Perioperative Management Of Diabetes Research Articles

Perioperative Management Of Diabetes Mellitus In Older Hip Fracture Patients

Abstract Background Hip fracture is one of the most serious injuries sustained by older adults worldwide, associated with increased morbidity and almost 25% mortality at one year. Pre-existing comorbidity worsens prognosis, e.g. hip fracture patients with Diabetes Mellitus (DM) have increased mortality rates, worse functional outcomes, and higher post-operative complications rates. Perioperative blood glucose optimisation may improve outcomes, however this can be challenging due to periods of fasting and reduced intake, as well as complications such as infection. Local guidelines for the peri-operative management of DM have been developed and are sign-posted in our hip fracture integrated admission document. This audit aimed to compare current practice with those recommended in local guidance. Methods Since 1st January 2024, 31 hip fracture patients aged ≥65 years with DM have been admitted. Charts were available on twenty patients, and hence reviewed. Results Of 20 patients, four were on insulin; 13 on metformin; four on sulphonylureas; five on SGLT2 inhibitors; and six on DPP4 inhibitors. No intraoperative hypoglycemic events nor episodes of Diabetic Ketoacidosis were documented; however, ketones were not checked in the majority of patients during admission. Eleven (55%) had HbA1C either done in the previous six months or during admission. Blood Sugar Levels were checked on admission in 9/20 (45%). The protocol was followed in only one patient on insulin; and 5/13 metformin patients. The protocol was followed in all Sulphonylurea prescriptions, and in 4/5 SGLT2 inhibitor prescriptions, however these medications were not held by the Orthopaedic team, rather by nursing staff while the patient was fasting pre-operatively. Conclusion This audit demonstrates poor adherence to local guidance on peri-operative management of diabetes, particularly perioperative insulin adjustments. We aim to develop an educational intervention (including group teaching, plus distribution of flashcards and posters) for Orthopaedic SHOs and interns and re-audit in the coming months.

Perioperative Management of Patients with Diabetes and Cancer: Challenges and Opportunities.

Both diabetes and cancer are major global health issues that are among the leading causes of morbidity and mortality. There is a high prevalence of diabetes among cancer patients, many of whom require a surgical procedure. This review focuses on the operative complications in patients with diabetes and cancer, and the perioperative management of diabetes in cancer patients. A literature search of articles in English-published between January 2010 and May 2024-was carried out using the databases PubMed, MEDLINE, Google Scholar, and the Cochrane Database of Systematic Reviews. The search primarily focused on the operative complications in patients with diabetes and cancer, and perioperative management strategies. The relationship between cancer and diabetes is complex; cancer patients have a high risk of developing diabetes, while diabetes is a risk factor for certain cancers. In addition, various cancer therapies can induce or worsen diabetes in susceptible patients. Many individuals with cancer and diabetes require surgery, and due to underlying diabetes, they may have elevated risks for operative complications. Optimal perioperative management for these patients includes managing perioperative glycemia and other comorbid illnesses, adjusting diabetic and cancer treatments, optimizing nutrition, minimizing the duration of fasting, supporting early mobilization, and providing patient education to enable self-management. While evidence is limited, optimal perioperative management for patients with both diabetes and cancer is necessary in order to reduce surgical complications. Future studies are needed to develop evidence-informed perioperative strategies and improve outcomes for these patients.

Perioperative management of diabetes

Perioperative management of diabetes

The impact of diabetes on physical and mental health status and patient satisfaction after total hip and knee arthroplasty.

