preop blood sugar

[GaseousClay]

I know we've discussed this a few times but just wondering what some of you guys in private and academics are doing with elevated blood sugars in preop. specifically had a patient, who went to preop clinic 2 weeks prior to surgery (incisional hernia repair, s/p liver transplant so a huge incisional hernia repair), and had a BS of 350 at preop clinic. preop nurse practitioners leave the patient a message saying call your primary and get your sugar better controlled before surgery. patient arrives on day of surgery with BS of 320, when asked about that message from preop clinic he said he heard it but didn't do much about it (shocker). surgeon is aware and fine with BS that high and suggests some insulin to bring it down preop. Other attendings (anesth) here agree to just control it preop, intraop and good mgmt post-op. I think cancelling the case may be questionable because the patient may just go home and come back weeks later still not optimized. however the patient is on immunosuppression for liver transplant and infection risk with those sugars would be really high. Discussed that with the surgeon and he wishes to proceed. What do you guys think? Whats the liability on us if there is a big wound infection and we document our concern and the willingness of the surgeon to proceed despite that.

---

Members don't see this ad.

 

[deleted171991]

In my book, this sick guy with poorly-controlled diabetes is far from being optimized for an elective surgery. I don't care what the surgeon says; he can do it with a different anesthesiologist. I would not care about a one-time BS of 320 after the patient skipped a high dose of insulin, but I bet this guy's Hb A1c is above 10. Which means that the entire body is nicely glucosylated and f*cked up.

I think cancelling the case may be questionable because the patient may just go home and come back weeks later still not optimized. however the patient is on immunosuppression for liver transplant and infection risk with those sugars would be really high.

"So, doctor, would you please tell the jury why you proceeded with surgery despite the patient's diabetes being out of control? Oh, you were looking after his best interests, not after your anesthesia fee... Because I could line up three experts that would say, under oath, that they would have not done this surgery with such a ravaging diabetes in an already immunocompromised patient."

Let me put it this way: you are not responsible for the patient being STUPID (and the hernia will not kill him, unlike a post-op infection), but you are responsible for the welfare of your own family. No good deed goes unpunished.

My litmus test for situations like this is: would I do it to my mom? If no, then I don't do it to the patient either. There is this thing called tough love, and it's exactly what the public expects from doctors; the patients and their families will seldom take responsibility if the outcome is bad, despite having been well-informed and consented about the risks.

 

[GaseousClay]

I thought the same way but all 3 academic attgs I told said to just proceed so as a lowly resident the case was done. I kept the sugar around 180-200 during the case and post op, also told Surg resident to make sure this guy gets under control after

 

[dpmd]

Would you guys really be held liable for the wound infection post op? That is crazy. As a surgeon I would have checked an A1c and not proceeded unless that was good (not worried so much about a one time high as someone posted earlier), but not every surgeon follows that strategy (although the literature is pretty clear about the benefit). However, I would never expect anesthesia to have to force the surgeon to comply so why should they share liability. Would be different if it is something that caused an intraoperative problem.

 

[deleted171991]

I used to think the same way when I was a resident: "What's the big deal? We'll just start an insulin drip intraop, and let the surgeon worry post-PACU."

As an attending, my thinking centers on two things: 1. What's in the patient's best interest? 2. What's in my (family's) best interest? Even being deposed for the surgeon's malpractice suit is not fun. So I have become much more risk-averse than I used to be as a resident, while trying to keep as many people as possible happy.

On the other hand, I will bend the rules if the risks are small and the patient has jumped through hoops for the procedure. (I have a high threshold to cancel a colonoscopy, for example, especially in a patient with a history of polyps - but I would still cancel it for a sugar of 320.)

I don't think it's OK to do elective surgery on a poorly-controlled diabetic immunosuppressed patient, just because "There is a fracture. I need to fix it."

 

[Mman]

"So, doctor, would you please tell the jury why you proceeded with surgery despite the patient's diabetes being out of control? Oh, you were looking after his best interests, not after your anesthesia fee... Because I could line up three experts that would say, under oath, that they would have not done this surgery with such a ravaging diabetes in an already immunocompromised patient."

as devil's advocate...

