Anaesthetic management of diabetes

Diabetes is a complex, chronic metabolic disorder affecting approximately 8.5% of the adult population with the number of people living with diabetes worldwide having almost quadrupled since 1980. This increase has largely been attributed to global urbanization and lifestyle changes. Diabetes affects 10–15% of the surgical population. These patients are now frequently elderly, have complex medical co-morbidities and present for both high-risk elective and emergency surgery. This multisystem disease poses a significant challenge to both anaesthesia and surgery with diabetic patients demonstrating higher morbidity and mortality rates compared to their non-diabetic counterparts. As the management of diabetes becomes more complex, it is vital that the anaesthetist, as a member of the multidisciplinary team, remains up-to-date and plays a key role in patient optimization and perioperative glycaemic control. It is crucial that good glycaemic control is maintained throughout the perioperative period as this has been shown to correlate with positive patient outcomes. Patients themselves are well experienced in managing their own diabetes and should be involved in doing so whenever possible.     

Anaesthetic management of diabetes

Diabetes is a complex metabolic disorder that is increasing in incidence globally. It is the most common non-communicable disease worldwide. Diabetic patients pose a challenge to anaesthesia and surgery due to the organs and systems affected by the disease. Good glycaemic control perioperatively is essential to minimize complications. There is an increasing number of therapies to control diabetes, and this is rapidly evolving, so a multidisciplinary approach to the management of these patients is recommended, and increasingly the patients themselves should be participating in managing their diabetes as long as possible.     

Optimal perioperative medication utilization in patients having arterial intervention

Perioperative medical management of patients undergoing carotid, aortic, or peripheral arterial procedures, both open and endovascular, should be optimized in all cases to achieve excellent outcomes. This particular patient population is often plagued with multiple comorbidities, primarily of the cardiovascular system, but frequently involving other systems. For this reason, management of these comorbidities is complex and should be carefully addressed in every patient throughout the surgical encounter, in many cases through a multidisciplinary approach. Most recently, the perioperative use of statins, antiplatelet agents, and β-blockers have been scrutinized in the literature specifically targeting peripheral vascular disease patients, and results have sometimes been conflicting. The objective of this review is to summarize current available evidence regarding optimal perioperative medical management of patients undergoing arterial vascular surgical procedures, open and endovascular.     

Perioperative management of the diabetic patient.

Diabetes mellitus is a significant global public health problem and is a major source of morbidity and mortality in the world today. Type 2 diabetes mellitus is the predominant form of diabetes worldwide and represents approximately 90% of all cases. There is an epidemic of type 2 diabetes mellitus in the world today in both developed and developing countries. Globally, it is expected that the number of people with diabetes will increase from the current 150 million to 220 million by the year 2010 and to 300 million by the year 2025. In addition, there has been an alarming increase in the incidence of type 2 diabetes in children and adolescents. It is therefore increasingly likely that diabetic patients will appear for dental and oral maxillofacial surgical treatment in both the office and ambulatory surgery clinic setting. Surgical stress often produces hyperglycemia in the perioperative period. Hyperglycemia has been shown to cause a significant increase in perioperative morbidity and mortality. It is the general consensus that strict glycemic control is beneficial and should be achieved for diabetic patients in the perioperative period. Preoperative, intraoperative, and postoperative management protocols for improved perioperative glycemic control of both type 1 and type 2 diabetics are presented.     

Multidisciplinary care in surgery: Are team-based interventions cost-effective?

