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cancel for hyperglycemia?

Discussion in 'Anesthesiology' started by furfur, Sep 3, 2009.

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  1. furfur

    furfur

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    50 y.o. w/ DMII w/ bld glc 350 in preop holding. No symptoms suggestive of active infection s/f cysto w/ stent. seen in diabetic clinic 1 month ago. chem 7 at that time revealed glc of 307. Thoughts? Will you proceed with this case?
  2. Bertelman

    Bertelman Maverick!

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    to the OR. 10 U insulin, recheck.

    tell him he needs to get that **** under control
  3. jwk

    jwk AA-C ASA-PAC Contributor

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    We would do the case, but he'd see someone from IM before he left the hospital - he's either non-compliant or poorly managed.
  4. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

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    If scheduled for typical surgery proceed with case. If scheduled for major vascular/CABG or open thoracotomy would consider checking HgA1C and if greater than 8.5 reschedule.

    Blade
    Last edited: Sep 4, 2009
  5. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

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    Eur J Vasc Endovasc Surg. 2006 Aug;32(2):188-97. Epub 2006 Mar 31.[​IMG] Links

    Haemoglobin A1c (HbA1C) in non-diabetic and diabetic vascular patients. Is HbA1C an independent risk factor and predictor of adverse outcome?

    O'Sullivan CJ, Hynes N, Mahendran B, Andrews EJ, Avalos G, Tawfik S, Lowery A, Sultan S.
    Department of Vascular and Endovascular Surgery, Western Vascular Institute, University College Hospital, Galway, Ireland.
    BACKGROUND: Plasma Haemoglobin A1c (HbA1c) reflects ambient mean glycaemia over a 2-3 months period. Reports indicate that patients, with and without diabetes, with an elevated HbA1c have an increased risk of adverse outcome following surgical intervention. Our aim was to determine whether elevated plasma HbA1c level was associated with increased postoperative morbidity and mortality in patients undergoing vascular surgical procedures. METHODS: Plasma HbA1c was measured prospectively in 165 consecutive patients undergoing emergency and elective vascular surgical procedures over a 6-month period. Patients were categorized into four groups depending on whether their plasma HbA1c was < or =6%, 6.1-7%, 7.1-8% or >8% and clinical data was entered into a prospectively maintained database. Patients were also classified by diabetic status with suboptimal HbA1c in a patient without diabetes being >6 to < or =7% and suboptimal HbA1c in a patient with diabetes being >7%. Patients with plasma HbA1c >7% were reclassified as having undiagnosed diabetes mellitus. Composite primary endpoints were all cause 30-day morbidity and mortality and all cause 6-month mortality. Composite secondary endpoints were procedure specific complications, adverse cardiac events, stroke, infection and mean length of hospital stay. RESULTS: Of the 165 patients studied, 43 (26.1%) had diabetes and the remaining 122 (73.9%) did not. The mean age was 72 years and 59% were male. Suboptimal HbA1c levels were found in 58% patients without diabetes and in 51% patients with diabetes. In patients without diabetes those with suboptimal HbA1c levels (6-7%) had a significantly higher incidence of overall 30-day morbidity compared to patients with HbA1c levels < or =6% (56.5 vs 15.7%, p<0.001). Similarly, for patients with diabetes those with suboptimal HbA1c levels (HbA1c >7%) had a significantly higher incidence of 30-day morbidity compared to those with HbA1c levels < or =7% (59.1% vs 19%, p=0.018). Multivariate analysis revealed that a plasma HbA1c level of >6 to < or =7% was a significant independent predictor of overall 30-day morbidity in patients without diabetes undergoing vascular surgical procedures. No difference in mortality, composite secondary endpoints, procedure specific complications, stroke or mean length of hospital stay was observed between any of the groups in the study. CONCLUSION: Suboptimal HbA1c levels may hold prognostic significance in patients without diabetes undergoing vascular surgery.
  6. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

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    Thorac Cardiovasc Surg. 2008 Sep;136(3):631-40.[​IMG] Links

    Elevated preoperative hemoglobin A1c level is predictive of adverse events after coronary artery bypass surgery.

