConclusionsIncreased intraoperative blood glucose was associated with an increased risk of AKI. Among patients undergoing on-pump cardiac surgery, avoiding a high glucose peak (i.e., below 127.8 mg/dL [7.1 mmol/L]) may reduce the risk of postoperative AKI.

Comparison of Del Nido (a different application) and crystalloid blood cardioplegia on arrhythmia and early results.

The results of the use of del-Nido(DN) solution using a different method or crystalloid blood cardioplegia in coronary bypass patients were compared. We aimed to investigate the effects on intraoperative and postoperative arrhythmias, arrhythmia durations and early results. The study included 175 patients using crystalloid blood cardioplegia (Group 1) and 150 patients using DN solution(Group 2). In the DN group, 75% of the calculated plegia dose was given first. the remaining part was applied by giving from grafts. Intraoperative/postoperative data were compared. There was no significant difference between the groups in terms of demographic characteristics. Preop troponin level was similar.(p = 0.190) However, there was a statistical difference between the postoperative 6th hour.(p = 0.001) There was no difference in troponin values at the postoperative 24th hour. (p = 0.631) Spontaneous rhythm occurred at the cardiopulmonary by pass (CPB) weaning stage in most of the patients in Group 2 (95.3%). Although the need for temporary pacing was less in Group 2, it was not significant.(p = 0.282) No patient required permanent pacing. CPB duration, cross clamp times and intraoperative glucose levels, intensive care follow-up times and hospitalization times were found to be shorter in Group 2. Although the postoperative atrial fibrillation frequency was similar (p = 0.261), the time to return to sinus was lower in Group 2.(p = 0.001). The use of DN cardioplegia solution provides significant positive contributions to avoid arrhythmias compared to crystalloid blood cardioplegia. DN solution applied with this method may contribute to reducing the anxieties associated with its use in isolated coronary artery bypass surgery.

Efficacy and safety of intraoperative partial spray of 50% glucose for patients with spontaneous pneumothorax

ObjectivesThe management for pneumothorax patients involves surgical intervention, nevertheless postoperative recurrences are often encountered. To reduce the rates of recurrence, thoracic surgeons have experimented with various novel techniques, such as pleural abrasion, chemical pleurodesis, and staple line coverage with absorbable sheets, in addition to bullectomy. And in recent years, there have been reports of the effectiveness of the use of intraoperative glucose intrapleural spray (GIS) containing 50 ml of 50% glucose solution in addition to bullectomy. However, information on the effects and adverse events of GIS is limited. Current study was aimed to assess the efficacy and safety of GIS in preventing recurrence of pneumothorax.Patients and methodsWe conducted a retrospective study with 74 cases of bullectomy with or without GIS between 2018 and 2021 at Okazaki City Hospital. Of these cases, 50 received GIS (GIS group) while 24 were treated conservatively (C group).ResultThe GIS group consisted of 46 males and 4 females, whereas the C group consisted of 23 males and 1 female, with mean ages of 38.5 ± 5.7 years and 30.5 ± 6.7 years, respectively. The GIS group exhibited a mean increase in blood glucose of 23.8 mg/dL postoperatively, and postoperative infections were observed in 2 cases in the GIS group (4.0%) and 2 cases in the C group (8.3%). The NRS scores of the patients in the GIS group and the C group three hours postoperatively were 4.0 and 3.1, respectively (p = 0.28). No prolongation of postoperative drainage period by GIS was observed (1.2 days and 1.4 days in the GIS and C groups, respectively). Postoperative recurrence occurred in two patients from the C group. The postoperative total drainage volumes were 341.8 ± 25.2 ml and 74.2 ± 25.5 ml in the GIS and C groups, respectively, showing a significant increase in drainage volume (p < 0.01). None of them presented dehydration-related symptoms.ConclusionsThe use of intraoperative glucose intrapleural spray is effective and safe in terms of preventing recurrences and postoperative complications.

