The Role of HbA1c as a Positive Perioperative Predictor of Surgical Site and Other Postoperative Infections: An Explorative Analysis in Patients Undergoing Minor to Major Surgery.
TL;DR: In this paper, the impact of surgical and metabolic stress as defined by the surrogate marker hemoglobin A1c (HbA1c), in relation to self-reported DM2, on perioperative infection rates in a subcohort of the Surgical Site Infection (SSI) Trial population was analyzed.
Abstract: Patients with diabetes mellitus type 2 (DM2) inhere impaired peripheral insulin action leading to higher perioperative morbidity and mortality rates, with hospital-acquired infections being one important complication. This post hoc, observational study aimed to analyze the impact of surgical and metabolic stress as defined by the surrogate marker hemoglobin A1c (HbA1c), in relation to self-reported DM2, on perioperative infection rates in a subcohort of the Surgical Site Infection (SSI) Trial population. All patients of the SSI study were screened for HbA1c levels measured perioperatively for elective or emergency surgery and classified according to the American Diabetes Association HbA1c cutoff values. SSI and nosocomial infections, self-reported state of DM2 and type of surgery (minor, major) were assessed. HbA1c levels were measured in 139 of 5175 patients (2.7%) of the complete SSI study group. Seventy patients (50.4%) self-reported DM2, while 69 (49.6%) self-reported to be non-diabetic. HbA1c levels indicating pre-diabetes were found in 48 patients (34.5%) and diabetic state in 64 patients (46%). Forty-five patients of the group self-reporting no diabetes (65.2%) were previously unaware of their metabolic derangement (35 pre-diabetic and 10 diabetic). Eighteen infections were detected. Most infections (17 of 18 events) were found in patients with HbA1c levels indicating pre-/diabetic state. The odds for an infection was 3.9-fold (95% CI 1.4 to 11.3) higher for patients undergoing major compared to minor interventions. The highest percentage of infections (38.5%) was found in the group of patients with an undiagnosed pre-/diabetic state undergoing major surgery. These results encourage investment in further studies evaluating a more generous and specific use of HbA1c screening in patients without self-reported diabetes undergoing major surgery. Trial registration Clinicaltrials.gov identifier: NCT 01790529
Citations
More filters
••
TL;DR: In this article , the authors summarise available evidence underpinning current guidelines on preoperative assessment and optimisation, perioperative management of prescribed insulin and oral hypoglycaemic medication, intraoperative glycaemic control, and postoperative patient care.
Abstract: The prevalence of diabetes is increasing, and patients with diabetes mellitus have both an increased likelihood of requiring surgery and of developing postoperative complications when they do. We summarise available evidence underpinning current guidelines on preoperative assessment and optimisation, perioperative management of prescribed insulin and oral hypoglycaemic medication, intraoperative glycaemic control, and postoperative patient care.
1 citations
••
TL;DR: In this article , a retrospective observational cohort study was conducted to assess the association between pre-operative HbA1c and post-operative infections after elective craniotomy.
••
TL;DR: The importance of the use of HbA1c levels as a more accurate predictor of glycemic control in pre-operative patients rather than blood glucose levels is emphasized, especially in low-income countries where the healthcare burden is already huge.
Abstract: Introduction: Diabetic patients undergoing surgery are more susceptible to hospital-acquired infection, particularly surgical site infection (SSI). Good glycemic control in preoperative patients significantly decreases the risk of SSI. There is a scarcity of data from low-income countries studying the relation between perioperative glycated hemoglobin (HbA1c) levels and postoperative SSI. We aim to establish statistical relation between HbA1c and SSI which will help decrease post-operative infections and morbidity. Methods: This study was conducted in the surgical unit of Jinnah Sindh Medical University, Karachi, Pakistan, from August 2020 to April 2022. Patients who underwent elective surgical procedures (n= 1024) were included in the study and divided into two groups based on their HbA1c levels. Patients with HbA1c levels higher than 6.5% were classified as group A and those with HbA1c less than 6.5% belonged to group B. For statistical analysis, IBM SPSS Statistics for Windows, Version 24.0 (Released 2016; IBM Corp., Armonk, New York, United States) was used. Results: Group A comprised 579 (56.5%) patients. The presence of SSI in participants with HbA1c >6.5% was statistically significant (p-value: 0.011). Genderwise comparison with the presence of SSI was found to be insignificant (p-value: 0.28). Smoking was positively correlated with the absence of SSI. No significance in terms of presence or absence of SSI was found in the comparison of the type of wounds (p-value: 0.25). Conclusion: There is a positive relationship between raised HbA1c levels and the development of SSI. Our study emphasizes the importance of the use of HbA1c levels as a more accurate predictor of glycemic control in pre-operative patients rather than blood glucose levels. It is imperative that surgeons must check HbA1c levels before selecting patients for elective surgeries, especially in low-income countries where the healthcare burden is already huge.