To assess the impact of diabetes on physical and mental health status, as well as patient satisfaction, one-year following knee and hip total joint arthroplasty (TJA) for osteoarthritis (OA). Participants were 626 hip and 754 knee TJA patients. Pre-surgery data were collected on socio-demographics and health status. The 12-item Short Form Health Survey (SF-12) was collected pre- and one year post-surgery, and physical (PCS) and mental component (MCS) summary scores computed. One-year patient satisfaction was also recorded. Four regression models tested the effect of diabetes on: 1) PCS change score; 2) MCS change score; 3) achieving minimal clinically important improvement (MCII) on PCS; and 4) patient satisfaction ('Somewhat or Very Satisfied' vs. 'Somewhat or Very Dissatisfied'). An interaction between surgical joint and diabetes was tested in each model. Self-reported diabetes prevalence was 13.0% (95% CI: 11.2%-14.7%) and was more common in knee 16.1% (95% CI: 13.4%-18.7%) than hip 9.3% (95% CI: 7.0%-11.5%) patients. In adjusted analyses, change scores were 2.3 units less on the PCS for those with diabetes compared to those without (p = 0.005). Patients with diabetes were about half as likely to achieve MCII as patients without diabetes (p = 0.004). Diabetes was not significantly associated with satisfaction or changes in MCS scores. Diabetes effects did not differ by surgical joint. Findings support that diabetes has a negative impact on improvements in physical health after TJA. Considering the growing prevalence of OA and diabetes in the population, our findings support the importance of perioperative screening and management of diabetes in patients undergoing TJA.

Protocol for a prospective multicentre cohort study to address the question whether diabetes and its management is still a risk factor in fast-track joint arthroplasty

IntroductionPerioperative glycaemic control is important. However, the complexity of guidelines for perioperative diabetes management is complicated due to different and novel antihyperglycaemic medications, limited procedure-specific data and lack of data...

Peri-operative management of diabetes mellitus - A survey of current practices among Indian anesthesiologists.

Increased burden of diabetes in India has resulted in a spurt in the number of patients with diabetes posted for surgeries. The paucity of national guidelines can lead to marked practice variations in the peri-operative management of diabetes. This survey intends to discern current peri-operative practices among anesthesiologists working in medical colleges, tertiary care government, and private health care institutes of the country. An anonymous online survey comprising of 25 closed-ended questions was conducted using Google Forms® and disseminated through social media, emails, and messaging platforms. The questionnaire dealt primarily with the peri-operative management of diabetes in patients scheduled for elective surgery. The survey was conducted over a period of 1 month and targeted anesthesia resident trainees with more than 1-year experience, senior residents, and consultants working in India. Statistically significant difference was observed between the three types of health facilities with respect to prior evaluation for diabetes (P = 0.007), prioritizing operative list (P = 0.006), hospital encouragement of day care surgery (P < 0.001), glycated hemoglobin level (HbA1c) level >8.5 for postponement of surgery (P < 0.05), insulin infusion preference (P < 0.001), hourly intra-operatively capillary blood glucose (CBG) assessment (P = 0.021), and avoiding peri-operative use of Ringer's lactate (RL) (P = 0.025). This survey primarily highlights the lack of prioritizing the operative list, early discontinuation of metformin, and reduced tendency to consider diabetics for day care surgeries.

Perioperative management of diabetes audit (POMODA)

BackgroundSuboptimal perioperative management of diabetes is associated with postoperative morbidity and mortality. Australian healthcare providers should primarily be guided by the Australian Diabetes Society Perioperative Diabetes Management Guidelines in caring for the perioperative diabetic patient when local or state guidelines do not exist. MethodsA retrospective, single-center, quality improvement audit was conducted on diabetic patients aged ≥18 years undergoing surgical procedures at the Townsville University Hospital, Australia, over a 12-week period. Perioperative outcomes were analyzed to establish compliance with the guidelines. Secondary objectives analyzed outcomes for Indigenous and non-Indigenous Australian patients, and patients’ age. Results202 patients were reviewed. 53 (26%) had preoperative blood glucose levels (BGLs) measured hourly. Of the patients requiring intraoperative BGLs, 93% did not have BGLs hourly and 71% did not have any intraoperative BGL. 23 (11%) had hourly BGLs postoperatively. Average preoperative haemoglobin A1c (HbA1c) was 7.5%, above target, and not measured in 45% of patients. 16/42 (38%) on metformin having major surgery had it restated appropriately. 29/41 (71%) on Sodium-Glucose Cotransporter-2 (SGLT2) inhibitors did not have a perioperative ketone level measured. Categorizing subjects into American Society of Anesthesiologists (ASA) classes revealed a greater proportion of patients aged <60 years were of class II (34%) compared to patients aged 60–70 (16%) and >70 (15%) (p = 0.015). Indigenous patients were more likely to be younger than non-Indigenous patients, 59 compared to 68 (p<0.001), and have a higher preoperative BGL, 9.0 mmol/L (162 mg/dL) compared to 8.2 mmol/L (148 mg/dL) (p = 0.19). Conclusions: POMODA has displayed multiple areas for improvement in the perioperative management of diabetes. The authors recommend that pre-anaesthetic clinics for diabetic patients requiring surgery, particularly Indigenous Australians, be held at least two weeks prior to surgery to allow for optimisation of glycaemic control and clear perioperative instructions, and anticipate this being an important first step in improving guideline compliance.

