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Safe A1c For Surgery

Bariatric Surgery For Diabetes

Bariatric Surgery For Diabetes

New guidelines last week recommended surgery as Type 2 diabetes treatment for people who are obese, including some who are mildly obese. Is “metabolic surgery” something you should consider? The guidelines were approved by the American Diabetes Association, the International Diabetes Federation, and 43 other medical groups around the world. They were published in the June issue of the journal Diabetes Care. If you are heavy and have an HbA1c of 7.0 or above, your doctor may soon advise you to have one of these surgeries. You will be told the surgery will lower your blood sugar and your weight, which usually happens. You may not be told the negative effects. How do you decide? When performed to manage diabetes, bariatric or weight-loss surgery is known as “metabolic surgery.” The term covers Roux-en-Y “gastric bypass” surgeries, which reduce your stomach to a small pouch and plug it into the middle of the small intestine. It also includes “sleeve gastrectomy,” in which the deep part of the stomach is removed and the rest stapled together into a sleeve shape. Wrapping a band around the stomach to shrink it (“gastric banding“) is also now considered metabolic surgery. There are other surgeries that restructure the bowel in different ways, which I’ll write about next week. Surgeons have been pleased to learn that their weight-loss operations also lower blood sugars, though they are working to fully understand how that happens. It’s probably not the weight loss. Often, the improvements in diabetes numbers come long before significant weight loss occurs. A conference in Rome in 2007 reported that people were getting off their diabetes medications and lowering their HbA1c scores after surgery. Eight years later, a follow-up conference in London decided Continue reading >>

Ultimate Guide To The A1c Test: Everything You Need To Know

Ultimate Guide To The A1c Test: Everything You Need To Know

The A1C is a blood test that gives us an estimated average of what your blood sugar has been over the past 2-3 months. The A1c goes by several different names, such aswa Hemoglobin A1C, HbA1C, Hb1C, A1C, glycated hemoglobin, glycohemoglobin and estimated glucose average. What is Hemoglobin? Hemoglobin is a protein in your blood cells that carries oxygen. When sugar is in the blood, and it hangs around for a while, it starts to attach to the red blood cells. The A1C test is a measurement of how many red blood cells have sugar attached. So, if your A1C result is 7%, that means that 7% of your red blood cells have sugar attached to them. What are the Symptoms of a High A1C Test Level? Sometimes there are NO symptoms! That is probably one of the scariest things about diabetes, your sugar can be high for a while and you may not even know it. When your blood sugar goes high and stays high for longer periods of time you may notice the following: tired, low energy, particularly after meals feel very thirsty you may be peeing more than normal, waking a lot in the middle of the night to go dry, itchy skin unexplained weight loss crave sugar, hungrier than normal blurred vision, may feel like you need new glasses tingling in feet or hands cuts or sores take a long time to heal or don’t heal well at all frequent infections (urinary tract, yeast infections, etc.) When your blood sugar is high, this means the energy that you are giving your body isn’t getting into the cells. Think about a car that has a gas leak. You put gas in, but if the gas can’t get to the engine, the car will not go. When you eat, some of the food is broken down into sugar and goes into your bloodstream. If your body can’t get the sugar to the cells, then your body can’t “go.” Some of the sugar tha Continue reading >>