    Halkos ME, Puskas JD, Lattouf OM, Kilgo P, Kerendi F, Song HK, Guyton RA, Thourani VH.
    Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA.
    OBJECTIVE: Diabetes mellitus has been associated with an increased risk of adverse outcomes after coronary artery bypass grafting. Hemoglobin A1c is a reliable measure of long-term glucose control. It is unknown whether adequacy of diabetic control, measured by hemoglobin A1c, is a predictor of adverse outcomes after coronary artery bypass grafting. METHODS: Of 3555 consecutive patients who underwent primary, elective coronary artery bypass grafting at a single academic center from April 1, 2002, to June 30, 2006, 3089 (86.9%) had preoperative hemoglobin A1c levels obtained and entered prospectively into a computerized database. All patients were treated with a perioperative intravenous insulin protocol. A multivariable logistic regression model was used to determine whether hemoglobin A1c, as a continuous variable, was associated with in-hospital mortality, renal failure, cerebrovascular accident, myocardial infarction, and deep sternal wound infection after coronary artery bypass grafting. Receiver operating characteristic curve analysis identified the hemoglobin A1c value that maximally discriminated outcome dichotomies. RESULTS: In-hospital mortality for all patients was 1.0% (31/3089). An elevated hemoglobin A1c level predicted in-hospital mortality after coronary artery bypass grafting (odds ratio 1.40 per unit increase, P = .019). Receiver operating characteristic curve analysis revealed that hemoglobin A1c greater than 8.6% was associated with a 4-fold increase in mortality. For each unit increase in hemoglobin A1c, there was a significantly increased risk of myocardial infarction and deep sternal wound infection. By using receiver operating characteristic value thresholds, renal failure (threshold 6.7, odds ratio 2.1), cerebrovascular accident (threshold 7.6, odds ratio 2.24), and deep sternal wound infection (threshold 7.8, odds ratio 5.29) occurred more commonly in patients with elevated hemoglobin A1c. CONCLUSION: Elevated hemoglobin A1c level was strongly associated with adverse events after coronary artery bypass grafting. Preoperative hemoglobin A1c testing may allow for more accurate risk stratification in patients undergoing coronary artery bypass grafting.
    [​IMG] [​IMG] [​IMG]
  7. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

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    1: Ann Thorac Surg. 2008 Nov;86(5):1431-7.[​IMG] Links

    Elevated preoperative hemoglobin A1c level is associated with reduced long-term survival after coronary artery bypass surgery.

    Halkos ME, Lattouf OM, Puskas JD, Kilgo P, Cooper WA, Morris CD, Guyton RA, Thourani VH.
    Clinical Research Unit, Division of Cardiothoracic Surgery, Rollins School of Public Health, Emory University School of Medicine, Atlanta, Georgia, USA.
    BACKGROUND: The predictive role of hemoglobin A1c (HbA1c) on long-term outcomes after coronary artery bypass surgery has not been evaluated. METHODS: Preoperative HbA1c levels were obtained in 3,201 patients undergoing primary, elective coronary artery bypass surgery at Emory Healthcare Hospitals from January 2002 to December 2006 and entered prospectively into a computerized database. Long-term survival status was determined by cross-referencing patient records with the Social Security Death Index. Log-rank (unadjusted) and Cox proportional hazards regression models (adjusted) were employed to determine whether HbA1c and diabetes mellitus were independent risk factors for reduced long-term survival, adjusted for 29 covariates. Hazard ratios for each unit increase in continuous HbA1c were calculated. RESULTS: Patients with HbA1c of 7% or greater had lower unadjusted 5-year survival compared with patients with HbA1c less than 7% (p = 0.001). Similarly, patients with diabetes mellitus had lower unadjusted 5-year survival compared with patients without diabetes (p < 0.001). After multivariable adjustment, higher HbA1c (measured as a continuous variable) was associated with reduced long-term survival for each unit increase in HbA1c (hazard ratio 1.15, p < 0.001), but preoperative diagnosis of diabetes was not associated with reduced long-term survival after coronary artery bypass surgery (p = 0.41). Other multivariable predictors of reduced long-term survival included age, cerebrovascular disease, elevated serum creatinine, renal insufficiency, congestive heart failure, previous myocardial infarction, chronic lung disease, and peripheral vascular disease. CONCLUSIONS: Poor preoperative glycemic control, as measured by an elevated HbA1c, is associated with reduced long-term survival after coronary artery bypass surgery. Optimizing glucose control in these patients may improve long-term survival.
    [​IMG] [​IMG] [​IMG]
  8. Frank Rizzo

    Frank Rizzo Member

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    board answer: reschedule.
    real world answer: do the case.
  9. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

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    Sure do the case. But, if a relative or good friend of yours is scheduled for MAJOR SURGERY the evidence points to checking a Hgb A1C. The more important point in this thread is to remember the patient comes first in terms of safety. Perhaps, we should be promoting the value of good long term glucose control to our surgical colleagues? How about telling the Vascular/Thoracic/Cardiac Surgeons about the fourfold increased mortality with extremeley elevated Hgb A1C?

