Perioperative Management of Diabetes Mellitus: Novel Approaches

Abstract

Purpose of Review

Several studies have demonstrated the benefits of glycemic control in the perioperative period and there is ongoing interest in development of systematic approaches to achieving glycemic control. This review discusses currently available data and proposes a new approach to the management of hyperglycemia in the perioperative period.

Recent Findings

In a recent study, we demonstrated that early preoperative identification of patients with poorly controlled diabetes and proactive treatment through various phases of surgery improves glycemic control, lowers the risk of surgical complications, and decreases the length of hospital stay.

Summary

Implementation of a perioperative diabetes program that systematically identifies and treats patients with poor glycemic control early in the preoperative period is feasible and improves clinical care of patients undergoing elective surgery.

This is a preview of subscription content, log in to check access.

Fig. 1

References

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

  1. 1.

    Garg R, Grover A, McGurk S, Rawn JD. Predictors of hyperglycemia after cardiac surgery in nondiabetic patients. J Thorac Cardiovasc Surg. 2013;145(4):1083–7. https://doi.org/10.1016/j.jtcvs.2012.07.089.

    Article  PubMed  Google Scholar 

  2. 2.

    King JT Jr, Goulet JL, Perkal MF, Rosenthal RA. Glycemic control and infections in patients with diabetes undergoing noncardiac surgery. Ann Surg. 2011;253(1):158–65. https://doi.org/10.1097/SLA.0b013e3181f9bb3a.

    Article  PubMed  Google Scholar 

  3. 3.

    Mraovic B, Hipszer BR, Epstein RH, Pequignot EC, Parvizi J, Joseph JI. Preadmission hyperglycemia is an independent risk factor for in-hospital symptomatic pulmonary embolism after major orthopedic surgery. J Arthroplast. 2010;25(1):64–70. https://doi.org/10.1016/j.arth.2008.10.002.

    Article  Google Scholar 

  4. 4.

    Frisch A, Chandra P, Smiley D, Peng L, Rizzo M, Gatcliffe C, et al. Prevalence and clinical outcome of hyperglycemia in the perioperative period in noncardiac surgery. Diabetes Care. 2010;33(8):1783–8. https://doi.org/10.2337/dc10-0304.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  5. 5.

    Buehler L, Fayfman M, Alexopoulos AS, Zhao L, Farrokhi F, Weaver J, et al. The impact of hyperglycemia and obesity on hospitalization costs and clinical outcome in general surgery patients. J Diabetes Complicat. 2015;29(8):1177–82. https://doi.org/10.1016/j.jdiacomp.2015.07.027.

    Article  PubMed  Google Scholar 

  6. 6.

    Lilienfeld DE, Vlahov D, Tenney JH, McLaughlin JS. Obesity and diabetes as risk factors for postoperative wound infections after cardiac surgery. Am J Infect Control. 1988;16(1):3–6.

    CAS  Article  Google Scholar 

  7. 7.

    Garg R, Tripathy D, Dandona P. Insulin resistance as a proinflammatory state: mechanisms, mediators, and therapeutic interventions. Curr Drug Targets. 2003;4(6):487–92.

    CAS  Article  Google Scholar 

  8. 8.

    Alexiewicz JM, Kumar D, Smogorzewski M, Klin M, Massry SG. Polymorphonuclear leukocytes in non-insulin-dependent diabetes mellitus: abnormalities in metabolism and function. Ann Intern Med. 1995;123(12):919–24.

    CAS  Article  Google Scholar 

  9. 9.

    Rassias AJ, Marrin CA, Arruda J, Whalen PK, Beach M, Yeager MP. Insulin infusion improves neutrophil function in diabetic cardiac surgery patients. Anesth Analg. 1999;88(5):1011–6.

    CAS  Article  Google Scholar 

  10. 10.

    Saito Y, Takahashi I, Iwane K, Okubo N, Nishimura M, Matsuzaka M, et al. The influence of blood glucose on neutrophil function in individuals without diabetes. Luminescence. 2013;28(4):569–73. https://doi.org/10.1002/bio.2495.