Guidelines For Perioperative Management Of The Diabetic Patient

Guidelines For Perioperative Management Of The Diabetic Patient

Surgery Research and Practice Volume 2015 (2015), Article ID 284063, 8 pages 1Texas A&M Health Science Center, 8447 State Highway 47, Bryan, TX 77807, USA 2Division of Pulmonary, Critical Care & Sleep Medicine, Texas A&M Health Science Center, Corpus Christi, 1177 West Wheeler Avenue, Suite 1, Aransas Pass, TX 78336, USA Academic Editor: Roland S. Croner Copyright © 2015 Sivakumar Sudhakaran and Salim R. Surani. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Management of glycemic levels in the perioperative setting is critical, especially in diabetic patients. The effects of surgical stress and anesthesia have unique effects on blood glucose levels, which should be taken into consideration to maintain optimum glycemic control. Each stage of surgery presents unique challenges in keeping glucose levels within target range. Additionally, there are special operative conditions that require distinctive glucose management protocols. Interestingly, the literature still does not report a consensus perioperative glucose management strategy for diabetic patients. We hope to outline the most important factors required in formulating a perioperative diabetic regimen, while still allowing for specific adjustments using prudent clinical judgment. Overall, through careful glycemic management in perioperative patients, we may reduce morbidity and mortality and improve surgical outcomes. 1. Introduction Diabetes has classically been defined as a group of metabolic diseases characterized by hyperglycemia due to defects in insulin secretion, insulin action, or a combination of both [1]. The vast majority of di Continue reading >>

Preoperative Glycemic Control For Adult Patients With Diabetes Undergoing Elective Surgery

Preoperative Glycemic Control For Adult Patients With Diabetes Undergoing Elective Surgery

Tristan B. Weir, BS, Florida State University College of Medicine, Larry C. Deeb, MD, Florida State University College of Medicine As the prevalence of diabetes continues to increase in the United States, a higher proportion of elective surgical candidates will require specific preoperative education and guidelines to maximize patient outcomes and reduce the costs of care. The purpose of this article is to review the current literature to determine how preoperative glycemic control affects the lengths of hospital stays, postoperative complications, and mortality in people living with type 1 and 2 diabetes. Additional recommendations are provided for preoperative hypo- and hyperglycemia, the use of insulin pumps or continuous glucose monitors, and day-of-surgery management of insulin and oral hypoglycemic agents. Gaps in medical evidence are acknowledged and future directions in research are proposed to provide high-quality guidelines for the preoperative care of adult patients with diabetes. Introduction As the prevalence of diabetes increases in the United States, practicing physicians must be able to educate and manage these patients in the preoperative setting. With 29.1 million (9.3% of the U.S. population) Americans living with diabetes today, nearly 1 in 10 surgical candidates may have diabetes and require special recommendations before surgery [1]. While the 2011 Joint British Diabetes Societies Inpatient Care Group (JBDS) created guidelines for the preoperative management of patients with diabetes undergoing elective surgery, many physicians in the U.S. may not know these guidelines exist [2]. In a 2014 study on preoperative hemoglobin A1C (A1C) and its effect on clinical outcomes for patients undergoing surgery, the authors say “there are no standards of care Continue reading >>

Saying ‘no’ To Patients With Diabetes

Saying ‘no’ To Patients With Diabetes

Patients with diabetes are no strangers to dealing with the complications associated with their disease. As foot and ankle surgeons, we also often face the challenge of treating the complications and sequelae of this pathologic process including lower extremity deformity, non-healing wounds, Charcot neuroarthropathy and infection to name a few. However, what happens when we, as intervening medical professionals, are the cause of a relatively predictable complication? What about when a patient with diabetes at increased risk for complication requests elective surgery? Is it our obligation to treat these patients as we do those without diabetes or should we approach these patients with a more wary and conservative eye? In other words, when is it okay to say “no” to a patient with diabetes? Although these are certainly questions without definitive answers, a review of recent literature may help podiatric surgeons make relatively judicious decisions. There are times when the medical profession may be a little too eager to please and when it seems like patients can always find a surgeon who will say “yes.” In a similar way, it can sometimes be difficult to remember that it is not our primary job to please our patients but instead to diagnose, educate and recommend. Just because a patient is willing to entertain increased perioperative surgical risk does not mean that we have to as well. It is okay to say “no.” Saying ‘No’ Because Of Poor Glycemic Control There is an increasing body of evidence that one should reconsider elective surgical intervention in the setting of uncontrolled hyperglycemia, both in terms of short-term and long-term control. Perhaps one can most easily appreciate this with long-term control of the hemoglobin A1c value. It can sometimes be Continue reading >>

