Perioperative Hypoglycemia Research Articles

Protecting tiny patients: preventing perioperative hypoglycaemia in paediatric surgery

Protecting tiny patients: preventing perioperative hypoglycaemia in paediatric surgery

Postattenuation neurologic signs after surgical correction of congenital portosystemic shunts in cats: A narrative review.

Development of postattenuation neurological signs (PANS) is a potentially severe complication after surgical attenuation of congenital portosystemic shunts in cats. This review summarizes findings of 15 publications that report occurrence of PANS in cats. PANS includes seizures but also milder neurologic signs such as blindness, ataxia, abnormal behavior, tremors, and twitching. Incidence of PANS and specifically postattenuation seizures in studies including a minimum of five cats ranges from 14.3% to 62.0% and 0% to 32.0%, respectively. Etiology of PANS in cats is unknown, however, several hypotheses have been proposed including central nervous system disease/derangement, perioperative hypoglycemia and electrolyte disturbances, and postoperative portal hypertension. A number of possible risk factors have been identified including lower grades of intraoperative postocclusion mesenteric portovenography and osmolality at 24 h postoperatively. Evidence for use of prophylactic antiepileptics such as levetiracetam to prevent or reduce incidence of PANS in cats is limited and does not support their use. Because the cause is unknown, treatment is aimed at controlling neurologic signs, preventing progression to more severe signs, and providing general supportive care. Prospective studies comparing the efficacy of different antiepileptics for treatment of PANS in cats are required. Prognosis for recovery is variable and dependent on severity of neurologic signs. For cats surviving to discharge, long-term survival is possible but persistence or recurrence of neurologic signs in the long-term is not uncommon.

Development and validation of a prediction model of perioperative hypoglycemia risk in patients with type 2 diabetes undergoing elective surgery

AimTo develop and validate a prediction model to evaluate the perioperative hypoglycemia risk in hospitalized type 2 diabetes mellitus (T2DM) patients undergoing elective surgery.MethodsWe retrospectively analyzed the electronic medical records of 1410 T2DM patients who had been hospitalized and undergone elective surgery. Regression analysis was used to develop a predictive model for perioperative hypoglycemia risk. The receiver operating characteristic (ROC) curve and the Hosmer–Lemeshow test were used to verify the model.ResultsOur study showed an incidence of 10.7% for level 1 hypoglycemia and 1.8% for level 2 severe hypoglycemia during the perioperative period. A perioperative hypoglycemic risk prediction model was developed that was mainly composed of four predictors: duration of diabetes ≥ 10 year, body mass index (BMI) < 18.5 kg/m2, standard deviation of blood glucose (SDBG) ≥ 3.0 mmol/L, and preoperative hypoglycemic regimen of insulin subcutaneous. Based on this model, patients were categorized into three groups: low, medium, and high risk. Internal validation of the prediction model showed high discrimination (ROC statistic = 0.715) and good calibration (no significant differences between predicted and observed risk: Pearson χ2 goodness-of-fit P = 0.765).ConclusionsThe perioperative hypoglycemic risk prediction model categorizes the risk of hypoglycemia using only four predictors and shows good reliability and validity. The model serves as a favorable tool for clinicians to predict hypoglycemic risk and guide future interventions to reduce hypoglycemia risk.

Perioperative use of glucose containing solutions in infants less than 6months of age: A clinical practice survey among US academic centers.

Although there is a wide breadth of literature on glucose homeostasis in infants, standardization of perioperative hypoglycemia diagnosis and management is lacking. Survey of academic pediatric anesthesiology departments across the USA to evaluate institutional policies regarding the perioperative use of glucose containing solutions in infants less than 6months of age. A questionnaire was sent to 20 United States university affiliated academic pediatric anesthesiology departments. The responses suggest that, in the centers surveyed, glucose administration in infants is largely practitioner dependent. Two respondents (10%) claim to have a departmental policy regarding glucose administration in infants less than 6months of age. In premature infants, 75% of respondents administer glucose. When administering glucose, 75% of physicians surveyed replete infants at their maintenance intravenous fluid rate. There was discrepancy among practitioners regarding initiation of hypoglycemia treatment, 35% treat infants at a blood glucose level of 70mg/dl, 30% at BG 60mg/dl, 25% at 50mg/dl, and 10% are unsure. This survey highlights the lack of consensus, at least among pediatric anesthesiologists working in US academic centers, regarding blood glucose management in infants less than 6months of age. There is a need to define the indications for using glucose containing solutions in infants during the perioperative period, their ideal content, the appropriate thresholds for hypo- and hyperglycemia as well as the optimal point-of care glucose monitoring intervals.