Improving the perioperative pathway of patients with diabetes undergoing surgery – a quality improvement project

Background: More than 323 000 operations take place in the UK each year in diabetic patients, accounting for 15% of all operative procedures.1 This group continues to have a longer length of stay and higher rates of adverse postoperative outcome.2 As per the 2019 National Diabetes Inpatient Audit (NaDIA), our institution currently operates below the benchmark (staff knowledge and patients’ ability to take control of their diabetes).3 Our length of stay for elective diabetes patients was 0.36 days above the national average.4 Methods: Data were collected prospectively in diabetic patients undergoing elective surgery between 1 and 30 September 2021. Pregnant, paediatric, and non-elective patients were excluded. Patient characteristics and information relevant to perioperative management was collected and analysed against The Centre for Perioperative Care (CPOC) recommendations.4 Results: Our data are shown in Table 1.Table 1Data collected perioperatively in diabetic patients.Characteristics of study subjects. Values are given as mean or n (%). DM, type of diabetes mellitus; CBG, capillary blood glucose.n27Age (yr)69 (49–89)BMI30.4 (18–38.8)ASA 10 214 (51.8%) 312 (44.4%) 41 (0.037%)DM 11 (0.037%) 226 (96.2%)Preop HbA1C <69 mmol L–122 (81.5 %) >69 mmol L–15 (18.5%)Fasting >10 h15 (55.5%)Not first on list20 (74%)WHO Checklist completed27 (100%)Anaesthetic technique GA15 (55.5%) Other12 (44.4%)CBG not measured Intraoperatively12 (44.4%) Postoperatively4 (14.8%)Duration in recovery <1 h20 (74%) >24 h1 (0.037%)Postoperative diabetes management plan As per protocol21 (77.7%) No plan identifiable6 (22.2%)Discharged Day care18 (16.6%) Ward8 (29.6%) HDU1 (0.037%) Open table in a new tab Conclusions: Compliance with CPOC guidelines was variable with some evidence of good practice and some requiring further improvement and education. To improve delivery of care in this group of patients, perioperative interventions were recommended including introduction of individualised perioperative care plans for diabetic patients, flash cards designed for glycaemic management, and development of institutional guidelines for perioperative diabetes management. We emphasise the need for teaching and training of nursing staff and educating patients about their perioperative journey and diabetes management. 1.Rotruck S, Suszan L, Vigersky R, et al. AANA J 2018; 86: 194–2002.Sampson MJ et al. Diabetes Res Clin Pract 2007; 77: 92–83.National Diabetes Inpatient Audit. NHS Digital, 2019. Available from: https://digital.nhs.uk/data-and-information/clinical-audits-and-registries/national-diabetes-inpatient-audit4.Guidelines for perioperative care for people with diabetes mellitus undergoing elective and emergency surgery. Centre for Perioperative Care, 2021. Available from: https://cpoc.org.uk/guidelines-resources-guidelines-resources/guideline-diabetes

Perioperative management of diabetes in patients undergoing bariatric and metabolic surgery: a narrative review and the Cleveland Clinic practical recommendations.

