Meta-analysis of lower perioperative blood glucose target levels for reduction of surgical-site infection

Vries, Fleur E.E. de; Gans, Sarah L.; Solomkin, Joseph S.; Allegranzi, Benedetta; Egger, Matthias; Dellinger, E. Patchen; Boermeester, Marja A.

doi:10.1002/bjs.10424

Cited by 111 publications

(94 citation statements)

References 58 publications

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“…reported that a glucose level >140 mg/dL was the only significant risk factor associated with SSI in patients undergoing colorectal surgery. Meta‐analysis23 confirmed the benefits of an intensive protocol targeting <150 mg/dL for reducing SSI, and recent guidelines7 recommended that perioperative glycemic control should be between 110 and 150 mg/dL. A dose–response relationship between BG level and SSI rate was reported in general surgery patients 14.…”

Section: Relationship Between Perioperative Bg and Ssi In Patients Whmentioning

confidence: 88%

“…Although a higher risk of hypoglycemic events was observed with the intensive protocol, the protocol including a very strict control group did not increase the risk of postoperative death and stroke compared with the conventional protocol in surgical patients,23 and it was concluded that an intensive protocol can be carried out safely without the risk of serious adverse events in surgical patients (Table 2). The result of this meta‐analysis, however, should be interpreted with caution.…”

Section: Indication For Intensive Protocol In Critically Ill Patientsmentioning

confidence: 97%

“…demonstrated that 66.7% of non‐DM patients who underwent colorectal surgery experienced hyperglycemia (>125 mg/dL) which was independently associated with septic complications. A meta‐analysis by de Vries et al 23. showed that the benefit of an intensive protocol over a conventional protocol in reducing SSI was consistent in patients both with and without DM.…”

Section: Relationship Between Perioperative Bg and Ssi In Patients Whmentioning

confidence: 98%

“…Although the recommended target BG is 140–180 mg/dL for most ICU patients,27 a recent meta‐analysis23 comparing the efficacy between an intensive and a conventional protocol in patients undergoing surgery showed a significant benefit for the intensive protocol in reducing SSI. Beneficial effects in reducing SSI were confirmed in studies with very strict and moderately strict control, and the effect was similar in both groups ( P = 0.328) 6…”

Section: Indication For Intensive Protocol In Critically Ill Patientsmentioning

confidence: 99%

“…Vigorous studies have been recently conducted to clarify the efficacy of tight (strict) glycemic control in patients undergoing gastroenterological surgery, and four of 15 randomized clinical trials (RCT) comparing intensive with conventional protocols were carried out in patients undergoing abdominal surgery (nine were conducted for cardiac surgery) 23. The definition of intensive protocol varies from ‘moderately strict glycemic control’ with an upper limit target of 150 mg/dL to ‘very strict control’ with a target of 110 mg/dL (Table 1).…”

Section: Introductionmentioning

confidence: 99%

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Strict glycemic control to prevent surgical site infections in gastroenterological surgery

Takesue

Tsuchida

2017

Annals of Gastroent Surgery

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Perioperative hyperglycemia is a risk factor for surgical site infections (SSI). Although the recommended target blood glucose level (BG) is 140–180 mg/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 post‐hoc analysis of the previously published data from research on the risk factors for SSI. The highest BG within 24 hours after surgery was evaluated. A total of 1555 patients were enrolled in the study. In multivariate analysis, a dose–response relationship between the level of hyperglycemia and the odds of SSI was demonstrated when compared with the reference group (≤150 mg/dL) (odds ratio [OR] = 1.68, 95% confidence interval [CI] 1.14–2.49 for 150–200 mg/dL; and OR = 2.15, 95% CI 1.40–3.29 for >200 mg/dL). Unexpectedly, hyperglycemia was not a significant risk factor for SSI among diabetes patients. By contrast, non‐diabetes patients with a BG of >150 mg/dL were found to have increased odds of SSI. In conclusion, a target BG of ≤150 mg/dL is recommended in patients without diabetes who undergo gastroenterological surgery. Additional study is required to determine an optimal target BG in diabetes patients. Because of the risk of hypoglycemia, a conventional protocol is indicated for patients admitted to the general ward where frequent glucose measurement is not assured.

