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 SS  Vol.5 No.3 , March 2014
Clinically Relevant Assessment of the Variability of Glycemic Response and Its Affect on Surgical Site Infection Rates?
Abstract: Purpose: Despite growing interest in perioperative glycemic control, little data existdefining the optimal value(s) to use to define appropriate glycemic management and the impact on the incidence of surgical site infection (SSI). The aim of this study was to assess variation in glycemic response and risk of SSI and hospital stay as defined by themaximum, minimum, and area under the curve for perioperative glucose in patients undergoing colectomy. We specifically used standard of care obtained glucose levels to reflect limitations of observations typically used to assess quality of care. Methods: All patients undergoing colectomy from 7/2007 to 6/2008 were assessed for the maximum and minimum levels of standard of care glucose levels, as well as area under the curve (AUC) for elevated glucose perioperatively. These were assessed for patients with and without SSI (SSI vs nSSI). Results: 183 consecutive patients were evaluated (22 diabetics). The incidence of SSI for the entire population was 17/183 (9.3%) without significant difference between the groups with respect to mean blood glucose level (SSI-136; nSSI-136). However, the SSI group had a higher maximum glucose level (SSI-194; nSSI 162; p < 0.05) and a lower minimum glucose level (SSI-100; nSSI 117; p < 0.05). Using AUCs for elevated glucose, there was no significant difference in the percentage of SSI patients with glucose > 110 mg/dl (SSI-59%; nSSI-62%) or glucose > 150 mg/dl (SSI 6%; nSSI 18%). Conclusions: The data demonstrate that patients with SSI have wider fluctuations inglycemic response compared to non-SSI when standard of care serum glucose levels wasreviewed. Therefore, quality program monitoring of glucose impact on SSI should focus on both maximum and minimum levels during the perioperative period to better define process improvement in colectomy patients.
Cite this paper: Mahmood, A. , El-Badawi, K. , Asgeirsson, T. , Gajula, V. and Senagore, A. (2014) Clinically Relevant Assessment of the Variability of Glycemic Response and Its Affect on Surgical Site Infection Rates?. Surgical Science, 5, 84-89. doi: 10.4236/ss.2014.53017.
References

[1]   Gale, S.C., Sicoutris, C., Reilly, P.M., et al. (2007) Poor Glycemic Control Is Associated with Increased Mortality in Critically Ill Trauma Patients. The American Surgeon, 73, 454-460.

[2]   Van den Berghe, G., Wouters, P.J., Bouillon, R., et al. (2003) Outcome Benefit of Intensive Insulin Therapy in the Critically Ill: Insulin Dose versus Glycemic Control. Critical Care Medicine, 31, 359-366. http://dx.doi.org/10.1097/01.CCM.0000045568.12881.10

[3]   Cochran, A., Scaife, E.R., Hansen, K.W., et al. (2003) Hyperglycemia and Outcomes from Pediatric Traumatic Brain Injury. Journal of Trauma, 55, 1035-1038. http://dx.doi.org/10.1097/01.TA.000003 1175.96507.48

[4]   Yendamuri, S., Fulda, G.J., Tinkoff, G.H., et al. (2003) Admission Hyperglycemia as a Prognostic Indicator in Trauma. Journal of Trauma, 55, 33-38. http://dx.doi.org/10.1097/01.TA.0000074434. 39928.72

[5]   Sung, J., Bochicchio, G.V., Joshi, M., et al. (2005) Admission Hyperglycemia Is Predictive of Outcome in Critically Ill Trauma Patients. Journal of Trauma, 59, 80-83. http://dx.doi.org/10.1097/01.TA.000 0171452.96585.84

[6]   Finney, S.J., Zekveld, C., Elia, A., et al. (2003) Glucose Control and Mortality in Critically Ill Patients. JAMA, 290, 2041-2048. http://dx.doi.org/10.1001/jama.290.15.2041

[7]   Ali, N.A., O’Brien, J.M. and Dungan, K. (2008) Glucose Variability and Mortality in Patients with Sepsis. Critical Care Medicine, 36, 2316-2321. http://dx.doi.org/10.1097/CCM.0b013e3181810378

[8]   Hayes, M.A., Timmins, A.C., Yau, E.H., et al. (1994) Elevation of Systemic Oxygen Delivery in the Treatment of Critically Ill Patients. The New England Journal of Medicine, 330, 1717-1722.
http://dx.doi.org/10.1056/NEJM199406163302404

[9]   Deal, E.N., Hollands, J.M., Schramm, G.E., et al. (2008) Role of Corticosteroids in the Management of Acute Respiratory Distress Syndrome. Clinical Therapeutics, 30, 787-799. http://dx.doi.org/10.1016/ j.clinthera.2008.05.012

