Preoperative Screening for Hyperglycemia Risk, Preoperative CHO, and Perioperative Glucose Control. E. Patchen Dellinger, MD

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1 Preoperative Screening for Hyperglycemia Risk, Preoperative CHO, and Perioperative Glucose Control E. Patchen Dellinger, MD

2 Disclosure Slide Dr. Dellinger has worked in the area of clinical trials with industry sponsorship since During the past 4 years he has received grants for clinical research from, served on an advisory board for, and/or lectured for honoraria from, Merck, Baxter, Ortho-McNeil, Targanta, Schering-Plough, Astellas, Allergan, Care Fusion, Durata, Pfizer, Applied Medical, Rib-X, Affinium, Tetraphase, Televancin, R- Pharm, Cubist, Melinta, Motif, Microdermis, and 3M. He is not a member of any speakers bureaus and has not received any company-provided speaker s training and never uses any company-provided slides or other visual materials.

3 Diabetes, Glucose Control, and SSIs After Median Sternotomy 20 % Infections < >300 Latham. ICHE 2001; 22:

4 Hyperglycemia and Risk of SSI after Cardiac Operations No increased risk: Elevated HgbA1c Preoperative hyperglycemia Increased risk: Diagnosed diabetes Undiagnosed diabetes Post-op glucose > 200 mg% within 48h Latham. Inf Contr Hosp Epidemiol. 2001;22:607 Dellinger. Inf Contr Hosp Epidemiol. 2001;22:604

5 Hyperglycemia and Risk of SSI after Cardiac Operations Hyperglycemia - doubled risk of SSI Hyperglycemic: 48% of diabetics 12% of nondiabetics 30% of all patients 47% of hyperglycemic episodes were in nondiabetics Latham. Inf Contr Hosp Epidemiol. 2001;22:607 Dellinger. Inf Contr Hosp Epidemiol. 2001;22:604

6 200 Glucose Levels and Infection after CABG in NonDiabetics Glucose No infection Any infection Mediastinitis Day Swenne. J Hosp Inf 2005; 61: 201

7 Hyperglycemia and Infection Does it apply only to cardiac surgery? Do WBC struggling to work in syrup know whether they are in a median sternotomy or an abdominal incision?

8 Early (48h) Postoperative Glucose Levels and SSI after Vascular Surgery >151 mg% <103 mg% mg% mg% Vriesendorp. Eur J Vasc Endovasc Surg 2004; 28:520-5

9 Perioperative Hyperglycemia in Noncardiac Surgical Patients Ramos. Ann Surg 2008;248:

10 Mastectomy, Hyperglycemia, and SSI 260 patients, 5 glucose determinations (pre-op, at anesthesia induction, intra-op, in PACU, at 24 hrs) Odds Risk Factor Ratio C.I. Age > ( ) Pre-Op ChemoRads 2.8 ( ) Any gluc > 150 mg% 2.9 ( ) Villar-Compte. AJIC 2008; 36:192-8

11 Postop Glucose (within 48h) and SSI General Surgery Glucose Ata. Arch Surg 2010: 145:

12 Glucose & Infection Risk Non-Cardiac Surgery & Diabetes Multivariate analysis: All the usual risk factors significant. HgbA1c NOT significant. PostOp glucose > 150 very significant. King. Ann Surg 2011; 253:158-65

13 Postoperative Glucose and Mortality in Noncardiac Surgery Hyperglycemia in nondiabetic patients was more dangerous than hyperglycemia in diabetics! Frisch. Diabetes Care. 2010; 33:

14 Rabbit 2 Study Surgery Basal/Bolus vs Sliding Scale Insulin Basal Bolus Sliding Scale p value Patients Mean Fasting Mean Daily Readings < % 31%.001 Wound infections Any complication Umpierrez. Diabetes Care 2011; 34:

15 Perioperative Hyperglycemia and Total Knee or Hip Arthroplasty Fasting Blood Glucose POD #1 16.0% 14.0% 12.0% Infection rate 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% < > 200 Mraovic. J Diab Science & Technol 2011; 5: 412-8

16 Hgb A1c vs. Glucose as Risk Factor for SSI Gastric Bypass A1c Level n < 6.5% % 92 > 8% 66 Perna. Surg Obes Rel Dis 2012; 8:

17 Hgb A1c vs. Glucose as Risk Factor for SSI Gastric Bypass Multivariate Analysis Odds ratio = 1.27 ( ) for every 20 mg% increase in mean glucose level during hospitalization (p=0.008). Mean glucose more significant than any level above 200 Mg% or not. Hgb A1c not significant. Perna. Surg Obes Rel Dis 2012; 8:

