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Why Insulin After Surgery

Postoperative Glycemic Control In Cardiac Surgery Patients

Postoperative Glycemic Control In Cardiac Surgery Patients

Blood glucose management in critically ill patients remains an ongoing controversy. In recent years, clinical trials evaluating blood glucose control in critically ill patients advocated for intense blood glucose management, with target blood glucose levels between 80 and 110 mg/dL (1). Intense blood glucose control resulted in a reduction in morbidity and mortality in the critically ill patient population, with a large portion of these patients being cardiovascular surgery patients. Clinical trials evaluating other patient populations have shown a reduction in morbidity with a lesser impact on mortality using tight blood glucose control (2). Additional clinical trials conducted to evaluate the benefit of tight blood glucose control have shown a negative impact on mortality due to hypoglycemia and contribute to the body of evidence disputing the need for tight blood glucose control (3). Given the conflicting results from these recent trials, the target blood glucose range for critically ill patients, specifically postoperative cardiac surgery patients, is still not clearly defined. Blood glucose disturbances from cardiac bypass pump exposure are well documented (4). However, the ability of hyperglycemia to impair leukocyte function via impaired phagocytosis and bacterial killing and lead to infection—specifically surgical or sternal wound infections—was not well established until later (5). Postoperative blood glucose management has been evaluated in diabetic patients, and recent literature includes both diabetic and nondiabetic patients undergoing cardiac surgery. These studies attempt to define optimal postoperative blood glucose goal ranges in both populations. Initial research assessed benefits of blood glucose management for prevention of sternal wound infectio Continue reading >>

Perioperative Management Of Diabetes

Perioperative Management Of Diabetes

Maintaining glycemic and metabolic control is difficult in diabetic patients who are undergoing surgery. The preoperative evaluation of all patients with diabetes should include careful screening for asymptomatic cardiac or renal disease. Frequent self-monitoring of glucose levels is important in the week before surgery so that insulin regimens can be adjusted as needed. Oral agents and long-acting insulin are usually discontinued before surgery, although the newer long-acting insulin analog glargine may be appropriately administered for basal insulin coverage throughout the surgical period. The usual regimen of sliding scale subcutaneous insulin for perioperative glycemic control may be a less preferable method because it can have unreliable absorption and lead to erratic blood glucose levels. Intravenous insulin infusion offers advantages because of the more predictable absorption rates and ability to rapidly titrate insulin delivery up or down to maintain proper glycemic control. Insulin is typically infused at 1 to 2 U per hour and adjusted according to the results of frequent blood glucose checks. A separate infusion of dextrose prevents hypoglycemia. Potassium is usually added to the dextrose infusion at 10 to 20 mEq per L in patients with normal renal function and normal preoperative serum potassium levels. Frequent monitoring of electrolytes and acid-base status is important during the perioperative period, especially in patients with type 1 diabetes because ketoacidosis can develop at modest levels of hyperglycemia. Diabetic patients who require surgery present special challenges in perioperative management. Special attention must be paid to prevention and treatment of metabolic derangements. Vigilance for the development of acute complications that lead to hig Continue reading >>

Diabetes Patients Do Better After Surgery When Their Blood Sugar Is Managed By Pharmacists

Diabetes Patients Do Better After Surgery When Their Blood Sugar Is Managed By Pharmacists

PORTLAND, Ore. — A pharmacy-led glycemic control program is linked to improved outcomes for surgical patients with diabetes and those who develop stress-induced hyperglycemia or high blood sugar as a result of surgery, according to a new Kaiser Permanente study published in the American Journal of Pharmacy Benefits. The study compared patients who had surgery after the glycemic control program started to patients who had surgery before the program started. Patients in the glycemic control program were more than twice as likely to have well-controlled blood sugar after surgery. They also had fewer post-surgical complications and associated costs, fewer hospital readmissions and fewer visits to the emergency department. “Patients with diabetes and uncontrolled blood sugar are more likely to have complications after surgery, such as wound infections that can land them back in the hospital,” said David Mosen, PhD, lead author and researcher at the Kaiser Permanente Center for Health Research in Portland, Oregon. “We know that controlling blood sugar in these patients produces better clinical outcomes, but surgeons and anesthesia providers may not have the time or expertise to appropriately monitor and adjust insulin regimens after surgery,” said Karen Mularski, MD, coauthor and hospitalist from Kaiser Permanente in Portland. “Establishing a pharmacy-led care team dedicated to addressing the specific needs of diabetes patients undergoing surgery was crucial to improving blood sugar and overall outcomes.” The authors say this is the first study to show that a pharmacist-based glucose control program can potentially improve outcomes for surgery patients, and also lead to lower costs. Most prior research has focused on cardiovascular surgery patients and those in Continue reading >>

