Continuous Perioperative Insulin Infusion Decreases Major Cardiovascular Events in Patients Undergoing Vascular Surgery

Subramaniam, Balachundhar; Panzica, Peter; Novack, Victor; Mahmood, Feroze; Matyal, Robina; Mitchell, John D.; Sundar, Eswar; Bose, Ruma; Pomposelli, Frank B.; Kersten, Judy R.; Talmor, Daniel

doi:10.1097/aln.0b013e3181a1005b

Cited by 98 publications

(63 citation statements)

References 30 publications

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“…16,17 The best current evidence for intraoperative glucose control in non-cardiac surgery recommends a range from 110-150 mgÁdL -1 (6.1-8.3 mmoLÁL -1 ). 18 We are expecting the results from one arm of the Dexamethasone, Light Anesthesia, and Tight Glucose Control (DeLiT) Trial, which is evaluating levels of intraoperative glucose control (i.e., 80-110 mgÁdL -1 vs 180-200 mgÁdL -1 [5.0-6.1 mmoLÁL -1 vs 10-11.1 mmoLÁL -1 , respectively]) in major non-cardiac surgery. 19 This is a retrospective review of our database, and, as such, there is the potential that unavailable data might confound the relationships of interest.…”

Section: Discussionmentioning

confidence: 99%

The prevalence of undiagnosed diabetes in non-cardiac surgery patients, an observational study

Abdelmalak

Knittel

et al. 2010

Can J Anesth/J Can Anesth

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Purpose Given that preoperative hyperglycemia is associated with poor outcomes and many non-diabetic patients have high plasma glucose (PG) levels, the purpose of our study was to estimate the prevalence of undiagnosed diabetes among non-cardiac surgery patients and to identify predictors of hyperglycemia in non-diabetics. MethodsWe included all non-cardiac surgery patients with complete records in the Clinical Database of the Anesthesiology Institute at the Cleveland Clinic during January 2007 to April 2009, and we estimated the prevalence of undiagnosed diabetes and impaired fasting glucose (IFG) among the non-diabetic patients. The mean glucose levels for known diabetics and undiagnosed diabetics were compared using two-tailed Student's t tests, and we assessed the association between PG levels and demographic variables within the non-diabetics. Results Of the 39,434 patients analyzed, 5,511 (14%) were known diabetics. Of the 33,923 known non-diabetics, 3,426 (10 %) were undiagnosed diabetics and another 3,549 (11%) had IFG. Thus, 6,975 patients (21%) of the non-diabetic patients presented with abnormally high glucose. Previously undiagnosed diabetics had higher preoperative glucose levels compared with known diabetics, with a mean ± standard deviation (SD) of 161 ± 48 vs 146 ± 67 mgÁdL -1 (8.9 ± 2.7 vs 8.1 ± 3.7 mmoLÁL -1 ), respectively. The difference remained highly significant after adjusting for body mass index, age, sex, and American Society of Anesthesiologists (ASA) physical status (P \ 0.001). Among non-diabetics, older age, obesity, male sex, and a higher ASA physical status were collectively significant predictors of hyperglycemia, with a c-statistic (95% confidence interval) of 0.67 (0.66-0.68). Conclusion A significant proportion of non-cardiac surgery patients have previously undiagnosed diabetes and pre-diabetes. Previously undiagnosed patients have higher fasting glucose levels compared with diabetic patients. Further studies should be conducted to identify the implications of these findings on patient outcomes. RésuméObjectif E´tant donne´que l'hyperglyce´mie pre´ope´ratoire est associe´e à un mauvais pronostic et que de nombreux Preliminary results were presented at

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Section: Discussionmentioning

confidence: 99%

The prevalence of undiagnosed diabetes in non-cardiac surgery patients, an observational study

Abdelmalak

Knittel

et al. 2010

Can J Anesth/J Can Anesth

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“…Perioperative hyperglycemia during major surgery has a significant impact on the occurrence of postoperative complications, including various infections, impaired wound healing, and myocardial infarction. 6,7,[15][16][17] Treating perioperative hyperglycemia has been shown to reduce postoperative infections. 15,18 The underlying pathophysiologic mechanisms by which hyperglycemia leads to an increase in deleterious outcomes have not yet been fully elucidated.…”

Section: Perioperative Hyperglycemia and Complicationsmentioning

confidence: 99%

“…6,7,[15][16][17] Treating perioperative hyperglycemia has been shown to reduce postoperative infections. 15,18 The underlying pathophysiologic mechanisms by which hyperglycemia leads to an increase in deleterious outcomes have not yet been fully elucidated. 19 However, multiple mechanisms by which hyperglycemia might contribute to postoperative complications have been proposed.…”

