Importance of Perioperative Glycemic Control in General Surgery

Abstract

Objective To determine the relationship of perioperative hyperglycemia and insulin administration on outcomes in elective colon/rectal and bariatric operations. Background There is limited evidence to characterize the impact of perioperative hyperglycemia and insulin on adverse outcomes in patients, with and without diabetes, undergoing general surgical procedures. Methods The Surgical Care and Outcomes Assessment Program is a Washington State quality improvement benchmarking-based initiative. We evaluated the relationship of perioperative hyperglycemia (>180 mg/dL) and insulin administration on mortality, reoperative interventions, and infections for patients undergoing elective colorectal and bariatric surgery at 47 participating hospitals between fourth quarter of 2005 and fourth quarter of 2010. Results Of the 11,633 patients (55.4 ± 15.3 years; 65.7% women) with a serum glucose determination on the day of surgery, postoperative day 1, or postoperative day 2, 29.1% of patients were hyperglycemic. After controlling for clinical factors, those with hyperglycemia had a significantly increased risk of infection [odds ratio (OR) 2.0; 95% confidence interval (CI), 1.63–2.44], reoperative interventions (OR, 1.8; 95% CI, 1.41–2.3), and death (OR, 2.71; 95% CI, 1.72–4.28). Increased risk of poor outcomes was observed both for patients with and without diabetes. Those with hyperglycemia on the day of surgery who received insulin had no significant increase in infections (OR, 1.01; 95% CI, 0.72–1.42), reoperative interventions (OR, 1.29; 95% CI, 0.89–1.89), or deaths (OR, 1.21; 95% CI, 0.61–2.42). A dose-effect relationship was found between the effectiveness of insulin-related glucose control (worst 180–250 mg/dL, best <130 mg/dL) and adverse outcomes. Conclusions Perioperative hyperglycemia was associated with adverse outcomes in general surgery patients with and without diabetes. However, patients with hyperglycemia who received insulin were at no greater risk than those with normal blood glucoses. Perioperative glucose evaluation and insulin administration in patients with hyperglycemia are important quality targets.

Strict glycemic control to prevent surgical site infections in gastroenterological surgery

“…reported that every 40 mg/dL increase from normoglycemia (<110 mg/dL) led to a 30% increased risk of infection. Kwon et al 13. also found a clear dose–response relationship between BG and SSI in favor of a lower BG level.…”

“…Although non‐DM patients had a lower incidence and decreased severity of hyperglycemia compared with DM patients, hyperglycemia was also associated with adverse outcomes in non‐DM patients 13, 16, 17. In the assessment of operative‐day BG in non‐DM patients who underwent colectomy, normoglycemia (≤120 mg/dL) endured in 26.2%, whereas 53.6% had BG of 121–160 mg/dL, 15.1% had 161–200 mg/dL, and 4.5% >200 mg/dL 18.…”

“…There are currently several debates regarding the benefits of strict glucose control in less critically ill patients undergoing elective surgery as opposed to critically ill (medical) patients12, 13, 14, 15, 16, 17, 18 (Table 2). Although the recommended target BG is 140–180 mg/dL for most ICU patients,27 a recent meta‐analysis23 comparing the efficacy between an intensive and a conventional protocol in patients undergoing surgery showed a significant benefit for the intensive protocol in reducing SSI.…”

“…The Surgical Care Improvement Project5 (SCIP) developed a quality performance measure to maintain the 6 a.m. controlled blood glucose level (BG) at <200 mg/dL in cardiac surgery (<180 mg/dL in the updated version11). This recommendation has been challenged by recent studies suggesting that an even lower target BG is required to prevent SSI 12, 13, 14, 15, 16, 17, 18. The intensive insulin administration protocol (intensive protocol), however, leads to an increased risk of hypoglycemia, which, in turn, is associated with increased morbidity and mortality 19, 20.…”

“…It seems that very strict glycemic control has modest benefits, with adverse effects often outweighing these advantages in critically ill patients. However, recent studies have indicated differing results for certain patient subgroups, such as surgical patients with acute operative hyperglycemia in the immediate postoperative period 12, 13, 14, 15, 16…”