Advertisement

Current Diabetes Reports

, Volume 12, Issue 1, pp 108–118 | Cite as

Management of Hyperglycemia During the Perioperative Period

  • Ariana Pichardo-LowdenEmail author
  • Robert A. Gabbay
Hospital Management of Diabetes (M Korytkowski, Section Editor)

Abstract

Hyperglycemia is frequently encountered in the inpatient setting and is distinctly associated with poor clinical outcomes. Recent literature suggests an association between stringent glycemic control and increased mortality, thus keeping optimal glycemic targets a relevant subject of debate. In the surgical population, hyperglycemia with or without diabetes mellitus may be unrecognized. Factors contributing to hyperglycemia in the hospital include critical illness, use of certain drugs, use of enteral or parenteral nutrition, and variability in oral or nutritional intake as can occur when patients are prepared for procedures or surgery. A sensible approach to managing hyperglycemia in this population includes preoperative recognition of diabetes mellitus and risks for inpatient hyperglycemia. Judicious control of glycemia during the pre-, intra-, and postoperative time periods with avoidance of hypoglycemia mandates the need for a strategy for patient management that extend to time of discharge. We review the consequences of uncontrolled perioperative hyperglycemia, discuss current clinical guidelines and recent controversies, and provide practical tools for glycemic control in the surgical population.

Keywords

Perioperative glycemic control Inpatient hyperglycemia Diabetic and nondiabetic populations 

