Perioperative Glucose Control and Infection Risk in Older Surgical Patients

Abstract

The aging of the U.S. population is leading to an increasing number of surgical procedures performed on older adults. At the same time, the quality of medical care is being more closely scrutinized. Surgical site infection is a widely-assessed outcome. Evidence suggests that strict perioperative serum glucose control among patients with or without diabetes can lower the risk of these infections, but it is unclear whether this control should be applied to older surgical patients. In this clinical review, we discuss current research on perioperative serum glucose management for cardiothoracic, orthopedic, and general/colorectal surgery. In addition, we summarize clinical recommendations and quality-of-care process indicators provided by surgical, diabetes, and geriatric medical organizations.

Choosing wisely and preoperative hemoglobin A1c testing: what should it mean?

“…3 Nous savons que l'hyperglycémie restreint la fonction immunitaire 6 et il a été démontré qu'elle constituait un facteur de risque d'ISO dans divers contextes périopératoires. 7 La disponibilité d'un traitement accepté et efficace (soit l'insulinothérapie) rehausse son attrait en tant que facteur de risque facile à modifier. Bien que nous ne sachions pas précisément si l'hyperglycémie provoque une ISO ou si elle y est seulement associée, ni quel taux de glycémie cibler pour trouver l'équilibre optimal entre la réduction du risque d'ISO et l'augmentation du risque de complications hypoglycémiques, ou encore comment organiser les soins 9 En effet, seule une fraction des cas d'ISO seraient attribuables à l'hyperglycémie postopératoire et bénéficieraient donc d'un dépistage accru.…”

“…En raison des coûts supplémentaires encourus si l'on admettait des patients à l'hôpital pour prendre en charge leur glycémie ou leur enseigner à surveiller et traiter leur hyperglycémie postopératoire à la maison, il est fort peu probable qu'un dépistage en masse de cette population s'avère rentable. 10 La rentabilité de cette mesure est mieux justifiée par la prévalence plus élevée d'ISO chez les patients hospitalisés, 7 mais seulement si les incertitudes énumérées ci-dessus sont élucidées. Toutefois, Yang et coll.…”

“…3 Hyperglycemia is known to impair immune function 6 and has been shown to be a risk factor for SSI in a variety of perioperative settings. 7 The availability of an accepted, effective treatment (i.e., insulin) makes it an easily modifiable risk factor. Although uncertainty remains as to (1) whether hyperglycemia causes SSI or is just associated with it, (2) which target glucose range optimally balances a reduced SSI risk with increased risk of hypoglycemic events, and (3) how care should be organized to achieve these goals, routine monitoring for, and treatment of, postoperative hyperglycemia have been recommended by well-regarded organizations.…”

“…With additional costs incurred by admitting patients to hospital for glucose management or teaching them to monitor for and treat postoperative hyperglycemia at home, it is highly unlikely that mass screening in this population would be cost effective. 10 The higher prevalence of SSI in inpatients provides a stronger case for cost effectiveness, 7 assuming that the uncertainties mentioned above are resolved. However, Yang et al found that, although both the hemoglobin A1c and the preoperative CBG measurements had acceptable specificity ([ 75%) for predicting postoperative hyperglycemia in this surgical population, they each had insufficient sensitivity (\ 40%) to be an effective screening test.…”

Considerations for Geriatric Patients Undergoing Colorectal Surgery

“…Strict glucose management has been well established to improve peri-operative outcomes in surgical patients. It is particularly important in the elderly population when you consider that over 27 % of patients older than 65 carry the diagnosis of diabetes, and another 50 % are at risk for development [ 97 ]. In fact, poor glycemic control (defi ned as any episode >150 mg/ dL) has been independently associated with worsened mortality (OR 11.5) and increased risk of surgical site infections in elderly patients over 70 years undergoing abdominal surgery [ 98 ].…”