    As Perioperative Physicians we should be concerned if the patients survive their entire hospital stay and not just the first 24 hours.


    Blade
  10. Frank Rizzo

    Frank Rizzo Member

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    The OP is talking about a cysto with stent, not an aortic arch or AAA repair. Obviously things are different with that kind of case.
  11. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

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    I would NOT cancel any case scheduled for minor surgery based on a singe glucose reading. I would treat the hyperglycemia preoperatively and postoperatively.

    However, I wanted you all to be aware that MAJOR surgery with elevated HGbA1C readings may carry a FOURFOLD increased risk of mortality compared with readings less than 7.

    At this time I would use a HgbA1c reading of greater than 8.5 to delay major Vascular or Cardiac Surgery.
    Last edited: Sep 6, 2009
  12. Hawaiian Bruin

    Hawaiian Bruin Breaking Good

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    Just to be jackass- what would you do with an A1c of 8.4, and why?
  13. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

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    Good question. If the patient was having minor surgey then nothing. I would discuss the need for better glucose control with both the patient and surgeon. Proceed with the case.

    If the patient was having major surgery I would discuss the implications of a high HbA1c with the surgeon and stress good postoperative glucose control. Proceed with the case.

    A HgbA1c of 8.5 is my cutoff. You may have your own cutoff or decide this is not an "anesthesia" issue. However, I believe any significant preoperative medical condition which can lead to increased morbidity/mortality is our concern. In fact, It is the main reason I am there.
    Last edited: Sep 6, 2009
  14. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

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    Hemoglobin A1c test results show your average blood sugar level over time. The result is reported as a percentage. Your goal is to keep your hemoglobin A1c level as close to the normal level as possible. Studies suggest that the lower the hemoglobin A1c level, the lower the incidence of diabetic complications (eye, kidney, heart, blood vessel, and nerve disease). The American Diabetes Association (ADA) recommends keeping the hemoglobin A1c less than 7%.
    The result of your hemoglobin A1c test can also be used to estimate your average blood sugar level. This is called your estimated average glucose, or eAG. Your eAG and A1c show the same thing in two different ways. They both help you know about your average blood sugar over the past 2 to 3 months.

    Hemoglobin A1c

    Normal: Less than 6.5
    Excellent: 6.5-7.5
    Good: 7.5-8.5
    Fair: 8.5-9.5
    Poor: Greater than 9.5
  15. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

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    While I may choose greater than 8.5 for my cutoff others may ignore the value completely. However, the data strongly suggests that poorly controlled Diabetes over a long period of time and Major Surgery are not not a "healthy" combination.

    Of course, the urgency of the surgery must always be considered along with the absolute HgA1C value. A HbA1C of 8.5 represents an average blood glucose reading of 197.


    8.5% = 197 mg/dl. 9.0% = 212 mg/dl. 9.5% = 226 mg/dl. 10.0% = 240 mg/dl ...
    Last edited: Sep 6, 2009
  16. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

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    A 62 year old Female with HTN, IDDM presents for an elective CABG X5.
    Her Blood Glucose reading (fasting) is 220. Her Hgb A1C is 9.0


    Would you proceed with the case? Most private practice MD (A)s would just do the case as usual with an Insulin drip. Many would keep the blood glucose level in the 150-180 range during the case and post operatively.
    Currently, that is what is expected of you.

    But, is her HgA1C a better marker of morbidity/mortality than her perioperative glucose level? Why wouldn't her A1C level also be of concern prior to the operation itself? Does it make any sense to start with Chicken poop and expect Chicken salad at the end?


    Poor preoperative glycemic control, as measured by an elevated HbA1c, is associated with reduced long-term survival after coronary artery bypass surgery. Optimizing glucose control in these patients may improve long-term survival.
  17. blacksquadron44

    blacksquadron44

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    Not saying that HGB A1c is not important because it is but how do way the risk of delaying the surgery vs the risk of elevated HGB A1c. Most of the times this is related to poor compliance of a regimen by a patient, question How do you get them compliant?
  18. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

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    1) 8.6 or less is not exactly "optimized" for surgery. Most can take their meds and/or Insulin for a HgBA1c of less than 8.6. Consult Endocrinology

    2) Explain they have a 4 fold increased risk of DYING if they fail to get their blood sugars under control before the Big Surgery.

    3) If the patient won't try or can not improve (??) their HgbA1C document your recommendation on the chart and the fact you explained the risks to the patient.

    4) Sometimes you can't help those who won't help themselves.