Postoperative Delirium is Common in the Elderly Patient, Before and After their Surgical Event is Related to Increased Mortality and Prolongation of Hospital Stay

Objective: To evaluate Delirium and the patient's state of consciousness as risk factors after a surgical event, establishing a prognosis for the patient's hospital process, determining the severity of the patient's condition. Method: From the registry of patients of the Neurology and Geriatrics services, patients over 65 years of age who meet the selection criteria and from the clinical record to their neurological risks (predisposition to delirium) will be selected, recording the variables: age, sex, weight, height, BMI and previous cognitive activity. The statistical program Excel for Windows will be used.Results: In this study, a total of 50 patients with a mean age of 70.8 (±7.1) years were included. By sex, 60.0% (30) were women and 40.0% were (20) men. The patients underwent gastrointestinal-abdominal (34%), orthopedic (26%), urological (16%), cardiovascular (12%) and other (12%) surgeries. DPO was detected in 22 (44.0%) patients, subsequently no significant differences by age and sex were found. The variables associated with DPO were duration of surgery (OR = 1.04 [95% CI 1.01-1.06, p = 0.004]) and the presence of elevated intraoperative glucose levels (OR = 1.02 [95% CI 1.00-1.04, p = 0.049]). Conclusions: DPO is a frequent complication in the elderly, which is why an opportune diagnosis and the implementation of prevention strategies are needed for this population. DPO is a frequent complication in the elderly, which is why an opportune diagnosis and the implementation of prevention strategies are needed for this population.

Association between intraoperative hyperglycemia/hyperlactatemia and acute kidney injury following on-pump cardiac surgery: a retrospective cohort study.

Despite the long-lasting notion about the substantial contribution of intraoperative un-stabilization of homeostasis factors on the incidence on acute kidney injury (AKI), the possible influence of intraoperative glucose or lactate management, as a modifiable factor, on the development of AKI remains inconclusive. To investigated the relationship between intraoperative hyperglycemia, hyperlactatemia, and postoperative AKI in cardiac surgery. A retrospective cohort study was conducted among 4,435 adult patients who underwent on-pump cardiac surgery from July 2019 to March 2022. Intraoperative hyperglycemia and hyperlactatemia were defined as blood glucose levels >10 mmol/L and lactate levels >2 mmol/L, respectively. The primary outcome was the incidence of AKI. All statistical analyses, including t tests, Wilcoxon rank sum tests, chi-square tests, Fisher's exact test, Kolmogorov-Smirnov test, logistic regression models, subgroup analyses, collinearity analysis, and receiver operating characteristic analysis, were performed using the statistical software program R version 4.1.1. Among the 4,435 patients in the final analysis, a total of 734 (16.55%) patients developed AKI after on-pump cardiac surgery. All studied intraoperative metabolic disorders was associated with increased AKI risk, with most pronounced odds ratio (OR) noted for both hyperglycemia and hyperlactatemia were present intraoperatively [adjusted OR 3.69, 95% confidence intervals (CI) 2.68-5.13, p < 0.001]. Even when hyperglycemia or hyperlactatemia was present alone, the risk of postoperative AKI remained elevated (adjusted OR 1.97, 95% CI 1.50-2.60, p < 0.001). The presence of intraoperative hyperglycemia and hyperlactatemia may be associated with postoperative acute kidney injury (AKI) in patients undergoing on-pump cardiac surgery. Proper and timely interventions for these metabolic disorders are crucially important in mitigating the risk of AKI.

