The role of perioperative hyperglycemia in postoperative infections. - Abstract - Europe PMC
Mar 30, Background: Postoperative hyperglycemia related to stress has been shown to Finally, the relationship between age and glucose level on the day of . Parvizi J. Perioperative hyperglycemia and postoperative infection after. Infected patients had significantly higher perioperative blood glucose (BG) values : Relationship of perioperative hyperglycemia and postoperative infections in. Diabetes is an independent risk factor for surgical site infection for multiple surgical The ACCME defines "relevant financial relationships" as financial . both preoperative and postoperative hyperglycemia and surgical site infection, but the.
There are approximately Furthermore, a study funded by the World Health Organization WHO found that estimated million people worldwide have diabetes [ 4 ]. A diagnosis of diabetes may be confirmed through several different techniques. Proper glycemic control and attainment of other management goals cholesterol, Body Mass Index BMIand blood pressure are essential in prevention of long-term complications of diabetes as well as reduction of overall disease management costs [ 6 ].
Tight glycemic control is becoming increasingly recognized as a perioperative goal in surgical patients [ 8 — 12 ]. However, there is still no overall consensus on the optimal perioperative management of the diabetic patient [ 13 — 21 ]. In this paper we hope to outline risk factors associated with hyperglycemia due to diabetes in the surgical patient, as well as review broad glucose management strategies during surgery as well as the pre- and postoperative stages.
Surgical procedures may result in a number of metabolic perturbations that can alter normal glucose homeostasis. The resulting hyperglycemia due to abnormal glucose balance is a risk factor for postoperative sepsis [ 22 ], endothelial dysfunction [ 23 ], cerebral ischemia [ 24 ], and impaired wound healing [ 2526 ].
In addition, the stress response may also cause other diabetic pathologies including diabetic ketoacidosis [ 27 ] DKA or hyperglycemic hyperosmolar syndrome [ 28 ] HHS during surgery or postoperatively. However, recent evidence suggests that careful management of glucose levels in patients undergoing major surgeries, including cardiac [ 29 ] and orthopedic [ 30 ] procedures may minimize the aforementioned negative sequela and overall promote better outcomes.
On average, diabetics require more hospitalizations, longer durations of stay, and cost more to manage than nondiabetics. Hospitalized diabetics generally tend to be older, less active, and based on hemoglobin-AIC measurements and control their glycemic levels less aggressively [ 32 ]. Furthermore, diabetics undergo certain procedures and surgeries more commonly than nondiabetics and have increased morbidity and mortality rates when acutely compromised or ill [ 33 — 35 ].
Glycemic monitoring in the perioperative setting is done in a passive manner to combat any potential neuroglycopenic sequelae from underlying unrecognized hypoglycemia. Unmanaged hypoglycemia may result in a number of neurological complications including somnolence, unconsciousness, and seizures and depending on the duration, irreversible neurological insult, or death [ 35 ].
In general, complications from surgical wounds are more prevalent in diabetics, and healing is impaired when glycemic levels are not well managed [ 38 ].
As diabetics tend to sustain increased perioperative morbidity and mortality, identification of diabetic patients is imperative in the surgical setting. Slightly more than a third of perioperative diabetics remain unrecognized or untreated before surgery or admittance to the ICU [ 3940 ]; clinicians must remain alert to properly identify diabetes, glucose intolerance, insulin resistance, and associated diabetic pathologies.
Overall, with the use of careful glucose management strategies, the primary outcome measures of surgery are similar between diabetic and nondiabetic patients [ 41 ]. A Brief Summary of the Metabolic Response to Surgery and Anesthesia The trauma associated with surgery results in increased production of stress hormones, the magnitude of which depends on the severity of the surgery or any postoperative complications.
Perioperative glycaemic control for diabetic patients undergoing surgery | Cochrane
In specific, the increases in cortisol and catecholamine levels related to surgery have been well documented [ 4243 ]. Increased cortisol and catecholamines reduce insulin sensitivity, while heightened sympathetic activity reduces insulin secretion while simultaneously increasing growth hormone and glucagon secretion [ 4445 ].
In the diabetic patient, insulin production is already marginalized; the metabolic changes outlined above that occur during surgery cause a marked catabolic state.
Changes in normal metabolic patterns due to surgery trigger gluconeogenesis, glycogenolysis, proteolysis, lipolysis, and ketogenesis ultimately resulting in hyperglycemia and ketosis [ 46 ]. There are a number of anesthetic drugs, each of which has a variable effect on glycemic control. Most intravenous IV induction agents have a relatively negligible effect on blood glucose, although a notable exception is the induction agent etomidate.
Etomidate is known to cause less hypotension during induction and generally fewer hangover-like effects upon recovery [ 47 ]. Review of the etomidate mechanism shows suppressed adrenocortical function mediated by blocking the activity of beta-hydroxylase, ultimately causing decreased steroidogenesis [ 48 ].
In fact, the literature reports that acute adrenocortical insufficiency and crisis may occur after a standard induction dose of etomidate [ 49 ].
However, due to diminished cortisol secretion, etomidate triggers a subsequent decrease in the hyperglycemic response to surgery [ 47 ]. Additionally, if used in high doses during surgery, benzodiazepines decrease ACTH secretion. Benzodiazepines also stimulate release of growth hormone, while reducing sympathetic stimulation [ 50 ]. Opiates given in high doses such as during the postoperative recovery phase block the sympathetic nervous system as well as the hypothalamic-pituitary axis, essentially abolishing the hyperglycemic response to surgery [ 51 ].