Perioperative Management Of The Diabetic Patient

Perioperative Management Of The Diabetic Patient

Perioperative Management of the Diabetic Patient Author: Mira Loh-Trivedi, PharmD; Chief Editor: William A Schwer, MD more... Diabetes mellitus (DM) is an increasingly common medical condition affecting approximately 8% of the population of the United States. Of these 25 million people, it is estimated that nearly 7 million are unaware that they have the disease until faced with associated complications. [ 1 , 2 ] The prevalence of DM is even greater in hospitalized patients. The American Diabetes Association conservatively estimates that 12-25% of hospitalized adult patients have diabetes mellitus (DM). With the increasing prevalence of diabetic patients undergoing surgery, and the increased risk of complications associated with diabetes mellitus, appropriate perioperative assessment and management are imperative. 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. Chronic complications resulting in microangiopathy (retinopathy, nephropathy, and neuropathy) and macroangiopathy (atherosclerosis) directly increase the need for surgical intervention and the occurrence of surgical complications due to infections and vasculopathies. [ 3 , 4 , 5 , 6 ] Infections account for 66% of postoperative complications and nearly one quarter of perioperative deaths in patients with DM. Data suggest impaired leukocyte function, including altered chemotaxis and phagocytic activity. Tight control of serum glucose is important to minimize infection. In addition to postoperative infectious complications, postoperative myocardial ischemia is increased among patients with DM undergoing cardiac and noncardiac su Continue reading >>

High Preoperative Hemoglobin A1c Is A Risk Factor For Surgical Site Infection After Posterior Thoracic And Lumbar Spinal Instrumentation Surgery.

High Preoperative Hemoglobin A1c Is A Risk Factor For Surgical Site Infection After Posterior Thoracic And Lumbar Spinal Instrumentation Surgery.

High preoperative hemoglobin A1c is a risk factor for surgical site infection after posterior thoracic and lumbar spinal instrumentation surgery. Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjyuku, Tokyo, Japan. J Orthop Sci. 2014 Mar;19(2):223-8. doi: 10.1007/s00776-013-0518-7. Epub 2013 Dec 25. BACKGROUND: Diabetes mellitus (DM) is reported to be a risk factor for surgical site infection (SSI), which is a serious complication after spinal surgery. The effect of DM on SSI after instrumented spinal surgery remains to be clarified. The aim was to elucidate perioperative risk factors for infection at the surgical site after posterior thoracic and lumbar spinal arthrodesis with instrumentation in patients with DM. METHODS: Consecutive patients who underwent posterior instrumented thoracic and lumbar spinal arthrodesis during the years 2005-2011, who could be followed for at least 1 year after surgery, were included. These included 36 patients with DM (19 males and 17 females; mean age 64.3 years). The patients' medical records were retrospectively reviewed to determine the SSI rate. The characteristics of the DM patients were examined in detail, including the levels of serum glucose and HbA1c, which indicate the level of diabetes control. RESULTS: Patients with DM had a higher rate of SSI (6 of 36 patients, 16.7 %) than patients without DM (10 of 309 patients, 3.2 %). Although the perioperative serum glucose level did not differ between DM patients that did or did not develop SSI, the preoperative HbA1c value was significantly higher in the patients who developed SSI (7.6 %) than in those who did not (6.9 %). SSI developed in 0.0 % of the patients with controlled diabetes (HbA1c <7.0 %) and in 35.3 % of the patients with unco Continue reading >>

Is Weight Loss Surgery The Answer For Diabetes?

Is Weight Loss Surgery The Answer For Diabetes?