18 HgA1c and Postoperative Glucose Abdominal Surgery Relation of Preoperative A1c to Postoperative Glucose Gluc<160 Gluc> HgA1c < >7.0 Goodenough. J Amer Coll Surg 2015; 221:

19 SCOAP Data on Perioperative Glucose Levels and Insulin Use patients from with Bariatric operation (5360) Colectomy (6273) Who either Experienced glucose > 180 (3383) Or did not (8247) During the perioperative period or on POD 1 or POD 2 Kwon. Ann Surg. 2013; 257: 8-14

20 SCOAP Data on Perioperative Glucose Levels and Insulin Use Diabetic pts 4098 (35%) Hyperglycemic 2369 (58%) Nondiabetic pts 7532 (65%) Hyperglycemic 1014 (13%) 30% of all hyperglycemic patients were not diabetic! Kwon. Ann Surg. 2013; 257: 8-14

21 Composite Infection Hyperglycemia vs No Hyperglycemia Diabetic Patients ** Both Ops Bariatric Colectomy * * p<0.05 ** p<0.01 Normal Gluc>180 Kwon. Ann Surg. 2013; 257: 8-14

22 Composite Infection Hyperglycemia vs No Hyperglycemia Nondiabetic Patients All p< Normal Gluc>180 0 All Pts Bariatric Colectomy Kwon. Ann Surg. 2013; 257: 8-14

23 Composite Infection in Hyperglycemic Patients With and Without Use of Insulin Kwon. Ann Surg. 2013; 257: 8-14

24 Operative Reintervention in Hyperglycemic Patients With and Without Use of Insulin Kwon. Ann Surg. 2013; 257: 8-14

25 Mortality in Hyperglycemic Patients With and Without Use of Insulin Kwon. Ann Surg. 2013; 257: 8-14

26 Composite Infection in Hyperglycemic Patients Patients with glucose > 180 Odds Ratio for Infection Only D.O.S. Only POD 1 or 2 Both POD 1 & Kwon. Ann Surg. 2013; 257: 8-14

27 S.C. vs I.V. Insulin 24 hrs PostOp Gynecologic Oncology Operations SQ I.V. Nondiab Grp 1 Diabetics, intermittent s.c. insulin Grp 2 Diabetics or any gluc >150, IV insulin Grp 3 - NonDiabetics Al-Niaimi. Gynecol Oncol 2015; 136: 71-6

28 S.C. vs I.V. Insulin 24 hrs PostOp Gynecologic Oncology Operations 24 h ave gluc Hypoglycemia Grp 1 (SQ) 162 mg% 5.4%% Grp 2 (I.V.) 110 mg% 0.7% P <0.01 <0.05 Grp 1 Diabetics, intermittent s.c. insulin Grp 2 Diabetics or any gluc >150, IV insulin Al-Niaimi. Gynecol Oncol 2015; 136: 71-6

29 Hyperglycemia Impairs Immunity Impairs Immunity Increases Collagenase Activity Impairs Leukocyte Function Impairs cardiac ischemic preconditioning Reduces collateral blood flow

30 Glucose Control Proven important for SSI risk: Cardiac surgery General surgery Colorectal surgery Vascular surgery Breast surgery Gynecologic Oncology surgery Hepato-pancreatico-biliary surgery Orthopedic surgery Trauma surgery

31 Regardless of the Diagnosis of Diabetes (or not) Hyperglycemia Increases Morbidity Mortality Length of Stay

32 Which Patients Are at Risk for Hyperglycemia?

33 Glucose in NonDiabetics having Colectomy at Cleveland Clinic Highest Gluc N (%) < 125 mg% 816 (33%) mg% 1289 (53%) 200 mg% 342 (14%) 2/3 All patients 2447 (100%) Kiran, et al. Ann Surg 2013; 258:

34 Glucose in NonDiabetics having Colectomy at Cleveland Clinic 8 7 *p<0.03, p<0.01, + p<0.05 Per Cent incidence Mort+ Sepsis SSI* Reop 0 < >200 Kiran, et al. Ann Surg 2013; 258:

35 Preoperative Glucose as a Screening Tool for Patients Without Diabetes Random glucose within 30 days of operation Average 8 days before operation 16% within one day and 29% within 3 days 6683 patients < > pts 4251 pts 1801 pts 187 pts 60 pts Wang. J Surg Res. 2014; 186: 371-8