Ladies and gentlemen of the jury, his diabetes was not out of control. I controlled it. His glucose was < 200 prior to going to the OR and was maintained at an appropriate level throughout his periop care. Furthermore I am unaware of any scientific literature that conclusively demonstrates a benefit to the patient by cancelling his case. He was given informed consent and elected to have the procedure done despite any possible increased risk from his diabetes including risk of wound infection. Besides I didn't get paid crap for his case because he doesn't have insurance so I can assure you I was not financially motivated.



While I agree you will find "experts" that will say under oath they would never do such a case, you can find "experts" to testify to anything. We have a big lack of evidence of benefit from cancelling cases for glucose control. I'm not saying you should never do such a thing, but as a specialty we probably are too strict in this area.

 

[deleted171991]

He was given informed consent and elected to have the procedure done despite any possible increased risk from his diabetes including risk of wound infection.

Now that's the part where it has been argued successfully before that the wonderful entitled member of society has very little responsibility about his own choices, even if informed properly by his physician.

As in "You should have known better, doctor, than to even offer this choice to the patient. Of course the patient accepted, with his thinking clouded by the preoperative stress." And this part is very easy to argue if even one member of the jury has had surgery or has accompanied a very close family member to surgery. I have been in the latter situation, for a minor procedure, and I was not myself that day.

 

[Mman]

Now that's the part where it has been argued successfully before that the wonderful entitled member of society has very little responsibility about his own choices, even if informed properly by his physician.

As in "You should have known better, doctor, than to even offer this choice to the patient. Of course the patient accepted, with his thinking clouded by the preoperative stress." And this part is very easy to argue if even one member of the jury has had surgery or has accompanied a very close family member to surgery. I have been in the latter situation, for a minor procedure, and I was not myself that day.

Correct. But I don't have any literature to support him having a better outcome by not having surgery that day and sending him home to wallow in his diabetes. We've got some crystal clear ACC/AHA guidelines regarding cardiac disease and presurgical testing indications. We don't have that for blood sugar. So should I have known better? Is a blood sugar of 350 not OK but a blood sugar of 299 OK? What's the magic number and what's the evidence to support that magic number?

 

[deleted171991]

There is no magic number (although mine is 300-ish). However, given not only the diabetes but also the immunosuppression for liver transplant, my threshold is way lower. This guy needs his diabetes to be controlled, not for post-op healing only, but for intra- and post-op immunity. He simply cannot afford any infection. And **** him for continuing to **** up his health and wasting a half-million dollar-liver.

The argument is very simple: the patient is far from being optimized for elective surgery. I sympathize with any patient who has a surgeon like his. I bet the transplant surgeon wouldn't be so happy to risk his health.

 

[BuzzPhreed]

In private practice my number is 250-ish. If it's a truly elective case. Why? I can't justify the increased infection risk, especially in a joint case, if they can't keep their sugar controlled. You're talking thousands and thousands of dollars of extra care if they get infected. No one every died from a bad native knee in an obese diabetic. They have from infections in knee replacements, not to mention sometimes years of problems afterwards. But we're not talking about that here so I digress.

In this guy I'd immediately be on the phone with the transplant surgeon. If he's not strangulated I think you gotta get his sugar under better control before you proceed to the OR. Moreover I think the transplant team would want to know why this guy is so outta whack. He should probably be admitted and adjusted. Once he's cleared by the transplant team then you can fix his hernia (assuming the transplant surgeon isn't doing the hernia repair because most of them can't be bothered with that type of operation). No problems postponing this operation (never use the word 'cancel' if you're the anesthesiologist making the call) if it is truly elective, especially at at an academic center.

Get the guy in the hospital and get him under control. The fleas love this kind of stuff. Don't rush the guy to the OR. Remember being a true peri-operative specialist means you gotta think about what happens to this guy after he leaves the OR.

 

[bigdan]

I agree w/those saying to tread carefully/conservatively; in an elective case, why take the risk? I'm at a liver transplant center, and this guy's case would have been delayed here for that BG level. We get the transplant service involved for all planned surgeries, too, so they'd weigh in before things proceeded.

That said, you can prolly make the numbers look nice with insulin if you want to. If the guy gets a post-op infection, my money is on the combination of meds he's taking every day for the desired effect of eliminating his body's native defense system, not because of an elevated A1c. I really have no idea what BG or A1c level increases risk for post-op infection, and who knows what the benefit of "controlling" the BG is? What if Medicine gets it to 80-120 for a week? Does that undo the past several months of circulating candy in his blood?