With commentary by Anita P. Courcoulas MD, MPH, FACS, professor of surgery and director of minimally invasive bariatric & general surgery at the University of Pittsburgh Medical Center Is weight-loss surgery better than nutrition and physical activity alone for reversing type 2 diabetes? That controversial question has occupied researchers, doctors, insurers and people with diabetes for more than a decade. Now, a small yet well-designed study seems to have the answer: Surgery. University of Pittsburgh researchers randomly assigned 61 obese women and men with type 2 diabetes to receive gastric bypass surgery, an adjustable gastric band or an intensive lifestyle change program. Study volunteers were tracked closely for three years, as scientists monitored their weight, fasting blood sugar, A1c levels (a test of long-term blood sugar control) and use of insulin and other diabetes medications. The results: More weight (and fat) lost: Gastric bypass recipients lost an average of 25% of their body weight (and nearly 11% of their body fat), gastric band wearers dropped 15% of their weight (and 5.6% of their body fat) and lifestyle group members lost 5.7% of their weight and 3% of their body fat. People in the gastric bypass also saw their waist size shrink the most, an indicator that they’d lost the most visceral fat – the kind that packs around internal organs and contributes to blood sugar processing problems. Lower blood sugar: People in the gastric bypass group saw fasting blood sugar drop 66 mg/dL and their A1c levels fall 1.4%. In comparison, gastric band recipients got a 35-point reduction in fasting blood sugar and a 0.8% reduction in A1c levels. For the lifestyle-only group, fasting blood sugar fell an average of about 28 mg/dL but A1c levels rose slightly. Less d Continue reading >>

"a!c Level Before Surgery": Diabetes Community - Support Group

The risk of infection and poor healing is very high with your glucose levels out of control. I can understand why a surgeon would want your A1C to be in a safe range before performing surgery. Follow my journey at www.mch-breastcancer.blogspot.com I've had lots of surgeries and no one ever tested my A1C as part of my pre-op work-up I had back surgery when my blood glucose was way too high and it took forever to heal. I was in an emergency situation and it was determined that the risk was higher to not have the surgery than to have the surgery. Five months later I had another back surgery and my A1c had dropped from 11.9 to mid 7's, my healing time was much quicker. The bottom line is that the better your A1c is and the better your overall health is the lower the risk for complications is and the opportunity for better outcome is higher. I do not know what "requirements" each doc has for surgery but I would be looking for a good discussion with your doctor to understand specifically what he is looking for and why. It also may be time for another opinion. I am not a Dr or nurse but I can say I have T-2 (in remission) and have been through a partially torn rotator cuff surgery. I did not have an A1c done before surgery, I did have the normal blood tests which included the glucose readings. But then my A1c has never been over 6.2. Perhaps that is why they did not do the A1c. I can see the need for your A1c to be within the normal range prior to surgery because it is a healing aid. We as diabetics do not heal well to begin with and a high A1c will only prolong the healing process. Not only that if your A1c is not in the 5 to 7 range now it could get worse after the surgery due to stress, pain and medications. It is typical to have complete rotator cuff tears surgery repairs Continue reading >>

Diabetes And Its Negative Impact On Outcomes In Orthopaedic Surgery

Diabetes And Its Negative Impact On Outcomes In Orthopaedic Surgery

Go to: PATHOPHYSIOLOGY Diabetes mellitus can be broadly classified into three types, based on the onset of symptoms and the absolute need for insulin replacement. Patients who have an absolute requirement for insulin, secondary to autoimmune dysfunction of the pancreatic beta cells, have type 1 DM. The vast majority of patients have type 2 DM which is associated with older patients, elevated body mass index (BMI), genetic predisposition, history of DM during pregnancy, less active individuals, and certain ethnic groups. Four out five patients with type 2 DM have an elevated BMI. Children and adolescents, particularly from certain ethnic and racial groups (African - American, Mexican American, and Pacific Islander), are being diagnosed with type 2 DM at an increasing rate. During the early stages of type 2 DM the pancreas usually produces insulin, however insulin resistance is present and glucose metabolism is negatively impacted. A small percentage of pregnant women develop gestational DM and 40% to 60% of these patients will ultimately develop type 2 DM within 5 to 10 years. The end result of DM, regardless of the etiology, is hyperglycemia. The primary energy source for our body is glucose, and glucose is stored as glycogen in the liver and skeletal muscle. Insulin facilitates glucose uptake into the peripheral cells, assisting with the storage of glycogen. While patients with type 1 DM have an absolute need for insulin replacement, patients with type 2 DM initially produce insulin, sometimes in high amounts. The problem is so called “insulin resistance”, in which the cells become less sensitive to insulin and hyperglycemia results. Stress hyperglycemia can occur in hospitalized patients without a previous history of DM and is defined as any serum glucose > 140 mg Continue reading >>

