AACE ePoster Library

Introduction:
Patients with diabetes mellitus are at a greater risk for perioperative complications. Hyperglycemia increases the risk
of infections and other post- operative complications. A diabetes protocol for patients undergoing procedures or
surgeries has not previously been implemented or evaluated at Advocate Christ Medical Center (ACMC).

Objective:
The aim of the study was to evaluate the outcomes of a standardized protocol for preoperative management of
diabetes mellitus (DM) on the rates of hypoglycemia and hyperglycemia in patients undergoing surgical procedures.

Methods:
Design:
• Data were collected from the electronic medical record of surgical inpatients placed into two cohorts: a baseline
group and a protocol group
• Single center, retrospective, comparative trial
Sample Criteria: N=117
• Diabetics, 18 years or older on hypoglycemic medications
• Undergoing surgical procedures
• Baseline group: n=48. Data was collected from January- February 2011
• Protocol group: n=69. Protocol implementation and data collection was between November 2011- March 2013
Primary outcome: Hypoglycemia and hyperglycemia risk
• In the protocol/order set, hypoglycemia was defined as a blood glucose (BG) <=70mg/dl, and hyperglycemia as BG >=300mg/dl
Protocol Implementation:
• Protocol implementation was studied over a 15 month period
• The protocol/order set, standardized orders included the
following :
• Hold all oral hypoglycemic medications
• Reduction of intermediate or long acting insulin dose
• Pre-op NPO
• Dextrose containing IVF
• Correction sliding scale insulin, with blood glucose check q.i.d. prior to surgery and q2h the AM of surgery
• Measuring and recording pre- surgical blood glucose level, and using a correction sliding scale insulin (aspart/lispro) while NPO.

Data Analysis:
• Chi-square test
• Independent t-test
(*) Significance was determined with a p value <0.05

Table 1. DEMOGRAPHIC DATA
Table 1. The majority of subjects in each group were Type 2 DM on oral hypoglycemic medications.

Table 2. PROTOCOL MEASURES
Table 2. Chi-square test used to compare: % of appropriate orders, % BG value in target 140-180 mg/dl.
There was no significant relationship between groups for categorical glucose values, NPO status or written orders for IVF.

Table 3. SIGNIFICANT OUTCOME MEASURES WHILE NPO
Table 3. Chi-square test used to compare episodes of hypo and hyperglycemia. Using the protocol led to significantly fewer episodes of hypoglycemia while NPO.

Table 4. MEAN GLUCOSE
Table 4. Independent t-test was used to compare the mean pre-surgical BG value. A significantly higher pre-surgical
BG value was found in the protocol cohort (t=-2.73. p=0.007).

Results:
• The majority of subjects in each group were Type 2 DM on oral hypoglycemic medications: baseline 18/48, (41%)
and protocol 21/69, (32%).
• Using the protocol led to significantly fewer episodes of hypoglycemia (baseline 21%, protocol 4%, p=0.012) while NPO.
• There was a significantly higher number of subjects with hyperglycemia in the protocol group (baseline 4%, protocol 17%, p=0.041) and higher pre-surgical BG values as well (baseline 140.9±45, protocol 167.9±62, p=0.007).
• The protocol group had significantly more subjects receive dextrose (baseline 32%, protocol 83%, p<0.000) versus saline IV fluid while NPO.

Conclusion:
Our study demonstrated that a standardized approach to perioperative DM management may be beneficial in reducing hypoglycemia. Further work is needed to identify strategies that do not concurrently increase the risk of hyperglycemia.

Discussion:
• Although the prescribed IVF in the protocol cohort contained dextrose, this was subject to change by the ordering physician, and some patients received saline IVF.
• Medication and IV fluid modifications should be made pre and post operatively, taking into consideration the patient’s oral intake.
• The American Association of Clinical Endocrinologists recommends developing and implementing protocols to improve standardized care of diabetes patients.
• An individualized approach, even within a protocol to tease out patients with hypo or post-operative hyperglycemia risks would be helpful for patients.

References:
Sheehy, A. & Gabbay, R. (2009). An Overview of Perioperative Glucose Evaluation, Management, and Perioperative Impact. Journal of Diabetes Science and Technology.
Raju, T, Torjman, M & Goldberg, M. (2009). Perioperative Blood Glucose Monitoring in the General Surgical Population. Journal of Diabetes Science and Technology.
AACE website, “The Health Economics of Inpatient Hyperglycemia and Diabetes and Its Management”)