Perioperative Glucose Control in the Diabetic or Nondiabetic Patient

Emory University, Atlanta, Georgia, United States
Southern Medical Journal (Impact Factor: 0.93). 07/2006; 99(6):580-9; quiz 590-1. DOI: 10.1097/01.smj.0000209366.91803.99
Source: PubMed


Patients with diabetes are more likely to undergo surgery than nondiabetics, and maintaining glycemic control in subjects with diabetes can be challenging during the perioperative period. Surgery in diabetic patients is associated with longer hospital stay, higher health care resource utilization, and greater perioperative mortality. In addition, several observational and interventional studies have indicated that hyperglycemia is associated with adverse clinical outcomes in surgical and critically ill patients. This paper reviews the pathophysiology of hyperglycemia during trauma and surgical stress and will provide practical recommendations for the preoperative, intraoperative, and postoperative care of diabetic patients.

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    • "Patients receiving oral antidiabetic medications should have these held for 24 h prior to surgery. Intravenous insulin is optimal in the immediate perioperative period for type 1 diabetes, as well as for many type 2 diabetic patients undergoing major procedures and should typically be continued until a patient resumes eating (66,67). When subcutaneous insulin is used, long-acting analogs (e.g., glargine and detemir) may be given at usual dose the evening before surgery, but the dose should be reduced if the patient’s typical fasting blood sugars are lower than 90–100 mg/dL. "
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    ABSTRACT: The implementation of an inpatient diabetic foot service should be the goal of all institutions that care for patients with diabetes. The objectives of this team are to prevent problems in patients while hospitalized, provide curative measures for patients admitted with diabetic foot disorders, and optimize the transition from inpatient to outpatient care. Essential skills that are required for an inpatient team include the ability to stage a foot wound, assess for peripheral vascular disease, neuropathy, wound infection, and the need for debridement; appropriately culture a wound and select antibiotic therapy; provide, directly or indirectly, for optimal metabolic control; and implement effective discharge planning to prevent a recurrence. Diabetic foot ulcers may be present in patients who are admitted for nonfoot problems, and these ulcers should be evaluated by the diabetic foot team during the hospitalization. Pathways should be in place for urgent or emergent treatment of diabetic foot infections and neuropathic fractures/dislocations. Surgeons involved with these patients should have knowledge and interest in limb preservation techniques. Prevention of iatrogenic foot complications, such as pressure sores of the heel, should be a priority in patients with diabetes who are admitted for any reason: all hospitalized diabetic patients require a clinical foot exam on admission to identify risk factors such as loss of sensation or ischemia. Appropriate posthospitalization monitoring to reduce the risk of reulceration and infection should be available, which should include optimal glycemic control and correction of any fluid and electrolyte disturbances.
    Full-text · Article · Sep 2013 · Diabetes care
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    • "Patients with diabetes are more likely to undergo surgery than people without diabetes (1). Surgery in diabetic patients is associated with longer hospital stay, greater perioperative morbidity and mortality, and higher health care resource utilization than nondiabetic subjects (1,2). Increased morbidity and mortality in diabetic patients relates in part to higher incidence of comorbid conditions including coronary heart disease, hypertension, and renal insufficiency (1,3,4), as well as adverse effects of hyperglycemia on clinical outcome (5,6). "
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    ABSTRACT: The optimal treatment of hyperglycemia in general surgical patients with type 2 diabetes mellitus is not known. This randomized multicenter trial compared the safety and efficacy of a basal-bolus insulin regimen with glargine once daily and glulisine before meals (n = 104) to sliding scale regular insulin (SSI) four times daily (n = 107) in patients with type 2 diabetes mellitus undergoing general surgery. Outcomes included differences in daily blood glucose (BG) and a composite of postoperative complications including wound infection, pneumonia, bacteremia, and respiratory and acute renal failure. The mean daily glucose concentration after the 1st day of basal-bolus insulin and SSI was 145 ± 32 mg/dL and 172 ± 47 mg/dL, respectively (P < 0.01). Glucose readings <140 mg/dL were recorded in 55% of patients in basal-bolus and 31% in the SSI group (P < 0.001). There were reductions with basal-bolus as compared with SSI in the composite outcome [24.3 and 8.6%; odds ratio 3.39 (95% CI 1.50-7.65); P = 0.003]. Glucose <70 mg/dL was reported in 23.1% of patients in the basal-bolus group and 4.7% in the SSI group (P < 0.001), but there were no significant differences in the frequency of BG <40 mg/dL between groups (P = 0.057). Basal-bolus treatment with glargine once daily plus glulisine before meals improved glycemic control and reduced hospital complications compared with SSI in general surgery patients. Our study indicates that a basal-bolus insulin regimen is preferred over SSI in the hospital management of general surgery patients with type 2 diabetes.
    Full-text · Article · Feb 2011 · Diabetes care
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    • "By these definitions, most of these studies may not qualify for global recommendation of strict BG control until such time that other multicenter trials verify these findings, both in surgical and medical ICUs. The latter statement, however, does not contradict the acceptance of the well-established beneficial effects of standardized BG control in diabetic patients with severe hyperglycemia and acute metabolic decomposition of diabetic ketoacidosis or hyperglycemic hyperosmolar state [33], as well as diabetic patients undergoing various surgical procedures [9] [34]. "
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    ABSTRACT: Inpatient hyperglycemia in patients with and without a history of diabetes is common and is associated with increased hospital morbidity and mortality. The objectives of this communication are to examine results of randomized clinical trials of strict inpatient glucose control in medical and surgical intensive care units and to provide guidelines for achieving and maintaining glycemic control in patients admitted to critical and noncritical settings. We propose a more conservative approach of glycemic control than current American Association of Clinical Endocrinology recommendations until results of prospective, multicenter, randomized studies become available.
    Full-text · Article · Feb 2008 · Metabolism
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