An Update on Measures of Preoperative Glycemic Control

Abstract

Summary: Glycemic control represents a modifiable preoperative risk factor in surgery. Traditionally, hemoglobin A1c (HbA1c) and plasma glucose are utilized as measures of glycemic control. However, studies show mixed results regarding the ability of these conventional measures to predict adverse surgical outcomes. This may be explained by the time window captured by HbA1c and serum glucose: long-term and immediate glycemic control, respectively. Fructosamine, glycosylated albumin, and 1,5-anhydroglucitol constitute alternative metrics of glycemic control that are of growing interest but are underutilized in the field of surgery. These nontraditional measures reflect the temporal variations in glycemia over the preceding days to weeks. Therefore, they may more accurately reflect glycemic control within the time window that most significantly affects surgical outcomes. Additionally, these alternative measures are predictive of negative outcomes, even in the nondiabetic population and in patients with chronic renal disease and anemia, for whom HbA1c performs poorly. Adopting these newer metrics of glycemia may enhance the value of preoperative evaluation, such that the effectiveness of any preoperative glycemic control interventions can be assessed, and adverse outcomes associated with hyperglycemia better predicted. The goal of this review is to provide an update on the preoperative management of glycemia and to describe alternative metrics that may improve our ability to predict and control for the negative outcomes associated with poor glycemic control.

Early Experience With an Endocrinology Preoperative Fast-Track Program for Optimizing Spine Surgery Candidates With Poorly Controlled Diabetes Mellitus

“…Similarly, acceptable fructosamine levels and HbA1c conversion formulas can vary somewhat from publication to publication. 12-17 For this study, we relied on the expert consensus of our endocrinology group. Fructosamine levels have been directly studied in the total joint arthroplasty literature, 12-14 but we are not aware of studies specific to fructosamine levels and spine surgery outcomes.…”

“…[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17] This has been reported by multiple authors in spine surgery patients, specifically, [1][2][3][4][5][6][7] and other major surgeries including joint arthroplasty. [8][9][10][11][12][13][14][15][16][17] In a recent meta-analysis, Luo et al 1 reported that patients with diabetes undergoing spinal surgery have an increased risk of postoperative mortality, surgical site infection, deep vein thrombosis, and prolonged hospitalization. Machino et al 2 reported a poor postoperative recovery rate after cervical laminoplasty in patients with preoperative HbA1c .6.5%.…”

“…[12][13][14][15][16] Serum fructosamine is a measure of average blood glucose over a 2 to 3-week period, as opposed to the longer 2 to 3-month period measured by HbA1c. [12][13][14][15][16] Currently, HbA1c is a more commonly used preoperative measure because it is frequently available in the patient's medical chart because of standardization of diabetes management programs. When a patient's preoperative HbA1c is elevated, surgery can be postponed until the marker is within acceptable ranges.…”

“…1-17 Recent studies in the surgical and endocrinology literature have supported the use of serum fructosamine as an alternative for assessing preoperative glycemic control. 12-16 Serum fructosamine is a measure of average blood glucose over a 2 to 3-week period, as opposed to the longer 2 to 3-month period measured by HbA1c. 12-16…”

Association of Preoperative Hemoglobin A1c and Body Mass Index with Wound Infection Rate in Spinal Surgery

“…Fructosamine levels 292 lmol/L had a significant association with deep wound infection, but HbA1c level 7% did not. Ngaage et al 20 provide an excellent review of fructosamine and 2 other serum biomarkers (glycosylated albumin and 1,5-anhydroglucitol) and propose further investigation into their use as predictors of outcomes in spinal surgery. It is possible that similar evaluation of these newer markers of glycemic control will shed light on the exact relationship between diabetes, its management, and the risks associated with spinal surgery.…”