Inpatient glycemic management can present many challenges for care teams – some due to clinical factors and others due to extenuating circumstances within their facility. For example, severe illness and surgical stressors predispose patients to insulin resistance, which is why hyperglycemia is common in hospitals nationwide. As such, more than 30% of all hospitalized patients experience hyperglycemia during their stay. That number swells up to 40% for those admitted for surgical procedures, making perioperative glycemic management a critical component of patient safety.
Given what we know about the impact dysglycemia has on patient outcomes, lengths of stay and cost of care, I dove deeper into the top ways health systems and providers can optimize their perioperative glycemic management at Glytec’s annual industry event, Time to Target. Let’s explore some of the key considerations.
Identify the Challenges of Perioperative Glycemic Control
Surgical stress with resultant hyperglycemia necessitates treatment with insulin. Surgical prescribers are with varying levels of comfort in prescribing this high-alert and high-risk medication. Add to this the limited endocrine support structures within their health systems This leads to surgical units often deprioritizing glycemic control for fear of inducing hypoglycemia. In addition to insulin prescribing the coordination of glucose testing, meal delivery and insulin administration each come with their own unique obstacles that can negatively impact perioperative glycemic control.
Recognize the Patients at Greatest Risk for Hypoglycemia and Develop Prevention Strategies
Well-regulated blood sugar is a balance between the liver, pancreas, and glucose utilization in peripheral tissue. Surgery and anesthesia alter this balance by increasing hormonal counter-regulatory response. Perioperative stress hyperglycemia is common in general surgery and occurs in up to 80% of patients admitted for cardiac procedures. For those scheduled for elective surgery it is imperative to screen patients for diabetes because patients may be unaware they have been living with diabetes until a provider reviews their A1C. The screening process allows clinicians to be proactive in achieving glycemic control before surgery. This helps reduce mortality risk and improves surgical outcomes.
Define Goals for Surgical Patients’ Glycemic Management
Providers want to ensure their patients have a blood glucose level within target ranges before, during and after surgery. Based on recommendations from multiple authoritative organizations, a range of 140-180 mg/dL is appropriate for most patients and does not carry a significant risk for hypoglycemia. Studies have shown that preoperative blood glucose levels greater than 216 mg/dL increase mortality from 3% to 12% in year one for patients undergoing elective non-cardiac surgery. In cardiac surgery intraoperative glycemic control evaluations revealed that for every 20 mg/dL above 100 mg/dL, there was a 30% increase in adverse outcomes. An intraoperative blood glucose level greater than 250 mg/dL had a 63% risk of adverse outcomes. The postoperative glycemic management goal is to maintain glucose levels below 180 mg/dL. This will reduce the number of surgical site infections and ensure wound healing occurs for patients under their care. As discussed here, hyperglycemia increases the risk for many adverse outcomes, especially in those patients experiencing stress hyperglycemia without a current diagnosis of diabetes. Avoidance of hypoglycemia is equally as important as it has been shown to increase post-operative mortality risk significantly.
Health care professionals that utilize Glucommander™, Glytec’s insulin dosing decision support module, are able to get their patient’s glucose into target range, avoid hypoglycemia, and maintain levels within that range throughout the procedure and support a safe transition to the ICU. The solution has been proven successful in more than 300 hospitals and validated by hundreds of clinical studies to combat challenges of perioperative care, identify at-risk patients, get patients to target range quickly and safely, and drive a technology-first approach to quality care.
Check out my Time to Target presentation to learn more about perioperative glycemic management, including insights from clinical studies, target ranges, special considerations for certain populations and more!