Notes

Disclosure

Conflicts of interest: A. Pichardo-Lowden: none; R.A. Gabbay: has been a consultant for Roche, Animas, and Johnson & Johnson.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Narayan KM, Boyle JP, Thompson TJ, et al. Lifetime risk for diabetes mellitus in the United States. JAMA. 2003;290(14):1884–90.PubMedCrossRefGoogle Scholar
  2. 2.
    Economic costs of diabetes in the U.S. In 2007. Diabetes Care, 2008; 31(3): p. 596–615.Google Scholar
  3. 3.
    •• Moghissi, E.S., M.T. Korytkowski, M. DiNardo, et al., American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care, 2009; 32(6): p. 1119–31. This is the consensus statement on inpatient glycemic control from leading diabetes societies—AACE and ADA. PubMedCrossRefGoogle Scholar
  4. 4.
    • Cook, C.B., G.L. Kongable, D.J. Potter, et al., Inpatient glucose control: a glycemic survey of 126 U.S. hospitals. J Hosp Med, 2009; 4(9): p. E7-E14. This is an important survey on inpatient glucose control of 126 US hospitals that provides a figure of the prevalence of hospital hyperglycemia and hypoglycemia. PubMedCrossRefGoogle Scholar
  5. 5.
    Umpierrez GE, Isaacs SD, Bazargan N, et al. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002;87(3):978–82.PubMedCrossRefGoogle Scholar
  6. 6.
    Furnary AP, Gao G, Grunkemeier GL, et al. Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2003;125(5):1007–21.PubMedCrossRefGoogle Scholar
  7. 7.
    Furnary AP, Zerr KJ, Grunkemeier GL, et al. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg. 1999;67(2):352–60. discussion 360–2.PubMedCrossRefGoogle Scholar
  8. 8.
    Furnary AP, Wu Y. Clinical effects of hyperglycemia in the cardiac surgery population: the Portland Diabetic Project. Endocr Pract. 2006;12 Suppl 3:22–6.PubMedGoogle Scholar
  9. 9.
    Krinsley JS. Effect of an intensive glucose management protocol on the mortality of critically ill adult patients. Mayo Clin Proc. 2004;79(8):992–1000.PubMedCrossRefGoogle Scholar
  10. 10.
    Malmberg K. 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. 1997;314(7093):1512–5.PubMedCrossRefGoogle Scholar
  11. 11.
    Malmberg K, Norhammar A, Wedel H, et al. Glycometabolic state at admission: important risk marker of mortality in conventionally treated patients with diabetes mellitus and acute myocardial infarction: long-term results from the Diabetes and Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) study. Circulation. 1999;99(20):2626–32.PubMedGoogle Scholar
  12. 12.
    Pittas AG, Siegel RD, Lau J. Insulin therapy for critically ill hospitalized patients: a meta-analysis of randomized controlled trials. Arch Intern Med. 2004;164(18):2005–11.PubMedCrossRefGoogle Scholar
  13. 13.
    van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med. 2001;345(19):1359–67.PubMedCrossRefGoogle Scholar
  14. 14.
    Moghissi ES, Hirsch IB. Hospital management of diabetes. Endocrinol Metab Clin North Am. 2005;34(1):99–116.PubMedCrossRefGoogle Scholar
  15. 15.
    Gandhi GY, Nuttall GA, Abel MD, et al. Intraoperative hyperglycemia and perioperative outcomes in cardiac surgery patients. Mayo Clin Proc. 2005;80(7):862–6.PubMedCrossRefGoogle Scholar
  16. 16.
    Baird TA, Parsons MW, Barber PA, et al. The influence of diabetes mellitus and hyperglycaemia on stroke incidence and outcome. J Clin Neurosci. 2002;9(6):618–26.PubMedCrossRefGoogle Scholar
  17. 17.
    McAlister FA, Majumdar SR, Blitz S, et al. The relation between hyperglycemia and outcomes in 2,471 patients admitted to the hospital with community-acquired pneumonia. Diabetes Care. 2005;28(4):810–5.PubMedCrossRefGoogle Scholar
  18. 18.
    Baker EH, Janaway CH, Philips BJ, et al. Hyperglycaemia is associated with poor outcomes in patients admitted to hospital with acute exacerbations of chronic obstructive pulmonary disease. Thorax. 2006;61(4):284–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Malmstedt J, Wahlberg E, Jorneskog G, et al. Influence of perioperative blood glucose levels on outcome after infrainguinal bypass surgery in patients with diabetes. Br J Surg. 2006;93(11):1360–7.PubMedCrossRefGoogle Scholar
  20. 20.
    Marchant Jr MH, Viens NA, Cook C, et al. The impact of glycemic control and diabetes mellitus on perioperative outcomes after total joint arthroplasty. J Bone Joint Surg Am. 2009;91(7):1621–9.PubMedCrossRefGoogle Scholar