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.

Anesthesia management in a patient with very long-chain acyl-Coenzyme A dehydrogenase deficiency

BackgroundIn a patient with very long-chain acyl-Coenzyme A dehydrogenase (VLCAD) deficiency, metabolism of fatty acids is impaired and a supply of alternative energy is limited when glucose level is insufficient on starvation.Case presentationA 37-year-old woman with VLCAD deficiency was diagnosed with an ovarian cyst and was scheduled for laparoscopic ovarian cystectomy. Glucose was administered intravenously with the start of fasting. Anesthesia was induced with remifentanil, midazolam, and thiamylal, maintained with desflurane and remifentanil. Body temperature was maintained at 36.2–36.7 °C. During anesthesia, hypoglycemia did not occur, creatine kinase levels were in the normal range, and myoglobinuria was not detected. No shivering was observed after extubation.ConclusionsGlucose was administered to avoid perioperative hypoglycemia. Body temperature was controlled to avoid shivering, which would otherwise increase skeletal muscle energy needs. Blood creatine kinase did not increase, and myoglobinuria was not detected; thus, rhabdomyolysis was unlikely to develop.

A randomized control study of preoperative fasting and oral glucose fluid on incidence of perioperative hypoglycemia and hemodynamic

A randomized control study of preoperative fasting and oral glucose fluid on incidence of perioperative hypoglycemia and hemodynamic

Effects of dietary intervention before selective coronary intervention in patients with type 2 diabetes mellitus

Objective To explore the effects of dietary intervention before selective coronary intervention on patients with type 2 diabetes mellitus and to provide reference and basis for building a feasible and practical preoperative dietary management system. Methods Totally 300 patients with type 2 diabetes mellitus who received coronary intervention in the Cardiac Catheterization Room of Peking Union Medical College Hospital from December 2016 to December 2017 were selected by convenient sampling and divided into the control group (n=150) and the observation group (n=150) according to the random number table. Patients in the control group were fasted for solids and liquids for 4 hours before coronary intervention, while patients in the observation group received foods and drinks for diabetic patients rather than being fasted for solids and liquids as well as individualized dietary guidance from dieticians, specialized diabetes nurses and intervention nurses jointly. The incidence rate of perioperative hypoglycemia. hunger, thirst, anxiety score before and after the intervention, comfort of dietary management were evaluated between the two groups. Results The control group scored higher in hunger, thirst and anxiety than the observation group (P<0.05); the comfort of dietary management was higher in the observation group than in the control group (P<0.05); the incidence rate of perioperative asymptomatic hypoglycemia in the observation group was 2.0%, while that in the control group was 20.6%; the incidence rate of perioperative symptomatic hypoglycemia in the observation group was 0, while that in the control group was 1.3%. Conclusions Patients with type 2 diabetes mellitus should not be fasted for solids and liquids as conventionally did before selective coronary intervention. Rather, a scientific preoperative dietary management model can prevent the incidence of perioperative hypoglycemia in patients with type 2 diabetes mellitus, enhancing the comfort and safety of operation during the perioperative period. Key words: Diabetes mellitus, type 2; Clinical governance; Coronary vessels; Intervention; Fasting for solids and liquids

Impact of perioperative hypoglycaemia in subjects with diabetes undergoing colorectal surgery.

