Not Too Sweet in the OR Suite: Perioperative Glucose Management Update

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1 Not Too Sweet in the OR Suite: Perioperative Glucose Management Update Legacy Emanuel Medical Center, Portland, Oregon Ron Barbosa, MD, NSQIP Surgeon Champion Becky Swick, BSN, NSQIP SCR (Retired) Presented by Krista Curtis, BSN, MPH, NSQIP SCR (Current)

2 Disclosures There are no actual or potential conflicts of interest in relation to this presentation.

3 Hyperglycemia and Surgical Outcomes Hyperglycemia: A marker for surgical complications in both diabetic (DM) and non-diabetic (NDM) patients (Kwon, 2013; Frisch, 2010). Dose-response effect between hyperglycemia and adverse events in NDM patients (Kotagal, 2015) Dose-response effect between treatment with insulin and fewer adverse events (Kwon, 2013) RCTs are needed to determine if/how treatment decreases morbidity and mortality (Frisch, 2010). Current expert consensus supports peri-operative glucose control not too high or not too low for better surgical outcomes (Nair, 2016; Greco, 2016).

4 Surgery-Induced Stress Hyperglycemia Potential Harmful Mechanisms Oxidative Stress Inflammatory Cytokines Sympatho-Adrenal Response Free Fatty Acids Vascular Dysfunction Altered Immune System Pro-Coagulant State Hormone Counterregulation (Duggan et al., 2016)

5 Oregon s Focus on Glucose 2009 Oregon NSQIP Collaborative (ONC) White Paper ONC Glucose Project 5 Hospitals 17,000 Inpatients 2013 Legacy Emanuel Glucose Management Committee

6 Legacy Emanuel Glucose Management Committee Surgeons Anesthesiologists Pharmacists Perioperative Implementation Hospital Leadership/QI Hospitalists Nurses/DM Educators Preadmission POC glucose on all patients A1c on all elective, >40yo, BMI>35, POC>120 mg/dl Results reported to surgeon and PCP Day of Surgery POC glucose on all patients on admission Insulin gtt started in pre-op unit for glucose >140mg/dL. Intraoperative POC glucose on all patients hourly (glucometers in every OR) Insulin gtt started for glucose >140mg/dL Postoperative PACU and ICU start insulin gtt for glucose >140mg/dL

7 LEMH Adult NSQIP: 1 st Post-Operative Glucose (PACU or ICU)

8 LEMH Adult NSQIP: 1 st Post-Operative Glucose (PACU or ICU)

9 Peak Glucose Levels (>180 mg/dl) Within 72 Hours of Surgery

10 Monthly Comparison: % Peak Post-operative Glucose >180 mg/dl within 72 hrs and NSQIP % Overall Occurrence

11 Monthly Comparison: % Peak Post-operative Glucose >180 mg/dl within 72 hrs and NSQIP % Overall Occurrence

12 Conclusions Perioperative glucose control protocols have been effective in decreasing post-op hyperglycemia, while ongoing monitoring and education is central for protocol adherence NSQIP Custom Fields useful for monitoring protocol adherence and trends Hyperglycemia trends show some correlation (r = 0.4) with NSQIP surgical morbidity trends ( ). Correlation has previously been established in the literature (Kwon, 2013; Frisch, 2010; Kotagal, 2015). Internal data trends have been important in physician and staff adoption of protocols RCTs continue to be needed to determine ideal glucose ranges in diabetic and nondiabetic patients

13 References Duggan, E. W., Klopman, M. A., Berry, A. J., & Umpierrez, G. (2016). The Emory University Perioperative Algorithm for the Management of Hyperglycemia and Diabetes in Non-cardiac Surgery Patients. Current diabetes reports, 16(3), Greco, G., Ferket, B. S., D Alessandro, D. A., Shi, W., Horvath, K. A., Rosen, A.,... & Greenberg, A. (2016). Diabetes and the association of postoperative hyperglycemia with clinical and economic outcomes in cardiac surgery. Diabetes care, 39(3), Frisch, A., Chandra, P., Smiley, D., Peng, L., Rizzo, M., Gatcliffe, C.,... & Umpierrez, G. E. (2010). Prevalence and clinical outcome of hyperglycemia in the perioperative period in noncardiac surgery. Diabetes care, 33(8), Kotagal, M., Symons, R. G., Hirsch, I. B., Umpierrez, G. E., Dellinger, E. P., Farrokhi, E. T., & Flum, D. R. (2015). Perioperative hyperglycemia and risk of adverse events among patients with and without diabetes. Annals of surgery, 261(1), 97. Kwon, S., Thompson, R., Dellinger, P., Yanez, D., Farrohki, E., & Flum, D. (2013). Importance of perioperative glycemic control in general surgery: a report from the Surgical Care and Outcomes Assessment Program. Annals of surgery, 257(1), 8. Nair, B. G., Horibe, M., Neradilek, M. B., Newman, S. F., & Peterson, G. N. (2015). The Effect of Intraoperative Blood Glucose Management on Postoperative Blood Glucose Levels in Noncardiac Surgery Patients. Anesthesia and analgesia. Tsai, L. L., Jensen, H. A., & Thourani, V. H. (2016). Intensive Glycemic Control in Cardiac Surgery. Current diabetes reports, 16(4), 1-9.

Learning Objectives. Perioperative SWEET Success

Learning Objectives. Perioperative SWEET Success Perioperative SWEET Success PERIOPERATIVE SWEET SUCCESS PRESENTED BY: KENDRA MARTIN, RN, BSN, CDE JENNIFER SIMPSON, RN, BC-ADM, MSN, CNS Disclosure to Participants Notice of Requirements For Successful