Objectives for the call: Provide an overview of why glucose control is important in surgical patient outcomes .Demonstrate an understanding of how anesthetics and surgery can impact the body's ability to remain within glycemic boundaries .Outline the optimal surgical patient glycemic goal range .To identify the effectiveness of tight glycemic control on mortality and morbidity of adult patients during the intra and post-operative period .To discuss possible change ideas to implement glucose control WATCH: http://goo.gl/3vGq2B

1. What’s so sweet about glycemic
control?
June 3, 2016

4. • Provide an overview of why glucose control is important in surgical
patient outcomes.
• Demonstrate an understanding of how anesthetics and surgery can
impact the body’s ability to remain within glycemic boundaries
• Outline the optimal surgical patient glycemic goal range.
• Identify the effectiveness of glycemic control on mortality and
morbidity of adult patients during the intra and post-operative
period.
• Discuss possible change ideas to implement glucose control.
Objectives

5. 2016 CANADIAN SURGICAL
SITE INFECTION
PREVENTION AUDIT
Dr. Claude Laflamme
March 24, 2016

6. Audit Participation
Sites 52
Patients 2082
Clean I & II 1998

7. Participants by Type of Surgery

8. I. Hair Removal Method
Sites 52
Patients 1998
96%
4%
n = 1816
Not Recorded = 15

9. E. Prophylactic Abx administration
Sites 52
Patients 1998
n = 1957
91%
9%

10. K. Temperature at end of surgery or on
arrival in PACU - 36.0 - 38.0 degrees C
Sites 52
Patients 1998n = 1563
85%
15%
Not Recorded = 100

11. J. Glucose was below 11.1 mmol/L on
each of POD 0, 1 and 2
Sites 34
Patients 474
Note: Not at Risk (not diabetic) excluded from this
measure (n=1513)
n = 390
57%
43%
Not Recorded = 7

12. J. Glucose was below 11.1 mmol/L on
each of POD 0, 1 and 2
Total
Patients 355
56%
66%
32% 60%
Note: Not at Risk (not diabetic) excluded from this measure
n = 111 n = 141 n = 31 n = 10

13. Goal
Evidence
Time
Never
• Pre, Intra and Post Blood Glucose
• below 10.0-11.1 mmol/L
• SHEA: Less than 10 mmol/L
• CDC (draft): Less than 11.1 mmol/L
• 24-48 hrs pre-op
• Intra-op
• 48-72 hrs post-op
• Aim for 4-6 mmol/L
Peri-Operative Glucose Control

14. The BC Perspective
Curt Smecher
Anesthesiologist Abbotsford Regional
Hospital

15. Surgical Site Infections and
Diabetes
Marshall DahlMD PhD FRCPC cert Endo
Clinical Professor, Endocrinology, University of British Columbia
Jordanna Kapeluto MD FRCPC
Endocrinology Fellow, University of British Columbia

16. People with Diabetes are More Susceptible to Infections
1
Foot infections
Urinary tract
infections
Superficial fungal
infections
Mucormycosis
Malignant otitis externa
Emphysematous
cholecytisis
Pyomyositis
Necrotizing fascitis
Surgical site
infections

17. People with Diabetes are More Susceptible to Infections
1
Foot infections
Urinary tract
infections
Superficial fungal
infections
Mucormycosis
Malignant otitis externa
Emphysematous
cholecytisis
Pyomyositis
Necrotizing fascitis
Surgical site
infections

18. Hyperglycemia Impairs Immune Response
• Neutrophil function is impaired during hyperglycemia
– Chemotaxis, phagocytosis
• Cell-mediated immunity and Complement system are
also impaired
• Occurs in laboratory setting by increasing glucose
concentration in normal blood (glucose >11.1)
• Occurs in diabetes serum vs non-diabetes serum
2

19. Surgical Site Infection (SSI)
• CDC definition:
• SSIs are often localized to the incision site but can
also extend into deeper adjacent structures
Horan TC et al: Infect Control Hosp Epidemiol. 1992;13(10):606
3
infection related to an operative procedure
occurs at or near the surgical incision
• within 30 days of the procedure
• within one year if prosthetic material is
implanted at surgery