BackgroundMultidisciplinary care has been shown to improve outcomes for patients, and interprofessional collaboration has been demonstrated to be beneficial for providers. In the field of surgery, although a large number of multidisciplinary care teams have been described, no study to date has examined whether or not these team-based interventions are generally cost-effective. This is the first systematic review to examine cost savings attributable to multidisciplinary care across all surgical fields.MethodsA comprehensive literature review of articles published on cost outcomes associated with multidisciplinary surgical teams was performed. Selected articles reported on cost outcomes directly attributable to a collaborative intervention. Cost savings were totaled on a per-patient basis. Each article was also reviewed to determine whether the authors ultimately recommended the team-based intervention described.ResultsA total of 1421 articles were identified in the initial query, of which 43 met inclusion criteria. Thirty-nine studies (91%) reported multidisciplinary care to be cost effective, with an average cost savings among all studies of $5815 per patient. No significant differences in the amount of savings achieved were found between different intervention subtypes. All studies ultimately recommended (40) or gave mixed reviews (3) of multidisciplinary care, regardless of whether cost savings were achieved.ConclusionMultidisciplinary surgical care is beneficial not only in terms of patient and provider outcomes, but also in reference to its cost-effectiveness. Well-designed multidisciplinary teams tend to optimize perioperative care for all involved parties. Efforts to improve surgical care should employ multidisciplinary teams to promote both quality and cost-effective care.     

Characteristics,comorbidity burden and outcomes in centenarians undergoing surgery in a university hospital: A case series

IntroductionAs the population ages, so too does the age of those requiring surgery. People over the age of 100, centenarians, often have a greater degree of comorbidity and frailty than their younger counterparts but may also have a greater incidence of events requiring surgical intervention. There is, however, a dearth of literature describing the clinical course and practical considerations for this vulnerable population undergoing surgery. We aimed to describe the demographics of centenarians undergoing surgery, the procedures they receive, their intraoperative anaesthesia management, and their postoperative outcomes.Presentation of casesA retrospective cohort study was completed to understand key perioperative and intraoperative variables linked to improved outcomes. Of the 25 patients included in this study, 22 (88%) were female and the median age was 101 years. Emergency cases predominated (72%) and 44% of surgeries occurred after hours. 60% underwent an intermediate risk surgery, and no centenarians underwent high risk surgery in this study period.Discussion64% of patients experienced at least one episode of intraoperative hypotension, with a median 3.5 epochs per patient. 68% of patients experienced postoperative complications and 20% of patients had a complication of Clavien-Dindo severity ≥ III. In centenarians, the risk of high severity postoperative complications was independent of the intrinsic procedural risk.ConclusionCentenarian patients have an elevated burden of comorbidity, presenting often in the emergent setting. However, age alone should not preclude surgical intervention as expert multidisciplinary care can have acceptable outcomes.     

Expert opinion on the preoperative medical optimization of adults with diabetes undergoing metabolic surgery

Diabetes mellitus(DM) and obesity are interrelated in a complex manner, and their coexistence predisposes patients to a plethora of medical problems. Metabolic surgery has evolved as a promising therapeutic option for both conditions. It is recommended that patients, particularly those of Asian origin, maintain a lower body mass index threshold in the presence of uncontrolled DM. However, several comorbidities often accompany these chronic diseases and need to be addressed for successful surgical outcome. Laparoscopic Roux-en-Y gastric bypass(RYGB) and laparoscopic sleeve gastrectomy(LSG) are the most commonly used bariatric procedures worldwide. The bariatric benefits of RYGB and LSG are similar, but emerging evidence indicates that RYGB is more effective than LSG in improving glycemic control and induces higher rates of long-term DM remission. Several scoring systems have been formulated that are utilized to predict the chances of remission. A glycemic target of glycated hemoglobin 7% is a reasonable goal before surgery. Cardiovascular, pulmonary, gastrointestinal, hepatic, renal, endocrine, nutritional, and psychological optimization of surgical candidates improves perioperative and long-term outcomes. Various guidelines for preoperative care of individuals with obesity have been formulated, but very few specifically focus on the concerns arising from the presence of concomitant DM. It is hoped that this statement will lead to the standardization of presurgical management of individuals with DM undergoing metabolic surgery.     