Bariatric and metabolic surgery is an effective treatment for patients with severe obesity and obesity-related diseases. In patients with type 2 diabetes, it provides marked improvement in glycemic control and even remission of diabetes. In patients with type 1 diabetes, bariatric surgery may offer improvement in insulin sensitivity and other cardiometabolic risk factors, as well as amelioration of the mechanical complications of obesity. Because of these positive outcomes, there are increasing numbers of patients with diabetes who undergo bariatric surgical procedures each year. Prior to surgery, efforts should be made to optimize glycemic control. However, there is no need to delay or withhold bariatric surgery until a specific glycosylated hemoglobin target is reached. Instead, treatment should focus on avoidance of early postoperative hyperglycemia. In general, oral glucose-lowering medications and noninsulin injectables are not favored to control hyperglycemia in the inpatient setting. Hyperglycemia in the hospital is managed with insulin, aiming for perioperative blood glucose concentrations between 80 and 180 mg/dL. Following surgery, substantial changes of the antidiabetic medication regimens are common. Patients should have a clear understanding of the modifications made to their treatment and should be followed closely thereafter. In this review article, we describe practical recommendations for the perioperative management of diabetes in patients with type 2 or type 1 diabetes undergoing bariatric surgery. Specific recommendations are delineated based on the different treatments that are currently available for glycemic control, including oral glucose-lowering medications, noninsulin injectables, and a variety of insulin regimens.

The Pro-Diab Melbourne Perioperative Study: A structured pre-admission perioperative diabetes management plan to improve medication usage in elective surgery.

BackgroundPerioperative diabetes management has become increasingly complex; management is often inconsistent resulting in dysglycaemia and associated morbidity.AimTo evaluate a structured pre‐admission perioperative diabetes management plan (PDMP) for safe and appropriate recommendation, prescription and administration of diabetes medications in the perioperative period for people with diabetes undergoing elective, non‐cardiac surgery.MethodsA multidisciplinary team developed the intervention, a structured PDMP (including diabetes medication reconciliation, management guide, individualised plan) to standardise optimal perioperative diabetes management. A single centre prospective pre‐ and post‐intervention pilot study was performed, including all individuals with diabetes medications attending the pre‐admissions clinic during two 4‐month periods (February to May) in 2016 (control period) and 2017 (intervention period). The primary outcome was appropriate recommendation, prescription and administration of diabetes medications (including insulin), according to the PDMP, in the perioperative period. Secondary outcomes measures were glycaemia. Analysis was by intention to treat.ResultsControl and intervention groups included 131 and 133 participants, respectively; they were well matched in clinical characteristics. The PDMP was completed correctly in 100 (75%) individuals in the intervention group. The appropriate use of diabetes medications increased from 30% in the control group to 71% in the intervention group (p < 0.001). Following the PDMP implementations, glycaemia improved in the overall perioperative period (8.7 ± 2.9 vs. 9.8 ± 3.3 mmol/L, p = 0.005) and at all time points (from admission and over entire hospital stay).ConclusionA structured pre‐admission perioperative diabetes management plan for elective surgery improved safe and appropriate diabetes medication use and glycaemia in the perioperative period.

Continuous Glucose Monitoring Reveals Perioperative Hypoglycemia in Most Patients With Diabetes Undergoing Major Surgery: A Prospective Cohort Study.

To investigate the frequency and duration of hypo- and hyperglycemia, assessed by continuous glucose monitoring (CGM) during and after major surgery, in departments with implemented diabetes care protocols. Inadequate glycemic control in the perioperative period is associated with serious adverse events, but monitoring currently relies on point blood glucose measurements, which may underreport glucose excursions. Adult patients without (A) or with diabetes [non-insulin-treated type 2 (B), insulin-treated type 2 (C) or type 1 (D)] undergoing major surgery were monitored using CGM (Dexcom G6), with an electrochemical sensor in the interstitial fluid, during surgery and for up to 10 days postoperatively. Patients and health care staff were blinded to CGM values, and glucose management adhered to the standard diabetes care protocol. Thirty-day postoperative serious adverse events were recorded. The primary outcome was duration of hypoglycemia (glucose <70 mg/dL). Clinicaltrials.gov: NCT04473001. Seventy patients were included, with a median observation time of 4.0 days. CGM was recorded in median 96% of the observation time. The median daily duration of hypoglycemia was 2.5 minutes without significant difference between the 4 groups (A-D). Hypoglycemic events lasting ≥15 minutes occurred in 43% of all patients and 70% of patients with type 1 diabetes. Patients with type 1 diabetes spent a median of 40% of the monitoring time in the normoglycemic range 70 to 180 mg/dL and 27% in the hyperglycemic range >250 mg/dL. Duration of preceding hypo- and hyperglycemia tended to be longer in patients with serious adverse events, compared with patients without events, but these were exploratory analyses. Significant duration of both hypo- and hyperglycemia was detected in high proportions of patients, particularly in patients with diabetes, despite protocolized perioperative diabetes management.