Glycemic Control In Cardiac Surgery: Implementing An Evidence-based Insulin Infusion Protocol

Glycemic Control In Cardiac Surgery: Implementing An Evidence-based Insulin Infusion Protocol

Abstract Background Acute hyperglycemia following cardiac surgery increases the risk of deep sternal wound infection, significant early morbidity, and mortality. Insulin infusion protocols that target tight glycemic control to treat hyperglycemia have been linked to hypoglycemia and increased mortality. Recently published studies examining glycemic control in critical illness and clinical practice guidelines from professional organizations support moderate glycemic control. Objectives To measure critical care nurses’ knowledge of glycemic control in cardiac surgery before and after education. To evaluate the safety and effectiveness of an evidence-based insulin infusion protocol targeting moderate glycemic control in cardiac surgery patients. Methods This evidence-based practice change was implemented in the cardiovascular unit in a community teaching hospital. Nurses completed a self-developed questionnaire to measure knowledge of glycemic control. Blood glucose data, collected (retrospectively) from anesthesia end time through 11:59 PM on postoperative day 2, were compared from 2 months before to 2 months after the practice change. Results Nurses’ knowledge (test scores) increased significantly after education (pretest mean = 53.10, SD = 11.75; posttest mean = 79.10, SD = 12.02; t54 = −8.18, P < .001). Mean blood glucose level after implementation was 148 mg/dL. The incidence of hypoglycemia, 2.09% before and 0.22% after the intervention, was significantly reduced ( [n = 29] = 13.9, P < .001). The percentage of blood glucose levels less than 180 mg/dL was 88.30%. Conclusions Increasing nurses’ knowledge of glycemic control and implementing an insulin infusion protocol targeting moderate glycemic control were effective for treating acute hyperglycemia following Continue reading >>

Postoperative Hyperglycemia Can Be Safely And Effectively Controlled In Both Diabetic And Nondiabetic Patients With Use Of A Subcutaneous Insulin Protocol

Postoperative Hyperglycemia Can Be Safely And Effectively Controlled In Both Diabetic And Nondiabetic Patients With Use Of A Subcutaneous Insulin Protocol

Background: Postoperative hyperglycemia related to stress has been shown to be an independent risk factor for periprosthetic joint infection. In a non-intensive care, general-surgery setting, a standardized postoperative insulin protocol has been shown to decrease the rate of wound infections. We hypothesized that the use of a similar protocol is both safe and effective for controlling hyperglycemia in patients who have undergone total joint replacement. Methods: We performed a retrospective cohort study of 489 consecutive patients who underwent primary or revision total hip or knee arthroplasty between January 2008 and April 2013. All patients were tested with point-of-care (finger-stick) glucose determinations postoperatively and were started on a subcutaneous insulin protocol if they had postoperative stress hyperglycemia of >140 mg/dL when fasting or >180 mg/dL after meals. Insulin was discontinued when blood glucose decreased to <100 mg/dL. Results: Of the 489 patients, 301 (62%) qualified for the insulin protocol. Thirty-seven (17%) of the 220 patients for whom the hemoglobin A1c level was available were diabetic, and 21 (11%) of the 187 patients for whom body mass index data were available were morbidly obese (body mass index, ≥40 kg/m2). Diabetes (p < 0.001), revision surgery (p < 0.001), male sex (p = 0.0110), and obesity (including morbid obesity) (p = 0.0051) were independent factors resulting in significant glycemic elevation. A trend toward hyperglycemia occurred in younger patients but did not reach significance (p = 0.063). The glucose levels of patients in all of these groups responded well to insulin. None of the patients who were managed with the insulin experienced a periprosthetic joint infection. There were no injuries related to hypoglycemia. Con Continue reading >>

Intensive Insulin Therapy In Patients Undergoing Coronary Artery Bypass Surgery (cabg)

Intensive Insulin Therapy In Patients Undergoing Coronary Artery Bypass Surgery (cabg)