    5) Canceling a Surgery based on a glucose or HgBA1C reading is controversial at this time. Many would NEVER cancel or delay a case based on a sugar reading alone. However, there is good data that such an approach may NOT be the best one for the patient.
  19. Edsalldw

    Edsalldw

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    this case should definitively be cancelled. There is ample evidence since 1973 that a blood sugar above 200 and some studies above 150 that hyperglycemia casues wound infections one of the major costs of surgery, makes brin hypoxia worse, impeeds healing,. patietns do better with BS<150. SO anyone hwo suggest that the case to go ahead is agreeign to terms that are worse for the patient and learrly putting themsleves at risk for litigation is a problem occurs. they are also raising the coasst of medicienby doing a 3-6 gfold increse in complications. To acutely treat a BS > 200 changes electrolytes creating hypokalemia and hypovolemia, as well as other issue that are avoid if you enter withe OR with a more normal BS.. I woudl pose the question Do you want to proceed so that you don't loose the income for teh case? Lets ask the qeustion thato the patient " your risk of probelms is much higher if we proceed vs getting you sugar under control slowly and steadily. Do you want to proceed" dont' fudge the questiong with some people think and msot world do it. - yes most want the money - there is no evidence to proceed and lots to delay the case. It is unethical to proceed without patient acceptance of increased risk and payor approval of increased cost. Those who say that if you cancel and jsut have them return they n you will have te same conditions" The answer is get another doctor becaseu they are admitting they can't treat you now or after the surgery. We cancel at 200 and treat all above 150 with insulin drips for 48 hours if in hospital. It is rare to cancel twice. The patients are very motivated to get the surgery and so they wil comply at least for the preop period. Our diabetic wound infection rate is < 1%. Ask those who want to proceed wath their measured infection rate is. Most will not know. If they do not know get another doctor if they do know and it is > 2% get another doctor.
  20. Edsalldw

    Edsalldw

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    A1C is not the issue , hyperglycemia is. A low A1C will indicated that it is more likley ( much) that you will be able to control the BS postop but it is the BS that is the issue. an a1C of 5.5 with BS runing > 200 for 12 hours is much worse thatn an A1c of 9.2 with an incsulin drip and all BS < 150 post op.
  21. Edsalldw

    Edsalldw

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    this is unfortunately themost accurate answer. It is reallly saying that we want to get our money and not iss off or inconvience anyone even if it means we do what is wrose for the patient. Lets make up lots of excuses as to why we don't cancel. blind excuses wrong excuses. assumption excusses. Facts are inconvienient
  22. Frank Rizzo

    Frank Rizzo Member

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    ... and the award for the most typos and/or spelling errors in a SDN member's first three posts goes to....

    Jesus Christ, that made my head hurt.

    Welcome to the forum!
  23. jwk

    jwk AA-C ASA-PAC Contributor

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    Are you typically this self righteous?

    For THIS CASE - you know, the diabetic that needs a stent placement - it may very well be PERFECTLY reasonable and prudent to proceed with the procedure. Nobody is arguing that the patient has an acceptable blood sugar, and Blade brings up interesting points regarding HbA1C as a predictor. But try and think a little outside the box and look at the whole patient. Why does a patient need a stent? Well, gee, usually because they're OBSTRUCTED, whether by stone, intrinsic or extrinsic tumor, etc. Obstructed ureters can do very bad things to kidneys in a very short period of time. I've seen one of my best friends go from first twinge of flank pain to being on a vent and at death's door from fulminant urosepsis in less than six hours.

    There are few absolutes in medicine, and cookbook medicine absolutes - "this case should definitively be cancelled" - with a lack of independent thought given the actual circumstances and patient involved is the worst kind.

    Care to look up any more three year old posts and commenting?
  24. btbam

    btbam

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    I'm at a public hospital so naturally we get lots of poorly controlled diabetics. Seeing BGs in the high 200s-low 300s is not at all uncommon. Never seen one cancelled for high reading, just give X units of insulin and monitor as needed.
  25. W222

    W222 2K Member

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    You treat BS between 200 and150 with an insulin drip? :eek: Are you friggin serious? You apparently haven't been following the latest evidence that tight BS control leads to an increase in adverse events and controlling below 200 with insulin infusion isn't recommended. "The patients are very motivated to get the surgery"? Where do you practice? Utopia hospital?
  26. militarymd

    militarymd SDN Angel

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    I can't believe a real attending would even ask about proceeding...
  27. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

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    I have never seen a simple urology case cancelled from a high blood sugar under 350. This case would not get cancelled at Da U or my local hospital.
  28. Consigliere

    Consigliere

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    That's funny because that was the FIRST thought that entered my mind...
  29. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

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    Source: Eur J Cardio-Thoracic Surg | Posted 38 weeks ago