Del Nido versus blood cardioplegia in cardiac surgery: A multicenter analysis of over 40,000 patients

ObjectivesThe use of del Nido cardioplegia in adult cardiac surgery is rising in popularity. The objective of this large multicenter study was to evaluate the use and associated outcomes of del Nido versus blood cardioplegia in adult cardiac surgery. MethodsPatients undergoing coronary artery bypass grafting (CABG) and/or valve (mitral, aortic), and/or nondescending thoracic aortic surgery (July 2014 to March 2022) across 39 centers were extracted from the Perfusion Measures and Outcomes registry. Patients were stratified by cardioplegia type for unadjusted analysis and multivariable mixed-effects models were used for risk adjustment. ResultsOf 44,175 patients, 42.5% used del Nido, with use increasing 48% over time. Overall, the del Nido group had shorter median crossclamp time (74 minutes vs 87 minutes, P < .001) and lower median peak intraoperative glucose levels (161 mg/dL vs 180 mg/dL, P < .001). Use of del Nido was not associated with operative mortality (adjusted odds ratio [ORadj], 1.16; P = .075) nor major morbidity (ORadj, 1.05; P = .25). Findings for valve cases were similar, except crossclamp time differences were variable by type of valve procedure. Within the CABG subgroup there was a trend toward increased operative mortality with del Nido (ORadj, 1.24; P = .069), whereas the risk of renal failure approaches statistical significance in the aortic subgroup (ORadj, 1.54; P = .056). ConclusionsIn this large, multicenter study, the use of del Nido was associated with variable crossclamp time differences, lower intraoperative glucose levels, and no significant difference in major morbidity or mortality. Efficiency benefits of del Nido may be limited in valve cases, whereas outcomes in CABG and aortic cases warrant further study.

Intraoperative Insulin Infusion Regimen versus Insulin Bolus Regimen for Glucose Management during CABG Surgery: A Randomized Clinical Trial

Background and Aim: The stress induced by surgery disrupts the delicate balance between hepatic glucose production and glucose utilization in the body. Despite the significance of intraoperative glycaemic control for diabetic patients, limited attention has been given to this aspect. Two methods for administering insulin to manage glucose levels during surgery exist. This study aimed to compare intraoperative glucose levels in diabetic patients undergoing Coronary Artery Bypass Graft (CABG) surgery using either insulin infusion or the bolus method. Method: This was a Randomized Clinical Trial (RCT). Seventy diabetic patients aged 40 or older scheduled for CABG surgery were enrolled in the trial. They were randomly assigned, using block randomization, to receive intraoperative insulin via either infusion or the bolus method. The primary outcome measure was intraoperative glucose levels. Subsequent insulin unit requirements and intraoperative potassium levels were secondary outcomes. Data was monitored throughout the CABG procedure and recorded at six different checkpoints. Results: Male patients constituted the majority in both groups, with no significant differences in the preoperative characteristics of patients, including HbA1c levels and comorbidities. The infusion regimen demonstrated a statistically significant reduction in glucose levels (-19.12 mg/dL, 95% CI: -27.68 to -10.55, P&lt;0.001, Cohen's d=1.06) compared to the bolus regimen. The total insulin units administered in the infusion group were 480 units, as opposed to 600 units in the bolus group (P=0.001, Cohen's d=0.85). Importantly, no cases of hypoglycemia or hyperkalemia were reported among the patients. Conclusion: Intraoperative glucose control using insulin was effective for CABG patients with diabetes. However, the infusion regimen exhibited statistically superior results compared to the bolus regimen. Clinical Trials Registry and Registration Number: The trial received approval from the Ethics Committee on 2/1/2019/2020 and was registered on Clinicaltrials.gov under ID: NCT04824586.

The efficacy of intraoperatie continuous glucose monitoring in patients undergoing liver transplantation: a study protocol for a prospective randomized controlled superiority trial