 

[BobBarker]

I will post a similar case in a couple years.

I second waiting until blood sugar is fixed but at my a university center this case would have proceeded as scheduled.

 

[dpmd]

I agree w/those saying to tread carefully/conservatively; in an elective case, why take the risk? I'm at a liver transplant center, and this guy's case would have been delayed here for that BG level. We get the transplant service involved for all planned surgeries, too, so they'd weigh in before things proceeded.

That said, you can prolly make the numbers look nice with insulin if you want to. If the guy gets a post-op infection, my money is on the combination of meds he's taking every day for the desired effect of eliminating his body's native defense system, not because of an elevated A1c. I really have no idea what BG or A1c level increases risk for post-op infection, and who knows what the benefit of "controlling" the BG is? What if Medicine gets it to 80-120 for a week? Does that undo the past several months of circulating candy in his blood?

I have read a lot supporting an a1c below 7 but can't quote the risk reduction amounts or anything.

 

[BuzzPhreed]

Preoperative and postoperative hyperglycemia (defined as any blood glucose measurement above 200 mg/dl) as well as elevated A1C levels (above 6.5 percent or 48 mmol/ml) were significantly associated with increased rates of dehiscence (odds ratio, 3.2, p = 0.048; odds ratio, 3.46, p = 0.028; and odds ratio, 3.54, p = 0.040, respectively). Variability in preoperative glucose (defined as a range of glucose levels exceeding 200 points) was significantly associated with increased rates of reoperation (odds ratio, 4.14, p = 0.025) and trended toward significance with increased rates of dehiscence (p = 0.15). In multivariate regression, only perioperative hyperglycemia and elevated A1c were significantly associated with increased rates of dehiscence.

http://www.ncbi.nlm.nih.gov/pubmed/23783058

Might have to change my cutoff point.

 

[pgg]

So if you cancel the elective case with a preop glucose of 250 or 300, and the patient comes back in a month and the glucose is 250 or 300 again, do you cancel again?

Controlling diabetes is about as easy as sustainably losing 50 pounds ... which is to say most people who need to do it, can't do it. So these people need to live with their diabetes AND the hernia or bad knee, forever? I'm all for tough love but sometimes the answer is just that a patient is higher risk and the best thing for their quality of life is to just get on with the surgery.


I'm uncertain what to make of these studies that cite statistically significant differences in rare, non-catastrophic events. But I'm skeptical that one wound infection is more clinically significant than the all the cases you wound have to postpone or not do to prevent it.

My soft cutoff is somewhere above 300 or so if I think nothing else is going on and that's where the patient lives (ie, there's no missed preop insulin dose to easily explain it). But every patient is different and you just have to talk to them and see what their circumstances and risk tolerance is.


Something else to think about when the patient shows up with a glucose of 300 ... the patient may ALREADY have an infection brewing somewhere which is responsible for the hyperglycemia. If grandma's hyperglycemic because she's got a raging UTI obviously the right answer isn't insulin and a new knee.

 

[dpmd]

So if you cancel the elective case with a preop glucose of 250 or 300, and the patient comes back in a month and the glucose is 250 or 300 again, do you cancel again?

Controlling diabetes is about as easy as sustainably losing 50 pounds ... which is to say most people who need to do it, can't do it. So these people need to live with their diabetes AND the hernia or bad knee, forever? I'm all for tough love but sometimes the answer is just that a patient is higher risk and the best thing for their quality of life is to just get on with the surgery.


I'm uncertain what to make of these studies that cite statistically significant differences in rare, non-catastrophic events. But I'm skeptical that one wound infection is more clinically significant than the all the cases you wound have to postpone or not do to prevent it.

My soft cutoff is somewhere above 300 or so if I think nothing else is going on and that's where the patient lives (ie, there's no missed preop insulin dose to easily explain it). But every patient is different and you just have to talk to them and see what their circumstances and risk tolerance is.


Something else to think about when the patient shows up with a glucose of 300 ... the patient may ALREADY have an infection brewing somewhere which is responsible for the hyperglycemia. If grandma's hyperglycemic because she's got a raging UTI obviously the right answer isn't insulin and a new knee.

An infection in a pt with a mesh can be catastrophic or life changing, but for other surgeries it is not a big deal which is why I would put the burden on the surgeon to make the right decision rather than make anesthesiologists try to fight with them about it.