General thoracic surgery and perioperative management in the patients with endocrine dysfunction

Patients with perioperative endocrine dysfunction represent a particular challenge to general thoracic surgeons. This article focuses on the 3 most commonly experienced endocrine disorders:diabetes mellitus, thyroid deficiency( hyper- and hypothyroidism), and long-term steroid administration. The point is to control those endocrine disorders as best as possible before surgery to avoid severe perioperative complications. For the patients with uncontrolled endocrine disorders who are presenting for elective surgery, their surgical procedures should be postponed. Surgeons should understand the clinical condition of their patients with endocrine disorders and closely coordinate with endocrinologists and anesthesiologists for the appropriate perioperative management. Diabetes mellitus is the most common endocrinopathy in patients presenting for surgery. Surgeons should be particularly careful for their surgical technique to avoid surgical site infection and bronchopleural fistula for diabetic patients undergoing lung resection. It is advisable to normalize thyroid function in hyper- and hypothyroidism because thyroid storm and myxedema coma are severe complications and the mortality of them is high. Perioperative steroid replacement therapy is necessary for the patients taking steroids according to the magnitude of the surgical stress to avoid perioperative hemodynamic instability due to adrenal insufficiency.     

Should what we know about neurobehavioral development,complex congenital heart disease,and brain maturation affect the timing of corrective cardiac surgery?

Despite remarkable improvements in perioperative care, adverse neurobehavioral outcomes following neonatal and infant cardiac surgery are commonplace and are associated with substantial morbidity. It is becoming increasingly clear that complex congenital heart disease is associated with both abnormalities in neuroanatomic development and a delay in fetal brain maturation. Substantial cerebral ischemic/hypoxic injury has been detected in neonates with complex congenital heart disease both prior to and following corrective cardiac surgery. The brain of the neonate with complex congenital heart disease appears to be uniquely vulnerable to the types of ischemic/hypoxic injury associated with perioperative care. It remains to be determined whether delaying surgical correction to allow for brain maturation will be associated with improvements in neurobehavioral outcomes.     

Use of continuous subcutaneous insulin infusion (CSII) therapy in pediatric diabetes patients in the perioperative period

Diabetes mellitus is one of the most common endocrinopathies encountered in the perioperative period, and the pediatric population is increasingly using continuous subcutaneous insulin infusions for diabetes management. As these patients present for procedures or surgery requiring anesthesia, the anesthesia provider is charged with the task of managing these pumps perioperatively. Here, we review our experience from a large tertiary care academic medical center and propose recommendations for the perioperative management of children and adolescents with diabetes who use insulin pumps.     

Poor glycemic control is a strong predictor of postoperative morbidity and mortality in patients undergoing vascular surgery

ObjectiveHyperglycemia is a common occurrence in patients undergoing cardiovascular surgery. It has been identified in several surgical cohorts that improved perioperative glycemic control reduced postoperative morbidity and mortality. A significant portion of the population with peripheral arterial disease suffers from the sequelae of diabetes or metabolic syndrome. A paucity of data exists regarding the relationship between perioperative glycemic control and postoperative outcomes in vascular surgery patients. The objective of this study was to better understand this relationship and to determine which negative perioperative outcomes could be abated with improved glycemic control.MethodsThis is a retrospective review of a vascular patient database at a large academic center from 2009 to 2013. Eligible procedures included carotid endarterectomy and stenting, endovascular and open aortic aneurysm repair, and all open bypass revascularization procedures. Data collected included standard demographics, outcome parameters, and glucose levels in the perioperative period. Perioperative hyperglycemia was defined as at least one glucose value >180 mg/dL within 72 hours of surgery. The primary outcome was 30-day mortality, with secondary outcomes of complications, need to return to the operating room, and readmission.ResultsOf the total 1051 patients reviewed, 366 (34.8%) were found to have perioperative hyperglycemia. Hyperglycemic patients had a higher 30-day mortality (5.7% vs 0.7%; P < .01) and increased rates of acute renal failure (4.9% vs 0.9%; P < .01), postoperative stroke (3.0% vs 0.7%; P < .01), and surgical site infections (5.7% vs 2.6%; P = .01). In addition, these patients were also more likely to undergo readmission (12.3% vs 7.9%; P = .02) and reoperation (6.3% vs 1.8%; P < .01). Furthermore, multivariable logistic regression demonstrated that perioperative hyperglycemia had a strong association with increased 30-day mortality and multiple negative postoperative outcomes, including myocardial infarction, stroke, renal failure, and wound complications.ConclusionsThis study demonstrates a strong association between perioperative glucose control and 30-day mortality in addition to multiple other postoperative outcomes after vascular surgery.     