This study explores the association between perioperative hypoglycaemia and surgical outcomes in subjects with diabetes, undergoing colorectal surgery. A retrospective review of 149 subjects with Type 2 Diabetes Mellitus (DM) who underwent colorectal surgery between 2010 and 2015 was performed. Perioperative glucose levels, glycated haemoglobin (HbA1c) measurements within 3months of surgery and surgical complications based on Clavien-Dindo classification were analysed. The mean age was 67years (67±11.2). Perioperative hypoglycaemia was found in 7.4% of subjects. The mean HbA1c of subjects with Clavien 2 and above surgical complications were higher than patients with Clavien 1 or no complications, Hba1c 7.6% (7.6±2.5%) and 7.0% (7.0±1.1%, p=0.008), respectively. Similar findings in subjects with Clavien 3 and above complications, HbA1c of 8.2% (8.2±3.9%) as compared to those with Clavien 2 and below complications, 7.2% (7.2±1.5%, p=0.001). Adjusted multivariate analysis showed that hypoglycaemia was significantly associated with Clavien 2 and above surgical complications, OR of 19.0 (CI 2.23-162, p=0.007). Preoperative hypoglycaemia was associated with Clavien 2 and above surgical complications, OR 10.7 (CI 1.22-94.1, p=0.032). Suboptimal glycaemic control (Hba1c >8.0%) was significantly associated with Clavien 2 and above complications, OR 2.48 (CI 1.04-5.91, p=0.04), but not with Clavien 3 and above complications, OR 1.50 (CI 0.450-4.98, p=0.511). Perioperative hypoglycaemia is associated with adverse surgical outcomes in diabetic patients undergoing colorectal surgery. Prevention of hypoglycaemia may improve surgical outcomes. HbA1c is an independent predictor for adverse surgical outcomes.

Perioperative glycaemic control in diabetic patients undergoing cataract surgery under local anaesthesia: a survey of practices of Singapore ophthalmologists and anaesthesiologists.

Perioperative glycaemic control is an important aspect of clinical management in diabetic patients undergoing cataract surgery under local anaesthesia. While poor long-term glycaemic control has significant implications for surgery, perioperative hypoglycaemia or hyperglycaemia may also compromise patient safety and surgical outcomes. We aimed to survey ophthalmologists and anaesthesiologists on their approach and to identify the prevalent practice patterns in Singapore. This was a cross-sectional questionnaire-based survey conducted in four public hospitals in Singapore with established ophthalmology and anaesthesia units. Respondents were approached individually, and the self-administered questionnaires comprised questions related to practice patterns, clinical scenarios and awareness of pre-existing guidelines. A total of 129 doctors responded to the questionnaire survey. 76 (58.9%) were from ophthalmology departments and 53 (41.1%) were from anaesthesia departments. The majority chose to withhold oral hypoglycaemic agents (82.9%) and/or insulin (69.8%), and keep the patient fasted preoperatively. A blood glucose level ≥ 17 mmol/L prompted 86.0%-93.8% of respondents to adopt a treat-and-defer strategy, while a level ≥ 23 mmol/L prompted 86.0%-96.9% of respondents to cancel the cataract surgery. The respondents were consistently more concerned about perioperative hyperglycaemia (n = 99, 76.7%) than intraoperative hypoglycaemia (n = 83, 64.3%). The current study presented the prevalent practice patterns of ophthalmologists and anaesthesiologists in the perioperative management of diabetic patients undergoing cataract surgery in four public hospitals in Singapore. Further research in this field is required, and may be useful for the future formulation of formal guidelines and protocols.

Comparison of Ringer’s solution with 0.4% glucose or without in intraoperative infusion regimens for the prevention of hypoglycemia in juvenile pigs

Juvenile pigs are prone to hypoglycemia, nevertheless they are commonly used in preclinical studies. The optimal perioperative fluid management with crystalloid solutions in such settings has not yet been studied. The aim of the current study was to correlate the perioperative fluid administration of Ringer's solution, with and without the addition of a minimal amount of glucose (0.4% glucose) to the blood glucose, and the incidence of perioperative hypoglycemia in 20 juvenile pigs (31.7 ± 5.2 kg) undergoing surgery for approximately one hour. Infusion of Ringer's solution without glucose (group Ri, n = 10) led to a significant decrease of the serum blood glucose level from 105.7 ± 27.1 mg/dL at baseline compared with 87.8 ± 31.7 mg/dL post surgery. The pigs (50%) in group Ri were observed to be hypoglycemic (<72 mg/dL). The second group received Ringer's solution containing a final concentration of 0.4% glucose (group Ri-Glu, n = 10) and showed a significant increase in blood glucose level from 104.4 ± 15.8 mg/dL at baseline compared with 122.3 ± 14.3 mg/dL post surgery. No animal in group Ri-Glu was observed to be hypoglycemic. In conclusion, we showed that even minor changes in perioperative crystalloid fluid management significantly influence blood glucose levels. In order to avoid hypoglycemia in juvenile pigs we recommend adding a minimal amount of glucose (0.4% final concentration) to the Ringer's solution given perioperatively during surgery of approximately one hour.