Section: Perioperative Hyperglycemia and Complicationsmentioning

confidence: 99%

“…36 As stated before, hyperglycemia during major surgery is associated with adverse outcomes. 6,[15][16][17] In a prospective cohort study in ambulatory patients, DM was found to be a risk factor for postoperative complications after minor ambulatory surgery, such as postoperative infections or unplanned admissions. 10 Hyperglycemia (glucose .7.…”

Section: Perioperative Hyperglycemia and Complicationsmentioning

confidence: 99%

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Ambulatory anesthesia: optimal perioperative management of the diabetic patient

Polderman¹,

Wilpe²,

Eshuis³

et al. 2016

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Given the growing number of patients with diabetes mellitus (DM) and the growing number of surgical procedures performed in an ambulatory setting, DM is one of the most encountered comorbidities in patients undergoing ambulatory surgery. Perioperative management of ambulatory patients with DM requires a different approach than patients undergoing major surgery, as procedures are shorter and the stress response caused by surgery is minimal. However, DM is a risk factor for postoperative complications in ambulatory surgery, so should be managed carefully. Given the limited time ambulatory patients spend in the hospital, improvement in management has to be gained from the preanesthetic assessment. The purpose of this review is to summarize current literature regarding the anesthesiologic management of patients with DM in the ambulatory setting. We will discuss the risks of perioperative hyperglycemia together with the pre-, intra-, and postoperative considerations for these patients when encountered in an ambulatory setting. Furthermore, we provide recommendations for the optimal perioperative management of the diabetic patient undergoing ambulatory surgery.

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“…During surgeries, patients can suffer from stress-induced glucose fluctuations (Bochicchio et al (2005)). Data suggests that specialized inpatient glucose level management within a safe range can minimize the hypoglycemia risk and improve clinical outcomes (Subramaniam et al (2009); Lazar et al (2004)). Clinicians currently follow rule-based protocols to administer insulin and glucose during surgeries (e.g., see Kohl et al (2013)), but those protocols are still far from foolproof (Meijering et al (2006)).…”

Section: Introductionmentioning

confidence: 99%

An Intraoperative Glucose Control Benchmark for Formal Verification

et al. 2015

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Diabetes associated complications are affecting an increasingly large population of hospitalized patients. Since glucose physiology is significantly impacted by patient-specific parameters, it is critical to verify that a clinical glucose control protocol is safe across a wide patient population. A safe protocol should not drive the glucose level into dangerous low (hypoglycemia) or high (hyperglycemia) ranges. Verification of glucose controllers is challenging due to the high-dimensional, non-linear glucose physiological models which contain both unobservable states and unmeasurable patient-specific parameters. This paper presents a hybrid system model of a closed-loop physiological system that includes an existing FDA-accepted high-fidelity physiological model tailored to intraoperative settings and a validated improvement to a clinical glucose control protocol for diabetic cardiac surgery patients. We propose the closed-loop model as a physiological system benchmark for verification and present our initial results on verifying the system using the SMT-based hybrid system verification tool dReach. edu).Abstract: Diabetes associated complications are affecting an increasingly large population of hospitalized patients. Since glucose physiology is significantly impacted by patient-specific parameters, it is critical to verify that a clinical glucose control protocol is safe across a wide patient population. A safe protocol should not drive the glucose level into dangerous low (hypoglycemia) or high (hyperglycemia) ranges. Verification of glucose controllers is challenging due to the high-dimensional, non-linear glucose physiological models which contain both unobservable states and unmeasurable patient-specific parameters. This paper presents a hybrid system model of a closed-loop physiological system that includes an existing FDA-accepted highfidelity physiological model tailored to intraoperative settings and a validated improvement to a clinical glucose control protocol for diabetic cardiac surgery patients. We propose the closedloop model as a physiological system benchmark for verification and present our initial results on verifying the system using the SMT-based hybrid system verification tool dReach.

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Continuous Perioperative Insulin Infusion Decreases Major Cardiovascular Events in Patients Undergoing Vascular Surgery

Abstract: Continuous insulin infusion reduces perioperative myocardial infarction after vascular surgery.

Cited by 98 publications

References 30 publications

The prevalence of undiagnosed diabetes in non-cardiac surgery patients, an observational study

The prevalence of undiagnosed diabetes in non-cardiac surgery patients, an observational study

Ambulatory anesthesia: optimal perioperative management of the diabetic patient

An Intraoperative Glucose Control Benchmark for Formal Verification

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