BackgroundThe high incidence of intraoperative glucose dysregulations in liver transplantation (LT) is related to the lack of highly orchestrated control of intraoperative blood glucose. Glucose monitoring based on a single arterial blood gas test can only provide a simple glucose profile and is insufficient in monitoring intraoperative glycemic variability (GV), which is not conducive to controlling GV and may have a lag in the management of hyper/hypoglycemia. Continuous glucose monitor (CGM), which has been successfully applied in the management of chronic disease in diabetes, provides more detailed blood glucose records and reflect GV parameters such as coefficient of variation (CV%). However, its effectiveness and accuracy for guiding blood glucose management in major surgeries remains unclear.MethodsThis is a single-center, randomized, controlled, superiority trial. One hundred and eighty patients scheduled for orthotopic LT will be recruited and randomized into two groups. All patients are monitored for intraoperative glucose using CGM combined with arterial blood gas (ABG). In the intervention group (group CG), ABG will be performed when CGM value is < 6.1 mmol/L or > 10.0 mmol/L, or the rate of change of CGM value > 1.67 mmol/(L·min). In the control group (group G), intraoperative ABG tests will be performed every 2 h, and the frequency of ABG tests will be adjusted based on the previous arterial glucose result. Patients in both groups will have their blood glucose adjusted according to arterial glucose values and a uniform protocol. Surgical and other anesthetic management is completed according to standard LT practices.DiscussionThis study intends to investigate the effectiveness of CGM-based intraoperative glucose management and its impact on the prognosis of LT patients by comparing the GV, mean glucose values, and the incidence of hypo/hypoglycemic events guided by the above two glucose monitoring methods.Trial registrationThis study is registered at www.chictr.org.cn on January 4, 2022, under the registration number ChiCTR2200055236.

Association of intraoperative hyperglycemia with postoperative composite infection after cardiac surgery with cardiopulmonary bypass: A retrospective cohort study.

The association between intraoperative hyperglycemia (IH) and postoperative infections in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) is inadequately studied. A total of 3,428 patients who underwent cardiac surgery with CPB at our institution between June 1, 2019 and July 30, 2021 were enrolled to evaluate the association of IH (blood glucose ≥ 180 mg/dL) with postoperative infection in patients. The new onset of any type of infection and the optimal cutoff values of intraoperative glucose to predict in-hospital infection were determined. The composite outcome occurred in 497 of 3,428 (14.50%) patients. IH was associated with an increased risk of postoperative composite infection [adjusted odds ratio: 1.39, (95% confidence interval), 1.06-1.82, P = 0.016]. Restricted cubic splines were applied to flexibly model and visualize the association of intraoperative peak glucose with infection, and a J-shaped association was revealed. Besides, it was demonstrated that the possibility of infection was relatively flat till 150 mg/dL glucose levels which started to rapidly increase afterward. We summarize that IH is associated with an elevated risk of postoperative new-onset composite infections and perioperative blood glucose management should be more stringent, i.e., lesser than 150 mg/dL in patients undergoing cardiac surgery.

Evaluating the Utilization of a Perioperative Hyperglycemic Protocol: A Quality Improvement Project

PurposeThe purpose of this project to evaluate adherence to the perioperative hyperglycemic protocol among Certified Registered Nurse Anesthetists (CRNAs) at a large academic hospital. A secondary objective of this project is CRNAs' perceptions of barriers to point-of-care (POC) testing and the protocol. DesignA quality improvement project. MethodsUsing Donabedian's conceptual framework, a Phase 1 retrospective chart analysis of 297 patients with diabetes undergoing noncardiac surgery before and after implementing POC testing for intraoperative glucose control was performed. Only patients with preoperative BG ≥ 180 mg/dL were included in this phase of the project, which involved a comparison of the protocol utilization before and after implementation of POC testing. Phase 2 included an assessment of CRNA's perceptions of the protocol. FindingsThe final sample included 91 (37 preimplementation; 54 postimplementation) participants. There were no significant demographic differences between the groups. Overall, 52.7% of patients had intraoperative glucose checks, and only 16.5% received insulin. Preoperative BG levels decreased 11.4-points, and postoperative BG levels increased 20.4 points when comparing pre- and postimplementation groups. However, there were significant differences in postoperative glucose levels, pre- and postimplementation. The survey showed that the majority (65.5%) of CRNAs identified difficulty locating the protocol as the primary barrier to utilization. ConclusionsAlthough all patients included in this project qualified for an intraoperative glucose check, findings revealed that only half of the patients had a glucose check and less than one fifth of the patients received insulin treatment, indicating poor adherence to the protocol. Thus, while implementing protocols is essential, utilization and adherence to the protocol are critical to improving patient outcomes. Recommendations for continued improvement include increasing protocol accessibility, staff training, compliance monitoring, and a more simple protocol structure.

