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

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Abstract

Aims

A sliding-scale (SS) regimen is discouraged to correct hyperglycemia in hospital patients, but there is resistance to adoption of basal–bolus (BB) treatment in surgical units. We tested the feasibility and the effects of a nurse-based BB regimen in orthopedic surgery.

Methods

Following an intense training to implement a protocol amenable by nurses, a group of patients admitted with hyperglycemia in an orthopedic institute were prospectively followed according to a basal–bolus insulin regimen (BB, n = 80). They were compared with a hyperglycemic group eventually treated by sliding-scale insulin on demand (SS, n = 122). Diabetes was present in 196 cases. Metabolic control was assessed during the first 3 days of surgery; outcome data were tested by logistic regression, after adjusting for propensity score.

Result

Average blood glucose and glucose variability were lower in BB versus SS (P < 0.001), in the presence of similar 3-day insulin doses. Complications were recorded in 68 cases (16.2% vs. 45.1% in BB and SS, respectively). BB regimen was associated with propensity-adjusted reduction in all adverse events [odds ratio (OR) 0.36; 95% confidence interval (CI) 0.17–0.76] and of systemic infections (OR 0.18; 95% CI 0.07–0.50) and with shorter hospital stay (8.8 ± SD 5.2 days vs. 12.5 ± 7.4; P < 0.01). The superiority of BB regimen was confirmed in the pair-matched analysis.

Conclusions

The study proves the feasibility and the superiority of nurse-based BB versus SS treatment in metabolic control and on the risk of adverse events in orthopedic surgery patients with hyperglycemia.

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References

  1. Pieralli F, Bazzini C, Fabbri A et al (2016) The classification of hospitalized patients with hyperglycemia and its implication on outcome: results from a prospective observational study in internal medicine. Intern Emerg Med 11:649–656

    Article  Google Scholar 

  2. Pagano E, De Rosa M, Rossi E et al (2016) The relative burden of diabetes complications on healthcare costs: the population-based CINECA-SID ARNO Diabetes Observatory. Nutr Metab Cardiovasc Dis 26:944–950

    Article  CAS  Google Scholar 

  3. Dungan KM, Braithwaite SS, Preiser JC (2009) Stress hyperglycaemia. Lancet 373:1798–1807

    Article  CAS  Google Scholar 

  4. Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE (2002) Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab 87:978–982

    Article  CAS  Google Scholar 

  5. Capes SE, Hunt D, Malmberg K, Pathak P, Gerstein HC (2001) Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients: a systematic overview. Stroke 32:2426–2432

    Article  CAS  Google Scholar 

  6. Paciaroni M, Agnelli G, Caso V et al (2009) Acute hyperglycemia and early hemorrhagic transformation in ischemic stroke. Cerebrovasc Dis 28:119–123

    Article  CAS  Google Scholar 

  7. Martin ET, Kaye KS, Knott C et al (2016) Diabetes and risk of surgical site infection: a systematic review and meta-analysis. Infect Control Hosp Epidemiol 37:88–99

    Article  Google Scholar 

  8. Yang Y, Kim TH, Yoon KH et al (2017) The stress hyperglycemia ratio, an index of relative hyperglycemia, as a predictor of clinical outcomes after percutaneous coronary intervention. Int J Cardiol 241:57–63

    Article  Google Scholar 

  9. Dhatariya K, Levy N, Kilvert A et al (2012) NHS Diabetes guideline for the perioperative management of the adult patient with diabetes. Diabet Med 29:420–433

    Article  CAS  Google Scholar 

  10. Associazione Medici Diabetologi (AMD), Società Italiana di Diabetologia (SID). Standard Italiani per la Cura del Diabete. In: AMD, SID, 2018

  11. Akiboye F, Rayman G (2017) Management of hyperglycemia and diabetes in orthopedic surgery. Curr Diab Rep 17:13

    Article  Google Scholar 

  12. Kerby JD, Griffin RL, MacLennan P, Rue LW 3rd (2012) Stress-induced hyperglycemia, not diabetic hyperglycemia, is associated with higher mortality in trauma. Ann Surg 256:446–452

    Article  Google Scholar 

  13. American Diabetes Association (2019) 15. Diabetes care in the hospital: standards of medical care in diabetes-2019. Diabetes Care 42:S173–S181

    Article  Google Scholar 

  14. Gallagher JM, Erich RA, Gattermeyer R, Beam KK (2017) Postoperative hyperglycemia can be safely and effectively controlled in both diabetic and nondiabetic patients with use of a subcutaneous insulin protocol. JB JS Open Access 2:e0008

    Article  Google Scholar 

  15. Sternthal E, Underwood P, Mantzoros CS (2015) Slip sliding away: the need for continued discussion of the use of insulin sliding scale in hospitalized patients. Metabolism 64:935–936

    Article  CAS  Google Scholar 

  16. Lee YY, Lin YM, Leu WJ et al (2015) Sliding-scale insulin used for blood glucose control: a meta-analysis of randomized controlled trials. Metabolism 64:1183–1192

    Article  CAS  Google Scholar 

  17. Umpierrez GE, Smiley D, Jacobs S et al (2011) Randomized study of basal–bolus insulin therapy in the inpatient management of patients with type 2 diabetes undergoing general surgery (RABBIT 2 surgery). Diabetes Care 34:256–261

    Article  CAS  Google Scholar 

  18. Malmberg K (1997) Prospective randomised study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus. DIGAMI (Diabetes Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction) Study Group. BMJ 314:1512–1515