20. Perioperative Hyperglycemia and SSI Risk
• N = 2090 general and vascular surgery patients
• Retrospective review
• Multivariate analysis:
– age, emergency status, ASA classes P3-P5, operative time, diabetes,
plus postoperative glucose level.
• Colorectal patients: only postoperative glucose control a
significant predictor of SSI (OR 3.2)
• Vascular surgery patients: operative time and diabetes were
independent predictors of SSI
• “Postoperative hyperglycemia may be the most important risk
factor for SSI. Aggressive early postoperative glycemic control
should reduce the incidence of SSI.”
Ata el al; Arch Surg 2010; 145 (9): 858
4

21. Ata el al; Arch Surg 2010; 145 (9): 858
What glucose levels correlate with infection risk?
5
≤6.1
6.2-7.8
7.9-10.0
10.1- 12.2
≥12.3
≤6.1
6.2-7.8
7.9-10.0
10.1- 12.2
≥12.3

22. Controlled diabetes: more UTIs vs non-diabetes
Uncontrolled diabetes: more UTIs and overall infections vs controlled diabetes
J Bone Joint Surg Am. 2009;91(7):1621
One Million US Joint Arthroplasty Patients
6

23. Is it pre-existing diabetes control or perioperative
control?
• Prospective, 1000 patients, cardiothoracic surgery
• Predictors of SSI: independent risk factors
– Diabetes (OR 2.76)
– Postoperative hyperglycemia [>11.1] (OR 2.02)
• Among patients with known diabetes, elevated A1c not
associated with risk of SSI
• Perioperative management and acute control of glucose more
important than diabetes status before surgery
Infect Control Hosp Epidemiol. 2001;22(10):607
7

24. When do SSIs occur?
• NSQIP, 50,000
patients, vascular
surgery
• Diabetes
significantly
associated with SSI
post discharge
J Vasc Surg. 2015;62(4):1023.
8

25. Effects of target glucose on postoperative
infections
• Systematic review
– Cardiac surgery intervention trials
– four randomized
– six cohort studies
• Continuous insulin infusion vs
sub-cutaneous sliding-scale
– target < 11 mmol/L
• Note that control is not “tight”
• Significant reduction in SSIs
compared with standard
management.
Heart Lung. 2015;44(5):430
9

26. Other Factors in Diabetes that Predispose to SSIs
• Vascular Insufficiency
– Tissue ischemia, anaerobic bacteria
• Sensory peripheral neuropathy
– Local trauma and ulceration
• Autonomic neuropathy
– Urinary retention and stasis
• Increased skin and nasal colonization
– More frequent S. Aureus and methicillin-resistance
• Increased E. Coli binding to bladder epithelium
10

27. Hyperglycemia in Hospital
11
12%
26%
62%
New Hyperglycemia
Known Diabetes
Normoglycemia
• Common:
– ICD Codes 13%
• DM reason for
hospitalization in
8%
– Laboratory values
13%
– Patients admitted
with AMI; OGTT at
discharge 31%; 3
months 25%
Umpierrez G et al. J Clin Endocrinol Metab 2002;87:978-982
Clement S et al. Diab Care 2004; 27(2): 553-591

28. Hyperglycemia in Hospital
12
12%
26%
62%
New Hyperglycemia Known Diabetes Normoglycemia
HospitalizationType 2 Diabetes Hyperglycemia
• Coronary artery disease
• Cerebrovascular disease
• Peripheral vascular disease
• Nephropathy
• Infection
• Amputations
• Surgery
• Infection
• Glucocorticoids
• Vasopressors
• Calcineurin
inhibitors
• Total parenteral
nutrition (TPN)
• Continuous enteral
feeds
Umpierrez G et al. J Clin Endocrinol Metab 2002;87:978-982
Clement S et al. Diab Care 2004; 27(2): 553-591

29. Hyperglycemia in Hospital
13
HospitalizationType 2 Diabetes Hyperglycemia
Umpierrez G, et al. J Hosp Med 2006;1:141-44
Clement S et al. Diab Care 2004; 27(2): 553-591
Umpierrez G, et al. Am J Med 2007;120:563-67
Barriers to glycemic control
• Fear of hypoglycemia
• Holding usual diabetes
treatment
• Reliance on reactive insulin
regimens (sliding scale)
• Caregiver comfort with
management
• PO intake/ Meal timing
• Meal interruption
• Timing of medication
administration
• Dextrose in IVF
• AKI
• Activity/Mobility

