Perioperative Diabetes Care Research Articles

86-LB: Accuracy of a Factory-Calibrated, Real-Time Continuous Glucose Monitoring (CGM) System during Elective Abdominal Surgery

Aim: To assess the accuracy of the Dexcom G6 CGM system during elective abdominal surgery. Methods: Twenty adults with (pre-)diabetes scheduled for abdominal surgery (>2h) (5 females, age 69±13 yrs, BMI 27.3±6.6 kg/m2, HbA1c 7.0±1.3%) wore the Dexcom G6 sensor from 7±2 days preoperatively until hospital discharge. Reference capillary glucose values were obtained every 20min from induction of anaesthesia until 2h post-surgery using the Accu-Chek® Inform II meter. The primary endpoint was the mean absolute relative difference (ARD) between sensor and reference method. Results: Mean±SD operating time was 306±170min and included pancreas/liver (45%), upper GI (10%), lower GI (40%) and kidney (5%) surgeries. The mean±SD and median [interquartile range] ARD of 523 paired CGM/reference values were 12.7±8.7% and 10.4% [4.3%, 19.7%], respectively. A total of 99.4% pairs were in Clarke error grid Zones A or B (A, 76.5%, B 22.9%, Figure 1). Overall, 65.8% of sensor readings were within the limits specified by the ISO 15197:2013 norm. Sensor readings were available for 98.6% [95.9%, 100%] of the perioperative time. Intraoperative sensor replacement was required in one instance. There were no adverse device effects. Conclusion: Perioperative use of the Dexcom G6 system showed satisfying accuracy, opening new avenues for perioperative diabetes care. Disclosure A. Tripyla: None. D. Herzig: None. C. Nakas: None. J. Dehais: None. A. Andreou: None. F. Amiet: None. B. Gloor: None. A. Vogt: None. L. Bally: None. Funding Dexcom, Inc. (HOS-2019-005)

Improving the peri-operative pathway of people with diabetes undergoing elective surgery: the IP3D project.

To determine whether outcomes for people with diabetes undergoing elective surgery improve following the introduction of innovations in the peri-operative care pathway. Following a baseline audit of 185 people with diabetes listed for elective surgery (July to December 2017) with a length of stay > 24 hours, a number of changes in practice were implemented. These included dissemination of a 'diabetes peri-operative passport' to participants preoperatively, formation of a diabetes surgery working group, recruitment of surgical diabetes champions and the roll-out of surgical diabetes study days. Crucial was recruitment of a diabetes peri-operative nurse, whose role included engaging and educating others and supporting individuals throughout their peri-operative diabetes care. Records of 166 individuals listed for surgery during the implementation period (July to December 2018) were then audited using the same methodology. The availability of a recent HbA1c measurement significantly increased (63% vs 92%; P ≤ 0.001). The mean HbA1c of those seen for optimizations by the diabetes peri-operative nurse significantly decreased [84 mmol/mol (9.8%) vs 62 mmol/mol (7.8%); P ≤ 0.001]. Recurrent hypoglycaemia significantly decreased (7.0% vs 0.6%; P = 0.002) and the mean number of hyperglycaemic events in people experiencing hyperglycaemia almost halved (3.0 vs 1.7; P=0.007). The mean length of hospital stay significantly decreased (4.8 vs 3.3 days; P=0.001) and, crucially, 30-day readmissions did not increase (12% vs 9%; P=0.307). Postoperative complications significantly decreased (28% vs 16%; P=0.008), including a composite of dysglycaemic complications, poor wound healing, wound infection and other infections (12% vs 5.4%; P=0.023). The new pathway improved important peri-operative outcomes for people with diabetes undergoing elective surgery with the potential for cost savings. These findings could have important implications for peri-operative care on a wider scale.

Perioperative glucose management: Current status and future directions.

Hyperglycemia in surgical patients is common and associated with increased morbidity and mortality. Optimal perioperative care includes pre-surgery evaluation of glucose control, adequate preoperative management of glucose-lowering therapies, and repeated blood glucose monitoring on the day of surgery. There is consensus regarding the maintenance of intraoperative glucose levels below 10.0mM through the use of subcutaneous or intravenous insulin, and over the avoidance of aggressive strategies in order to minimize the risk of hypoglycemia. As staffing levels are stretched and prevalence and complexity of cases increase, novel diabetes technologies such as continuous glucose monitoring, insulin pumps and closed-loop glucose control systems can potentially address unmet needs in the provision of perioperative diabetes care. This potential calls for well-designed clinical trials covering various aspects of perioperative glucose management in order to establish evidence-based and standardized practices. This long-term goal relies heavily on communication and collaboration in multidisciplinary teams that include anesthesiologists, surgeons, and endocrinologists.