Perioperative diabetes management of adult patients with diabetes: a best practice implementation project.

The objectives of this project were to conduct a retrospective healthcare records audit to determine the current compliance with evidence-based criteria regarding perioperative management of patients with diabetes; to identify barriers and facilitators to achieve compliance and develop strategies to address areas of non-compliance, and to implement evidence-based best practice recommendations for perioperative diabetic management and to assess the effectiveness of these strategies in improving compliance of perioperative diabetic management across five participating clinical areas in a large tertiary referral hospital. Type 2 diabetes is a frequent co-morbidity among inpatients. It affects up to 20% of the general surgical population. Patients with diabetes undergoing surgery have a greater complication rate and length of hospital stay. Optimization of diabetes management of hospitalized patients will improve quality of care delivery, prevent postoperative complications and reduce length of stay and costs. However, there is limited knowledge and understanding of whether the current nursing practices concerning perioperative diabetic management meet the best practice recommendations outlined by JBI best practice criteria. A pre-post intervention healthcare record audit was conducted to examine compliance with nine best practice recommendations for perioperative diabetic management across five clinical areas. Following pre-intervention data analysis along with two focus group discussions, barriers to compliance with best practice criteria were identified and targeted strategies were used to address the issues. This project used the JBI Practice Application of Clinical Evidence System (PACES) and Getting Research into Practice (GRiP) tools. Face to face education sessions and educational resources relating to perioperative diabetic management were delivered to nursing staff, which resulted in improved compliance for most of the audit criteria, with significant improvement in the areas of regular blood glucose level monitoring and nursing staff receiving education and training in the post-implementation analysis.

Duke University Medical Center Perioperative Diabetes Management Program.

Quality Improvement Success Stories are published by the American Diabetes Association in collaboration with the American College of Physicians and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes a project at an academic tertiary-care medical center aimed at identifying surgical patients with uncontrolled diabetes early in the preoperative process to improve their perioperative glycemic control and surgical outcomes.

Variability of Clinical Practice Management of Type 1 and Type 2 Diabetes During Surgery Across Canada

ObjectiveAs part of a larger project to develop quality standards in perioperative diabetes management, the goal of this project was to assess self-reported management of surgical patients with diabetes across healthcare institutions and specialties in Canada. MethodsCurrent practice of perioperative management of patients with diabetes was assessed using multiple-choice questions based on commonly encountered clinical scenarios involving patients with type 1 and type 2 diabetes. The survey was sent to a broad stakeholder group of individuals involved in perioperative medicine in academic and community settings across Canada. ResultsResponses to clinical case scenarios demonstrated more consistent approaches for patients with type 1 diabetes undergoing cardiac surgery, possibly reflecting more robust evidence. There was more variability in the management of noninsulin antihyperglycemic agents and hyperglycemia in patients with type 2 diabetes undergoing noncardiac surgery. ConclusionsGiven the variability in clinical practice, standards and clinical tools are required for perioperative and periprocedural glycemic management in Canada to inform practice, improve the experience and outcomes for people with diabetes and provide a foundation for quality improvement initiatives and benchmarking.

Diabetes management during cardiac surgery in the UK: A survey

To determine current practice regarding the diabetes management of people undergoing cardiac surgery in the UK. We conducted an online survey of UK cardiothoracic surgeons. All cardiothoracic surgeons listed in the Society of Cardiothoracic Surgery membership directory were invited to participate. The survey, compiled using SurveyMonkey software, comprised 15 closed and open-ended questions about the management of people with diabetes pre- and peri-operatively. Sixty-two cardiothoracic surgeons from all 33 UK cardiac centres completed the survey. Of these, 44% responded that they routinely measure HbA1c preoperatively for all patients, 19% had an HbA1c threshold above which they would not operate and 21% currently undertake a point-of-care HbA1c measurement during the cardiothoracic outpatient visit. A total of 74% of respondents reported that it was 'easy' or 'very easy' to obtain a diabetes team review; diabetes nurse specialists were the members of the diabetes team working most closely with cardiac surgeons. Up to a third of the surgeons did not provide physical activity recommendations prior to admission and over 80% did not have a different preoperative or surgical diabetes protocol. Inconsistency in the responses within centres suggests that differences in practice may depend on individual surgeons rather than local policy. The study demonstrates there is only limited peri-operative management of diabetes in people undergoing cardiac surgery in the UK. There is an opportunity for greater involvement of the diabetes specialist team both before and during admission for surgery to improve outcomes. (Trial registration: ISRCTN10170306).