    CAS  Article  PubMed  Google Scholar 

  11. 11.

    Esposito K, Nappo F, Marfella R, Giugliano G, Giugliano F, Ciotola M, et al. Inflammatory cytokine concentrations are acutely increased by hyperglycemia in humans: role of oxidative stress. Circulation. 2002;106(16):2067–72.

    CAS  Article  Google Scholar 

  12. 12.

    Dandona P, Aljada A, Dhindsa S, Garg R. Insulin as an anti-inflammatory and antiatherosclerotic hormone. Clin Cornerstone. 2003;Suppl 4:S13–20. https://doi.org/10.1016/S1098-3597(03)90062-7.

  13. 13.

    Dandona P, Chaudhuri A, Ghanim H, Mohanty P. Proinflammatory effects of glucose and anti-inflammatory effect of insulin: relevance to cardiovascular disease. Am J Cardiol. 2007;99(4A):15B–26B. https://doi.org/10.1016/j.amjcard.2006.11.003.

    CAS  Article  PubMed  Google Scholar 

  14. 14.

    Dandona P, Aljada A, Chaudhuri A, Mohanty P. Endothelial dysfunction, inflammation and diabetes. Rev Endocr Metab Disord. 2004;5(3):189–97. https://doi.org/10.1023/B:REMD.0000032407.88070.0a.

    CAS  Article  PubMed  Google Scholar 

  15. 15.

    Carson JL, Scholz PM, Chen AY, Peterson ED, Gold J, Schneider SH. Diabetes mellitus increases short-term mortality and morbidity in patients undergoing coronary artery bypass graft surgery. J Am Coll Cardiol. 2002;40(3):418–23.

    Article  Google Scholar 

  16. 16.

    Szabo Z, Hakanson E, Svedjeholm R. Early postoperative outcome and medium-term survival in 540 diabetic and 2239 nondiabetic patients undergoing coronary artery bypass grafting. Ann Thorac Surg. 2002;74(3):712–9.

    Article  Google Scholar 

  17. 17.

    Ramos M, Khalpey Z, Lipsitz S, Steinberg J, Panizales MT, Zinner M, et al. Relationship of perioperative hyperglycemia and postoperative infections in patients who undergo general and vascular surgery. Ann Surg. 2008;248(4):585–91. https://doi.org/10.1097/SLA.0b013e31818990d1.

    Article  PubMed  Google Scholar 

  18. 18.

    Marchant MH Jr, Viens NA, Cook C, Vail TP, Bolognesi MP. 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. https://doi.org/10.2106/JBJS.H.00116.

    Article  PubMed  Google Scholar 

  19. 19.

    • Sathya B, Davis R, Taveira T, Whitlatch H, Wu WC. Intensity of peri-operative glycemic control and postoperative outcomes in patients with diabetes: a meta-analysis. Diabetes Res Clin Pract. 2013;102(1):8–15. https://doi.org/10.1016/j.diabres.2013.05.003. This study highlights the correlation of glucose levels with postoperative outcomes and suggests perioperative glycemic targets.

    CAS  Article  PubMed  Google Scholar 

  20. 20.

    Furnary AP, Zerr KJ, Grunkemeier GL, Starr A. 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 60-2.

    CAS  Article  Google Scholar 

  21. 21.

    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. https://doi.org/10.4158/ep.12.S3.22.

    Article  PubMed  Google Scholar 

  22. 22.

    Lazar HL, Chipkin SR, Fitzgerald CA, Bao Y, Cabral H, Apstein CS. Tight glycemic control in diabetic coronary artery bypass graft patients improves perioperative outcomes and decreases recurrent ischemic events. Circulation. 2004;109(12):1497–502. https://doi.org/10.1161/01.CIR.0000121747.71054.79.

    CAS  Article  PubMed  Google Scholar 

  23. 23.

    van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, et al. Intensive insulin therapy in the surgical intensive care unit. N Engl J Med. 2001;345(19):1359–67.

    Article  Google Scholar 

  24. 24.