  21. 21.
    McConnell YJ, Johnson PM, Porter GA. Surgical site infections following colorectal surgery in patients with diabetes: association with postoperative hyperglycemia. J Gastrointest Surg. 2009;13(3):508–15.PubMedCrossRefGoogle Scholar
  22. 22.
    Vriesendorp TM, Morelis QJ, Devries JH, et al. Early post-operative glucose levels are an independent risk factor for infection after peripheral vascular surgery. A retrospective study. Eur J Vasc Endovasc Surg. 2004;28(5):520–5.PubMedCrossRefGoogle Scholar
  23. 23.
    Olsen MA, Nepple JJ, Riew KD, et al. Risk factors for surgical site infection following orthopaedic spinal operations. J Bone Joint Surg Am. 2008;90(1):62–9.PubMedCrossRefGoogle Scholar
  24. 24.
    Ambiru S, Kato A, Kimura F, et al. Poor postoperative blood glucose control increases surgical site infections after surgery for hepato-biliary-pancreatic cancer: a prospective study in a high-volume institute in Japan. J Hosp Infect. 2008;68(3):230–3.PubMedCrossRefGoogle Scholar
  25. 25.
    Vilar-Compte D, Alvarez I. de Iturbe, A. Martin-Onraet, et al., Hyperglycemia as a risk factor for surgical site infections in patients undergoing mastectomy. Am J Infect Control. 2008;36(3):192–8.PubMedCrossRefGoogle Scholar
  26. 26.
    Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27(2):553–91.PubMedCrossRefGoogle Scholar
  27. 27.
    • Dungan, K.M., S.S. Braithwaite, and J.C. Preiser, Stress hyperglycaemia. Lancet, 2009; 373(9677): p. 1798–807. This document constitutes a recent comprehensive review of the mechanisms, classification, and management strategies of stress hyperglycemia. PubMedCrossRefGoogle Scholar
  28. 28.
    Levetan CS, Passaro M, Jablonski K, et al. Unrecognized diabetes among hospitalized patients. Diabetes Care. 1998;21(2):246–9.PubMedCrossRefGoogle Scholar
  29. 29.
    Screening for type 2 diabetes. Diabetes Care. 2003;26 Suppl 1:S21–4.Google Scholar
  30. 30.
    Norris, S.L., D. Kansagara, C. Bougatsos, et al., Screening for Type 2 Diabetes Mellitus: Update of 2003 Systematic Evidence Review for the U.S. Preventive Services Task Force. 2008, U.S. National Library of Medicine. National Institute of Health. http://www.ncbi.nlm.nih.gov/books/NBK33981/. Date accessed 08/08/2011.
  31. 31.
    Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. J Am Coll Cardiol. 2007;50(17):e159–241.PubMedCrossRefGoogle Scholar
  32. 32.
    •• Standards of medical care in diabetes--2011. Diabetes Care, 2011; 34 Suppl 1: p. S11-61. This document contains the latest guideline from the ADA for inpatient glycemic care. Google Scholar
  33. 33.
    International Expert Committee report on the role of the A1C assay in the diagnosis of diabetes. Diabetes Care, 2009; 32(7): p. 1327–34.Google Scholar
  34. 34.
    • Sato, H., G. Carvalho, T. Sato, et al., The association of preoperative glycemic control, intraoperative insulin sensitivity, and outcomes after cardiac surgery. J Clin Endocrinol Metab, 2010; 95(9): p. 4338–44. The investigators reported an association between preoperative levels of glycohemoglobin and insulin sensitivity during cardiac surgery and indicated a potential impact on outcome. PubMedCrossRefGoogle Scholar
  35. 35.
    Imran SA, Ransom TP, Buth KJ, et al. Impact of admission serum glucose level on in-hospital outcomes following coronary artery bypass grafting surgery. Can J Cardiol. 2010;26(3):151–4.PubMedCrossRefGoogle Scholar
  36. 36.
    •• Joshi, G.P., F. Chung, M.A. Vann, et al., Society for Ambulatory Anesthesia consensus statement on perioperative blood glucose management in diabetic patients undergoing ambulatory surgery. Anesth Analg, 2010; 111(6): p. 1378–87. This is the Society for Ambulatory Anesthesia consensus statement on perioperative blood glucose management in diabetic patients undergoing ambulatory surgery. PubMedCrossRefGoogle Scholar
  37. 37.
    Sheehy AM, Gabbay RA. An overview of preoperative glucose evaluation, management, and perioperative impact. J Diabetes Sci Technol. 2009;3(6):1261–9.PubMedGoogle Scholar
  38. 38.
    Garber AJ, Moghissi ES, Bransome Jr ED, et al. American College of Endocrinology position statement on inpatient diabetes and metabolic control. Endocr Pract. 2004;10(1):77–82.PubMedGoogle Scholar