In-hospital Management of Diabetes

In-hospital Management of Diabetes

Intensive Intraoperative Insulin Therapy Versus Conventional Insulin Therapy During Cardiac Surgery: A Meta-Analysis

The goal of this meta-analysis was to determine the benefits and risks of rigorous glycemic control during cardiac surgery. The authors conducted searches of MEDLINE (January 1966 through February 2011), Embase (January 1985 through February 2011), the Cochrane Central Register of Controlled Trials (Cochrane Library issue 2, 2011), and the reference lists of the included trials. The authors searched for studies in any language in which adult cardiac surgical patients were assigned randomly to intensive insulin therapy (IIT) versus conventional insulin therapy (CIT). Two authors independently extracted the information and assessed the methodologic quality of the trials. The summary effects were estimated with the risk ratio or risk difference using random- and fixed-effects models. Randomized controlled trials. A meta-analysis of 5 randomized control trials. Five randomized controlled trials that included 706 patients were identified. Overall, the risk difference of 30-day/in-hospital mortality with IIT compared with CIT was 0.01 (95% confidence interval [CI] = -0.01 to 0.03; p = 0.25) and the risk difference of hypoglycemic events with IIT was -0.02 (95% CI = 0.05-0.01; p = 0.26) and thus not different between treatments. The infection rate was lower in patients randomized to the IIT arm (risk ratio = 0.50; 95% CI = 0.29-0.84; p = 0.009). Among the 4 trials that reported cardiovascular events, the pooled risk ratio with IIT was 0.85 (95% CI = 0.45-1.59; p = 0.61). The intraoperative use of IIT may decrease the infection rate in cardiac surgical patients compared with the CIT group. However, IIT may not decrease mortality, the incidence of hypoglycemia, or the incidence of cardiovascular events. Additional well-designed randomized trials are required to clarify the potential benefit of IIT on 30-day/in-hospital mortality and the incidence of perioperative hypoglycemia.

A novel isotonic balanced electrolyte solution with 1% glucose for intraoperative fluid therapy in neonates: results of a prospective multicentre observational postauthorisation safety study (PASS)

Neonates have a higher metabolic rate and an increased risk of perioperative hypoglycemia and lipolysis, but during anesthesia, both oxygen consumption and metabolic rate are decreased, and this may lead to reduced intraoperative glucose requirements. The objective of this prospective multicentre observational postauthorisation safety study was to evaluate the intraoperative use of a novel isotonic balanced electrolyte solution with a low glucose concentration of 1% (BS-G1) in neonates with a particular focus on changes in acid-base, electrolyte, and glucose concentrations. Following the local ethics committee approval, neonates with a postmenstrual age under 45 weeks and an ASA risk score of I-IV undergoing intraoperative administration of BS-G1 were enrolled. Patient demographics, the performed procedure, adverse drug reactions, hemodynamic data, and the results of blood gas analysis before and after infusion were documented with a focus on changes in acid-base, electrolyte, and glucose concentrations. In 66 neonates (ASA I-IV; postmenstrual age 38 ± 4, range 25-45 weeks; body weight 2.9 ± 0.9, range 0.65-4.6 kg), the mean infusion rate was 10.4 ± 3.2 (range 4.5-19.6) ml·kg(-1) ·h(-1) BS-G1. During the infusion, hemoglobin, hematocrit, bicarbonate, base excess, anion gap, strong ion difference, and calcium decreased, and chloride and glucose increased significantly within the physiological range. All other measured parameters including sodium and lactate remained stable. Neither hypoglycemia (glucose < 3 mm) nor hyperglycemia (glucose > 10 mm) was documented after BS-G1 infusion. No adverse drug reactions were reported. The study shows that the intraoperative use of an isotonic balanced electrolyte solution with 1% glucose and a mean infusion rate of 10 ml·kg(-1) ·h(-1) helps to avoid acid-base dysbalance, hyponatraemia, hypoglycemia, ketoacidosis, and hyperglycemia in surgical neonates. A careful intraoperative monitoring and adaptation of the infusion rate as needed is crucial because the glucose and fluid requirements may vary widely between subjects.