    <h3>Preoperative hemoglobin A1c predicts atrial fibrillation after off-pump coronary bypass surgery; Kino****a T, Asai T, Suzuki T, Kambara A, Matsubayashi K; European Journal of Cardio-Thoracic Surgery (May 2011)


    Read/Add Comments | Email This | Print This | PubMed


    Objective: Diabetes mellitus has been recognized as a risk factor for mortality and morbidity after coronary bypass grafting, but a significant association between diabetes mellitus and postoperative atrial fibrillation (AF) has not been found. Although a recent study demonstrated a potential link between preoperative hemoglobin A1c level and risk of postoperative AF, there has not been sufficient examination of this relationship. We aimed to investigate the association between preoperative hemoglobin A1c and AF after isolated off-pump coronary bypass grafting. Methods: Of 912 consecutive patients undergoing isolated coronary bypass surgery, 805 were retrospectively analyzed for AF after excluding the following 107 cases: emergency (n=81), chronic AF (n=18), and pacemaker rhythm (n=8). We performed a group analysis with hemoglobin A1c levels categorized into tertiles of the baseline distribution and a continuous analysis based on 1% increments in hemoglobin A1c levels. The cutoff points for the tertiles were as follows: lower, 3.8-5.6% (n=283); middle, 5.7-6.7% (n=282); upper, 6.8-11.4% (n=240). Results: AF occurred in 159 patients (19.8%) after surgery. The median value (25th-75th percentile) of preoperative hemoglobin A1c was significantly lower in patients who developed AF than in those who did not (5.8 (5.4-6.3) vs 6.1 (5.5-7.2), p=0.01). The incidence of postoperative AF was 28.3% (80/283) in the lower tertile, 17.4% (49/282) in the middle tertile, and 12.5% (30/240) in the upper tertile (p for trend=0.01). The unadjusted odds ratio (95% confidence interval) for the association between hemoglobin A1c and postoperative AF was 0.70 (0.61-0.83) per 1% increase and 0.42 (0.29-0.70) for the upper versus the lower tertile. This association persisted after adjustment for the univariate predictors (0.74 (0.60-0.92) per 1% increase; 0.54 (0.31-0.90) for upper vs lower tertile) and the known risk factors (0.78 (0.63-0.95) per 1% increase; 0.55 (0.35-0.88) for upper vs lower tertile). The area under the receiver operator characteristic curve (95% confidence interval) for preoperative hemoglobin A1c as a predictor of postoperative AF was 0.70 (0.65-0.75) (p=0.01). Conclusions: Preoperative hemoglobin A1c independently predicts the occurrence of AF after isolated off-pump coronary bypass grafting.
  30. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

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    The major


    [FONT=AdvOTb97f513e+fb][FONT=AdvOTb97f513e+fb][FONT=AdvOTb97f513e+fb]fi...nding of the present study, which enrolled 805

    patients undergoing elective off-pump coronary bypass surgery

    by a single surgeon, was that higher preoperative HbA1c was independently

    associated with a lower risk of postoperative AF. (all patients were Japanese).
  31. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

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    Dr. Meneghini: I haven't seen any guidelines for glycemic control in patients undergoing outpatient surgery. If a patient has poor glycemic control coming into surgery, even for a minor procedure, the risk of an infectious complication may be increased. Keeping blood glucose below 180 mg/dL and avoiding electrolyte imbalances is likely sufficient in such patients. On the second question, if it's an elective procedure and can be delayed a few hours, you can certainly institute IV insulin therapy to correct hyperglycemia rapidly&#8212;just ensure adequate replacement of fluids since the patient may have had volume depletion or dehydration as a result of the preceding osmotic diuresis. Once glycemic control is improved (blood glucose < 180&#8211;200 mg/dL), the patient can proceed to surgery.


    http://www.ccjm.org/content/76/Suppl_4/S53.full
  32. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

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    Stable blood sugar associated with better outcomes after TJA