Impact of a multifaceted strategy to improve perioperative diabetes care.

To assess the impact of a multifaceted strategy to improve perioperative diabetes care throughout the hospital care pathway. We conducted a controlled before-and-after study in six hospitals. The purpose of the strategy was to target four predominant barriers that obstruct optimal care delivery. We provided feedback on baseline indicator performance, developed a multidisciplinary protocol and patient information, and provided professional education. After a 6-month intervention, we determined the performance changes against three outcome indicators and nine process indicators using data on 811 patients with diabetes who underwent major surgery. The progress of the interventions was monitored closely. Two process indicators improved significantly in the intervention hospitals: the proportion of patients for whom glycaemic control had been evaluated preoperatively increased by 9% (P < 0.002) and the proportion of patients with blood glucose measurements within 1 h after surgery increased by 29% (P < 0.0001). Four other process indicators and all three outcome indicators improved more in the intervention hospitals than in the control hospitals, but the differences were not statistically significant. These included the proportion of patients with all glucose values at 6-10 mmol/l (+3%) and the proportion of patients with hyperglycaemia (-8%). The implementation of the multidisciplinary protocol was still ongoing after the 6-month intervention period. The multifaceted improvement strategy had a limited impact on the quality of perioperative diabetes care. This study demonstrates the complexity of improving perioperative diabetes care throughout the multiprofessional hospital care pathway.

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

BackgroundIn 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...

PS12 - 2. Patients are insufficiently involved in perioperative diabetes care

To assess patient experiences with perioperative diabetes care and to identify determinants of these experiences.

Postoperative Mortality in Cancer Patients With Preexisting Diabetes

OBJECTIVEDiabetes appears to increase risk for some cancers, but the association between preexisting diabetes and postoperative mortality in cancer patients is less clear. Our objective was to systematically review postoperative mortality in cancer patients with and without preexisting diabetes and summarize results using meta-analysis.RSEARCH DESIGN AND METHODSWe searched the Medical Literature Analysis and Retrieval System Online (MEDLINE) and Excerpta Medica Database (EMBASE) for articles published on or before 1 July 2009, including references of qualifying articles. We included English language investigations of short-term postoperative mortality after initial cancer treatment. Titles, abstracts, and articles were reviewed by at least two independent readers. Study population and design, results, and quality components were abstracted with standard protocols by one reviewer and checked for accuracy by additional reviewers.RESULTSOf 8,828 titles identified in our original search, 20 articles met inclusion criteria for qualitative systematic review. Of these, 15 reported sufficient information to be combined in meta-analysis. Preexisting diabetes was associated with increased odds of postoperative mortality across all cancer types (OR = 1.85 [95% CI 1.40–2.45]). The risk associated with preexisting diabetes was attenuated but remained significant when we restricted the meta-analysis to models that controlled for confounders (1.51 [1.13–2.02]) or when we accounted for publication bias using the trim and fill method (1.52 [1.13–2.04]).CONCLUSIONSCompared with their nondiabetic counterparts, cancer patients with preexisting diabetes are ∼50% more likely to die after surgery. Future research should investigate physiologic pathways to mortality risk and determine whether improvements in perioperative diabetes care can reduce postoperative mortality.

The effects of a randomised multi‐centre trial and international accreditation on availability and quality of clinical guidelines

To examine the availability and quality of clinical guidelines on perioperative diabetes care in hospital units before and after a randomised clinical trial (RCT) and international accreditation. Interventional "before-after" study in 51 units (38 surgical and 13 anaesthetic) in nine hospitals participating in a RCT in the greater Copenhagen area; 27 of the units also underwent international accreditation. The proportion of units with guidelines increased from 24/51 (47 percent) units before to 38/51 (75 percent) units after the trial. Among the 27 units without guidelines before the trial, significantly more accredited units compared to non-accredited units had a guideline after the trial (9/10 (90 percent) compared to 5/17 (29 percent). The quality of the systematic development scale and the clinical scales improved significantly after the trial in both accredited units (both p < 0.001) and in non-accredited units (both p < 0.02). The improvement of the systematic development scale was significantly higher in accredited than in non-accredited units (p < 0.01). The combination of conducting both the DIPOM Trial and international accreditation led to a significant improvement of both dissemination and quality of guidelines on perioperative diabetic care.