Comorbid conditions in kidney transplantation: association with graft and patient survival

Although the impact of comorbidity on outcomes in ESRD has been evaluated extensively, its contribution after kidney transplantation has not been well studied. It is believed that comorbidity assessment is critical to the informed interpretation of kidney transplant outcomes. In this study, the Charlson Comorbidity Index was used to assess the comorbid conditions of 715 patients who underwent kidney transplantation at the Starzl Transplant Institute between January 1998 and January 2003. The impact of pretransplantation comorbidity on the development of acute cellular rejection after transplantation and on patient and graft survival was examined. The most common comorbid conditions among our patient population were diabetes (n = 217, 30.3%) and heart failure (n = 85, 11.9%). It was found the number of patients with high comorbidity at the Starzl Transplant Institute has increased significantly over time (P = 0.04). In multivariate adjusted models, high comorbidity was associated with an increased risk for patient death, both in the perioperative period (hazard ratio 3.20, 95% confidence interval 1.32 to 7.78; P = 0.01) and >3 mo after transplantation (hazard ratio 2.63; 95% confidence interval 1.62 to 4.28; P < 0.001). The Charlson Comorbidity Index is a practical tool for the evaluation of comorbidity in the transplant population, which has an increasing burden of comorbid disease. Increased comorbidity affects both perioperative and long-term patient outcomes and carries significant implications not only for the development of individual patient therapeutic strategies but also for the interpretation of patient trials and the development of policies that govern distribution of donor organs.     

Contemporary perioperative care strategies

Background:

Historically, the preoperative and postoperative care of patients with gastrointestinal cancer was provided by surgeons. Contemporary perioperative care is a truly multidisciplinary endeavour with implications for cancer‐specific outcomes.

Methods:

A literature review was performed querying PubMed and the Cochrane Library for articles published between 1966 to 2012 on specific perioperative interventions with the potential to improve the outcomes of surgical oncology patients. Keywords used were: fast‐track, enhanced recovery, accelerated rehabilitation, multimodal and perioperative care. Specific interventions included normothermia, hyperoxygenation, surgical‐site infection, skin preparation, transfusion, non‐steroidal anti‐inflammatory drugs, thromboembolism and antibiotic prophylaxis, laparoscopy, radiotherapy, perioperative steroids and monoclonal antibodies. Included articles had to be randomized controlled trials, prospective or nationwide series, or systematic reviews/meta‐analyses, published in English, French or German.

Results:

Important elements of modern perioperative care that improve recovery of patients and outcomes in surgical oncology include accelerated recovery pathways, thromboembolism and antibiotic prophylaxis, hyperoxygenation, maintenance of normothermia, avoidance of blood transfusion and cautious use of non‐steroidal anti‐inflammatory drugs, promotion of laparoscopic surgery, chlorhexidine–alcohol skin preparation and multidisciplinary meetings to determine multimodal therapy.