In vitro studies revealed that volatile anesthetic agents such as halothane and isoflurane inhibit normal insulin production triggered by glucose in a dose dependent fashion, essentially resulting in a hyperglycemic response [ 5253 ]. Further studies must be completed in order to understand the full clinical effects of this response in diabetic patients undergoing surgery.
Whereas most anesthetic agents cause hyperglycemia, epidural anesthesia tends to have a nominal effect on glucose metabolism [ 54 ]. Epidural anesthesia inhibits catecholamine release irrespective of spinal segmental levelas such noradrenaline and cortisol concentrations do not increase, preventing elevation in blood glucose levels [ 55 ]. In addition, sympathetic efferent signal blockade with enhanced fibrinolytic activity blunts the surgical stress response normally responsible for hyperglycemia [ 56 ].
However, physicians must be cognizant of certain complications related to epidural and regional anesthetic use. For example, use of localized anesthesia in diabetic patients with autonomic neuropathy may result in deleterious consequences such as life-threatening hypotension. It is imperative that the anesthetic technique used allows for rapid recovery after surgery to prevent concealment of hyperglycemic or hypoglycemic coma [ 46 ].
In general, the response to neuromuscular blocking agents is normal in diabetic patients; however in patients with neuropathies or irregular transmission across the neuromuscular junction abnormalities may occur. The dose can be titrated more rapidly than that of oral hypoglycaemic agents, and it does not have a dose ceiling. Insulin can be delivered either subcutaneously or intravenously as a continuous infusion, and the use of sliding-scale insulin SSI has traditionally been the mainstay of hyperglycaemia therapy.
However, recent studies have shown that the use of SSI alone is insufficient in providing adequate glycaemic control, and that a combination of basal and supplemental insulin is a more effective approach. The combined use of basal insulin i. Recommended perioperative BSL targets. Given that studies have failed to show a benefit and some even show increased mortality with intensive insulin therapy, the management of glucose concentrations has undergone drastic changes in the past decade.
Current recommendations from the UK, US, and Australia all recommend a similar range of blood glucose concentrations Figure 1. Most guidelines tolerate mild hyperglycaemia as it reduces the potential for developing hypoglycaemia.
- Perioperative glycaemic control in diabetic surgical patients – review
- Minerva Anestesiologica 2017 September;83(9):921-9
- Surgery Research and Practice
Insulin therapy in both general medical and surgical settings should consist of a mixture of basal, prandial, and supplemental insulin basal-bolusinstead of the sliding-scale regimen. However, differences in these recommendations indicate that the most optimal blood glucose concentrations are still unknown. Preoperative insulin therapy should focus on obtaining good glycaemic control, while avoiding episodes of hypoglycaemia.
Most guidelines suggest withholding oral anti-diabetic agents and non-insulin injectable medications on the day of surgery but not before.
For major surgeries, metformin should be withheld for at least 24 hours. This is because oral diabetic medications can potentially produce hypoglycaemia during the fasting period prior to surgery, as well as systemic effects that may affect postoperative outcomes. For example, sulfonylureas can interfere with the opening of cardiac KATP channels, which increases the risk for myocardial ischaemic injury.
Perioperative glycaemic control for diabetic patients undergoing surgery
Oral hypoglycaemic agents should not be restarted until adequate and regular oral intake is resumed. The majority of patients receiving insulin therapy should use a basal-bolus insulin schedule. The long-acting agents are aimed at providing a steady, basal level of insulin while the shorter-acting bolus insulin is used to counter acute increases in blood glucose.
It is important to note that not only type 1 diabetics, but all insulin dependent patients, will require insulin perioperatively, despite their fasting status.
This is because these patients are insulin deficient and require consistent basal insulin replacement to prevent unchecked gluconeogenesis and ketosis. Conclusion Hyperglycaemia has been shown to produce deleterious effects in multiple body systems, both acutely and chronically. Studies indicate that adequate glycaemic control during the perioperative period is beneficial for both short-term and long-term surgical outcomes.
The included trials did not demonstrate significant differences for most of the outcomes when targeting intensive perioperative glycaemic control compared with conventional glycaemic control in patients with diabetes mellitus. However, posthoc analysis indicated that intensive glycaemic control was associated with an increased number of patients experiencing hypoglycaemic episodes. Intensive glycaemic control protocols with near-normal blood glucose targets for patients with diabetes mellitus undergoing surgical procedures are currently not supported by an adequate scientific basis.
Read the full abstract Patients with diabetes mellitus are at increased risk of postoperative complications. Data from randomised clinical trials and meta-analyses point to a potential benefit of intensive glycaemic controltargeting near-normal blood glucose, in patients with hyperglycaemia with and without diabetes mellitus being submitted to surgical procedures.
However, there is limited evidence concerning this question in patients with diabetes mellitus undergoing surgery. To assess the effects of perioperative glycaemic control for diabetic patients undergoing surgery. We included randomised controlled clinical trials that prespecified different targets of perioperative glycaemic control intensive versus conventional or standard care Data collection and analysis: Two authors independently extracted data and assessed risk of bias.
We summarised studies using meta-analysis or descriptive methods. Twelve trials randomised diabetic participants to intensive control and diabetic participants to conventional glycaemic control.