    Jamsen E, Nevalainen P, Kalliovalkama J, Moilanen T. Preoperative hyperglycemia predicts infected total knee replacement. Eur J Intern Med. 2010;21(3):196–201. https://doi.org/10.1016/j.ejim.2010.02.006.

    CAS  Article  PubMed  Google Scholar 

  25. 25.

    Offodile AC II, Chou HY, Lin JA, Loh CYY, Chang KP, Aycart MA, et al. Hyperglycemia and risk of adverse outcomes following microvascular reconstruction of oncologic head and neck defects. Oral Oncol. 2018;79:15–9. https://doi.org/10.1016/j.oraloncology.2018.02.009.

    CAS  Article  PubMed  Google Scholar 

  26. 26.

    Gachabayov M, Senagore AJ, Abbas SK, Yelika SB, You K, Bergamaschi R. Perioperative hyperglycemia: an unmet need within a surgical site infection bundle. Tech Coloproctol. 2018;22(3):201–7. https://doi.org/10.1007/s10151-018-1769-2.

    CAS  Article  PubMed  Google Scholar 

  27. 27.

    Yong PH, Weinberg L, Torkamani N, Churilov L, Robbins RJ, Ma R, et al. The presence of diabetes and higher HbA1c are independently associated with adverse outcomes after surgery. Diabetes Care. 2018;41:1172–9. https://doi.org/10.2337/dc17-2304.

    Article  PubMed  Google Scholar 

  28. 28.

    • Underwood P, Askari R, Hurwitz S, Chamarthi B, Garg R. Preoperative A1C and clinical outcomes in patients with diabetes undergoing major noncardiac surgical procedures. Diabetes Care. 2014;37(3):611–6. https://doi.org/10.2337/dc13-1929. This study shows that HbA1c > 8% is associated with long hospital stay in patients undergoing a non-cardiac surgery. Therefore, HbA1c 8% is a good threshold for glycemic control before surgery.

  29. 29.

    O’Sullivan CJ, Hynes N, Mahendran B, Andrews EJ, Avalos G, Tawfik S, et al. Haemoglobin A1c (HbA1C) in non-diabetic and diabetic vascular patients. Is HbA1C an independent risk factor and predictor of adverse outcome? Eur J Vasc Endovasc Surg. 2006;32(2):188–97. https://doi.org/10.1016/j.ejvs.2006.01.011.

    Article  PubMed  Google Scholar 

  30. 30.

    Halkos ME, Puskas JD, Lattouf OM, Kilgo P, Kerendi F, Song HK, et al. Elevated preoperative hemoglobin A1c level is predictive of adverse events after coronary artery bypass surgery. J Thorac Cardiovasc Surg. 2008;136(3):631–40. https://doi.org/10.1016/j.jtcvs.2008.02.091.

    Article  PubMed  Google Scholar 

  31. 31.

    Godshaw BM, Ojard CA, Adams TM, Chimento GF, Mohammed A, Waddell BS. Preoperative glycemic control predicts perioperative serum glucose levels in patients undergoing Total joint arthroplasty. J Arthroplast. 2018;33(7s):S76–s80. https://doi.org/10.1016/j.arth.2018.02.071.

    Article  Google Scholar 

  32. 32.

    Jehan F, Khan M, Sakran JV, Khreiss M, O’Keeffe T, Chi A, et al. Perioperative glycemic control and postoperative complications in patients undergoing emergency general surgery: what is the role of plasma hemoglobin A1c? J Trauma Acute Care Surg. 2018;84(1):112–7. https://doi.org/10.1097/TA.0000000000001724.

    CAS  Article  PubMed  Google Scholar 

  33. 33.

    Yang L, Sun Y, Li G, Liu J. Is hemoglobin A1c and perioperative hyperglycemia predictive of periprosthetic joint infection following total joint arthroplasty?: a systematic review and meta-analysis. Medicine (Baltimore). 2017;96(51):e8805. https://doi.org/10.1097/MD.0000000000008805.

    Article  Google Scholar 

  34. 34.

