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 >>
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 >>
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 >>
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 >>
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 >>
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Diabetes And Joint Replacement Surgery 101
If you’re living with diabetes, you know better than anyone that your rulebook for general health is different than most. To add another layer to your health management puzzle, chances are you’ve found this post because you’re a diabetic preparing for a hip replacement or knee replacement or are trying to decide when the right time for a joint replacement is. With this, know that joint replacement surgery is one of the most successful procedures in all of modern medicine and that you have the power to further reduce your risk factors. What you do in the weeks leading up to your hip replacement or knee replacement will have a huge impact on your surgery results and recovery time. This is especially true for those with pre-existing conditions like diabetes. Taking action before surgery in a results-driven program is called “PreHab”. Read on as we talk about how diabetes can affect joint replacement surgery, examine surgical complications for those with diabetes, and offer some prehab diet suggestions to optimize your health before due day. How Can My Diabetes Affect Joint Replacement Surgery? Diabetes (especially when uncontrolled or paired with a related disease) greatly affects recovery time from joint replacement surgery. Those with diabetes are at a greater risk for infection, slower wound and incision repair, as well as a laundry list of secondary complications. Uncontrolled Diabetes: Blood sugar levels that are too high (240 and over or consistently outside of optimal zone) is often due to improper diet, lack of exercise, inconsistent medication use and other factors. The risks associated with uncontrolled diabetes include: heart disease, kidney disease, eye damage, neuropathy, amputations, dental issues and more. Controlled Diabetes: Blood sugar levels ma Continue reading >>
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Surgery For Acquired Cardiovascular Disease Elevated Preoperative Hemoglobin A1c Level Is Predictive Of Adverse Events After Coronary Artery Bypass Surgery
Diabetes mellitus has been associated with an increased risk of adverse outcomes after coronary artery bypass grafting. Hemoglobin A1c is a reliable measure of long-term glucose control. It is unknown whether adequacy of diabetic control, measured by hemoglobin A1c, is a predictor of adverse outcomes after coronary artery bypass grafting. Methods Of 3555 consecutive patients who underwent primary, elective coronary artery bypass grafting at a single academic center from April 1, 2002, to June 30, 2006, 3089 (86.9%) had preoperative hemoglobin A1c levels obtained and entered prospectively into a computerized database. All patients were treated with a perioperative intravenous insulin protocol. A multivariable logistic regression model was used to determine whether hemoglobin A1c, as a continuous variable, was associated with in-hospital mortality, renal failure, cerebrovascular accident, myocardial infarction, and deep sternal wound infection after coronary artery bypass grafting. Receiver operating characteristic curve analysis identified the hemoglobin A1c value that maximally discriminated outcome dichotomies. Results In-hospital mortality for all patients was 1.0% (31/3089). An elevated hemoglobin A1c level predicted in-hospital mortality after coronary artery bypass grafting (odds ratio 1.40 per unit increase, P = .019). Receiver operating characteristic curve analysis revealed that hemoglobin A1c greater than 8.6% was associated with a 4-fold increase in mortality. For each unit increase in hemoglobin A1c, there was a significantly increased risk of myocardial infarction and deep sternal wound infection. By using receiver operating characteristic value thresholds, renal failure (threshold 6.7, odds ratio 2.1), cerebrovascular accident (threshold 7.6, odds ratio 2.2 Continue reading >>
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A1c Is A Predictor Of Clinical Outcomes Following Noncardiac Surgery