Strategies for intraoperative glucose management: a scoping review.

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. 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. 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. Future studies examining intraoperative glycemic management should carefully consider the study population, surgical characteristics, and pre- and postoperative management of hyperglycemia.

Surgical universal euglycemic attainment during recovery (SUGAR) initiative: Sweet results through quality improvement (286)

<b>Objectives:</b> Perioperative hyperglycemia is associated with adverse postoperative outcomes. Lack of standardization leads to inconsistent detection and management of patients with diabetes during the perioperative period. Our objective was to improve perioperative glycemic control among patients with Type II diabetes mellitus undergoing open gynecologic surgery through a quality improvement initiative. <b>Methods:</b> We assembled a multidisciplinary team and implemented standardized screening guidelines, including obtaining a preoperative hemoglobin A1C in all patients before surgery. Algorithms were developed for patients with diabetes, and those at high risk were referred to Endocrinology to optimize glucose control in the preoperative period. We also standardized the intraoperative and postoperative management by increasing the frequency of intraoperative glucose monitoring and developing weight-based postoperative insulin order sets with basal, prandial, and correctional insulin. Outcomes were compared between a baseline (BL) group (February 2015-August 2017) and a post-implementation (PI) group (February 2018-April 2021). Summary statistics were used to describe the clinical and demographic characteristics. BL and PI groups were compared using the Chi-square test, Fisher's exact test, t-test, or Wilcoxon rank-sum test. A linear mixed effect model was constructed based on hours since initial preop measurement, time period measurement took place, and group (BL vs PI). <b>Results:</b> There were 81 patients in the BL group and 119 in the PI group. The BL and PI groups were similar in age, race, and indication for surgery (benign vs malignant). The PI group had lower median BMI (PI 32.7kg/m2 vs BL 35.3mg/m2; p=0.02), higher median Charlson Comorbidity Index (PI 4 vs BL 3; p=0.004), and surgical time (PI 258 minutes vs BL 197 minutes; p=0.009). The rate of obtaining a hemoglobin A1c prior to surgery increased from BL 14.8% to PI 89.0% (p<0.001). The rate of intraoperative glucose monitoring also increased from BL 50.6% to PI 76.5% (p<0.001). The linear mixed-effects model found PI estimated average glucose values decreased by 8.13mg/dL compared to BL levels (p=0.046). The percentage of postoperative glucose values that were at goal (<180mg/ dL) improved from BL 83% to PI 86% (p=0.008). There were no episodes of hypoglycemia or other safety events associated with the postoperative insulin order sets. <b>Conclusions:</b> The SUGAR initiative successfully increased compliance with preoperative screening for diabetes as well as improved perioperative monitoring and management of hyperglycemia. The impact of this initiative on glycemic control is evident not only by the improvement in average glucose values across all time periods but also by the percentage of glucose values that are at goal. This protocol safely improved perioperative glycemic control among patients with diabetes undergoing open gynecologic surgery.

Evaluation of machine learning models as decision aids for anesthesiologists.