    Patients with type 2 diabetes who had preoperative hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) fared worse after total joint replacement surgery than those who were able to keep their blood sugar (HbA1c) at normal levels, according to the results of a study presented in poster P102.
    Many individual factors (including timing of last meal) are examined to determine a "normal blood glucose level," but most physicians recommend keeping blood glucose levels between 70 mg/dL and 120 mg/dL. Patients with diabetes or hypoglycemia are urged to narrow that range even further and have their physician identify what is "normal" for them.
    Previous studies have found that patients with diabetes have a higher risk of complications after cardiac surgery, as well as a higher level of microvascular and macrovascular complications.
    The study involved 121 consecutive patients with type 2 diabetes who underwent primary total joint replacements (88 total knee arthroplasties and 33 total hip arthroplasties) at a single medical center. Patients were evaluated based on preoperative HbA1c levels and divided into three groups&#8212;25 percent of patients were hypoglycemic (mean 6 percent), 50 percent were within normal ranges (mean 6.9 percent) and 25 percent were hyperglycemic (mean 8.7 percent). Patient-oriented outcomes, complications, length of stay, and hospital costs were compared among the three groups.
    Researchers found a significant trend toward worse scores in all categories among patients whose blood sugar fell within the lowest and highest ranges. At 2.7 years (range: 2 to 5 years), they found no significant differences between quartiles. A trend for worse scores in the lowest and highest quartiles was identified for several different outcome measures, including physical and social functioning. Length of stay and hospital costs were higher in both the lowest and the highest quartiles.
    "When set in a graph, the results looked like an inverted bell, with complications spiking on both ends of the spectrum and dipping in the middle," said coauthor Carlos J. Lavernia, MD, chief of orthopaedics at Mercy Hospital in Miami. "Even after controlling for all external factors that could have affected the outcomes, the inverted-bell shape remained intact, indicating that diabetic patients who control their blood sugar prior to surgery will inevitably have better outcomes."
    Coauthors with Dr. Lavernia for "The Effect of Diabetic Control in Total Joint Arthroplasty Outcomes" are Juan S. Contreras; Jose Carlos Alcerro, MD; and Mark Rossi, PhD.
    Disclosure information: Dr. Lavernia&#8212;MAKO Surgical Corp., Johnson & Johnson, Zimmer, Journal of Arthroplasty, American Association of Hip and Knee Surgeons; Dr. Alcerro&#8212;no conflicts; Dr. Rossi&#8212;no conflicts.
    2011 Annual Meeting News
  33. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

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    Patients, such as diabetics, who have high blood-sugar levels before undergoing hip- or knee-replacement surgery are at increased risk of developing potentially life-threatening blood clots, according to a new study.
    "The take-home message is that all patients should get their blood sugar under control before undergoing elective surgery," said the study's lead author, Dr. Boris Mraovic, an assistant professor of anesthesiology at Thomas Jefferson University in Philadelphia.

    Mraovic's team examined records of 6,500 patients who underwent hip- or knee-replacement surgery at Thomas Jefferson University Hospital between 2003 and 2005. They identified 38 patients who had blood-glucose levels above 250 milligrams per deciliter during pre-operative testing and on the day of surgery. All but one of the patients were diabetic, which is defined as a fasting blood-glucose level above 126 mg/dl.

    "We found that 10.5 percent of those with high blood sugar developed a pulmonary embolism compared to only 1.7 percent of the other patients," Mraovic said. "This rate is more than six times higher than we would expect to see in the general population."

    Pulmonary embolism is a potentially life-threatening condition in which a blood clot forms in a vein and travels to the lungs. It's usually caused by clots that form in veins deep in the muscles of the legs or pelvic area, a condition known as deep-vein thrombosis.

    Pulmonary embolism is more likely to develop after major orthopedic surgery than after other types of surgery. Nationwide, about 600,000 patients develop a pulmonary embolism each year and 200,000 of them die.

    "Fortunately, none of the 38 patients in our study died," Mraovic said. "We treat pulmonary embolism aggressively."

    Mraovic was expected to present his study findings Monday at the annual meeting of the American Society of Anesthesiologists, in Chicago.

    "This is a fascinating study," said Dr. Samuel Goldhaber, a cardiologist at Brigham and Women's Hospital in Boston, who was not part of the study. "I'm not aware of previous studies linking poor glucose control with pulmonary embolism in patients undergoing surgery. So, this is the first one."

    Although Goldhaber called the new research "intriguing and thought-provoking," he cautioned that it's premature to draw any major conclusions from it.

    "This is just one exploratory study," he said. "It should prompt researchers to look through other databases to see if there's a similar relationship between high blood glucose levels and pulmonary embolism."

    Previously, researchers didn't know if high blood sugar, per se, was an independent risk factor for pulmonary embolism in patients who undergo major orthopedic surgery. In fact, some research suggested otherwise. In 2002, a Mayo Clinic study of 19,293 such patients found that type 2 diabetes was not an independent risk factor for either deep-vein thrombosis or pulmonary embolism.

    "The problem is, that study didn't examine high blood sugar," Mraovic said. "If you're diabetic, you can have normal blood sugar if you are taking medication."

    Recent evidence shows that tight blood-sugar control leads to better results in patients who undergo cardiovascular surgery, Mraovic said. It's associated with improved survival, fewer infections, shorter hospital stays and lower costs.