30. Hyperglycemia in Acute Illness
14
Increased stress hormone levels
• Increased epinephrine
• Increased cortisol
Decreased level of activity
Glucocorticoid therapy
Continuous enteral nutrition
Parenteral nutrition
Acute illness Hyperglycemia
Decreased immune function
Decreased wound healing
Increased oxidative stress
Endothelial dysfunction
Increase in inflammatory factors
Procoagulant state
Increased mitogen levels
Fluid shifts
Electrolyte fluxes
Potential exacerbation of myocardial
and cerebral ischemia
Inzucchi SE. N Engl J Med 2006;355:1903-1911
Clement S et al. Diab Care 2004; 27(2): 553-591

31. Hyperglycemia-Related Morbidity and Mortality
15
Study Patient Population Glycemic Cutoff Hyperglycemia Related
Outcomes
Pomposelli et al. 1998 DM undergoing
general surgery
procedure
BG >12.2 on
POD1
• Nosocomial infection
(Sn 85%)
Umpierrez et al. 2002 All surgical and
medical patients
(87% non-ICU)
FBG >7.0
RBG >11.1
• 2.7x RR in-hospital
mortality
• More ICU admission
• Longer LOS
Capes et al. 2000 Acute MI BG >6.1 no DM
BG >6.9 with DM
• 3.9x RR in-hospital
mortality in non-DM
• 1.7x RR in-hospital
mortality in DM
• Risk CHF and
cardiogenic shock
Pomposelli J et al. J Parenter Enter Nutr, 1998; 22:77-81
Umpierrez G et al. J Clin Endocrinol Metab 2002;87:978-982
Capes S et al. Lancet, 2000; 355: 773-778

32. Hyperglycemia-Related Morbidity and Mortality
16
Study Patient Population Glycemic Cutoff Hyperglycemia Related
Outcomes
Baker et al. 2006 AECOPD <6.0
6.0-6.9
7.0-8.9
>9.0
• Longer LOS
• 15% increase AE for
each 1.0mmol/L
increase BG
• Increased mortality
risk
Cheung et al. 2005 TPN ≥7.0 • Incr. 1.0 mmol/L 
incr. complications by
factor 1.58
McAlister et al. 2005 CAP ≥7.0 • Longer LOS
• Incr. in-hospital
complications
• Incr. mortality risk
Baker EH, et al. Thorax 2006;61:284-9
Cheung NW, et al. Diab Care 2005;28:2367-71;
McAlister FA, et al. Diabe Care 2005;28:810-5

33. Blood Glucose Targets: AACE/ADA Consensus
17
Non-critically Ill Patients
Critically Ill Patients (CDA)
Pre-meal Blood Glucose BG) Random Blood Glucose (BG)
Medical Illness <7.8 mmol/L <10.0 mmol/L
Surgical Illness <7.8 mmol/L <10.0 mmol/L
Peri-operative 5.0-10.0 mmol/L
CV Surgery intra-
op
5.5-10.0 mmol/L
Critical Care Unit 8.0-10.0 mmol/L
Malmberg K et al. J Am Coll Cardiol 1995;26(1):57-65
Clement S et al. Diab Care 2004; 27(2): 553-591
Moghissi ES, et al. Endocr Pract 2009;15:353-69

34. • Reactive
• Does not account for prandial intake
• Assumes all hyperglycemia is
uniform
• Stacking
Sliding Scale Insulin
18
BG (mmol/L) Bolus insulin (U)
<4 Hypoglycemia Protocol
and Call MD
4.1 – 6.0 0
6.1-8 0
8.1-10.0 2
10.1-12 4
12.1-14 6
14.1-16 8
16.1-18 10
>18.1 12 and Call MD
Under correct T2DM
Over correct T1DM

35. Sliding Scale Insulin (SSI)
19
4.0
10.0
Breakfast Lunch Dinner Bedtime
6.0
Bolus insulin QID
14.0
6.0
16.5
3.0
What do you do?
What do you do?
What do you do?
What do you do?
+8 U
0 U 0 U
+10 U
BG (mmol/L) BG (mmol/L) Bolus insulin (U)
<4 Hypoglycemia
Protocol and Call
MD
4.1 – 6.0 0
6.1-8 0
8.1-10.0 2
10.1-12 4
12.1-14 6
14.1-16 8
16.1-18 10
>18.1 12 and Call MD
Adapted – From Sliding Scale to Basal-Bolus

36. Sliding Scale Insulin (SSI) – Higher Mean Glucose
Levels and Poorer Outcomes
20
Adapted from: Becker T, et al. Diabetes Res Clin Pract 2007;78:392-7.
0
2
4
6
8
10
12
Mean BG (mmol/L)
No Sliding Scale
(Scheduled insulin)
Sliding-scale
insulin
BG: blood glucose; CI: confidence interval; ICU: intensive care unit
Odds
Ratio 95% CI
Cardiovascular
complications
or death
1.86 0.99–3.49
Sepsis or ICU
admission
4.98 2.38–10.42
Retrospective Chart review
391 patients, age > 45, pneumonia
Slide courtesy of Dr. Paty