High blood glucose levels (hyperglycemia) in cardiac surgery patients with diabetes are associated with increased risk of hospital complications. Blood sugar control with intravenous insulin may prevent such hospital complications. Many patients undergoing cardiac bypass surgery (CABG) develop high blood sugars and require insulin therapy (shortly before or after surgery). It is not clear what the best insulin regimen is or what is the best blood sugar target in these patients. Accordingly, this research study aims to determine optimal blood glucose levels during the in patients undergoing cardiac bypass surgery. Patients will be divided in two groups. The intensive insulin group will be maintained at blood glucose between 100-140 mg/dl and the conventional treatment group at a glucose level between 140-180 mg/dl. The insulins to be used in this trial (lantus, aspart and regular insulin) are approved for use in the treatment of patients with diabetes by the FDA (Food and Drug Administration). A total of 326 patients with high blood glucose after cardiac bypass surgery will be recruited in this study. Patients will be recruited at Emory University Hospital, Emory Midtown Hospital and Grady Memorial Hospital. Several prospective cohort studies as well as randomized clinical trials (RCT) in cardiac surgery patients have shown that intensified insulin therapy (target BG: 110-140 mg/dl) results in a reduction in short- and long-term mortality compared with conventionally treated patients. The results of recent international trials in critically ill patients; however, have failed to show a significant improvement in mortality or have even shown increased mortality risk as well as increased number of hypoglycemic events with intensive compared to less intensive glycemic contro Continue reading >>

Preparing For Surgery When You Have Diabetes

Preparing For Surgery When You Have Diabetes

Work with your health care provider to come up with the safest surgery plan for you. Focus more on controlling your diabetes during the days to weeks before surgery. Your provider will do a medical exam and talk to you about your health. Tell your provider about all the medicines you are taking. If you take metformin, talk to your provider about stopping it. Sometimes, it can be stopped 48 hours before and 48 hours after surgery to decrease the risk of a problem called lactic acidosis. If you take other types of diabetes drugs, follow your provider's instructions if you need to stop the drug before surgery. If you take insulin, ask your provider what dose you should take the night before or the day of your surgery. Your provider may have you meet with a dietitian, or give you a specific meal and activity plan to try to make sure your blood sugar is well-controlled for the week prior to your surgery. Some surgeons will cancel or delay surgery if your blood sugar is high when you arrive at the hospital for your surgery. Surgery is riskier if you have diabetes complications. So talk to your provider about your diabetes control and any complications you have from diabetes. Tell your provider about any problems you have with your heart, kidneys, or eyes, or if you have loss of feeling in your feet. The provider may run some tests to check the status of those problems. You may do better with surgery and get better faster if your blood sugar is controlled during surgery. So, before surgery, talk to your provider about your blood sugar target level during the days before your operation. During surgery, insulin is given by the anesthesiologist. You will meet with this doctor before surgery to discuss the plan to control your blood sugar during the operation. You or your nurses s Continue reading >>

Perioperative Management Of The Diabetic Patient

Perioperative Management Of The Diabetic Patient

Overview 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 surgery. [7, 8, 9] Fortunately, tighter glycemic control has been shown to have a profound effect on reducing the incidence of m Continue reading >>

Surgery Preparations

Surgery Preparations

Diabetic patients Diabetic patients need to pay particular attention to their diet and medication on the day of surgery. Individual management of each diabetic patient is necessary to provide a safe surgical experience. Prior to the day of surgery, patients should contact the physician who manages their diabetes. This will allow a specific plan for their diabetic management on the evening before the day of surgery and the day of surgery. It is always best if this is coordinated with your surgeon and diabetic management physician. All diabetic patients should continue to monitor their blood sugars before and after their surgery. Blood sugars will be monitored during your stay by the Surgery Center of Reno staff. Because anesthesia and surgery is a stressful time, blood sugars may fluctuate and require more frequent monitoring during the first few hours after surgery. We recommend most adult patients with diabetes not eat anything after midnight before surgery. The parents of children with diabetes should contact their physician for individual instructions. General Guidelines Suggested for diabetic patients: Type 1, juvenile or insulin dependent diabetics Patients on insulin pumps should continue using their pumps up to, during and after surgery using a basal rate only. Their routine use may be resumed after they commence their usual diet. Patients on long acting insulin such as NPH, Lente or Ultralente should take their evening dose as usual but reduce any morning doses by 1/3 if the surgery is in the morning, or by 1/2; if surgery is in the afternoon. Regular insulin should be held until a regular diet is resumed. Patients on long acting insulin such as Lantus should reduce their evening dose prior to surgery by 50%. Regular short acting insulin should be withheld until Continue reading >>

