Download Importance of Glycemic Control in the Treatment of

Importance of Glycemic
Control in the Treatment
of Surgical Patients
Michael J Patney, D.O., FAOAO
Notice of Disclosure
• I have no Disclosures in regards to this lecture or topic
Goals of this Lecture
• Understand why glycemic control is important
• Realize the contribution of tight glycemic control during the
preoperative and perioperative periods
• Achieve awareness of the importance of preoperative HgbA1C and
the necessary values in medical clearance
• Achieve awareness of the perioperative requirements of
perioperative blood glucose levels
Why this lecture?
• New government rules and regulations regarding:
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Bundled payments
Quality of care guidelines
Readmission rules
Monitoring of outcomes
• Insurance company limitations
• Insurances will now be limiting access to elective procedures for patients
with “modifiable” risk factors.
“Modifiable” Risk factors
• Bosco et al (2010)
• Preoperative considerations include:
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Inflammatory Disease
Sickle Cell
Diabetes
Renal Failure
Human Immunodeficiency Virus (HIV)
Smoking
Obesity
Diabetes as a risk factor
• Bosco et al
• Patients with diabetes all receive a preoperative check of their HgbA1C
• Recommend a preoperative HgbA1C < 6.9
• Also recommends that if this level can not be achieved or maintained then
an endocrine consult should be obtained.
More on “modifiable” risk factors
• Moucha et al (2011)
• Multiple modifiable risk factors for surgical site infection.
• Rheumatoid Arthritis
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NSAID
Corticosteroid
Methotrexate
Disease modifying agents
• Chemical
• Plaquenil
• Sulfasalazine
• Biologic
• TNF-antagonists
• IL-1 antagonists
More on “modifiable” risk factors
• Moucha cont’d
• Multiple modifiable risk factors for surgical site infection.
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Human Immunodeficiency Virus (HIV)
Diabetes Mellitus and Hyperglycemia
Malnutrition
Smoking
Obesity
Staph Colonization
Oral Hygiene
Urinary Tract Infection
Anemia
What are the risks of not having tight
glycemic control
• Lazar et al (2003)
• Studied blood glucose control post CABG using standard measures and a
combination of glucose, insulin and potassium (GIK) in the ICU
• 141 patients randomized into tight post op control with GIK and standard
sliding scale coverage.
• Showed an improvement in survivability with tight control
• Also showed a decrease in ischemic events and in wound complications.
Further Evidence of the need for glycemic
control
• Underwood et al (2014)
• 1775 Diabetics
• Only 622(35%) had a preoperative HgbA1C
• These were broken down into 4 groups
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<6.5
6.5-8
8-10
>10
Further Evidence of the need for glycemic
control
• Underwood Cont’d
• Results
• <6.5 and 6.5-8 groups had similar rates of complication
• Greater than 8 had a longer length of stay (LOS)
• The population was too small to determine the types of complications but were
able to determine that preoperative HgbA1C was a predictive variable for
hospital length of stay.
The importance of perioperative glycemic
control
• Richards et al (2012)
• Compared patients with 2 random BS >200 or a hyperglycemia index >1.76
to controls
• Hyperglycemia index was calculated as the area under the curve of all glucose
levels for the entire hospital stay. Averaged out to be a BS > 140 mg/dL
• Orthopedic trauma cases match for variables
• 294 patients had BS >200 at least twice
• 134 patients had a glycemic index greater than 1.76
The importance of perioperative glycemic
control
• Richards Cont’d
• Both the blood glucose being over 200 and the hyperglycemia index were
independent predictors of infection
• Further extrapolation leads to the conclusion that blood glucose over 140 mg/dL
would have an adverse effect on the chances of having an infection.
• In the conclusion they state their data corroborates other studies; however,
they made no treatment recommendations based on their conclusions
Results from a managed population
• Adams et al (2013)
• Retrospective cohort study from Kaiser Permanente
• Outcomes of total knee replacement according to diabetes status and
glycemic control.