  39. 39.
    Zerr KJ, Furnary AP, Grunkemeier GL, et al. Glucose control lowers the risk of wound infection in diabetics after open heart operations. Ann Thorac Surg. 1997;63(2):356–61.PubMedCrossRefGoogle Scholar
  40. 40.
    Kirdemir P, Yildirim V, Kiris I, et al. Does continuous insulin therapy reduce postoperative supraventricular tachycardia incidence after coronary artery bypass operations in diabetic patients? J Cardiothorac Vasc Anesth. 2008;22(3):383–7.PubMedCrossRefGoogle Scholar
  41. 41.
    • Griesdale, D.E., R.J. de Souza, R.M. van Dam, et al., Intensive insulin therapy and mortality among critically ill patients: a meta-analysis including NICE-SUGAR study data. Canadian Medical Association journal, 2009; 180(8): p. 821–7. This document reports the results of a large meta-analysis of 26 trials involving a total of 13,567 patients in ICUs and showed that ITT significantly increased the risk of hypoglycemia and did not have a mortality benefit among critically ill patients. CrossRefGoogle Scholar
  42. 42.
    Van den Berghe G, Wilmer A, Hermans G, et al. Intensive insulin therapy in the medical ICU. N Engl J Med. 2006;354(5):449–61.PubMedCrossRefGoogle Scholar
  43. 43.
    Wiener RS, Wiener DC, Larson RJ. Benefits and risks of tight glucose control in critically ill adults: a meta-analysis. JAMA. 2008;300(8):933–44.PubMedCrossRefGoogle Scholar
  44. 44.
    •• Kansagara, D., R. Fu, M. Freeman, et al., Intensive insulin therapy in hospitalized patients: a systematic review. Ann Intern Med, 2011; 154(4): p. 268–82. This publication, which constitutes the basis of the recent ACP guideline in inpatient glycemic management, reports the results of a systematic review meta-analysis of 21 trials, including several perioperative care trials, and indicates no benefit derived from ITT in short-term mortality. PubMedGoogle Scholar
  45. 45.
    •• Finfer, S., D.R. Chittock, S.Y. Su, et al., Intensive versus conventional glucose control in critically ill patients. N Engl J Med, 2009; 360(13): p. 1283–97. This study was a large randomized trial involving 6104 patients designed to test the hypothesis that intensive glucose control reduces mortality at 90 days. The study results indicated that intensive glucose control increased mortality among adults in the ICU. PubMedCrossRefGoogle Scholar
  46. 46.
    Grey NJ, Perdrizet GA. Reduction of nosocomial infections in the surgical intensive-care unit by strict glycemic control. Endocr Pract. 2004;10 Suppl 2:46–52.PubMedGoogle Scholar
  47. 47.
    Arabi YM, Dabbagh OC, Tamim HM, et al. Intensive versus conventional insulin therapy: a randomized controlled trial in medical and surgical critically ill patients. Crit Care Med. 2008;36(12):3190–7.PubMedCrossRefGoogle Scholar
  48. 48.
    De La Rosa Gdel C, Donado JH, Restrepo AH, et al. Strict glycaemic control in patients hospitalised in a mixed medical and surgical intensive care unit: a randomised clinical trial. Crit Care. 2008;12(5):R120.CrossRefGoogle Scholar
  49. 49.
    Preiser JC, Devos P, Ruiz-Santana S, et al. A prospective randomised multi-centre controlled trial on tight glucose control by intensive insulin therapy in adult intensive care units: the Glucontrol study. Intensive Care Med. 2009;35(10):1738–48.PubMedCrossRefGoogle Scholar
  50. 50.
    Bilotta F, Caramia R, Paoloni FP, et al. Safety and efficacy of intensive insulin therapy in critical neurosurgical patients. Anesthesiology. 2009;110(3):611–9.PubMedCrossRefGoogle Scholar
  51. 51.
    Barcellos Cda S, Wender OC, Azambuja PC. Clinical and hemodynamic outcome following coronary artery bypass surgery in diabetic patients using glucose-insulin-potassium (GIK) solution: a randomized clinical trial. Rev Bras Cir Cardiovasc. 2007;22(3):275–84.PubMedCrossRefGoogle Scholar
  52. 52.
    Butterworth J, Wagenknecht LE, Legault C, et al. Attempted control of hyperglycemia during cardiopulmonary bypass fails to improve neurologic or neurobehavioral outcomes in patients without diabetes mellitus undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2005;130(5):1319.PubMedCrossRefGoogle Scholar
  53. 53.
    Gandhi GY, Nuttall GA, Abel MD, et al. Intensive intraoperative insulin therapy versus conventional glucose management during cardiac surgery: a randomized trial. Ann Intern Med. 2007;146(4):233–43.PubMedGoogle Scholar