Machine Learning (ML) models have been developed to predict perioperative clinical parameters. The objective of this study was to determine if ML models can serve as decision aids to improve anesthesiologists' prediction of peak intraoperative glucose values and postoperative opioid requirements. A web-based tool was used to present actual surgical case and patient information to 10 practicing anesthesiologists. They were asked to predict peak glucose levels and post-operative opioid requirements for 100 surgical patients with and without presenting ML model estimations of peak glucose and opioid requirements. The accuracies of the anesthesiologists' estimates with and without ML estimates as reference were compared. A questionnaire was also sent to the participating anesthesiologists to obtain their feedback on ML decision support. The accuracy of peak glucose level estimates by the anesthesiologists increased from 79.0 ± 13.7% without ML assistance to 84.7 ± 11.5% (< 0.001) when ML estimates were provided as reference. The accuracy of opioid requirement estimates increased from 18% without ML assistance to 42% (p < 0.001) when ML estimates were provided as reference. When ML estimates were provided, predictions of peak glucose improved for 8 out of the 10 anesthesiologists, while predictions of opioid requirements improved for 7 of the 10 anesthesiologists. Feedback questionnaire responses revealed that the anesthesiologist primarily used the ML estimates as reference to modify their clinical judgement. ML models can improve anesthesiologists' estimation of clinical parameters. ML predictions primarily served as reference information that modified an anesthesiologist's clinical estimate.

The effect of glucose control in liver surgery on glucose kinetics and insulin resistance

Clinical outcome is negatively correlated to postoperative insulin resistance and hyperglycemia. The magnitude of insulin resistance can be modulated by glucose control, preoperative nutrition, adequate pain management and minimal invasive surgery. Effects of glucose control on perioperative glucose kinetics in liver surgery is less studied. 18 patients scheduled for open hepatectomy were studied per protocol in this prospective, randomized study. In the treatment group (n=9), insulin was administered intravenously to keep arterial blood glucose between 6 and 8mmol/l during surgery. The control group (n=9) received insulin if blood glucose >11.5mmol/l. Insulin sensitivity was measured by an insulin clamp on the day before surgery and immediately postoperatively. Glucose kinetics were assessed during the clamp and surgery. Mean intraoperative glucose was 7.0mM (SD 0.7) vs 9.1mM (SD 1.9) in the insulin and control group respectively (p<0.001; ANOVA). Insulin sensitivity decreased in both groups but significantly (p=0.03, ANOVA) more in the control group (M value: 4.6 (4.4-6.8) to 2.1 (1.2-2.6) and 4.6 (4.1-5.0) to 0.6 (0.1-1.8) mg/kg/min in the treatment and control group respectively). Endogenous glucose production (EGP) increased and glucose disposal (WGD) decreased significantly between the pre- and post-operative clamps in both groups, with no significant difference between the groups. Intraoperative kinetics demonstrated that glucose control decreased EGP (p=0.02) while WGD remained unchanged (p=0.67). Glucose control reduces postoperative insulin resistance in liver surgery. EGP increases and WGD is diminished immediately postoperatively. Insulin seems to modulate both reactions, but mostly the WGD is affected. Intraoperative EGP decreased while WGD remained unaltered. ANZCTR 12614000278639.

Sterility and Infection Prevention Standards for Anesthesiologists in LMICs: Preventing Infections and Antimicrobial Resistance

Surgical site infections (SSI) affect millions of individuals around the world, leading to a significant burden on perioperative morbidity and healthcare economy. Over the past decade low-income and middle-income countries (LMICs) have made substantial advancements on infection prevention strategies. However, the incidence of SSI is still increasing in many LMICs across all surgical specialties, denoting overlooked areas and ongoing challenges. This article aims to describe the role of anesthesiologists on current standards of infection prevention and sterility as well as ongoing developments in resource-limited settings, with a focus on LMICs. Recent estimates indicate a threefold increase in the incidence of SSI across LMICs over the past two decades, approaching two times the estimated SSI incidence of high-income countries. As a result, public health officials have promoted standard practices for infection prevention in the surgical arena by creating multidisciplinary teams and tailoring to the availability of equipment and resources. Anesthesiologists play a pivotal role for the implementation of infection prevention strategies such as antimicrobial prophylaxis, normothermia, intraoperative glucose control, and adequate handling of intravenous anesthetics. Unfortunately, the lack of cohesive practices and leadership structures, along with poor surveillance systems, are still common barriers. One potential method of overcoming these obstacles is investment in sustainable national infection prevention programs. Infection prevention standards should be tailored to local workflow and institutional resources. The successful implementation of programs in LMICs depends on sustainable national infection prevention programs which includes a well-trained team and an institutional climate of safety.