• Looked at complications of DVT, PE, Deep Infection and Revision
• Studied 3 groups
• Nondiabetic
• Well controlled Diabetic (HgbA1C <7)
• Median 6.2
• Poorly controlled Diabetic (HgbA1C >7)
• Median7.6
Results from a managed population
• Adams Cont’d
• Found no adverse effect in any cohort
• This corroborates the earlier Underwood study showing little effect of a
HgbA1C < 8 ; however, this study fails to evaluate those patients with higher
HgbA1c
• This may be due to restrictions in access to surgery in the Kaiser system to
patients with modifiable risk factors outside certain limits
• This may also be due to the fact that there is a focus of “resources on chronic
disease management through proactive involvement of clinicians and case
managers with patients.”
What are the other complications associated
with hyperglycemia
• Stryker et al (2013)
• Looked at 30 patients who had complications after a total knee
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Delayed healing
Drainage
Nondraining Hematoma
Draining Hematoma
Superficial Infection
Superficial Skin Necrosis
Dehiscence
What are the other complications associated
with hyperglycemia
• Stryker Cont’d
• Comparison of the study group with matched controls (both diabetic)
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Study group mean BS = 217
Study group max BS = 272
Control group mean BS = 185
Control group max BS = 227
• Also compared the preoperative HgbA1C
• Study group mean preop A1C = 6.8
• Control group mean preop A1C = 6.4
What are the other complications associated
with hyperglycemia
• Stryker Cont’d
• Concluded that both BS and A1C were associated with wound complications
within 30 days post op.
• Further concluded an upper limit on A1C to be 6.7 % from their statistical
analysis
• Discussed the limitations of the study with such a small subgroup, multifactorial
effects of the complications and the limitations in measuring A1C
Bringing it Full Circle
• Boraiah et al (2015)
• Developed a Readmission Risk Tool
• Incorporates multiple modifiable variables and takes into account:
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Colonization
Smoking
Obesity
Cardiovascular Disease
Venous Thromboembolic Disease
Neurocognitive, psychological and behavioral problems
Physical Deconditioning
Diabetes
Bringing it Full Circle
Bringing it Full Circle
Bringing it Full Circle
Bringing it Full Circle
• Boraiah Cont’d
• A RRT score of greater than 3 was significant for readmission and a score
greater than 5 was significantly predictive of readmission.
Bringing it Full Circle
• Everhart et al (2016)
• Develop a Surgical Site Predictor
• Includes type of procedure and risk factor
• Risk
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factors include
COPD
Diabetes
Long Term Insulin Use
Rheumatoid or inflammatory arthropathy
Tobacco use
Prior infection
Obesity
Septicemia
Bringing it Full Circle
Conclusions
• Preoperative HgbA1c
• Is an independent variable affecting the chances of post op infection
• Patients undergoing elective procedures should have a HgbA1C baseline
within 30 days of the proposed surgery
• Preoperative glycemic control with a goal of < 7% and ideally less than 6.8%
should be our target.
• Spot glucose monitoring is NOT enough to complete preoperative clearance
on a known diabetic
• Screening for Hyperglycemia with spot BS should prompt further workup and
treatment if elevated
Conclusions
• Perioperative tight control of the blood glucose should be our goal
• BS < 200mg/dL and ideally less than 180mg/dL in all hyperglycemic patients
• Close monitoring with the help of endocrinology to obtain this control in the
perioperative setting is beneficial to the patient.
• All “modifiable" risk factors should be maximized prior to surgical
clearance
• This will shortly be required when scheduling preop workup and patients not
meeting criteria will not be able to proceed with surgery
• Be aware of the new government guidelines and quality control measures
Finally
• The care we offer to patients shouldn’t be about their satisfaction
but about the quality of care they receive.
• Giving a peanut butter cup to a 350 lb. women with a BS of 350 may make
her satisfied but is it quality medicine?
Thank You
• Michael J Patney, D.O., FAOAO
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Bibliography available on request
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