Perioperative Hyperglycemia and Glucose Variability in Gynecologic Laparotomies

The glycemic response and its relation to postoperative complications following gynecologic laparotomies is unknown, although these surgeries carry a substantial risk for postoperative morbidity. Therefore, our objective was to assess the prevalence of perioperative hyperglycemia and glucose variability in women undergoing a gynecologic laparotomy. In this prospective cohort study, capillary glucose was measured every hour during the perioperative period. The primary outcome measures were the proportion of patients with postoperative hyperglycemia (glucose >180 mg d l(-1)) and the glucose variability in the intra- and postoperative period. Postoperative complications were assessed as secondary outcome measure. We included 150 women undergoing a gynecologic laparotomy. Perioperative hyperglycemia occurred in 33 patients without diabetes (23.4%) and in 8 patients with diabetes (89%). Glucose variability was significantly higher (mean absolute glucose change [MAG] 11 mg dl(-1) hr(-1) [IQR 8-18]) in the intraoperative compared to the postoperative period (MAG 10 mg dl(-1) hr(-1) [IQR 3-16], P = .03). Neither hyperglycemia nor glucose variability was associated with postoperative complications. Hyperglycemia and glucose variability seem to be a minor problem during gynecologic laparotomy. Based on the current data, we would not advocate standardized glucose measurements in every patient without diabetes undergoing gynecologic laparotom

Study protocol of a randomised controlled trial comparing perioperative intravenous insulin, GIK or GLP-1 treatment in diabetes-PILGRIM trial

Diabetes mellitus (DM) is associated with poor outcome after surgery. The prevalence of DM in hospitalised patients is up to 40%, meaning that the anaesthesiologist will encounter a patient with DM in the operating room on a daily basis. Despite an abundance of published glucose lowering protocols and the known negative outcomes associated with perioperative hyperglycaemia in DM, there is no evidence regarding the optimal intraoperative glucose lowering treatment. In addition, protocol adherence is usually low and protocol targets are not simply met. Recently, incretins have been introduced to lower blood glucose. The main hormone of the incretin system is glucagon-like peptide-1 (GLP-1). GLP-1 increases insulin and decreases glucagon secretion in a glucose-dependent manner, resulting in glucose lowering action with a low incidence of hypoglycaemia. We set out to determine the optimal intraoperative treatment algorithm to lower glucose in patients with DM type 2 undergoing non-cardiac surgery, comparing intraoperative glucose-insulin-potassium infusion (GIK), insulin bolus regimen (BR) and GPL-1 (liragludite, LG) treatment. This is a multicentre randomised open label trial in patients with DM type 2 undergoing non-cardiac surgery. Patients are randomly assigned to one of three study arms; intraoperative glucose-insulin-potassium infusion (GIK), intraoperative sliding-scale insulin boluses (BR) or GPL-1 pre-treatment with liraglutide (LG). Capillary glucose will be measured every hour. If necessary, in all study arms glucose will be adjusted with an intravenous bolus of insulin. Researchers, care givers and patients will not be blinded for the assigned treatment. The main outcome measure is the difference in median glucose between the three study arms at 1 hour postoperatively. We will include 315 patients, which gives us a 90% power to detect a 1 mmol l(-1) difference in glucose between the study arms. The PILGRIM trial started in January 2014 and will provide relevant information on the perioperative use of GLP-1 agonists and the optimal intraoperative treatment algorithm in patients with diabetes mellitus type 2. ClinicalTrials.gov, NCT0203637

An automated reminder for perioperative glucose regulation improves protocol compliance

A growing proportion of patients presenting for surgery have diabetes. Unfortunately, perioperative diabetes protocol compliance is low. Using digitalization of the perioperative environment, an automated reminder in the preoperative assessment platform proved to increase compliance and we advocate its use throughout the perioperative proces