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Section: Relationship Between Perioperative Bg and Ssi In Patients Whmentioning

confidence: 88%

Section: Indication For Intensive Protocol In Critically Ill Patientsmentioning

confidence: 97%

Section: Relationship Between Perioperative Bg and Ssi In Patients Whmentioning

confidence: 98%

Section: Indication For Intensive Protocol In Critically Ill Patientsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Strict glycemic control to prevent surgical site infections in gastroenterological surgery

Takesue

Tsuchida

2017

Annals of Gastroent Surgery

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Paradoxical Association of Hyperglycemia and Surgical Complications Among Patients With and Without Diabetes

et al. 2022

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IMPORTANCE Surgical complications associated with perioperative hyperglycemia are conventionally associated with diabetes, but, paradoxically, prior cohort studies have found that patients without diabetes have greater risk of complications at similar levels of hyperglycemia compared with patients with diabetes.OBJECTIVE To describe the association between perioperative hyperglycemia and surgical complications in a population of surgical patients without diabetes receiving routine blood glucose testing and insulin administration and to evaluate the potential correlation of perioperative hyperglycemia. DESIGN, SETTING, AND PARTICIPANTSThis retrospective cohort study of National Surgical Quality Improvement Program-defined complications after operation took place at a single academic medical center hospital from January 2013 to October 2016. Consecutive patients undergoing general, vascular, and gynecologic operations who were expected to have at least a 48-hour admission were included. Hyperglycemia was defined as blood glucose level of 140 mg/dL or higher within 24 hours after surgery. Multivariate regression was used to assess the association of hyperglycemia and complications, stratified by hyperglycemia severity and adjusted for diabetes status. Analysis began in February 2022.EXPOSURES Routine blood glucose testing and insulin administration. MAIN OUTCOMES AND MEASURESThe main outcomes are odds of experiencing perioperative hyperglycemia and postoperative complication, comparing patients with and without diabetes. RESULTSA total of 7634 patients (mean [SD] age, 53.5 [15.1] years; 6664 patients without diabetes [83.3%] and 970 patients with diabetes [17.7%]) underwent general (6204 [81.3%]), vascular (208 [2.7%]), and gynecologic (1222 [16%]) operations. Of these, 5868 (77%) had blood glucose testing (4899 individuals without diabetes [73.5%] and 969 [99.9%] with diabetes). Hyperglycemia occurred in 882 patients with diabetes (91%)and 2484 patients without diabetes (50.7%). Of those with blood glucose level more than 180 mg/dL, 1388 (72.7%) received insulin (658 patients with diabetes who had hyperglycemia [91%] and 680 patients without diabetes who had hyperglycemia [61%]). Adjusted odds of experiencing a complication were 83% greater for patients without vs with diabetes at blood glucose level of 140 to 179 mg/dL (odds ratio, 1.83 [95% CI, 0.93-3.6]), 49% greater for blood glucose level of 180 to 249 mg/dL (odds ratio, 1.49 [95% CI, 1.06-2.11]), and 88% greater for blood glucose level more than 250 mg/dL (odds ratio, 1.88 [95% CI, 1.11-3.17]). A similar trend was observed for serious complications. Insulin may mitigate the association of hyperglycemia and complications in patients without diabetes. CONCLUSIONS AND RELEVANCEIn this study, with near universal blood glucose testing and frequent insulin use, patients without diabetes paradoxically had worse outcomes than patients with diabetes at similar levels of hyperglycemia. Insulin may mitigate this effect and broader use may improve outcomes.

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Preventing Surgical Site Infections in the Era of Escalating Antibiotic Resistance and Antibiotic Stewardship

Long,

Cifu,

Salipante

et al. 2024

JAMA Surg

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ImportanceAccording to the Centers for Disease Control and Prevention and governing bodies within the American College of Surgeons, the administration of antibiotics as prophylaxis against infection prior to a planned elective procedure is, with rare exception, routinely recommended. The goal of “getting to zero” infections remains a high priority for policymakers, practitioners, and certainly for patients.ObservationsDespite the many advances in surgical technique, skin decontamination, sterile procedure, and enhanced recovery programs, surgical site infections continue to adversely affect procedures as diverse as dental implant surgery, joint arthroplasty, and major abdominal surgery. Although surgical site infection rates are at historically low levels, progress has stalled in recent reporting periods and such infections remain disabling, costly, and occasionally lethal. Stakeholders in the field, including surgeons, infectious diseases specialists, and industry, advocate for strategies emphasizing greater levels of intraoperative sterility or broader-spectrum antibiotic coverage as the most appropriate path forward.Conclusions and RelevanceThe current emphasis on ever-increasing levels of intraoperative sterility and extended-spectrum antibiotic use are not sustainable long-term solutions. Continuing to escalate these approaches may contribute to unintended consequences including antimicrobial resistance. Principles of antimicrobial stewardship and microbiome sciences can be applied to inform a more effective and sustainable approach to infection prevention in the field of surgery.

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Meta-analysis of lower perioperative blood glucose target levels for reduction of surgical-site infection

Cited by 111 publications

References 58 publications

Strict glycemic control to prevent surgical site infections in gastroenterological surgery

Strict glycemic control to prevent surgical site infections in gastroenterological surgery

Paradoxical Association of Hyperglycemia and Surgical Complications Among Patients With and Without Diabetes

Preventing Surgical Site Infections in the Era of Escalating Antibiotic Resistance and Antibiotic Stewardship

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