Reactive Rather than Proactive Diabetes Management in the Perioperative Period

Abstract

As perioperative hyperglycemia is associated with poor postoperative patient outcomes, clinical guidelines provide recommendations for optimal perioperative glucose control. It is unclear to what extent recommended glucose levels are met in daily practice, and little is known about factors that influence these levels. We describe blood glucose levels throughout the hospital care pathway in 375 non-critically ill patients with diabetes who underwent major surgery (abdominal, cardiac, or orthopedic) in 6 hospitals, examine determinants of these levels including adherence to 9 quality indicators for optimal perioperative diabetes care, and perform qualitative interviews to identify barriers for optimal care. Virtually all patients (95%) experienced at least one hyperglycemic value (>10 mmol/l); 9% had at least one value <4 mmol/l. Mean glucose increased from preoperative to postoperative day (POD) 1 (+2.3 mmol/l, 5–95% CI 1.9–2.7), and then gradually decreased on POD 2–14 (+1.8 mmol/l, 5–95% CI 1.4–2.2). Insulin-treated patients (with or without oral agents) had higher glucose levels (+1.7 mmol/l, 5–95% CI 0.5–3.0, and +1.2 mmol/l, −0.1 to −2.5) than patients using oral agents only. Indicator adherence tended to be associated with higher glucose levels. Barriers for optimal care included a lack of formalized agreements on target glucose levels, absence of directly obvious disadvantages of hyperglycemia, and concern about inducing hypoglycemia. Hyperglycemia is common after major surgery, in particular on POD1 and in insulin-treated patients. Our results suggest that perioperative diabetes care is reactive rather than proactive, and that current emphasis of professionals is on treating instead of preventing postoperative hyperglycemia.

Key words

diabetes mellitus type 1 - diabetes mellitus type 2 - diabetes complication - glucose