    Steely AM, Smith L, Callas PW, Nathan MH, Lahiri JE, Stanley AC, et al. Prospective study of postoperative glycemic control with a standardized insulin infusion protocol after infrainguinal bypass and open abdominal aortic aneurysm repair. Ann Vasc Surg. 2017. https://doi.org/10.1016/j.avsg.2017.04.020.

  35. 35.

    Lamos EM, Wijesinha MA, Ramhmdani S, Magder LS, Silver KD. Role of glycemic control on hospital-related outcomes in patients with diabetes mellitus undergoing renal transplantation. Diabetes Metab Syndr Obes. 2017;10:13–7. https://doi.org/10.2147/DMSO.S118437.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  36. 36.

    Cheisson G, Jacqueminet S, Cosson E, Ichai C, Leguerrier AM, Nicolescu-Catargi B, et al. Perioperative management of adult diabetic patients. Intraoperative period. Anaesth Crit Care Pain Med. 2018;37 Suppl 1:S21–s5. https://doi.org/10.1016/j.accpm.2018.02.018.

    Article  PubMed  Google Scholar 

  37. 37.

    •• Dhatariya K, Levy N, Kilvert A, Watson B, Cousins D, Flanagan D, et al. NHS Diabetes guideline for the perioperative management of the adult patient with diabetes. Diabet Med. 2012;29(4):420–33. https://doi.org/10.1111/j.1464-5491.2012.03582.x. This paper is British guidelines for the perioperative management of diabetes.

    CAS  Article  PubMed  Google Scholar 

  38. 38.

    American Diabetes A. Diabetes care in the hospital: standards of medical care in diabetes-2018. Diabetes Care. 2018;41(Suppl 1):S144–S51. https://doi.org/10.2337/dc18-S014.

    Article  Google Scholar 

  39. 39.

    •• Underwood P, Seiden J, Carbone K, Chamarthi B, Turchin A, Bader AM, et al. Early identification of individuals with poorly controlled diabetes undergoing elective surgery: improving A1C testing in the preoperative period. Endocr Pract. 2015;21(3):231–6. https://doi.org/10.4158/EP14228.OR. This study describes the process of implementation of a preoperative program for HbA1c testing and the outcomes of this program.

    Article  PubMed  Google Scholar 

  40. 40.

    Perna M, Romagnuolo J, Morgan K, Byrne TK, Baker M. Preoperative hemoglobin A1c and postoperative glucose control in outcomes after gastric bypass for obesity. Surg Obes Relat Dis. 2012;8(6):685–90. https://doi.org/10.1016/j.soard.2011.08.002.

    Article  PubMed  Google Scholar 

  41. 41.

    • Garg R, Metzger C, Rein R, Lortie M, Underwood P, Hurwitz S, et al. Nurse practitioner-mediated intervention for preoperative control of diabetes in elective surgery patients. J Am Assoc Nurse Pract. 2016;28(10):528–33. https://doi.org/10.1002/2327-6924.12365. This study showed that non-physician providers can improve the implementation of a perioperative diabetes program.

    Article  PubMed  Google Scholar 

  42. 42.

    •• Garg R, Schuman B, Bader A, Hurwitz S, Turchin A, Underwood P, et al. Effect of preoperative diabetes management on glycemic control and clinical outcomes after elective surgery. Ann Surg. 2018;267(5):858–62. https://doi.org/10.1097/SLA.0000000000002323. This study showed that a systematic identification of patients with poorly controlled diabetes and their proactive treatment can improve glycemic control and decrease length of hospital stay.

    Article  PubMed  Google Scholar 

  43. 43.

    Kielhorn BA, Senagore AJ, Asgeirsson T. The benefits of a low dose complex carbohydrate/citrulline electrolyte solution for preoperative carbohydrate loading: focus on glycemic variability. Am J Surg. 2018;215(3):373–6. https://doi.org/10.1016/j.amjsurg.2017.10.029.

    Article  PubMed  Google Scholar 

  44. 44.