[10]   Sakr, Y., Vincent, J.L., Reinhart, K., et al. (2005) High Tidal Volume and Positive Fluid Balance Are Associated with Worse Outcome in Acute Lung Injury. Chest, 128, 3089-3091. http://dx.doi.org/10. 1378/chest.128.5.3098

[11]   Numa, A.H. (2001) Acute Lung Injury: Outcomes and New Therapies. Numa AH. Pediatric Respiratory Review, 2, 22-31. http://dx.doi.org/10.1053/prrv.2000.0097

[12]   Hager, D.N., Krishnan, J.A., Hayden, D.L., et al. (2005) Tidal Volume Reduction in Patients with Acute Lung Injury When Plateau Pressures Are Not High. American Journal of Respiratory and Critical Care Medicine, 172, 1241-1245. http://dx.doi.org/10.1164/rccm.200501-048CP

[13]   Leibowitz, A.B. and Porter, S.B. (2009) Perioperative Beta-Blockade in Patients Undergoing Noncardiac Surgery: A Review of the Major Randomized Clinical Trials. Journal of Cardiothoracic and Vascular Anesthesia, 23, 684-693. http://dx.doi.org/10.1053/j.jvca.2009.01.017

[14]   Bangalore, S., Wetterslev, J., Pranesh, S., et al. (2008) Perioperative Beta Blockers in Patients Having Non-Cardiac Surgery: A Meta-Analysis. Lancet, 372, 1962-1976. http://dx.doi.org/10.1016/ S0140-6736(08)61560-3

[15]   Chopra, V., Plaisance, B., Cavusoglu, E., et al. (2009) Perioperative Beta-Blockers for Major Noncardiac Surgery: Primum Non Nocere. American Journal of Medicine, 122, 222-229.
http://dx.doi.org/10.1016/j.amjmed.2008.11.004

[16]   POISE Study Group, Devereaux, P.J., Yang, H., Yusuf, S., et al. (2008) Effects of Extended-Release Metoprolol Succinate in Patients Undergoing Non-Cardiac Surgery (POISE Trial): A Randomized Controlled Trial. Lancet, 31, 1839-1847.

[17]   Furnary, A.P., Zerr, K.J., Grunkemeier, G.L., et al. (1999) Continuous Intravenous Insulin Infusion Reduced the Incidence of Deep Sternal Wound Infection in Diabetic Patients after Cardiac Surgical Procedures. The Annals of Thoracic Surgery, 67, 352-360. http://dx.doi.org/10.1016/S0003-4975(99) 00014-4

[18]   Lazar, H.L., Chipkin, S.R. and Fitzgerald, C.A. (2004) Tight Glycemic Control in Diabetic Coronary Artery Bypass Graft Patients Improves Perioperative Outcomes and Decreases Recurrent Ischemic Events. Circulation, 109, 1497-1502. http://dx.doi.org/10.1161/01.CIR.0000121747.71054.79

[19]   Scott, J.F., Robinson, G.M. and French, J.M. (1999) Glucose Potassium Insulin Infusions in the Treatment of Acute Stroke Patients with Mild to Moderate Hyperglycemia: The Glucose Insulin in Stroke Trial (GIST). Stroke, 30, 793-799. http://dx.doi.org/10.1161/01.STR.30.4.793

[20]   Malmberg, K., Ryden, L., Efendic, S., et al. (1995) Randomized Trial of Insulin-Glucose Infusion Followed by Sub-Cutaneous Insulin Treatment in Diabetic Patients with Acute Myocardial Infarction (DIGAMI Study): Effects on Mortality at One Year. Journal of the American College of Cardiology, 26, 57-65. http://dx.doi.org/10.1016/0735-1097(95)00126-K

[21]   Krinsley, J.S. and Grover, A. (2007) Severe Hypoglycemia in Critically Ill Patients: Risk Factors and Outcomes. Critical Care Medicine, 35, 2262-2267. http://dx.doi.org/10.1097/01.CCM.0000282073. 98414.4B

[22]   Wintergerst, K.A., Buckingham, B., Gandrud, L., et al. (2006) Association of Hypoglycemia, and Glucose Variability with Morbidity and Death in the Pediatric Intensive Care Unit. Pediatrics, 118, 173-179. http://dx.doi.org/10.1542/peds.2005-1819

[23]   Belsey, J.D., Pittard, J.B., Rao, S., et al. (2009) Self Blood Glucose Monitoring in Type 2 Diabetes. A Financial Impact Analysis Based on UK Primary Care. International Journal of Clinical Practice, 63, 439-448. http://dx.doi.org/10.1111/j.1742-1241.2008.01992.x

[24]   Aspinall, S.L. and Glassman, P.A. (2008) Cost-Effectiveness of Blood Glucose Monitoring Is Controversial. American Journal of Managed Care, 14, 398-399.

 
 
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