Comparison of Dextrose Water and Hartmann's Solution in Each Low and High Doses for Adult Ambulatory Anesthesia: Effect on Recovery from Anesthesia

Background: Adequate fluid administration for ambulatory anesthesia has not been widely studied because most patients are healthy and operations are short durations and not invasive. However, long pre-operative nothing per os (NPO) time is known to affect post-operative complications like pain, headache, dizziness, drowsiness, fatigue, nausea, vomiting, thirsty, sore throat, or well-being sensation. And amount of administered fluid or inclusion of dextrose during the operation could exercise great influence on those symptoms. Therefore, we compared four fluid regimens; 5% dextrose water 2 ml/kg (D/W2), 20 ml/kg (D/W20) and Hartmann's solution 2 ml/kg (H/S2), 20 ml/kg (H/S20) regarding to post-operative complications of ambulatory anesthesia. Methods: One hundred and sixty ambulatory anesthesia patients of ASA 1 or 2 undergoing general anesthesia or monitored anesthesia care were randomly assigned into D/W2, D/W20, H/S2 or H/S20. Each group of patients received 5% dextrose water 2 ml/kg, 20 ml/kg, Hartmann's solution 2 ml/kg, or 20 ml/kg for 30 min, respectively. Complications like pain, headache, dizziness, drowsiness, fatigue, nausea, vomiting, thirsty, sore throat, or well-being sensation of patients were checked with systemized questionnaire check box graded 4 scales at recovery room, at evening and at 24 hours later. Results: H/S20 group was better in nausea, thirsty and well-being sensation. Sixteen percent of patients showed hypoglycemia before anesthesia. Dextrose water resulted transient hyperglycemia and osmotic diuresis. Conclusions: Large amount of Hartmann's solution was generally better regarding post-operative complications. We should pay attention at peri-operative hypoglycemia for ambulatory anesthesia. (Korean J Anesthesiol 2007; 52: 55～61)

Perioperative management of total parenteral nutrition, glucose containing solutions, and intraoperative glucose monitoring in paediatric patients: a survey of clinical practice.

Infants and children, particularly those who are chronically ill and maintained on total parenteral nutrition (TPN), are at risk for perioperative hypoglycaemia [blood glucose < 2.2 mmol x l(-1) (40 mg x dl(-1))] and hyperglycaemia [blood glucose > 11 mmol x l(-1) (200 mg x dl(-1))]. We surveyed paediatric anaesthesiologists regarding their perioperative management of blood glucose and TPN in paediatric patients to determine the current practice and its perceived success. Questionnaires were mailed to all members of the Study Group on Pediatric Anesthesia and the response rate was 70%. Results indicate that the current perioperative management of blood glucose and TPN is somewhat varied. Furthermore, greater than 10% of those surveyed report that their management results in a variable response in the maintenance of normoglycaemia. While the detrimental effects of perioperative hypoglycaemia and hyperglycaemia are rare, they are serious. A Medline search shows that no studies have been published regarding perioperative management of paediatric patients receiving TPN, although it appears that clinical study is warranted.

Plasma glucose levels in the peri-operative period in children.

Peri-operative plasma glucose levels were studied in one hundred children under 5 years of age and under 20 kg. All underwent procedures of less than 30 minutes. Of 32 cases under the third percentile for weight, ten developed low plasma glucose during the pre-operative and/or postoperative phase. This occurred despite receiving 5% dextrose by mouth 4 hours before induction. Even in children of normal weight there was a low incidence of peri-operative hypoglycaemia. Routine intravenous glucose-containing fluids are thus recommended during the peri-operative period.

Perioperative Hypoglycemia in a Child Treated with Propranolol

Perioperative Hypoglycemia in a Child Treated with Propranolol