Management Of Diabetes Mellitus In Surgical Patients

Management Of Diabetes Mellitus In Surgical Patients

Abstract In Brief Diabetes is associated with increased requirement for surgical procedures and increased postoperative morbidity and mortality. The stress response to surgery and the resultant hyperglycemia, osmotic diuresis, and hypoinsulinemia can lead to perioperative ketoacidosis or hyperosmolar syndrome. Hyperglycemia impairs leukocyte function and wound healing. The management goal is to optimize metabolic control through close monitoring, adequate fluid and caloric repletion, and judicious use of insulin. Patients with diabetes undergo surgical procedures at a higher rate than do nondiabetic people.1,2 Major surgical operations require a period of fasting during which oral antidiabetic medications cannot be used. The stress of surgery itself results in metabolic perturbations that alter glucose homeostasis, and persistent hyperglycemia is a risk factor for endothelial dysfunction,3 postoperative sepsis,4 impaired wound healing,5,6 and cerebral ischemia.7 The stress response itself may precipitate diabetic crises (diabetic ketoacidosis [DKA], hyperglycemic hyperosmolar syndrome [HHS]) during surgery or postoperatively, with negative prognostic consequences.8,9 HHS is a well known postoperative complication following certain procedures, including cardiac bypass surgery, where it is associated with 42% mortality.9,10 Furthermore, gastrointestinal instability provoked by anesthesia, medications, and stress-related vagal overlay can lead to nausea, vomiting, and dehydration. This compounds the volume contraction that may already be present from the osmotic diuresis induced by hyperglycemia, thereby increasing the risk for ischemic events and acute renal failure. Subtle to gross deficits in key electrolytes (principally potassium, but also magnesium) may pose an arrhy Continue reading >>

Preoperative Insulin Resistance Reduces Complications After Hip Replacement Surgery In Non-diabetic Patients

Preoperative Insulin Resistance Reduces Complications After Hip Replacement Surgery In Non-diabetic Patients

Abstract Insulin resistance negatively affects the outcome of surgery in patients with type 2 diabetes. This association is often believed to be present in other patient populations as well, but studies are lacking on the influence of preoperative insulin resistance on the clinical course of surgery in non-diabetic patients. Sixty non-diabetic patients with a mean age of 68 years underwent a 75-min intravenous glucose tolerance test (IVGTT) one day before and after elective hip replacement surgery. Patients were regarded to be either insulin resistant (< median insulin sensitivity) or not (> median insulin sensitivity). Hypotensive events occurring in the postoperative care unit and complications in the orthopedic ward were recorded. Fatigue and well-being were assessed via questionnaires. A total of 52 patients were included in the final analysis. Insulin resistance before surgery was associated with a lower risk of arterial hypotension in the postoperative care unit (systolic pressure < 80 mmHg; P < 0.05) and with fewer complications in the orthopedic ward (mean 1.9 versus 1.2 per operation, P < 0.01), particularly with respect to nausea/vomiting (P < 0.04) and arterial hypotension (P < 0.05). Fewer of these patients had more than one complication (23% versus 58%, P < 0.001), while no statistical link between preoperative insulin resistance and fatigue or well-being was evident. Insulin resistance, when measured one day postoperatively, did not correlate with the number of complications. Preoperative insulin resistance offers some benefit in the postoperative period and early convalescence in non-diabetic patients who undergo hip replacement surgery. Background Insulin resistance is an important aspect of glucose metabolism and implies that only a small amount of gluc Continue reading >>

Diabetes Medications: Blood Glucose Management Before Surgery

Diabetes Medications: Blood Glucose Management Before Surgery

F A C T S H E E T F O R P A T I E N T S A N D F A M I L I E S When you have diabetes, managing your blood glucose is always important. But before you have surgery, it’s vital. This sheet tells you why— and explains what you can do to prepare. Why is my blood glucose so important right now? Studies show that people with well controlled blood glucose have fewer problems during and after surgery. But unfortunately, staying in control might not be so easy. Surgery can cause big problems in blood glucose levels — even if you normally have things under control. Here’s why: • Surgery is stressful. Stress usually increases before, during, and after surgery. Beforehand, you’re probably a bit nervous. During and after surgery, your body is stressed, trying to heal itself. And unfortunately, stress makes your body release hormones that make it even more difficult than usual to regulate blood glucose. • You may go off your normal meal plan. Often your doctor will give you special instructions about eating and drinking in the hours before surgery. And for a few days after, you might not eat normally either. Going off your meal plan can cause changes in blood glucose levels. • Depending on what type you take, you may be told to stop taking your diabetes medications before surgery. Or you may need to switch to a different medication, or adjust your dose. The stress and changes that surgery brings can push your blood glucose too high — or too low. Very high or low blood glucose can be dangerous at any time. But they’re especially risky when they happen during or after surgery. They can cause dangerous complications and slow your recovery. So to avoid problems, feel better, and get well faster — control your blood Continue reading >>