 

[BuzzPhreed]

pgg, I agree with your post. I would move your "soft" cutoff point lower. But that's just me.

So if you cancel the elective case with a preop glucose of 250 or 300, and the patient comes back in a month and the glucose is 250 or 300 again, do you cancel again?

Yes, personally, I would move again to postpone it. But I've been in this situation and the motivated patient doesn't have a problem complying unless, as you point out, there is something else brewing that needs to be investigated. Now have I ever done an elective case where the BS is > 300. Yes. I don't make a habit of it. As dpmd says it does depend on the situation.

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

On a slightly separate note and for the residents, something to think about: two habits that I've tried hard to break are saying 'cancel' and 'paralyzed'.

I never tell a patient or the surgeon I'm going to cancel their case. I tell them that I would like to postpone it. To the patient that hears the word "cancel" it has all kinds of negative connotations. To the surgeon they feel like you're putting your foot down when you are often actually negotiating. You're not canceling their operation you're just agreeing to do it at a later time. Postponing means to a lot of people that you will do it in six hours because they ate breakfast. To me it means you will do it at a later time. Splitting hairs? Maybe. But it's nicer than saying cancel.

I try to tell nurse anesthetists or anyone else who says "we'll be paralyzing you to put the breathing tube in" etc. to say instead relaxing. We are giving a muscle relaxant. That's what it does. It works at the most distal part of the neuraxis at the neuromuscular junction. If something happens and, God forbid, the patient actually becomes paralyzed during the operation you're going to have a lot more explaining to do to the often not-too-medically-savvy family.

 

[killerleaf]

As a diabetic, and dealing with all the wonderful ups and downs, I can say with certainity: pain and stress make my numbers higher, no matter what I do to control them. My A1C may hover around 6.8 to 7; but pain and/or stress will make me spike.

 

[batina17]

I'm a bit less conservative (maybe because I haven't gotten burned yet) but I typically follow SAMBA Consensus Statment on Perioperative Blood Glucose for lack of better guidance. If glucose is high I check a urine dipstick for ketones, if positive I send to ER for management, if negative and surgeon wants to proceed I'm ok with it.

http://www.csahq.org/pdf/bulletin/v59_4_samba_consensus.pdf

 

[BuzzPhreed]

We are talking about (I believe) chronically poorly controlled diabetics here, and from the very consensus guideline you referenced, it says this:

In chronically poorly controlled diabetics, the decision to proceed
is made in conjunction with surgeon, taking into consideration
the presence of other comorbidities as well as the potential risks of
surgical complications.

Which is exactly what most of us are saying here. In other words you probably will postpone. Also they don't list any absolute values. So I don't find this consensus statement to be particularly helpful. Just a CYA type of thing.

 

[BLADEMDA]

If I followed your tight glucose control recommendation then about 1/3 of my cases may get cancelled each day. Instead, I treat the high sugar with insulin and do the case.

For elective total joint surgery or a CABG should we check the HGbA1c and make sure its below 8.0? The jury is still out on that one.

Ideally, we want less than 7.0 but will you cancel the case for 8.0?

http://www.healio.com/orthopedics/t...-were-able-to-achieve-threshold-level-for-tja

 

[BLADEMDA]

http://forums.studentdoctor.net/threads/cancel-for-hyperglycemia.662671/
Worth reading. I rarely cancel a case for a Hgb A1C under 8.5.

 

[Arch Guillotti]

Nobody wants to end up like this case.

I probably would have done the case though.

 

[MaximusD]

An infection in a pt with a mesh can be catastrophic or life changing, but for other surgeries it is not a big deal which is why I would put the burden on the surgeon to make the right decision rather than make anesthesiologists try to fight with them about it.

Then you wouldn't agree with the new Anes title of and orientation around "Perioperative Medicine", because that would surely cover the importance of perioperative glucose control...

 

[dpmd]

Then you wouldn't agree with the new Anes title of and orientation around "Perioperative Medicine", because that would surely cover the importance of perioperative glucose control...

On the contrary I would welcome the input, I just don't see the rationale in penalizing them if the surgeon goes rogue (and I don't think requiring the anesthesiologists to force the surgeon to comply would work out well unless it is in the context of protocols under a periop medicine umbrella in which case the postponing happens earlier than the day of surgery ideally)