Nurse-managed basal-bolus versus sliding-scale insulin regimen in subjects with hyperglycemia at admission for orthopedic surgery: a propensity score approach

Luzio, Raffaella Di; Dusi, Rachele; Morigi, Aristide; Nicolantonio, Daniela Di; Mittermaier, Petra; Marchesini, Giulio; Bianchi, Giampaolo

doi:10.1007/s00592-020-01503-x

Cited by 12 publications

(5 citation statements)

References 33 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Insulin treatment was intended to modulate the systemic inflammatory response and immune cells, activated in severe trauma, burn injury and sepsis [36], via possible modulation of glucose transporters [37], and several studies in these areas confirm that tailored insulin administration reduced the risk of local or systemic infections [35,38,39]. In the present study we could not reduce the risk of newly developed infections and did not confirm the superiority of the basal-bolus procedure vs. the sliding-scale regimen on infections previously documented in a surgical setting [17]. The basalbolus regimen reduced the risk of outcomes in univariate analysis only to an insignificant extent; negative results might be explained by the very high number of events occurring in the first few days after admission, before the more accurate insulin modulation of glucose disposal might have produced beneficial effects.…”

Section: Discussioncontrasting

confidence: 72%

“…There is compelling evidence that prompt treatment of any hyperglycemic state may help reduce adverse events, and in-hospital protocols for the implementation of basal-bolus regimens in the presence of hyperglycemia are advocated by national and international guidelines [14][15][16]. These regimens, which may be effectively managed by nurses with minimum impact on physicians' involvement [17], are aimed at achieving a rapid control of glucose levels with minimal risk of hypoglycemia compared with sliding-scale insulin treatment. Sliding-scale protocols continue to be largely in use outside diabetes units [18] because of their simplicity, although their use is discouraged by guidelines.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Prognostic Value of Stress Hyperglycemia in Patients Admitted to Medical/Geriatric Departments for Acute Medical Illness

et al. 2021

Self Cite

View full text Add to dashboard Cite

Introduction: Hyperglycemia is common in patients admitted to Italian medical/geriatric units and is associated with a poorer outcome. We tested the significance of diabetes and stressinduced hyperglycemia in clinical outcome. Materials and Methods: Three hundred seventy-eight consecutive patients with hyperglycemia at entry (C 126 mg/dl) (206 without known diabetes) were included, with a wide range of underlying diseases requiring hospital admission and independent of the presence of diabetes. Relative hyperglycemia was calculated as admission glucose divided by average glucose, estimated based of glycosylated hemoglobin. Values C 1.20 were considered indicative of stress hyperglycemia (SHR). The association of SHR with outcome variables (all-cause complications, infections, non-infectious events, deaths) was tested by logistic regression analysis, adjusted for sex, BMI, age-adjusted comorbidities (Charlson index) and known diabetes. Results: During hospital stay, one or more events were registered in 96 patients (25.4%); 44 patients died in hospital, and fatality rate was borderline higher in patients without diabetes (14.6% vs. 8.1% in diabetes; P = 0.052) and nearly three times higher in patients with stress hyperglycemia (15.0%) vs. those with SHR \ 1.2 (P = 0.005). Stress hyperglycemia-more common in the absence of diabetes (71% vs. 58%)and age were the only independent prognostic factors for death. At multivariable analysis, the risks of death (OR 4.31, 95% CI 1.25-14.81), of all complications (OR 5.90, 95% CI 2.22-15.71) and of newly developed systemic infections (OR 5.67, 95% CI 1.61-19.92) were associated with stress hyperglycemia in subjects without diabetes, as was the risk in non-insulin-treated cases (OR 4.02, OR 5.47, OR 5.15, respectively). Conclusion:The study confirms the prognostic value of stress-related hyperglycemia in patients requiring hospital admission to a geriatric/ medical unit for a variety of acute medical

show abstract

Section: Discussioncontrasting

confidence: 72%

Section: Introductionmentioning

confidence: 99%

Prognostic Value of Stress Hyperglycemia in Patients Admitted to Medical/Geriatric Departments for Acute Medical Illness

et al. 2021

Self Cite

View full text Add to dashboard Cite

show abstract

“…This is largely because of the high variability in the populations studied and the protocols used, and because most studies in this area describe both medical and surgical patients. Randomized controlled studies have demonstrated that sliding-scale insulin used alone is less effective than basal-bolus management for controlling BG and decreasing complications, including postoperative infection in medical and surgical populations 73-75 , with similar findings also reported in observational studies 76,77 . However, these studies also highlighted the importance of safe dosing, as hypoglycemic events have been shown to be more common with scheduled insulin approaches.…”

Section: Management Of Postoperative Hyperglycemiasupporting

confidence: 61%

Perioperative Identification and Management of Hyperglycemia in Orthopaedic Surgery

