Postoperative Glycemic Control Research Articles

Relationship of Perioperative Hyperglycemia and Postoperative Infections in Patients Who Undergo General and Vascular Surgery

Evaluate the association of perioperative hyperglycemia and postoperative infections (POI) in patients who had undergone general surgery. Intensive glucose control leads to less postoperative infections (POI) in critically ill surgical patients, but the relationship of hyperglycemia and POI in a general surgical population remains unknown. A retrospective study of 995 patients who had undergone general and vascular surgery investigated the association of perioperative acute hyperglycemia and risk of 30-day POI over an 18-month period. The primary predictor of interest was postoperative glucose (POG). Bivariate analyses determined the association of each independent variable with POI. Factors significant at P < 0.05 were used in multivariable logistic regression models. In bivariate analyses, preoperative blood glucose (P = 0.012), POG (P = 0.009), age (P = 0.002), diabetes (P = 0.04), American Society of Anesthesia Classification (ASAC) (P < 0.0001), operation length (P = 0.02), and blood transfusions (P = 0.02) were significant predictors of POI. In multivariate analyses, only POG (OR = 1.3, (1.03-1.64)), ASAC (OR = 1.9, (1.31-2.83)), and emergency status (OR = 2.2, (1.21-3.80)) remained significant predictors of POI. Postoperative hyperglycemia increased the risk of POI by 30% with every 40-point increase from normoglycemia (<110 mg/dL). Longer hospitalization was also observed for patients with POG from 110 to 200 mg/dL (OR = 1.4, (1.1-1.7)) and >200 mg/dL (OR = 1.8, (1.4-2.5)). The increased risk of POI and length of hospitalization posed by postoperative hyperglycemia is independent of diabetic status and needs further evaluation to assess for possible benefits of postoperative glycemic control in patients who have undergone general surgery.

Adverse Outcomes of Geriatric Patients Undergoing Abdominal Surgery Who Are at High Risk for Delirium

Among geriatric patients undergoing abdominal surgery who are at high risk for in-hospital delirium, clinical factors associated with delirium correlate with adverse outcomes. Retrospective case series study. University-affiliated referral hospital. Among 228 consecutive patients 70 years or older who underwent major abdominal surgery from September 1, 2002, through December 31, 2003, 89 patients with risk factors for delirium were included in the study. Preoperative, intraoperative, and postoperative clinical factors known to affect the incidence of in-hospital delirium were tested for correlation with adverse outcomes. Incidence of delirium, mortality, and prolonged length of stay (LOS) of 14 days or longer were evaluated as adverse outcomes. Postoperative delirium occurred in 60%, death in 20%, and prolonged LOS in 32% of patients. Multivariate analysis identified independent predictors of adverse outcomes. Poor preoperative functional and nutritional status correlated with postoperative delirium and mortality. Inadequate postoperative glycemic control also correlated with mortality. Complications in 2 or more organ systems and postoperative hypoalbuminemia (albumin level <3.0 mg/dL[<.003 g/dL; to convert to grams per liter, multiply by 10]) correlated with prolonged LOS. Suboptimal care was identified in the following clinical areas: use of precipitative medications, prolonged bedrest, uncontrolled pain, hypoxia, and glycemic control. In a subset of geriatric patients undergoing abdominal surgery who are at high risk for in-hospital delirium, adverse outcomes correlated only with key clinical variables, such as hyperglycemia and poor nutritional and functional states. A high incidence of suboptimal care was observed in several clinical areas, suggesting opportunities for intervention.