Understanding Perioperative Care

Understanding Perioperative Care

Preparation for elective surgery procedures that are planned in advance rather than in response to a medical emergency has historically required that patients undergo a series of tests to determine their medical fitness. Individuals who met an established set of criteria were considered to be cleared for surgery. Today, the patients medical readiness and comfort, as well as coordination and quality of his or her care before and after surgery, is the focus of an area of medicine known as perioperative care. Through integrated collaboration, the prevailing culture and essential commitment at HSS is to provide the highest quality of patient care, to achieve the best possible treatment outcomes and to assure patient satisfaction with all aspects of the patient experience. The patients surgeon relies on the team of physicians constituting Perioperative Services at HSS to oversee this integrated, collaborative care. Assessing a patients level of risk for a specific procedure is one of our primary objectives, explains Linda Russell, MD , Director of Perioperative Services at HSS. However, perioperative care also encompasses areas ranging from systematizing procedures so that every doctor involved with patient care has access to the same guidelines, to helping patients with discharge planning and returning to their homes. Practitioners of perioperative care are also attuned to individual patient needs before, during and after surgery. In order to assess the degree of risk associated with surgery, perioperative care specialists take into account factors including: risk of central nervous system complications This information is then considered in the context of the complexity of the planned surgery to arrive at an overall estimation of risk. Some surgeries inherently carry a gr Continue reading >>

Hb A1c 8% Prolongs Hospital Stay After Elective Surgery: Presented At Ada

Hb A1c 8% Prolongs Hospital Stay After Elective Surgery: Presented At Ada

Hb A1C 8% Prolongs Hospital Stay After Elective Surgery: Presented at ADA CHICAGO -- June 24, 2013 -- A preoperative haemoglobin (Hb) A1C of 8% is associated with increased length of stay (LOS) after elective noncardiac surgery, according to a study presented here at the 73rd Scientific Sessions of the American Diabetes Association (ADA). Rajesh Garg, MD, Brigham and Womens Hospital, Boston, Massachusetts, presented the study on June 24. The researchers set out to determine whether Hb A1C level has an effect on surgical outcomes independent of preoperative blood glucose levels in patients with diabetes. Of 1,515 patients with diabetes who were included in the analysis, 683 had an Hb A1C value available within 3 months before surgery. After excluding same-day surgeries, patients were divided into 4 groups based on Hb A1C: <6.5%, 6.5% to 8%, 8% to 10%, and >10%. The control group comprised 888 age-, sex-, and race-matched patients who did not have diabetes and were undergoing surgery during the same period. The researchers found that individuals with Hb A1C of 6.5% to 8% had hospital LOS similar to matched controls (not significant). However, in individuals with low Hb A1C or Hb A1C >8%, LOS was significantly longer than in the control group (P< .0001). On univariate regression analysis, patients with diabetes had significantly increased LOS, which remained significant after adjusting for age, sex, body mass index, race, type of surgery, smoking status, Charlson Comorbidity Index (CCI), and glucose on day of surgery (beta = 4.6; P = .005). Univariate regression also showed that higher Hb A1C was associated with increased LOS (P< .0001) when individuals with Hb A1C <6.5% were excluded from the analysis. This relationship remained significant after controlling for the same Continue reading >>