Conclusion:

Multidisciplinary management of perioperative patient care has improved outcomes. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Regional anaesthesia in patients with diabetes

Diabetes is the most common metabolic condition worldwide and about 20% of surgical patients will have this condition. It is a major risk-factor for worse outcomes after surgery including mortality; infective and non-infective complications; and increased length of stay. However, diabetes is a modifiable risk-factor, and programs to improve medical management have the potential to reduce peri-operative complications and the risk of harm. Regional anaesthesia has well-documented benefits in promoting the restoration of function but there are legitimate concerns that the incidence of complications of regional anaesthesia in patients with diabetes is higher. The aim of this review is to explore in detail the various potential advantages and disadvantages of regional anaesthesia in patients with diabetes. This, in turn, will allow practitioners to undertake more informed shared decision-making and potentially modify their anaesthetic technique for patients with diabetes.     

Chronic steroid use as an independent risk factor for perioperative complications

BackgroundCorticosteroid use continues to rise nationally. Studies have evaluated the impact of chronic steroid use on surgical outcomes in smaller populations. This study investigated the impact of chronic steroid use on perioperative surgical outcomes in a surgical cohort of more than 5 million surgical patients, using a statistically rigorous methodology.MethodsThe National Surgical Quality Improvement Program Database was queried 2008–2016 to evaluate chronic steroid use. Patient demographics, comorbidities, and outcomes were compared, using χ² and t test analysis, and then repeated after propensity score matching. Finally, a double-adjustment logistic regression was utilized, yielding odds ratios to assess the effect of chronic steroids on perioperative outcomes within the matched population.ResultsBetween 2008 and 2016, a total of 5,244,588 patients met inclusion criteria, of whom 181,901 (3.5%) were taking steroids for a minimum of 30 days before surgery. Patients on chronic steroids had significantly more comorbidities compared with the remaining population. After propensity score matching and double-adjusted logistic regression, chronic steroid use was found to be associated with increased surgical complications and poorer surgical outcomes. Chronic steroid use significantly increased a patient’s risk of having a hospital stay longer than 30 days by 19%, risk of readmission within 30 days by 58%, risk of reoperation by 21%, and risk of death by 32%.ConclusionAfter controlling for differences in comorbidities and demographics, patients on chronic steroids have significantly poorer perioperative outcomes. Chronic steroid use should be evaluated and, if possible, addressed before surgery, given their significant impact on surgical outcomes.     

Peri‐operative management of the surgical patient with diabetes 2015

Diabetes affects 10–15% 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 pre‐operative assessment and optimisation of their diabetes (as defined by a HbA1c < 69 mmol.mol^?1); deciding if the patient can be managed by simple manipulation of pre‐existing treatment during a short starvation period (maximum of one missed meal) rather than use of a variable‐rate 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 peri‐operative management of the surgical patient with diabetes that is specific to anaesthetists and to ensure that all current national guidance is concordant.     

Quality and safety improvement initiatives in complex spine surgery

The global health policy landscape is shifting. Health care is moving toward a value-based system with emphasis on reduced adverse events, improved patient outcomes, and increased cost efficiency. Studies have demonstrated that complex adult lumbar scoliosis surgery is accompanied by high variability in complication rates, which may be prevented with improved delivery of evidence-based care. In particular, standardized, systematic, multidisciplinary perioperative care protocols have been shown to significantly reduce the likelihood of a spectrum of negative outcomes associated with complex adult lumbar scoliosis surgery. This paper presents a review and analysis of multiple quality and safety improvement initiatives and methodologies in adult complex spine surgery. Achieving maximal quality and safety improvements in this field appears to require clinicians to go beyond focusing on specific elements of clinical practice and pay attention to optimizing the perioperative system. Two novel conceptual models were developed: the SpineSIM-D and the SpineSIM-C. They synthesize key success factors operating at the individual, team, and organizational levels to guide future quality and safety improvement initiatives. Comprehensive, systematic perioperative protocols that are multidisciplinary in nature appear to be rare in the field of complex spine surgery and have the potential to further improve quality and safety thereby meeting the requirements of health care’s value-driven future.     