  54. 54.
    Lazar HL, Chipkin SR, Fitzgerald CA, et al. Tight glycemic control in diabetic coronary artery bypass graft patients improves perioperative outcomes and decreases recurrent ischemic events. Circulation. 2004;109(12):1497–502.PubMedCrossRefGoogle Scholar
  55. 55.
    Li JY, Sun S, Wu SJ. Continuous insulin infusion improves postoperative glucose control in patients with diabetes mellitus undergoing coronary artery bypass surgery. Tex Heart Inst J. 2006;33(4):445–51.PubMedGoogle Scholar
  56. 56.
    Subramaniam B, Panzica PJ, Novack V, et al. Continuous perioperative insulin infusion decreases major cardiovascular events in patients undergoing vascular surgery: a prospective, randomized trial. Anesthesiology. 2009;110(5):970–7.PubMedCrossRefGoogle Scholar
  57. 57.
    Smith A, Grattan A, Harper M, et al. Coronary revascularization: a procedure in transition from on-pump to off-pump? The role of glucose-insulin-potassium revisited in a randomized, placebo-controlled study. J Cardiothorac Vasc Anesth. 2002;16(4):413–20.PubMedCrossRefGoogle Scholar
  58. 58.
    • Kao, L.S., D. Meeks, V.A. Moyer, et al., Peri-operative glycaemic control regimens for preventing surgical site infections in adults. Cochrane Database Syst Rev 2009, (3): p. CD006806. This document summarizes the evidence for the impact of glycemic control in the perioperative period on the incidence of surgical site infections from the systematic review of large databases. Google Scholar
  59. 59.
    Gandhi GY, Murad MH, Flynn DN, et al. Effect of perioperative insulin infusion on surgical morbidity and mortality: systematic review and meta-analysis of randomized trials.7. Mayo Clin Proc. 2008;83(4):418–30.PubMedCrossRefGoogle Scholar
  60. 60.
    Umpierrez GE, Smiley D, Zisman A, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial). Diabetes Care. 2007;30(9):2181–6.PubMedCrossRefGoogle Scholar
  61. 61.
    • Umpierrez, G.E., D. Smiley, S. Jacobs, et al., 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, 2011; 34(2): p. 256–61. This is the first randomized study that evaluates the effectiveness and safety of SQ basal-bolus insulin therapy versus sliding scale insulin in a non-ICU surgical population. PubMedCrossRefGoogle Scholar
  62. 62.
    •• Qaseem, A., L.L. Humphrey, R. Chou, et al., Use of intensive insulin therapy for the management of glycemic control in hospitalized patients: a clinical practice guideline from the American College of Physicians. Ann Intern Med, 2011; 154(4): p. 260–7. This is the clinical practice guideline for the management of glycemic control in hospitalized patients from the ACP, a leading professional organization for internal medicine that influences the practice of internists, internal medicine subspecialists, and hospital medicine providers. PubMedGoogle Scholar
  63. 63.
    Furnary AP. Intensive insulin therapy in hospitalized patients. Ann Intern Med. 2011;154(12):845–6.PubMedGoogle Scholar
  64. 64.
    Bentson L. Intensive insulin therapy in hospitalized patients. Ann Intern Med. 2011;154(12):845.PubMedGoogle Scholar
  65. 65.
    Garg R. Intensive insulin therapy in hospitalized patients. Ann Intern Med. 2011;154(12):846.PubMedGoogle Scholar
  66. 66.
    Korytkowski M, Moghissi E, Umpierrez G. Intensive insulin therapy in hospitalized patients. Ann Intern Med. 2011;154(12):846–7.PubMedGoogle Scholar
  67. 67.
    Mucha GT, Merkel S, Thomas W, et al. Fasting and insulin glargine in individuals with type 1 diabetes. Diabetes Care. 2004;27(5):1209–10.PubMedCrossRefGoogle Scholar
  68. 68.
    DiNardo M, Donihi AC, Forte P, et al. Standardized Glycemic Management and Perioperative Glycemic Outcomes in Patients with Diabetes Mellitus who Undergo Same-Day Surgery. Endocr Pract. 2011;17(3):404–11.PubMedCrossRefGoogle Scholar
  69. 69.
    Kanji S, Singh A, Tierney M, et al. Standardization of intravenous insulin therapy improves the efficiency and safety of blood glucose control in critically ill adults. Intensive Care Med. 2004;30(5):804–10.PubMedCrossRefGoogle Scholar
  70. 70.
    Brown G, Dodek P. Intravenous insulin nomogram improves blood glucose control in the critically ill. Crit Care Med. 2001;29(9):1714–9.PubMedCrossRefGoogle Scholar