Perioperative Management Of The Surgical Patient With Diabetes 2015

Perioperative Management Of The Surgical Patient With Diabetes 2015

Perioperative management of the surgical patient with diabetes 2015 Association of Anaesthetists of Great Britain and Ireland This is a consensus document produced by members of a Working Party established by the Association of Anaesthetists of Great Britain and Ireland (AAGBI). It has been seen and approved by the AAGBI Board of Directors. Date of review: 2020. Please review our Terms and Conditions of Use and check box below to share full-text version of article. I have read and accept the Wiley Online Library Terms and Conditions of Use. Use the link below to share a full-text version of this article with your friends and colleagues. Learn more. Diabetes affects 1015% of the surgical population and patients with diabetes undergoing surgery have greater complication rates, mortality rates and length of hospital stay. Modern management of the surgical patient with diabetes focuses on: thorough preoperative assessment and optimisation of their diabetes (as defined by a HbA1c <69mmol.mol1); deciding if the patient can be managed by simple manipulation of preexisting treatment during a short starvation period (maximum of one missed meal) rather than use of a variablerate intravenous insulin infusion; and safe use of the latter when it is the only option, for example in emergency patients, patients expected not to return to a normal diet immediately postoperatively, and patients with poorly controlled diabetes. In addition, it is imperative that communication amongst healthcare professionals and between them and the patient is accurate and well informed at all times. Most patients with diabetes have many years of experience of managing their own care. The purpose of this guideline is to provide detailed guidance on the perioperative management of the surgical patient with Continue reading >>

Surgery Doesn’t Have To Be An Ordeal For People With Diabetes

Surgery Doesn’t Have To Be An Ordeal For People With Diabetes

North Carolina-based Marc S. Stevens, MD, FACS, is one of the top orthopedic surgeons in the country. Previously, while practicing in Little Rock, he was named Arkansas Physician of the Year. In addition to his orthopedic expertise, Dr. Stevens has developed a reputation as an expert in nutrition, especially as it relates to wound healing, bone and joint health, and healthy weight. To learn more about Dr. Marc S. Stevens go to www.DRSHealthInc.com When Dr. Stevens spoke recently with Diabetes Health Publisher and Editor-in-Chief Nadia Al-Samarrie, he provided a surgeon’s point of view about surgery for people with diabetes. Nadia: Your focus on nutrition is wonderful-and unusual. Why are you so interested in nutrition? Dr. Stevens: You have to go back to the 1980s, when proponents started to claim that good nutrition could do anything: “It will grow your hair back, it will make you taller, it will make you stronger, it will make you 18 again.” Instead of getting involved and trying to redirect those outlandish claims in a more scientific direction, medicine kind of stepped back and said, “Well, we’re not going to have anything to do with nutrition anymore. We’re just going to go what’s called the allopathic route and focus on what we do best.” As a result, we lost a chance to connect with an important aspect of health. Most doctors still grasp that nutrition is vital. The reason we call certain things “vitamins” is because they are vital minerals, essential to good health. We all check for them, and we treat deficiencies when we find them lacking. But when it comes to prevention and how nutrition can support wound recovery or preparation for surgery, we just don’t typically think that way. Because I have paid close attention to nutrition, I’ve be Continue reading >>

Precautions For Patients With Diabetes Undergoing Surgery

Precautions For Patients With Diabetes Undergoing Surgery

Professional Reference articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use. You may find the Type 1 Diabetes article more useful, or one of our other health articles. There is a rising incidence and prevalence of diabetes mellitus. About 50% of people with diabetes mellitus are unaware of their condition. Approximately 25% of all patients with diabetes undergoing surgery are undiagnosed on admission to hospital. Patients with diabetes have a higher risk of cardiovascular disease. Patients with diabetes have a higher perioperative risk. They are more likely because of their disease to require surgery and those undergoing surgery are likely to be less well controlled and to have complications from their diabetes. Surgeons and anaesthetists operating on patients with diabetes should be familiar with the risks attached to having diabetes, and to the particular risks of the particular surgery and of anaesthesia in patients with diabetes. Risks and complications of diabetes mellitus Patients with diabetes mellitus are at risk of the complications of the disease. It is worth considering these in outline when considering how best to care for patients with diabetes undergoing surgery. See also separate Diabetes Mellitus article. Perioperative risks and complications of diabetes mellitus It is important in assessing risk of complications in patients with diabetes undergoing surgery to consider the specific type of surgery and anaesthetic technique. There is evidence for higher risk in those with diabetes undergoing surgery and, when such evidence is lacking, it may in part be testament to the relative safety of modern surgery and anaesthesia. However, the following risks and observati Continue reading >>

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