    Rushakoff RJ, Wick EC, McDonnell ME. Enhanced recovery in patients with diabetes: is it time for a moratorium on use of preoperative carbohydrate beverages? Ann Surg. 2018. https://doi.org/10.1097/sla.0000000000002989.

  45. 45.

    Gandhi GY, Nuttall GA, Abel MD, Mullany CJ, Schaff HV, O'Brien PC, et al. Intensive intraoperative insulin therapy versus conventional glucose management during cardiac surgery: a randomized trial. Ann Intern Med. 2007;146(4):233–43.

    Article  Google Scholar 

  46. 46.

    American Diabetes Association. Diabetes care in the hospital. Diabetes Care. 2016;39(Supplement 1):S99–S104. https://doi.org/10.2337/dc16-S016.

  47. 47.

    Aggarwal A, Rawn JD, Pendergrass ML, Garg RK. Long-acting subcutaneously administered insulin for glycemic control immediately after cardiac surgery. Endocr Pract. 2011;17(4):558–62. https://doi.org/10.4158/ep10354.Or.

    Article  PubMed  Google Scholar 

  48. 48.

    Umpierrez GE, Smiley D, Jacobs S, Peng L, Temponi A, Mulligan P, 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):256–61. https://doi.org/10.2337/dc10-1407.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  49. 49.

    Garg R, Schuman B, Hurwitz S, Metzger C, Bhandari S. Safety and efficacy of saxagliptin for glycemic control in non-critically ill hospitalized patients. BMJ Open Diabetes Res Care. 2017;5(1):e000394. https://doi.org/10.1136/bmjdrc-2017-000394.

    Article  PubMed  PubMed Central  Google Scholar 

  50. 50.

    Fayfman M, Davis G, Duggan EW, Urrutia M, Chachkhiani D, Schindler J, et al. Sitagliptin for prevention of stress hyperglycemia in patients without diabetes undergoing general surgery: a pilot randomized study. J Diabetes Complicat. 2018;32:1091–6. https://doi.org/10.1016/j.jdiacomp.2018.08.014.

    Article  PubMed  Google Scholar 

  51. 51.

    Pasquel FJ, Gianchandani R, Rubin DJ, Dungan KM, Anzola I, Gomez PC, et al. Efficacy of sitagliptin for the hospital management of general medicine and surgery patients with type 2 diabetes (Sita-Hospital): a multicentre, prospective, open-label, non-inferiority randomised trial. Lancet Diab Endocrinol. 2017;5(2):125–33. https://doi.org/10.1016/s2213-8587(16)30402-8.

    CAS  Article  Google Scholar 

  52. 52.

    Garg R, Jarry A, Pendergrass M. Delay in blood glucose monitoring during an insulin infusion protocol is associated with increased risk of hypoglycemia in intensive care units. J Hosp Med. 2009;4(6):E5–7. https://doi.org/10.1002/jhm.436.

    Article  PubMed  Google Scholar 

  53. 53.

    Garg R, Hurwitz S, Turchin A, Trivedi A. Hypoglycemia, with or without insulin therapy, is associated with increased mortality among hospitalized patients. Diabetes Care. 2013;36(5):1107–10. https://doi.org/10.2337/dc12-1296.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  54. 54.

    Simha V, Shah P. Perioperative glucose control in patients with diabetes undergoing elective surgery. JAMA. 2019;321:399. https://doi.org/10.1001/jama.2018.20922.

    Article  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to Rajesh Garg.

Ethics declarations

Conflict of Interest

The authors declare that they have no conflict of interest. Many studies performed by the authors are cited in the text.

Human and Animal Right and Informed Consent

This is a review article and it did not involve conducting studies with humans or animals.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Health Care Delivery Systems and Implementation in Diabetes

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Palermo, N.E., Garg, R. Perioperative Management of Diabetes Mellitus: Novel Approaches. Curr Diab Rep 19, 14 (2019). https://doi.org/10.1007/s11892-019-1132-7

Download citation

Keywords

  • Diabetes mellitus
  • Hyperglycemia
  • Surgery outcomes
  • Perioperative treatment
  • Stress hyperglycemia