Perioperative management of diabetes and corticosteroid supplementation

Diabetes is one of the most common endocrinopathies with increasing prevalence worldwide. More patients with severe diabetes require elective and emergency surgery. Diabetes is also associated with increased postoperative morbidity and mortality. It is essential that good glycaemic control is maintained to avoid complications related to both hyperglycaemia and hypoglycaemia. Historically, the means of achieving this has been variable, but there is now a large volume of data underlying recommendations for good glycaemic control. The Joint British Diabetes Societies for Inpatient Care Group, alongside other societies including Diabetes UK and the British Association of Day Surgery have provided updated guidance on the management of adults with diabetes undergoing surgery and elective procedures. The management of glycaemia in the intensive care setting is beyond the remit of this article. Ideally, all hospitals should have a diabetes consultant lead for this service and inpatient diabetes nurse teams to help facilitate optimal management. Corticosteroids are amongst the most common medications prescribed for variety of medical conditions. This can result in suppression of hypothalamic–pituitary–adrenal (HPA) axis and patients on corticosteroids are unable to mount an effective stress response to surgery. This article aims to give guidance and provide protocols for the effective perioperative management of diabetes and glucocorticoid replacement. Data on the need for supra-physiological corticosteroid doses are based on two small randomized controlled trials and other observational studies; highlighting the need for further research in this area.     

Patient selection in ambulatory anesthesia — An evidence-based review: part II

PURPOSE: This is the second of two reviews evaluating the management of patients with selected medical conditions undergoing ambulatory anesthesia and surgery. Conditions highlighted in this review include: diabetes mellitus; morbid obesity; the ex-premature infant; the child with an upper respiratory infection; malignant hyperthermia; and the use of monoamine oxidase inhibitors. SOURCE: Medline search strategies and the framework for the evaluation of clinical evidence are presented in Part I. PRINCIPAL FINDINGS: Diabetes mellitus has not been linked with adverse events following ambulatory surgery. The morbidly obese patient is at an increased risk for minor respiratory complications in the perioperative period but these events do not increase unanticipated admissions. The ex-premature infant may be considered for ambulatory surgery if post-conceptual age is > 60 weeks and hematocrit is > 30%. The child with a recent upper respiratory tract infection is at an increased risk for perioperative respiratory complications, particularly if endotracheal intubation is required. Patients with malignant hyperthermia may undergo outpatient surgery but require four hours of postoperative temperature monitoring. Sporadic cases of drug interactions have been reported when meperidine and indirect-acting catecholamines are administered in the presence of monamine oxidase inhibitors. Ambulatory anesthesia and surgery is safe if these combinations of drugs are avoided. CONCLUSION: Ambulatory anesthesia can be performed in, and is being offered to, a variety of patients with significant coexistent disease. In many cases there is little evidence documenting the outcomes expected in such patients. Prospective observational and interventional trials are required to better define perioperative management.     

The goals of comprehensive and integrated disease state management for diabetic kidney-disease patients

Diabetes, cardiovascular disease, and chronic kidney disease present many challenges to clinicians as separate disease entities. Management and optimization of care of diabetic kidney-disease patients requires a proactive and integrated approach for all 3 disease states. To optimize the assessment, monitoring, and intervention in this population, comprehensive and integrated disease state management medical care plans must be established. Medical nutrition therapy is another key component that must be coordinated with these disease-state management medical care plans. Coordination of integrated disease-state management and medical nutrition therapy for diabetes, cardiovascular disease, and chronic kidney disease will help to improve patient outcomes and allow for a proactive approach to the identification, prevention, and management of potential disease-state complications. Several programs and guidelines have been established to accomplish these goals: the K/DOQI Clinical Practice Guidelines, the American Diabetes Association Standards of Medical Care for Diabetes (developed by the American Diabetes Association, the National Institute of Diabetes and Digestive Kidney Diseases, and the Centers for Disease Control-Diabetes Foundation), the National Diabetes Education Program, and the National Cholesterol Education Program. The multidisciplinary medical care team assumes an integral role in the success and implementation of this integrated approach as well as the empowerment of the patient in their own care.