The Dentoalveolar Surgical Patient

Dentoalveolar surgery comprises more than 50% of the practice of oral and maxillofacial surgeons worldwide and is the most commonly performed category of surgical procedure. Optimal strategies for management of many medical problems, however, remain unclear. Remaining current on medical and surgical perioperative strategies is a standard for best practice. This article provides contemporary approaches for the perioperative management of patients presenting for dentoalveolar surgery. Attention will be directed to the perioperative management of cardiovascular disease, diabetes, and obesity. These diseases are chosen owing to controversies with respect to good scientific evidence that supports a standard of perioperative care.

Principles of anesthetic management of surgeries in diabetes patients

The objective: to describe the modern aspects of perioperative management of diabetes patients.Results:glycemic level correction makes the main task of preoperative preparation. The article presents modern approaches to solving this problem in emergency and planned surgery, target parameters of blood glucose concentration, criteria of patients' readiness for surgery. The principles of choosing the anesthesia method, features of regional anesthesia, and infusion therapy are discussed.

Insight Into the Perioperative Management of Type 2 Diabetes.

Diabetic people are at risk of developing acute complications when exposed to stress. Surgery brings a stressful period when the patient is exposed not only to surgical stress but also the effects of medications used during that particular period. The patient’s comorbidities can influence the perioperative management of diabetes. Poorly controlled diabetes can complicate the hospital course.The literature was searched through PubMed and the articles of the last 5 years, from 2014 to 2019, were looked into. The studies available as a free text, in the English language and related to humans, were included. Inclusion criteria also included adults with type 2 diabetes undergoing surgery.The perioperative management of diabetes is a challenging one. Apart from the diabetes control; comorbidities, general health, intake, and interaction of medications both anti-diabetic and non-diabetic, type and duration of surgery, are some of the factors that influence the outcome of the surgery. With a variety of options available to manage diabetes currently, it is important to have a good insight into their effects to prevent complications to occur and ensure safe discharge from the hospital. The good control of diabetes is essential in bringing favorable outcomes.The perioperative management of diabetes should be individualized. Oral anti-hyperglycemic medications, other than sulfonylureas and SGLT2 inhibitors, provide a reasonable alternative to insulin and can be continued safely perioperatively depending upon the type of surgery and the patient is expected to resume oral intake soon postoperatively.

The peri-operative management of diabetes in elective major vascular procedures: a completed cycle quality improvement project (QIP)

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Perioperative Management of Diabetes for Total Joint Arthoplasty: A Consensus Article

Diabetes mellitus (DM) is an increasingly prevalent comorbidity among patients undergoing total joint arthroplasty. Uncontrolled DM is a known risk factor for a multitude of postoperative complications, the most dreaded of which is periprosthetic joint infection, but also includes wound complications, deep venous thrombosis, and worse functional outcomes. Given that uncontrolled DM is a modifiable risk factor, it would be prudent for the surgeon to do all that is possible to minimize perioperative risks related to DM while also avoiding unnecessary surgical delays. In this article, we review risk mitigating measures including surgical screening, cutoff thresholds for hemoglobin A1C and maintaining good perioperative glycemic control. We recommend that all presurgical patients be screened for DM by measuring A1C. A value of 8.0% is a reasonable cutoff in surgical candidates and those falling above this value should be referred for glucose optimization before proceeding with surgery. Hemoglobin A1C has not been found to be a good predictor of postoperative complications and thus a strict A1C cutoff should be evaluated on a case by case basis. Maintaining tight glucose control, specifically avoiding hyperglycemia and large glucose fluctuations, is beneficial in the perioperative period and striving for a glucose goal between 80 and180 mg/dL is recommended.