References
More filters
••
TL;DR: I would like to take issue with the use of the phrase “standards of medical care in diabetes,” which is used to describe diabetes care standards, in the recently updated and circulatedADA 2006 Clinical Practice Recommendations.
Abstract: I write in reference to the recently updated and circulated “Standards of Medical Care in Diabetes,” in particular part II, “Screening for Diabetes,” which were recently updated and published in the American Diabetes Association (ADA) 2006 Clinical Practice Recommendations (1). I would like to take issue with the use of the phrase “standards of medical care in diabetes,” which is used to …
8,436 citations
••
TL;DR: In this paper, the first-order term is removed from the asymptotic bias of maximum likelihood estimates by a suitable modification of the score function, and the effect is to penalize the likelihood by the Jeffreys invariant prior.
Abstract: SUMMARY It is shown how, in regular parametric problems, the first-order term is removed from the asymptotic bias of maximum likelihood estimates by a suitable modification of the score function. In exponential families with canonical parameterization the effect is to penalize the likelihood by the Jeffreys invariant prior. In binomial logistic models, Poisson log linear models and certain other generalized linear models, the Jeffreys prior penalty function can be imposed in standard regression software using a scheme of iterative adjustments to the data.
3,362 citations
••
TL;DR: In this article, the authors determined the prevalence of in-hospital hyperglycemia and determined the survival and functional outcome of patients with and without a history of diabetes in patients admitted to the Georgia Baptist Medical Center.
Abstract: Admission hyperglycemia has been associated with increased hospital mortality in critically ill patients; however, it is not known whether hyperglycemia in patients admitted to general hospital wards is associated with poor outcome. The aim of this study was to determine the prevalence of in-hospital hyperglycemia and determine the survival and functional outcome of patients with hyperglycemia with and without a history of diabetes. We reviewed the medical records of 2030 consecutive adult patients admitted to Georgia Baptist Medical Center, a community teaching hospital in downtown Atlanta, GA, from July 1, 1998, to October 20, 1998. New hyperglycemia was defined as an admission or in-hospital fasting glucose level of 126 mg/dl (7 mmol/liter) or more or a random blood glucose level of 200 mg/dl (11.1 mmol/liter) or more on 2 or more determinations. Hyperglycemia was present in 38% of patients admitted to the hospital, of whom 26% had a known history of diabetes, and 12% had no history of diabetes before the admission. Newly discovered hyperglycemia was associated with higher in-hospital mortality rate (16%) compared with those patients with a prior history of diabetes (3%) and subjects with normoglycemia (1.7%; both P < 0.01). In addition, new hyperglycemic patients had a longer length of hospital stay, a higher admission rate to an intensive care unit, and were less likely to be discharged to home, frequently requiring transfer to a transitional care unit or nursing home facility. Our results indicate that in-hospital hyperglycemia is a common finding and represents an important marker of poor clinical outcome and mortality in patients with and without a history of diabetes. Patients with newly diagnosed hyperglycemia had a significantly higher mortality rate and a lower functional outcome than patients with a known history of diabetes or normoglycemia.
1,771 citations
••
TL;DR: Clinicians will find the recommendations in these revised CPGs useful in their daily work and can be reassured that the recommendations have been vetted thoroughly by the most rigorous scientific process, so that cardiovascular clinicians worldwide may deliver optimal, standardized care.
Abstract: AAA
: abdominal aortic aneurysm
ACEI
: angiotensin converting enzyme inhibitor
ACS
: acute coronary syndromes
AF
: atrial fibrillation
AKI
: acute kidney injury
AKIN
: Acute Kidney Injury Network
ARB
: angiotensin receptor blocker
ASA
: American Society of Anesthesiologists
b.i.d.