    Article  CAS  Google Scholar 

  19. American Diabetes Association (2020) 15. Diabetes care in the hospital: standards of medical care in diabetes-2020. Diabetes Care 43:S193–S202

    Article  Google Scholar 

  20. Roberts GW, Quinn SJ, Valentine N et al (2015) Relative hyperglycemia, a marker of critical illness: introducing the stress hyperglycemia ratio. J Clin Endocrinol Metab 100:4490–4497

    Article  CAS  Google Scholar 

  21. Miller DB (2011) Why won’t the sliding scale go away? Can J Diabetes 35:340–343

    Article  Google Scholar 

  22. Golightly LK, Jones MA, Hamamura DH, Stolpman NM, McDermott MT (2006) Management of diabetes mellitus in hospitalized patients: efficiency and effectiveness of sliding-scale insulin therapy. Pharmacotherapy 26:1421–1432

    Article  CAS  Google Scholar 

  23. Umpierrez GE, Smiley D, Zisman A et al (2007) Randomized study of basal–bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial). Diabetes Care 30:2181–2186

    Article  CAS  Google Scholar 

  24. Canadian Agency for Drugs and Technologies in Health (2017) Basal–bolus versus sliding-scale insulin therapy in the acute care hospital setting: a review of comparative clinical effectiveness and cost-effectiveness. Canadian Agency for Drugs and Technologies in Health, Ottawa

    Google Scholar 

  25. Rubin DB (2007) The design versus the analysis of observational studies for causal effects: parallels with the design of randomized trials. Stat Med 26:20–36

    Article  Google Scholar 

  26. Chrastil J, Anderson MB, Stevens V, Anand R, Peters CL, Pelt CE (2015) Is hemoglobin A1c or perioperative hyperglycemia predictive of periprosthetic joint infection or death following primary total joint arthroplasty? J Arthroplast 30:1197–1202

    Article  Google Scholar 

  27. Karunakar MA, Staples KS (2010) Does stress-induced hyperglycemia increase the risk of perioperative infectious complications in orthopaedic trauma patients? J Orthop Trauma 24:752–756

    Article  Google Scholar 

  28. Krinsley JS (2003) Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients. Mayo Clin Proc 78:1471–1478

    Article  Google Scholar 

  29. Richards JE, Kauffmann RM, Obremskey WT, May AK (2013) Stress-induced hyperglycemia as a risk factor for surgical-site infection in nondiabetic orthopedic trauma patients admitted to the intensive care unit. J Orthop Trauma 27:16–21

    Article  Google Scholar 

  30. Richards JE, Kauffmann RM, Zuckerman SL, Obremskey WT, May AK (2012) Relationship of hyperglycemia and surgical-site infection in orthopaedic surgery. J Bone Joint Surg Am 94:1181–1186

    Article  Google Scholar 

  31. Di Luzio R, Dusi R, Mazzotti A, Petroni ML, Marchesini G, Bianchi G (2020) Stress hyperglycemia and complications following traumatic injuries in individuals with/without diabetes: the case of orthopedic surgery. Diabetes Metab Syndr Obes 13:9–17

    Article  Google Scholar 

  32. Foster EM (2003) Propensity score matching: an illustrative analysis of dose response. Med Care 41:1183–1192

    Article  Google Scholar 

  33. Rosenbaum PR, Rubin DB (1983) The central role of the propensity score in observational studies for causal effects. Biometrika 70:41–55

    Article  Google Scholar 

  34. Umpierrez GE, Palacio A, Smiley D (2007) Sliding scale insulin use: myth or insanity? Am J Med 120:563–567

    Article  Google Scholar 

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Funding

RDL was supported by grant of Fondazione Diabete Ricerca, Società Italiana di Diabetologia (SID) 2014, Rome, Italy.

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Authors and Affiliations

  1. UO Internal Medicine – ASL Bologna, Bologna, Italy

    Raffaella Di Luzio

  2. Department of Medical and Surgical Sciences (DIMEC), “Alma Mater” University, 9, Via Massarenti, 40138, Bologna, Italy

    Rachele Dusi, Giulio Marchesini & Giampaolo Bianchi

  3. IRCCS Rizzoli Orthopedic Institute, Bologna, Italy

    Aristide Morigi, Daniela Di Nicolantonio & Petra Mittermaier

Authors
  1. Raffaella Di Luzio
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  2. Rachele Dusi
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  3. Aristide Morigi
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  4. Daniela Di Nicolantonio
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  5. Petra Mittermaier
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  6. Giulio Marchesini
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  7. Giampaolo Bianchi
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Corresponding author

Correspondence to Giulio Marchesini.

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Conflict of interest

The authors declare that they have no conflict of interest in relation to the material included in the manuscript.

Ethical standard statement

The study was approved by the independent ethical committee of Sant’Orsola-Malpihi university hospital, Protocol n. 65/2015/O/0SS, Amendment n. 46/2016/O.

Informed consent

Informed consent was obtained from all patients included in the study.

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Di Luzio, R., Dusi, R., Morigi, A. et al. Nurse-managed basal-bolus versus sliding-scale insulin regimen in subjects with hyperglycemia at admission for orthopedic surgery: a propensity score approach. Acta Diabetol 57, 835–842 (2020). https://doi.org/10.1007/s00592-020-01503-x

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  • DOI: https://doi.org/10.1007/s00592-020-01503-x

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