    Mraovic said guidelines are needed to limit elective surgery in patients who have high blood sugar. He favors guidelines that would require the postponement of such surgery until patients get their blood sugar under control. "At present, there are no such guidelines from surgical or anesthesia associations," he said.

    Goldhaber disagreed. "I think more trials and studies are needed before we go that route," he said.

    But he didn't dispute that well-controlled blood sugar should be the "rule of thumb" for all surgical patients, especially now that so many of them are diabetic. "Diabetes is becoming pandemic as part of the metabolic syndrome," Goldhaber said. "We need to focus a lot more attention on tightening blood-sugar control."

    Mraovic said that additional studies are needed to confirm his results. He hopes to perform a prospective, randomized study of patients with high blood sugar to see if controlling their blood sugar before surgery lowers the risk of deep-vein thrombosis and pulmonary embolism.
  34. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

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    the normal group (Figure 2).
    Patients with very high preoperative blood glucose levels had 3.9 times the risk for PE as patients in the normal group, and 3.2-fold more than that for patients in the high-glucose group. No patient in the low-normal glucose group developed PE.[​IMG]
  35. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

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    "Whereas an association was observed between hyperglycemia and pulmonary embolism, this link must be interpreted with caution," Dr. Fontes told Anesthesiology News. "Major orthopedic surgery is known to induce a hypercoagulable state, which in susceptible individuals with other vascular morbid conditions&#8212;diabetes, hypertension, atherosclerotic disease&#8212;can cause fatal and nonfatal vascular events such as PE.
  36. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

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    The bottom line is the only thing well substantiated in the literature is Cardiac Surgery and high blood sugars in a poorly controlled Diabetic or an undiagnosed Diabetic MAY lead to worse outcome/increased morbidity.

    If I was doing an open Belly case with a large incision in a morbidly obese diabetic with poor blood glucose control I would discuss the risk/benefit with surgeon.

    Cancel the case outright over a blood sugar or HgA1c? Not likely.
  37. Lee123

    Lee123

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    Not entirely true. You need to put in context to what is going on, defending you position.

    After discussing with the surgeon the increased risk of infection and neurologic sequella for this elective case, the surgeon might prefer to delay the case for several days until there is better glycemic control. However, the surgeon may wish to proceed at which point, if there are no signs/symptoms of dka, you can bolus and start an infusion. You will also need to hydrate the patient if you believe he is hypovolemic from osmotic diuresis. After getting the glucose under 250 you can proceed, watching for ongoing diuresis and carefully padding all pressure/nerve points. If the case is an emergency you need to proceed sooner.

    follow up question: is there some glucose that you will not proceed for an elective case, despite the surgeon wishing to proceed?

    I would answer, "if the glucose is above 370 for an elective case, the risk for a cerebral/neurologic event, or the stress of the surgery pushing the glucose higher, possibly causing non-ketogenic coma during the perioperative period, is too great. I will do the following ... and proceed once there is better control.
  38. pgg

    pgg Laugh at me, will they? Moderator

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    Now there's a passing answer :thumbup:



    First post nailed it ... two years ago. :)
  39. bkell101

    bkell101 UDGRAD

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    my case tmrw....54 yo Bmi 39 , severe OSA (Cpap compliant), asthmatic (rescue inhaler 2x daily), prior PE, chronic pain on multiple narcs, 4 + mets per recent preop clinic visit but saw pulm 6 mos ago who says poor tolerance and adherence to regimen and recommended stress echo in light of dyspnea + EKG w/prior septal infarct (none of which was done and no f/u w/pulm).....with poorly controlled DM...glucose 3 days ago 345....no insulin therapy....A1c is 11 earlier this month and up from 10 the month prior....several glucose readings in the emr all between 235-345....elective outpatient rotator cuff/biceps tendonesis....
  40. bkell101

    bkell101 UDGRAD

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    Reading the above thread....seems data for major joint replacement gives risk to PE, but this isn't major joint....data is there for cardiac and vascular surgery....and wound healing for abdominal surgery...anything out there on low mod risk surgery as outpatient?

    Earlier somebody quoted 370 as the cut off for fear of neurological / non ketogenic coma....any other thoughts on this?

    What's the approach when this patient shows up with 355... Surgeon already notified of poor glycemic control and wants to proceed with insulin day of....

    Insulin ggt?
    Subq insulin?
    Single dose iv and check intraop?
    Treat in preop below a certain number then continue control to 180 intraop?