37. Basal Bolus Insulin (BBI)
21
• Insulin given consistently
• Long –acting
• 1-2x per day
• Baseline secretion
• Steady/Euglycemia
• Rapid or Short–acting
• 2+ per day
• Prandial surge
• Insulin given prn if above target
Scheduled Insulin Supplemental Insulin+
Basal
Bolus
Prandial
Nutritional
Correction
• Rapid or Short–acting
• ac meals
• Modified sliding scale

38. • Basal bolus insulin vs. sliding scale insulin
Basal Bolus Insulin (BBI) – RABBIT 2/Surgery
22
Patient Population Regimen Outcomes
RABBIT 2 (2007) T2DM; Medical
inpatients
Glargine
Glulisine
• Better with BBI vs. SSI
RABBIT 2 Surgery
(2011)
T2DM; Surgical
Inpatients
Glargine
Glulisine
• Better with BBI vs. SSI
• More hypoglycemia
• No difference severe
hypoglycemia
• Less hospital
complications
Umpierrez GE, et al. Diabetes Care 2007;30:2181-86.
Umpierrez GE, et al. Diabetes Care 2011;34:256-61.
Complications (trend):
• Nosocomial pneumonia
• Wound infection
• Renal failure
• Bacteremia
• Admission to ICU
• Death – 1 in each group

39. CDA 2013 - Recommendations
23
1. Provided that their medical conditions, dietary
intake, and glycemic control are acceptable,
people with diabetes should be maintained on
their pre-hospitalization oral anti-hyperglycemic
agents or insulin regimens [Grade D, Consensus]
Recommendation 1

40. CDA 2013 - Recommendations
24
2. For hospitalized patients with diabetes treated with insulin,
a proactive approach that includes basal, bolus, and
correction (supplemental) insulin, along with pattern
management, should be used to reduce adverse events and
improve glycemic control, instead of the reactive sliding-
scale insulin approach that uses only short- or rapid-acting
insulin [Grade B, Level 2]
Recommendation 2

41. CDA 2013 - Recommendations
25
3. For the majority of non critically ill patients treated with
insulin, pre-meal BG targets should be 5.0 to 8.0 mmol/L in
conjunction with random BG values <10.0 mmol/L, as long
as these targets can be safely achieved [Grade D, consensus]
4. For most medical/surgical critically ill patients with
hyperglycemia, a continuous IV insulin infusion should be
used to maintain glucose levels between 8.0-10.0 mmol/L
[Grade D, consensus]
Recommendation 3 and 4

42. CDA 2013 - Recommendations
26
5. To maintain intraoperative glycemic levels between 5.5-10.0
mmol/L for patients with diabetes undergoing CABG, a
continuous IV insulin infusion protocol administered by
trained staff, [Grade C, Level 3] should be used
6. Perioperative glycemic levels should be maintained
between 5.0-10.0 mmol/L for most other surgical situations,
with appropriate protocol and trained staff to ensure safe
and effective implementation of therapy and to minimize
the likelihood of hypoglycemia [Grade D, Consensus]
Recommendation 5 and 6

43. CDA 2013 - Recommendations
27
7. In hospitalized patients, hypoglycemia should be
avoided:
– Protocols for hypoglycemia avoidance, recognition and
management should be implemented with nurse –initiated
treatment, including glucagon for severe hypoglycemia when
IV access is not readily available [Grade D, consensus]
– Patients at risk of hypoglycemia should have ready access to
an appropriate source of glucose (oral or IV) at all times,
particularly when NPO or during diagnostic procedures [Grade D,
Consensus]
Recommendation 7

44. CDA 2013 - Recommendations
28
8. Healthcare professional education, insulin
protocols and order sets may be used to
improve adherence to optimal insulin use and
glycemic control [Grade C, Level 3]
9. Measures to assess, monitor, and improve
glycemic control within the inpatient setting
should be implemented, as well as diabetes-
specific discharge planning [Grade D, Consensus]
Recommendation 8 and 9

45. Questions?

49. The10K

50. Contact Us!
Geoff Schierbeck
gschierbeck@bcpsqc.ca
Kimberly McKinley
kmckinley@bcpsqc.ca