36 Preoperative Glucose as a Screening Tool for Patients Without Diabetes Infection Complication 5 0 < >180 Wang. J Surg Res. 2014; 186: 371-8

37 Preoperative Glucose as a Screening Tool for Patients Without Diabetes Of patients with preop glucose > 100, 15% were diagnosed with diabetes within one year, but 85% were not. Wang. J Surg Res. 2014; 186: 371-8

38 Can we do anything before the operation to reduce the risk of hyperglycemia and its associated complications?

39 PreOp CHO and Insulin Resistance 474 ml evening, 237 ml 3 h Preop Control CHO p HOMA-IR Insulin Glucose Perrone. Nutrition Journal 2011; 10: 66

40 Gastric Emptying After 400 ml CHO Drink in Diabetics Insulin treated diabetics Oral/diet treated diabetics Healthy subjects Gustafsson. ActaAnaesthScand 2008; 52:

41 400 ml CHO Drink 50 g CHO 12% monosaccharides 12% disaccharides 76% polysaccharides 285 mosm Nutricia Preop R Gustafsson. ActaAnaesthScand 2008; 52:

42 Cochrane Review on PreOp Fasting There was no evidence to suggest a shortened fluid fast results in an increased risk of aspiration, regurgitation or related morbidity compared with the standard nil by mouth from midnight fasting policy. Permitting patients to drink water preoperatively resulted in significantly lower gastric volumes. Brady M. Cochrane Database Syst Rev 2003; (4).CD004423

43 PreOp CHO and Muscle Mass Major Abdominal Surgery 800 ml evening, 400 ml 2 h Preop Triceps Skin Fold Arm Muscle Circum Svanfeldt. Br J Surg 2007; 94:

44 PreOp CHO and Insulin Levels Colorectal Surgery, 400 ml 3 h Preop Wang. Br J Surg 2010; 97:

45 PreOp CHO and Glucose Levels Colorectal Surgery, 400 ml 3 h Preop Wang. Br J Surg 2010; 97:

46 PreOp CHO and Insulin Resistance Colorectal Surgery, 400 ml 3 h Preop Wang. Br J Surg 2010; 97:

47 PreOp CHO, Gastric Volume & ph Colorectal Surgery, 400 ml 2 h Preop Measured Immediately After Induction ph Volume, ml Yagci. Nutrition 2008; 24: 212-6

Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated

48 Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology 2011;114: It is appropriate to fast from intake of clear liquids at least 2 h before elective procedures requiring general anesthesia, regional anesthesia, or sedation/analgesia. Examples of clear liquids include, but are not limited to, water, fruit juices without pulp, carbonated beverages, clear tea, and black coffee.... The volume of liquid ingested is less important than the type of liquid ingested.

49 SCOAP Adverse Events with Hyperglycemia Diabetics v. NonDiabetics Kotagal. Ann Surg 2015; 261:97-103

50 SCOAP Adverse Events with Hyperglycemia Diabetics v. NonDiabetics Kotagal. Ann Surg 2015; 261:97-103

51 Perioperative Blood Glucose at UWMC Amalga data Inpatient ops, 7/1/13 7/30/15 11,079 Nondiabetics among those 8,974 (81%) Nondiabetics with gluc > 140 mg% day of op 2,929 (33%) Nondiabetics with gluc > 140 mg%, day 0-2 4,834 (54%) Data courtesy of Ray Bunnage, Center for Clinical Excellence

52 Glucose Levels & SSI The exact best level of glucose control in the perioperative period is not known. High glucose levels unequivocally increase the risk of SSI and other perioperative infections. Tight glucose control in the perioperative period is tricky. Hypoglycemia increases the risk of morbidity and mortality. Some examples of successful glucose control programs follow.

GLUCOSE CONTROL ALGORITHMS The Rabbit 2 basal bolus protocol is online at http://care.diabetesjournals.org/lookup/su ppl/doi:10.

53 GLUCOSE CONTROL ALGORITHMS The Rabbit 2 basal bolus protocol is online at ppl/doi: /dc /-/dc1 The Society of Hospital Medicine Glycemic Control Resource room contains links to multiple insulin infusion protocols at eroomredesign/html/12clinical_tools/04 _Insulin_OrdersIV.cfm

QI Successes & Failures Learning from Both

QI Successes & Failures Learning from Both E. Patchen Dellinger, MD, FACS, FIDSA, FSHEA Professor of Surgery University of Washington Medical Center (UWMC), Seattle, Washington Conflict of Interest Over