Comparison of Microcirculatory Perfusion in Obese and Non-Obese Patients Undergoing Cardiac Surgery with Cardiopulmonary Bypass.

Obesity is a frequent comorbidity among patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). Cardiac surgery with CPB impairs microcirculatory perfusion, which is associated with multiple organ failure. As microvascular function is frequently compromised in obese patients, we studied whether cardiac surgery with CPB has a more detrimental effect on microcirculatory perfusion in obese patients. Sublingual microcirculatory perfusion was measured with sidestream dark field (SDF) imaging in obese patients (body mass index ≥32 kg/m2; n = 14) without type II diabetes mellitus and in lean patients (BMI 20–25 kg/m2; n = 22) undergoing cardiac surgery with CPB. CPB reduced systolic blood pressure and mean arterial pressure more profoundly in lean compared with obese patients (SBP: 38% vs. 18%; MAP: 11% vs. 8%, p < 0.05), and both restored after weaning from CPB. No differences were present in intraoperative glucose, hematocrit, hemoglobin, lactate, and blood gas values between obese and lean patients. Microcirculatory perfusion did not differ between obese and lean patients the day before surgery. CPB decreased microcirculatory perfusion with 9% in both groups, but this was only significant in lean patients (p < 0.05). Three days following surgery, microcirculatory perfusion was restored in both groups. In conclusion, microcirculatory perfusion was equally disturbed during cardiac surgery with CPB in metabolically healthy obese patients compared to lean patients.

Intraoperative dextrose rate during exploratory laparotomies in neonates and the incidence of postoperative hyperglycemia: A retrospective observational study.

Compared with the older pediatric population, neonates have greater perioperative morbidity and mortality. Difficulty with glucose regulation may be a contributing modifiable risk factor during perioperative anesthetic management. To mitigate the risk of hyperglycemia in neonates, some providers empirically halve the preoperative rate of dextrose-containing infusions during surgery. To assess the association between halving the preoperative maintenance dextrose rate and postoperative euglycemia in neonatal intensive care unit patients undergoing exploratory laparotomies. Neonatal intensive care unit patients who underwent exploratory laparotomy under general anesthesia from 1/1/2014 to 11/21/2019 were included in this analysis. Hyperglycemia and hypoglycemia were defined as >150mg/dL and <46mg/dL. A calculated dextrose ratio was utilized to categorize patients into full and half intraoperative dextrose rate cohorts. Univariate analyses were performed with Fisher's exact test, the Wilcoxon rank sum test, or Spearman's correlation. Multivariable analyses with regression models were conducted after graphical evaluation of a predetermined set of independent variables. 107 patients were included in the full dextrose rate cohort and 96 patients in the half dextrose rate cohort with postoperative hyperglycemia occurring in 47 and 28 patients, respectively. On univariate analysis, halving the preoperative dextrose rate was associated with decreased postoperative hyperglycemia (odds ratio: 0.53; 95% CI: 0.28-0.98, P= 0.041). This association continued in the regression model (adjusted odds ratio: 0.49; 95% CI: 0.25-0.80, P= 0.008) after controlling for preoperative dextrose rate, preoperative serum glucose, preoperative pH, surgical duration, postmenstrual age at surgery, and the presence of necrotizing enterocolitis. Only one patient was hypoglycemic postoperatively, and they were in the full dextrose cohort. Halving of preoperative dextrose rates intraoperatively during exploratory laparotomy in neonatal intensive care unit patients was associated with a decreased risk of postoperative hyperglycemia without substantially increasing the occurrence of postoperative hypoglycemia. The practice of halving preoperative dextrose rates may be an effective empirical approach for intraoperative glucose management in the high-risk neonatal population when blood glucose monitoring is challenging.