    Any good reading you guys can point me to on preop hyperglycemia management and its implications during the case...ie electrolyte shifts and fluid replacement?
    Last edited: Oct 17, 2013
  41. bkell101

    bkell101 UDGRAD

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    So i found this in society for ambulatory surgery special article in anesthesia and analgesia......." suggestions are based on data from hospitalized surgical patients and a consensus statement of the AACE/ADD.5 We suggest that in patients with well- controlled diabetes, intraoperative blood glucose levels be maintained &#56319;&#56330;180 mg/dL (10.0 mmol/L) (LoE category 2A). Of note, the selection of perioperative blood glucose level should depend upon the duration of surgery, invasiveness of surgical procedure, type of anesthetic technique, and expected time to resume oral intake and routine antidia- betic therapy. For example, higher blood glucose levels may be acceptable in patients undergoing short surgical procedures after which patients are promptly expected to resume oral intake and antidiabetic therapy.
    However, in patients with poorly controlled diabetes, if the decision to proceed with the surgery is made, the blood glucose levels should be maintained around their preoperative baseline values rather than temporarily (i.e., perioperatively) normalizing them (LoE category 2A). Chronically elevated blood glucose levels should not be decreased acutely in the perioperative period because the threshold at which a patient experiences symptoms or organ impairment due to hypoglycemia is dynamic and varies with their long-term glycemic control.22,25 Patients with poorly controlled type 2 diabetes have an altered counterregulatory response (i.e., release of epinephrine, norepinephrine, growth hormone, cortisol, and pancreatic polypeptide), resulting in hypogly- cemic symptoms at normal blood glucose levels.42&#8211; 44 Also, significant fluctuations in blood glucose levels caused by acute reduction in chronically elevated blood glucose levels can lead to detrimental biochemical effects including in- creased oxidative stress response45 and may increase peri- operative morbidity and mortality.1,46"

    Seems like pt comes in with 330 , similar to previous....do nothing and maybe monitor intraoperative to see if stress of surgery is hiking it up higher?....earlier in the article it said there isn't any good evidence available for low mod risk surgery...what are your thoughts?.......more from the article....In chronically poorly controlled diabetic patients, the decision to proceed with ambulatory surgery should be made in conjunction with the surgeon while taking into consideration the presence of other comorbidities and the potential risks of surgical complications (e.g., delayed wound healing and wound infection). There are no RCTs evaluating the effects of preoperative glycemic control on postoperative infection in ambulatory surgical proce- dures.40 However, a review of outcomes after noncardiac surgery found that HbA1c &#56319;&#56330;7% was associated with a significantly lower incidence of postoperative infections.41
  42. bkell101

    bkell101 UDGRAD

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    "Although IV infusion of regular insulin has been used to maintain optimal blood glucose levels in patients undergo- ing major surgical procedures and in critically ill patients, the AACE/ADA consensus statement recommends the subcutaneous route for noncritical patients.5 IV insulin infusion requires more frequent monitoring because there are concerns of hypoglycemia. Overall, insulin infusion may not be necessary or practical in the outpatient surgical setting. Furthermore, as is mentioned above, subcutaneous administration of rapid-acting insulin has been shown to provide similar control as IV infusion of regular insu- lin.47,48 Therefore, subcutaneous administration is the pre- ferred method for achieving and maintaining target glucose levels (LoE category 2A)."
  43. Ronin2258

    Ronin2258 Prometheus Unbound

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    Mastectomy in a 60 y.o. woman, speaks her native language only. Poor compliance with breast cancer therapy. Underwent chemo 6 months ago, was supposed to have this surgery 5 months ago. Very aggressive tumor. Other history includes remission from heroin dependence for 5 years, and distant alcohol use, but still smokes half a pack a day.

    Very poor diabetes control. Saw pre-op paperwork on her the day before: Fasting glucose 492, A1C 10 (down from 14 at the time when she was supposed to have the mastectomy.)

    See her day of surgery. No neuropathy, no missing extremities (I was thinking this woman was going to wheel herself in in a kid's wagon from the amputations with those sugars.) Finger stick in Pre-Op was 430. And she was talking, interactive, and appropriate throughout the entire thing.

    What was done: My Attending cancelled case. Patient admitted to surgery overnight with a consult for the fleas to crawl over her addressing her glucose. Aggressive resuscitation and control allowed her to have the surgery the next day (which I had nothing to do with.) Surgeon relayed her frustrations to us about how hard it was to get this woman to listen to anything. Only came in for the surgery at her daughter's insistence.

    *shakes head* I know there is fear of the needles and constant finger sticks to check. At times, I wish the consequences of these conditions were more acute, just to drive the fear for compliance into their lives.
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