Glycemic Control During Coronary Artery Bypass Graft Surgery

Glycemic Control During Coronary Artery Bypass Graft Surgery

ISRN Cardiology Volume 2012 (2012), Article ID 292490, 14 pages Department of Cardiothoracic Surgery, The Boston Medical Center and The Boston University School of Medicine, 88 East Newton Street, Boston, MA 02118, USA Academic Editors: G. A. Head and A. Politi Copyright © 2012 Harold L. Lazar. 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 Hyperglycemia, which occurs in the perioperative period during cardiac surgery, has been shown to be associated with increased morbidity and mortality. The management of perioperative hyperglycemia during coronary artery bypass graft surgery and all cardiac surgical procedures has been the focus of intensive study in recent years. This report will paper the pathophysiology responsible for the detrimental effects of perioperative hyperglycemia during cardiac surgery, show how continuous insulin infusions in the perioperative period have improved outcomes, and d Continue reading >>

Diabetes Mellitus And Surgery

Diabetes Mellitus And Surgery

Management of a patient with diabetes who needs surgery or a procedure that requires fasting See also: Diabetes Mellitus and Endoscopy The major aims are to prevent hypoglycaemia during and after surgery and acute hyperglycaemia +/- ketosis after surgery. Elective surgery should be planned in advance in consultation with the endocrinology team. During the admission, the endocrinology team will oversee the peri-operative management of diabetes. If the patient is admitted within usual working hours the diabetes team will prescribe the insulin doses; otherwise doses and management can be discussed with the Endocrinologist / fellow on call. Peri-operative management of diabetes will be influenced by: 1. Duration of procedure / period of fasting 'Minor': GA of <2 hours duration; anticipated to resume oral intake prior to discharge on the same day 2. Current diabetes regimen 3. Time of surgery 4. Urgency of surgery Categories discussed in this guideline include: B. Elective major surgery (GA >2hours or prolonged post-op fasting anticipated) Aim for morning surgery and for the child with diabetes to be first on the surgical list. It is preferable to have child admitted the day before surgery. If this is thought not to be possible, the endocrinology team must be informed as soon as possible in advance. A decision can then be made as to the safety / appropriateness of a same-day admission or the need to reschedule the procedure. Pre-op management will vary, depending on the patient's usual insulin regimen Please click on the link above that pertains to your patient's current insulin regimen (i) Elective minor surgery for patients on twice daily insulin regimens: The child can eat and drink normally before going to bed; however evening insulin dose should be adjusted as follows: Continue reading >>

Hyperglycemia In The Hospital

Hyperglycemia In The Hospital

Hyperglycemia is the medical term for blood glucose (sugar) that is too high. High blood glucose (HBG) is a common problem for people with diabetes. Blood glucose can also rise too high for patients in the hospital, even if they do not have diabetes. This patient guide explains why some patients develop HBG when they are hospitalized and how their HBG is treated. Until about 10 years ago, doctors thought that HBG in hospital patients was not harmful as long as their blood sugar stayed at or below 200 milligrams per deciliter (mg/dL). Recent research studies show that HBG above 180 increases the risk of complications in hospital patients. Keeping blood sugar below this level with insulin treatment lowers the risk for these problems. Most doctors agree that controlling blood sugar so it stays below 180 mg/dl is best for very ill patients in intensive care units ( ICU). Less clear is what the best target blood sugar should be for inpatients who are admitted for general surgery or non-critical medical conditions. In some patients, insulin treatment can cause low blood sugar, called hypoglycemia. Just like blood sugar levels that are too high, blood sugars that are too low are not safe and should be avoided. This patient guide for glucose control in the hospital is based on The Endocrine Society’s practice guideline for health care providers on preventing and treating HBG. This guide applies just to patients on a regular hospital floor, not those who are in an ICU. What causes HBG in the hospital? Many conditions can cause or worsen HBG in hospital patients. These include: Physical stress of illness, trauma, or surgery Inability to move around Steroids like prednisone and some other medicines Skipping diabetes medicines Liquid food given through a feeding tube or nutrition Continue reading >>

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