Tight Glycemic Control During Cardiac Surgery: No Benefit

Hyperglycemia is common during cardiac surgery, and strict postoperative glycemic control can decrease morbidity and mortality, but the risks and

Postoperative Glycemic Control after Central Pancreatectomy for Mid‐gland Lesions

Patients undergoing partial pancreatectomy are at risk for developing surgically induced diabetes. Patients with lesions in the neck and body of the pancreas are at increased risk because traditional resectional approaches (pancreaticoduodenectomy or distal pancreatectomy) must be extended to remove the tumor with adequate margins. Increasingly, we have been performing pancreatic parenchyma-sparing resections (central pancreatectomy with pancreaticogastrostomy) in an effort to reduce the risk of postpancreatectomy endocrine insufficiency. The operative records of patients who underwent pancreatectomy at our institution from 1999 to 2005 were reviewed. We identified 26 patients who underwent central pancreatectomy with pancreaticogastrostomy reconstruction for cystic lesions (n = 23), neuroendocrine tumors (n = 2), and Frantz's tumor (n = 1). Charts were reviewed for patient demographics, volume of resection, complications, and evaluation of postoperative glycemic control. The mean follow-up was 33 months (range 3-72 months). The average volume of pancreas resected was 49.6 +/- 38.6 cm(3), and the mean diameter of the lesions was 2.6 +/- 1.5 cm. Nine complications occurred in eight patients (overall morbidity 31%), and the average length of stay was 6.9 +/- 2.7 days. Pancreatic leaks (n = 2; 7.7%) were successfully managed nonoperatively. There was no operative mortality, and there has been no tumor recurrence. None of the patients were diabetic preoperatively. Postoperatively, two (7.7%) developed endocrine insufficiency with a mean postoperative hemoglobin A1c (HbA1c) value of 7.65%. Neither patient has required exogenous insulin. HbA1c in the remaining patients was 5.9% +/- 0.5%. Pancreatic parenchyma-sparing surgery for lesions in the midportion of the gland can be performed with acceptable morbidity. Postoperative glycemic control after pancreatic parenchyma-sparing surgery compares favorably with that reported for patients with traditional resections.

Re: Postoperative Glycemic Control in Patients Undergoing Central Pancreatectomy for Mid‐gland Lesions

Re: Postoperative Glycemic Control in Patients Undergoing Central Pancreatectomy for Mid‐gland Lesions

Description and Evaluation of a Glycemic Management Protocol for Patients with Diabetes Undergoing Heart Surgery

To evaluate a protocol for glycemic management in the treatment of postoperative heart patients with diabetes in the setting of a community hospital. The protocol included a standardized guideline in tabular form for nurse-implemented insulin infusion ("drip") therapy for postoperative glycemic control. At the time of discontinuation of the insulin drip, the glycemic status of patients with diabetes was managed by the endocrine department. Overall, 29 patients were assessed without and 29 patients with use of the protocol in a community hospital. From postoperative days 0 through 4, use of the protocol resulted in a greater number of blood glucose determinations, a trend toward greater utilization of insulin drip therapy without a significant increase in the number of patients treated with insulin drip, and no change in the frequency of hypoglycemic episodes. During the same time interval, the percentages of postoperative days during which at least one blood glucose value equaled or exceeded 250 mg/dL were 27.5% without the protocol and 16.8% with use of the protocol (P = 0.0318). The principal finding of the study was reduction in the percentage of postoperative days during which mean blood glucose values equaled or exceeded 200 mg/dL to less than half the previously observed frequency-from 38.4% without the protocol to 16.8% with the protocol (P = 0.0001). The effectiveness of the insulin drip component of the protocol is suggested by a trend, shown on postoperative days 2 through 4, of 70 patient days with mean blood glucose levels <200 mg/dL (58 of these days without insulin drip therapy) and 15 patient days with mean blood glucose values > or =200 mg/dL (none of these days associated with same-day insulin drip therapy). A standardized approach to insulin drip therapy, in combination with subspecialty consultation for follow-up glycemic management with use of subcutaneous administration of insulin, can improve glycemic control in postoperative heart patients without continuation of insulin drip therapy outside the critical-care unit. The trends observed on postoperative days 2 through 4, that most patients maintained glycemic control without insulin drip therapy and that all failures of glycemic control occurred among patients who no longer received insulin drip therapy, suggest the possibility of developing criteria for selection of patients for continuation of insulin infusion outside the critical-care unit.