Perioperative Glycemic Management for Patients with and without Diabetes

Abstract

People with diabetes are at an increased risk for worse postoperative outcomes, compared to people without diabetes. Notably, up to one in 10 people who undergo surgery have unrecognized diabetes and an additional 10% may have postoperative hyperglycemia without meeting the criteria for a diagnosis of diabetes. Management of postoperative hyperglycemia has been demonstrated to reduce the incidence of poor outcomes, but evidence demonstrates that postoperative hyperglycemia remains a quality gap for surgical patients. In this review, we will outline the evidence for preoperative screening for postoperative hyperglycemic risk, review the evidence for perioperative glycemic management, and examine the barriers to these best practices. RÉSUMÉLes personnes atteintes de diabète courent un risque accru de voir leurs résultats postopératoires moins bons que ceux des personne non atteinte de diabète. En particulier, près d’une personne sur dix qui subit une intervention chirurgicale présente un diabète non diagnostiqué et dix pour cent supplémentaires peuvent présenter une hyperglycémie postopératoire sans pour autant répondre aux critères de diagnostic du diabète. Il a été démontré que le traitement de l’hyperglycémie postopératoire réduit l’incidence des mauvais résultats, mais les données probantes montrent que l’hyperglycémie postopératoire demeure une lacune chez les patients opérés. Dans cette revue, nous présentons les données probantes relatives au dépistage préopératoire du risque d’hyperglycémie postopératoire, nous passons en revue les données probantes relatives à la gestion de la glycémie périopératoire et nous examinons les obstacles à ces meilleures pratiques.

Quality gaps in screening and monitoring for postoperative hyperglycemia in a Canadian hospital: a retrospective cohort study

“…This retrospective cohort study used electronic health record (EHR) data to measure process, outcome, and balancing measures tied to a previously described framework for perioperative glycemic management14 to assess the quality of perioperative diabetes management in a single hospital system 18. This manuscript is reported according to the Reporting of Studies Conducted Using Observational Routinely Collected Health Data extension19 of the Strengthening the Reporting of Observational Studies in Epidemiology guidelines20 and the Strengthening the Reporting of Cohort Studies in Surgery guideline 21…”

“…Outcomes were defined using the perioperative glycemic process map developed with input from endocrinologists, perioperative internists, surgeons, data analysts, and quality improvement experts (figure 1). 14 Measures are reported separately for patients with and without diabetes, and are stratified into screening measures, perioperative monitoring measures, perioperative glycemic outcome measures, and balancing measures. All measures are reported for the first 24 hours after surgery, which is based on previous work that suggests this is the most critical time period for development of adverse postoperative complications due to hyperglycemia 6.…”

“…We have previously reported a framework for understanding and evaluating perioperative glycemic management ( figure 1 ). 14 This framework requires: (1) preoperative screening for risk of postoperative hyperglycemia based on hemoglobin A1c (HbA1c) results; (2) proactive planning for patients at risk of postoperative hyperglycemia; (3) postoperative monitoring for hyperglycemia using capillary glucose point-of-care testing (POCT); (4) recognition of postoperative hyperglycemia; and (5) appropriate treatment of postoperative hyperglycemia.…”

“…10 11 We have previously reported a framework for understanding and evaluating perioperative glycemic management (figure 1). 14 This framework requires: (1) preoperative screening for risk of postoperative hyperglycemia based on hemoglobin A1c (HbA1c) results;…”

Prise en charge peropératoire de la glycémie : quand surveiller et qui traiter?

“…1 Diabetes is even more common in the surgical population, affecting 20-30% of patients. 2 Patients undergoing noncardiac surgery with diabetes have twofold higher mortality rates. 3 Poor glycemic control during the perioperative period, regardless of diabetes status, may significantly increase adverse outcomes, including postoperative infection risk, length of stay, 30-day readmission rates, and mortality.…”