Researchers discover that preoperative A1C is related to length of stay in the hospital following noncardiac surgeries…. Acute hyperglycemia at the time of surgery is associated with poor clinical outcomes in all patients. Furthermore, diagnosis of diabetes mellitus is known to be a risk factor for complications postoperatively. Some healthcare practitioners use insulin infusion protocols to provide better glycemic control and prevent hyperglycemia during and after surgery to help lower the risk of complications. Less is known about the effect of chronic hyperglycemia on surgical outcomes postoperatively, and whether addressing this issue prior to surgery would improve outcomes. A study was therefore designed to evaluate whether A1C impacts outcomes following surgery independent of any hyperglycemia that may occur perioperatively. Data for this study was obtained from the National Surgical Quality Improvement Program database and from the data registry of the Brigham and Women’s Hospital. Data for patients having noncardiac surgery from 2005-2010 and requiring admission to the hospital for ≥1 day following surgery were included in this study. The 622 patients were divided into four groups based on their A1C levels. The groups were as follows: A1C≤6.5%, A1C 6.5-8%, A1C.8-10%, and A1C >10%. Patients were compared to nondiabetic control subjects of the same age, sex, and BMI. The results of the data obtained showed patients with A1C 6.5-8% had a hospital LOS similar to the matched group of nondiabetic patients. Patients with an A1C≤6.5% or >8% had a hospital LOS that was significantly longer when compared to that of the matching nondiabetic patients. It may seem surprising that A1C≤6.5% was also associated with increased hospital LOS. It is thought that this co Continue reading >>
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High Blood Glucose Levels Linked To Higher Risk Of Wound Complications
Arlington Heights, Ill. - A new study released today shows that among patients undergoing surgery for chronic wounds related to diabetes, the risk of wound-related complications is affected by how well the patient's blood sugar levels are controlled before surgery. These findings appear in the October issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS). The risk of serious wound complications is more than three times higher for patients who have high blood glucose before and after surgery, and in those with poor long-term diabetes control, according to the study by ASPS Member Surgeons, Drs. Mathew Endara and Christopher Attinger of the Center for Wound Healing at Georgetown University, Washington, DC. The researchers emphasize the need for "tight control" of glucose levels before surgery for diabetic patients at high risk of wound complications. The researchers analyzed rates of wound-related complications in 79 patients undergoing surgery for closure of chronic wounds-a common and troublesome complication of diabetes. Blood glucose levels were measured five days before and after surgery. Hemoglobin A1c, a key indicator of long-term diabetes control, was measured an average of two weeks before surgery. Blood glucose levels and diabetes control were analyzed as risk factors for wound dehiscence (a serious complication in which the surgical incision re-opens), wound infections and need for repeat surgery. Blood glucose levels over 200 were considered to represent elevated blood glucose (hyperglycemia). The results showed a higher risk of wound complications in patients who had high blood glucose levels either before or after surgery. For example, wound dehiscence occurred in about 44 percent of pa Continue reading >>
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 >>
Strict Glycemic Control To Prevent Surgical Site Infections In Gastroenterological Surgery
Department of Infection Prevention and Control, Hyogo College of Medicine, Hyogo, Japan Department of Infection Prevention and Control, Hyogo College of Medicine, Hyogo, Japan 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. Perioperative hyperglycemia is a risk factor for surgical site infections (SSI). Although the recommended target blood glucose level (BG) is 140180mg/dL for critically ill patients, recent studies conducted in patients undergoing surgery showed a significant benefit of intensive insulin therapy for the management of perioperative hyperglycemia. The aim of the present review is to evaluate the benefits of strict glycemic control for reducing SSI in gastroenterological surgery. We carried out a posthoc analysis of the previously published data from research on the risk factors for SSI. The highest BG within 24hours after surgery was evaluated. A total of 1555 patients were enrolled in the study. In multivariate analysis, a doseresponse relationship between the level of hyperglycemia and the odds of SSI was demonstrated when compared with the reference group (150mg/dL) (odds ratio [OR]=1.68, 95% confidence interval [CI] 1.142.49 for 150200mg/dL; and OR=2.15, 95% CI 1.403.29 for >200mg/dL). Unexpectedly, hyperglycemia was not a significant risk factor for SSI among diabetes patients. By contrast, nondiabetes patients with a BG of >150mg/dL were found to have increased odds of SSI. In conclusion, a target BG of 150mg/dL is recommended in patients without diabetes who undergo gastroenterological surgery. Additional Continue reading >>
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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 >>
"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 >>
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 >>
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 >>
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