GLYCEMIC CONTROL AND SSI's

“According to the American Diabetes Association it is estimated that 12-25% of hospitalized adult patients have diabetes mellitus. With the increasing prevalence of diabetic patients undergoing surgery, and the increased risk of complications associated with DM, appropriate perioperative assessment and management are imperative.” http://emedicine.medscape.com

"An estimated 25% of diabetic patients will require surgery. Mortality rates in diabetic patients have been estimated to be up to 5 times greater than in nondiabetic patients, often related to the end-organ damage caused by the disease.” http://emedicine.medscape.com)

Tight control of blood glucose has been proven to reduce the rate of surgical infections.

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Currently, there is not a defined optimal target range for blood glucose to prevent in surgical patients, it has been suggested that 80-150mg/dl, will reduce the rate of postop surgical infections. Of course, the ultimate goal in the management of a diabetic patient is to achieve results equal to those in patients without DM.

Some evidence suggests that at least a quarter of diabetic patients are unaware of their disease, it may prove beneficial to screen all patients undergoing surgery. (At the facility I work at we currently check every patient who walks through our doors for diabetes. Every patient is screened 3 times via POC, if they have 1 blood sugar greater than 200mg/dl during the screening nurses initate the hyperglycemia protocols, which entails drawing an HbA1C, sliding scale coverage for BS greater than 150 until endocrinologist rounds and accu checks are changed to AC/HS. If they have two blood sugars greater than 150mg/dl we initiate the same protocol.  During our screening of all patients we diagnosis so many “new” diabetics it is scary, the disease is running rampant and most people are unaware of their condition.

General Preoperative Management

On day of surgery most patients will be advised not to take their diabetes medications, this will help reduce the number hypoglycemia events.

Patients who are on insulin are advice to reduce their bedtime basal dose the night before the surgery to prevent hypoglycemia while patient is not eating by mouth. Maintenance insulin maybe continued during surgery based on the recommendations of the physician.

Metabolic response to Anesthesia and Surgery

Surgery places considerable amount of stress on one’s body causing an increase in blood sugars


Anesthetic agents can also affect glucose metabolism resulting in hyperglycemia and possibly ketoacidosis

According the American Diabetes Association patients undergoing cardiac surgeries should have a blood glucose target of less than 150mg/dl, this will reduce mortality and reduce the risk of sternal wound infections.

Methods of achieving blood sugar control

“Because of the numerous potential perioperative complications in diabetic patients, close monitoring is imperative to maintain glycemic control, while minimizing hypoglycemia.” http://emedicine.medscape.com

After surgery patients who were taking oral agents may be able to resume their medications. Healthcare personnel need to assess if the oral medication is appropriate because of potential complications or if IV insulin is the best choices, as it is easily titratable.  


For example, Glyburide can cause hypoglycemia, has prolonged action, and is difficult to titrate. Metformin has potential risk of lactic acidosis and must be used cautiously in renal and CHF patients. Actos needs to be used cautiously in CHF patients and is also difficult to titrate.


Another method for controlling perioperative blood glucose is through the use of IV insulin. Several insulin protocols are available, including computer-based systems that will calculate the dosing based on the blood glucose. At the facility I work at we use such a computer based program for controlling BS postoperatively.

Discussion Topic: How to prevent SSI?

References:

http://emedicine.medscape.com

American Diabetes Association