• References

• 1 Kwon S, Thompson R, Dellinger P, Yanez D, Farrohki E, Flum D. Importance of perioperative glycemic control in general surgery: a report from the surgical care and outcomes assessment program. Ann Surg 2013; 257: 8-14
• 2 Frisch A, Chandra P, Smiley D, Peng L, Rizzo M, Gatcliffe C, Hudson M, Mendoza J, Johnson R, Lin E, Umpierrez GE. Prevalence and clinical outcome of hyperglycemia in the perioperative period in noncardiac surgery. Diabetes Care 2010; 33: 1783-1788
• 3 Doenst T, Wijeysundera D, Karkouti K. Hyperglycemia during cardiopulmonary bypass is an independent risk factor for mortality in patients undergoing cardiac surgery. J Thorac Cardiovasc Surg 2005; 130: 1144.e1-1144.e8
• 4 Golden SH, Peart-Vigilance C, Kao WH, Brancrati FL. Perioperative glycemic control and the risk of infectious complications in a cohort of adults with diabetes. Diabetes Care 1999; 22: 1408-1414
• 5 McConnell YJ, Johnson PM, Porter GA. Surgical site infections following colorectal surgery in patients with diabetes: association with postoperative hyperglycemia. J Gastrointest Surg 2009; 13: 508-515
• 6 Pomposelli J, Baxter J. Early postoperative glucose control predicts nosocomial infection rate in diabetic patients. J Parenter Enter Nutr 1998; 22: 77-81
• 7 Jacober SJ, Sowers JR. An update on perioperative management of diabetes. Arch Intern Med 1999; 159: 2405-2411
• 8 Cook CB, Zimmerman RS, Gauthier SM, Castro JC, Jameson KA, Littman SD, Magallanez JM. Understanding and improving management of inpatient diabetes mellitus: the Mayo Clinic Arizona experience. J Diabetes Sci Technol 2008; 2: 925-931
• 9 Knecht LA, Gauthier SM, Castro JC, Schmidt RE, Whitaker MD, Zimmerman RS, Mishark KJ, Cook CB. Diabetes care in the hospital: is there clinical inertia?. J Hosp Med 2006; 1: 151-160
• 10 Dhatariya K, Levy N, Kilvert A, Watson B, Cousins D, Flanagan D, Hilton L, Jairam C, Leyden K, Lipp A, Lobo D, Sinclair-Hammersley M, Rayman G. Joint British Diabetes Societies. NHS Diabetes guideline for the perioperative management of the adult patient with diabetes. Diabet Med 2012; 29: 420-433
• 11 Dutch Association of Internal Medicine (NIV). Guideline Diabetes Mellitus. 2014. http://www.internisten.nl/sites/internisten.nl/files/uploads/_e/ya/_eyaX0K4A4-e_S0jMr1zGw/richtlijn-module-Perioperatief_2013_Diabetes.pdf Last accessed 10 July 2016
• 12 American Diabetes Association . Standards of medical care in diabetes 2014. Diabetes Care 2014; 37 (Suppl. 01) S14-S80
• 13 Hommel I, Wollersheim H, Tack CJ, Mulder J, van Gurp PJ, Hulscher MEJL. Impact of a multifaceted strategy to improve perioperative diabetes care. Diabet Med 2016; [Epub ahead of print]
• 14 Hommel I, van Gurp PJ, Tack CJ, Wollersheim H, Hulscher ME. Perioperative diabetes care: development and validation of quality indicators throughout the entire hospital care pathway. BMJ Qual Saf 2016; 25: 525-534
• 15 Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, Rubin HR. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999; 282: 1458-1465
• 16 Wexler DJ, Meigs JB, Cagliero E, Nathan DM, Grant RW. Prevalence of hyper- and hypoglycemia among inpatients with diabetes: A national survey of 44 U.S. hospitals. Diabetes Care 2007; 30: 367-369
• 17 van Noord C, Kos S, Wulkan RW, Alkemade M, Dekker K, Schelfhout LJ, van der Linden J. Protocolised inpatient care of diabetes mellitus. Neth J Med 2012; 70: 406-410
• 18 Beliard R, Muzykovsky K, Vincent 3rd3 W, Shah B, Davanos E. Perceptions, barriers, and knowledge of inpatient glycemic control: a survey of health care workers. J Pharm Pract 2016; 29: 348-354
• 19 Cook CB, McNaughton DA, Braddy CM, Jameson KA, Roust LR, Smith SA, Roberts DL, Thomas SL, Hull BP. Management of inpatient hyperglycemia: assessing perceptions and barriers to care among resident physicians. Endocr Pract 2007; 13: 117-124
• 20 Kotagal M, Symons RG, Hirsch IB, Umpierrez GE, Dellinger EP, Farrokhi ET, Flum DR. SCOAP-CERTAIN Collaborative. Perioperative hyperglycemia and risk of adverse events among patients with and without diabetes. Ann Surg 2015; 261: 97-103
• 21 Gandhi GY, Nuttall GA, Abel MD, Mullany CJ, Schaff HV, O’Brien PC, Johnson MG, Williams AR, Cutshall SM, Mundy LM, Rizza RA, McMahon MM. Intensive intraoperative insulin therapy versus conventional glucose management during cardiac surgery: a randomized trial. Ann Intern Med 2007; 146: 233-243
• 22 Buchleitner AM, Martínez-Alonso M, Hernández M, Solà I, Mauricio D. Perioperative glycaemic control for diabetic patients undergoing surgery. Cochrane Database Syst Rev 2012 CD007315
• 23 Underwood P, Seiden J, Carbone K, Chamarthi B, Turchin A, Bader AM, Garg R. Early identification of individuals with poorly controlled diabetes undergoing elective surgery: Improving A1C testing in the preoperative period. Endocr Pract 2015; 21: 231-236
• 24 Umpierrez GE, Smiley D, Jacobs S, Peng L, Temponi A, Mulligan P, Umpierrez D, Newton C, Olson D, Rizzo M. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes undergoing general surgery (RABBIT 2 surgery). Diabetes Care 2011; 34: 256-261
• 25 Hommel I, van Gurp PJ, Tack CJ, Akkermans RP, Wollersheim H, Hulscher ME. Major gaps between recommended perioperative diabetes care and current practice. Eur J Intern Med 2016; 34: e11-e13
• 26 Hommel I, van Gurp PJ, Tack CJ, Liefers J, Mulder J, Wollersheim H, Hulscher ME. Perioperative diabetes care: room for improving the person centeredness. Diabet Med 2015; 32: 561-568
• 27 Health Consumer Powerhouse. Euro Diabetes Index. 2014; http://www.healthpowerhouse.com/files/EDI-2014/EDI-2014-report.pdf Last accessed10 july 2016