  71. 71.
    Krikorian A, Ismail-Beigi F, Moghissi ES. Comparisons of different insulin infusion protocols: a review of recent literature. Curr Opin Clin Nutr Metab Care. 2010;13(2):198–204.PubMedCrossRefGoogle Scholar
  72. 72.
    Nazer LH, Chow SL, Moghissi ES. Insulin infusion protocols for critically ill patients: a highlight of differences and similarities. Endocr Pract. 2007;13(2):137–46.PubMedGoogle Scholar
  73. 73.
    Wilson M, Weinreb J, Hoo GW. Intensive insulin therapy in critical care: a review of 12 protocols. Diabetes Care. 2007;30(4):1005–11.PubMedCrossRefGoogle Scholar
  74. 74.
    Umpierrez GE, Palacio A, Smiley D. Sliding scale insulin use: myth or insanity? Am J Med. 2007;120(7):563–7.PubMedCrossRefGoogle Scholar
  75. 75.
    Pichardo-Lowden AR, Fan CY, Gabbay RA. Management of hyperglycemia in the non-intensive care patient: featuring subcutaneous insulin protocols. Endocr Pract. 2011;17(2):249–60.PubMedCrossRefGoogle Scholar
  76. 76.
    Bode BW, Braithwaite SS, Steed RD, et al. Intravenous insulin infusion therapy: indications, methods, and transition to subcutaneous insulin therapy. Endocr Pract. 2004;10 Suppl 2:71–80.PubMedGoogle Scholar
  77. 77.
    Schmeltz LR, DeSantis AJ, Schmidt K, et al. Conversion of intravenous insulin infusions to subcutaneously administered insulin glargine in patients with hyperglycemia. Endocr Pract. 2006;12(6):641–50.PubMedGoogle Scholar
  78. 78.
    Shomali, M.E., D.L. Herr, P.C. Hill, et al., Conversion from intravenous insulin to subcutaneous insulin after cardiovascular surgery: transition to target study. Diabetes Technol Ther; 13(2): p. 121–6.Google Scholar
  79. 79.
    Olansky L, Sam S, Lober C, et al. Cleveland Clinic cardiovascular intensive care unit insulin conversion protocol. J Diabetes Sci Technol. 2009;3(3):478–86.PubMedGoogle Scholar
  80. 80.
    • Dungan, K., C. Hall, D. Schuster, et al., Differential response between diabetes and stress induced hyperglycemia to algorithmic use of detemir and flexible mealtime aspart among stable post-cardiac surgery patients requiring intravenous insulin. Diabetes Obes Metab, 2011. This randomized study addresses the question of SQ insulin requirement after cessation of IV insulin in patients with stress hyperglycemia following cardiac surgery. Google Scholar
  81. 81.
    Raju TA, Torjman MC, Goldberg ME. Perioperative blood glucose monitoring in the general surgical population. J Diabetes Sci Technol. 2009;3(6):1282–7.PubMedGoogle Scholar
  82. 82.
    • Brunner, R., R. Kitzberger, W. Miehsler, et al., Accuracy and reliability of a subcutaneous continuous glucose-monitoring system in critically ill patients. Crit Care Med 2011, 39(4): p. 659–64. A recent retrospective analysis of two randomized ICU studies that reports on the efficacy, reliability, and safety of continuous glucose monitoring systems. PubMedCrossRefGoogle Scholar
  83. 83.
    Okabayashi T, Maeda H, Sun ZL, et al. Perioperative insulin therapy using a closed-loop artificial endocrine pancreas after hepatic resection. World J Gastroenterol. 2009;15(33):4116–21.PubMedCrossRefGoogle Scholar
  84. 84.
    Okabayashi T, Nishimori I, Yamashita K, et al. Continuous postoperative blood glucose monitoring and control by artificial pancreas in patients having pancreatic resection: a prospective randomized clinical trial. Arch Surg. 2009;144(10):933–7.PubMedCrossRefGoogle Scholar
  85. 85.
    • Okabayashi, T., I. Nishimori, H. Maeda, et al., Effect of intensive insulin therapy using a closed-loop glycemic control system in hepatic resection patients: a prospective randomized clinical trial. Diabetes Care, 2009; 32(8): p. 1425–7. This document reports on the effect of ITT and provides further insight on postoperative glycemic control in hepatectomized patients using a closed-loop system. PubMedCrossRefGoogle Scholar
  86. 86.
    Hanazaki K, Maeda H, Okabayashi T. Tight perioperative glycemic control using an artificial endocrine pancreas. Surg Today. 2010;40(1):1–7.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  1. 1.Penn State College of Medicine, Penn State Hershey Diabetes and Obesity Institute, Division of Endocrinology, Diabetes and MetabolismHersheyUSA

Personalised recommendations