Lamanna

McDonnell

Chen

et al. 2022

Journal of Bone and Joint Surgery

View full text Add to dashboard Cite

The consequences of undermanaged perioperative hyperglycemia are notable and can have a serious impact on adverse postoperative outcomes, especially surgical site infections and periprosthetic joint infections (PJIs).Preoperative screening of hemoglobin A1c with a goal threshold of <7.45% is ideal.There are a variety of risk factors that contribute to hyperglycemia that should be considered in the perioperative period, including glucocorticoid use, nutritional factors, patient-specific factors, anesthesia, and surgery.There are expected trends in the rise, peak, and fall of postoperative blood glucose levels, and identifying and treating hyperglycemia as swiftly as possible are the fundamental aims of treatment and improved glucose control. Performing frequent postoperative blood glucose monitoring (in the post-anesthesia care unit, on the day of surgery at 1700 and 2100 hours, and in the morning of postoperative day 1) should be considered to allow for the early detection of alterations in glucose metabolism. In addition, instituting a postoperative dietary restriction of carbohydrates should be considered.The use of insulin as a hypoglycemic agent in orthopaedic patients is relatively safe and is an effective means of controlling fluctuating blood glucose levels. Insulin therapy should be administered to treat hyperglycemia at ≥140 mg/dL when fasting and ≥180 mg/dL postprandially. Insulin therapy should be ceased at blood glucose levels of <110 mg/dL; however, monitoring for glycemic dysregulation should be continued. In all cases of complex diabetes, consultation with diabetes specialty services should be considered.The emerging use of technology, including continuous subcutaneous insulin pump therapy and continuous glucose monitoring, is an exciting area of further research and development as such technology can more immediately detect and correct aberrations in blood glucose levels.

show abstract

“…Mild-to-moderate stress hyperglycemia is considered a protective reaction to providing fuel for the immune system and brain at a time of stress; however, the additional hyperglycemia and insulin resistance it creates may be potentially deleterious ( 39 ) directly contributing to adverse outcomes via endothelial dysfunction, increased free radical production (oxidative stress), inflammatory responses, and vascular and immune dysfunction ( 40 ). In recent studies, we found that immediate treatment of hyperglycemia by basal-bolus insulin injection, irrespective of the presence of diabetes, reduced adverse events, and septic complications in surgical patients ( 41 ). To improve outcomes of critical elderly patients, adequate treatment of hyperglycemia may be systematic implemented also in ED, in keeping with the results observed in ICUs ( 42 ).…”

Section: Discussionmentioning

confidence: 98%

Stress Hyperglycemia and Mortality in Subjects With Diabetes and Sepsis

Fabbri

Marchesini

Benazzi

et al. 2020

Critical Care Explorations

Self Cite

View full text Add to dashboard Cite

Objectives: Poor glycemic control is associated with mortality in critical patients with diabetes. The aim of the study was to assess the predicting value of stress hyperglycemia in patients with diabetes following hospital admission for sepsis. Design: Retrospective observational study. Setting: Adult, emergency department, and critical care in a district hospital. Patients: In a 10-year retrospective analysis of sepsis-related hospitalizations in the emergency department, we carried out a secondary analysis of 915 patients with diabetes (males, 54.0%) in whom both fasting glucose at entry and glycosylated hemoglobin were available. Interventions: None. Measurements and Main Results: Patients’ mean age was 79.0 ( sd 11.0), glucose at admission was 174.0 mg/dL (74.3 mg/dL), and glycosylated hemoglobin was 7.7% (1.7%). Stress hyperglycemia was defined by the stress hyperglycemia ratio, that is, fasting glucose concentration at admission divided by the estimated average glucose derived from glycosylated hemoglobin. A total of 305 patients died (33.3%) in hospital. Factors associated with in-hospital case fatality rate were tested by multivariable logistic model. Ten variables predicting outcomes in the general population were confirmed in the presence of diabetes (male sex, older age, number of organ dysfunction diagnoses, in particular cardiovascular dysfunction, infection/parasitic, circulatory, respiratory, digestive diseases diagnosis, and Charlson Comorbidity Index). In addition, also glycemic control (glycosylated hemoglobin: odds ratio, 1.17; 95% CI, 1.15–1.40) and stress hyperglycemia (stress hyperglycemia ratio: 5.25; 3.62–7.63) were significant case fatality rate predictors. High stress hyperglycemia ratio (≥ 1.14) significantly increased the discriminant capacity (area under the receiver operating characteristic curve, 0.864; se , 0.013; p < 0.001). Conclusions: Stress hyperglycemia, even in the presence of diabetes, is predictive of mortality following admission for sepsis. Stress hyperglycemia ratio may be used to refine prediction of an unfavorable outcome.

show abstract

Nurse-managed basal-bolus versus sliding-scale insulin regimen in subjects with hyperglycemia at admission for orthopedic surgery: a propensity score approach

Cited by 12 publications

References 33 publications

Prognostic Value of Stress Hyperglycemia in Patients Admitted to Medical/Geriatric Departments for Acute Medical Illness

Prognostic Value of Stress Hyperglycemia in Patients Admitted to Medical/Geriatric Departments for Acute Medical Illness

Perioperative Identification and Management of Hyperglycemia in Orthopaedic Surgery

Stress Hyperglycemia and Mortality in Subjects With Diabetes and Sepsis

Contact Info

Product

Resources

About