: bis in diem (twice daily)
BBSA
: Beta-Blocker in Spinal Anesthesia
BMS
: bare-metal stent
BNP
: B-type natriuretic peptide
bpm
: beats per minute
CABG
: coronary artery bypass graft
CAD
: coronary artery disease
CARP
: Coronary Artery Revascularization Prophylaxis
CAS
: carotid artery stenting
CASS
: Coronary Artery Surgery Study
CEA
: carotid endarterectomy
CHA2DS2-VASc
: cardiac failure, hypertension, age ≥75 (doubled), diabetes, stroke (doubled)-vascular disease, age 65–74 and sex category (female)
CI
: confidence interval
CI-AKI
: contrast-induced acute kidney injury
CKD
: chronic kidney disease
CKD-EPI
: Chronic Kidney Disease Epidemiology Collaboration
Cmax
: maximum concentration
CMR
: cardiovascular magnetic resonance
COPD
: chronic obstructive pulmonary disease
CPG
: Committee for Practice Guidelines
CPX/CPET
: cardiopulmonary exercise test
CRP
: C-reactive protein
CRT
: cardiac resynchronization therapy
CRT-D
: cardiac resynchronization therapy defibrillator
CT
: computed tomography
cTnI
: cardiac troponin I
cTnT
: cardiac troponin T
CVD
: cardiovascular disease
CYP3a4
: cytochrome P3a4 enzyme
DAPT
: dual anti-platelet therapy
DECREASE
: Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography
DES
: drug-eluting stent
DIPOM
: DIabetic Post-Operative Mortality and Morbidity
DSE
: dobutamine stress echocardiography
ECG
: electrocardiography/electrocardiographically/electrocardiogram
eGFR
: estimated glomerular filtration rate
ESA
: European Society of Anaesthesiology
ESC
: European Society of Cardiology
EVAR
: endovascular abdominal aortic aneurysm repair
FEV1
: Forced expiratory volume in 1 second
HbA1c
: glycosylated haemoglobin
HF-PEF
: heart failure with preserved left ventricular ejection fraction
HF-REF
: heart failure with reduced left ventricular ejection fraction
ICD
: implantable cardioverter defibrillator
ICU
: intensive care unit
IHD
: ischaemic heart disease
INR
: international normalized ratio
IOCM
: iso-osmolar contrast medium
KDIGO
: Kidney Disease: Improving Global Outcomes
LMWH
: low molecular weight heparin
LOCM
: low-osmolar contrast medium
LV
: left ventricular
LVEF
: left ventricular ejection fraction
MaVS
: Metoprolol after Vascular Surgery
MDRD
: Modification of Diet in Renal Disease
MET
: metabolic equivalent
MRI
: magnetic resonance imaging
NHS
: National Health Service
NOAC
: non-vitamin K oral anticoagulant
NSQIP
: National Surgical Quality Improvement Program
NSTE-ACS
: non-ST-elevation acute coronary syndromes
NT-proBNP
: N-terminal pro-BNP
O2
: oxygen
OHS
: obesity hypoventilation syndrome
OR
: odds ratio
P gp
: platelet glycoprotein
PAC
: pulmonary artery catheter
PAD
: peripheral artery disease
PAH
: pulmonary artery hypertension
PCC
: prothrombin complex concentrate
PCI
: percutaneous coronary intervention
POBBLE
: Peri-Operative Beta-BLockadE
POISE
: Peri-Operative ISchemic Evaluation
POISE-2
: Peri-Operative ISchemic Evaluation 2
q.d.
: quaque die (once daily)
RIFLE
: Risk, Injury, Failure, Loss, End-stage renal disease
SPECT
: single photon emission computed tomography
SVT
: supraventricular tachycardia
SYNTAX
: Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery
TAVI
: transcatheter aortic valve implantation
TdP
: torsades de pointes
TIA
: transient ischaemic attack
TOE
: transoesophageal echocardiography
TOD
: transoesophageal doppler
TTE
: transthoracic echocardiography
UFH
: unfractionated heparin
VATS
: video-assisted thoracic surgery
VHD
: valvular heart disease
VISION
: Vascular Events In Noncardiac Surgery Patients Cohort Evaluation
VKA
: vitamin K antagonist
VPB
: ventricular premature beat
VT
: ventricular tachycardia
Guidelines summarize and evaluate all available evidence, at the time of the writing process, on a particular issue with the aim of assisting health professionals in selecting the best management strategies for an individual patient with a given condition, taking into account the impact on outcome, as well as the risk–benefit ratio of particular diagnostic …
1,353 citations