Adverse side effects of dexamethasone in surgical patients

Background: In the perioperative period, dexamethasone is widely and effectively used for prophylaxis of postoperative nausea and vomiting (PONV), for pain management, and to facilitate early discharge after ambulatory surgery. Long-term treatment with steroids has many side effects, such as adrenal insufficiency, increased infection risk, hyperglycaemia, high blood pressure, osteoporosis, and development of diabetes mellitus. However, whether a single steroid load during surgery has negative effects during the postoperative period has not yet been studied. Objectives: To assess the effects of a steroid load of dexamethasone on postoperative systemic or wound infection, delayed wound healing, and blood glucose change in adult surgical patients (with planned subgroup analysis of patients with and without diabetes). Search methods: We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library, and the Web of Science for relevant articles on 29 January 2018. We searched without language or date restriction two clinical trial registries to identify ongoing studies, and we handsearched the reference lists of relevant publications to identify all eligible trials. Selection criteria: We searched for randomized controlled trials comparing an incidental steroid load of dexamethasone versus a control intervention for adult patients undergoing surgery. We required that studies include a follow-up of 30 days for proper assessment of the number of postoperative infections, delayed wound healing, and the glycaemic response. Data collection and analysis: Two review authors independently screened studies for eligibility, extracted data from relevant studies, and assessed all included studies for bias. We resolved differences by discussion and pooled included studies in a meta-analysis. We calculated Peto odds ratios (ORs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes. Our primary outcomes were postoperative systemic or wound infection, delayed wound healing, and glycaemic response within 24 hours. We created a funnel plot for the primary outcome postoperative (wound or systemic) infection. We used GRADE to assess the quality of evidence for each outcome. Main results: We included in the meta-analysis 38 studies that included adults undergoing a large variety of surgical procedures (i.e. abdominal surgery, cardiac surgery, neurosurgery, and orthopaedic surgery). Age range of participants was 18 to 80 years. There is probably little or no difference in the risk of postoperative (wound or systemic) infection with dexamethasone compared with no treatment, placebo, or active control (ramosetron, ondansetron, or tropisetron) (Peto OR 1.01, 95% confidence interval (CI) 0.80 to 1.27; 4931 participants, 27 studies; I2 = 27%; moderate-quality evidence). The effects of dexamethasone on delayed wound healing are unclear because the wide confidence interval includes both meaningful benefit and harm (Peto OR 0.99, 95% CI 0.28 to 3.43; 1072 participants, eight studies; I2 = 0%; low-quality evidence). Dexamethasone may produce a mild increase in glucose levels among participants without diabetes during the first 12 hours after surgery (MD 13 mg/dL, 95% CI 6 to 21; 10 studies; 595 participants; I2 = 50%; low-quality evidence). We identified two studies reporting on glycaemic response after dexamethasone in participants with diabetes within 24 hours after surgery (MD 32 mg/dL, 95% CI 15 to 49; 74 participants; I2 = 0%; very low-quality evidence). Authors' conclusions: A single dose of dexamethasone probably does not increase the risk for postoperative infection. It is uncertain whether dexamethasone has an effect on delayed wound healing in the general surgical population owing to imprecision in trial results. Participants with increased risk for delayed wound healing (e.g. participants with diabetes, those taking immunosuppressive drugs) were not included in the randomized studies reporting on delayed wound healing included in this meta-analysis; therefore our findings should be extrapolated to the clinical setting with caution. Furthermore, one has to keep in mind that dexamethasone induces a mild increase in glucose. For patients with diabetes, very limited evidence suggests a more pronounced increase in glucose. Whether this influences wound healing in a clinically relevant way remains to be established. Once assessed, the three studies awaiting classification and two that are ongoing may alter the conclusions of this review

Adverse side effects of dexamethasone in surgical patients

This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the effects of dexamethasone on postoperative infection, time to wound healing and blood glucose change in adult surgical patients. We will include a planned subgroup analysis for patients with and without diabetes

Relationship Between Asthma and High Blood Pressure Among Adolescents in Aracaju, Brazil

Background. Asthma has been linked to cardiovascular diseases (CVDs) and related risk factors such as hypertension in adults. It is unclear whether the relationship between asthma and hypertension found among adults is also observed in adolescents. Hence, the authors examined asthma and its association with prehypertension and hypertension among adolescents in Aracaju, Brazil. Methods. Data on asthma and blood pressure were collected among 1002 adolescents age 12 to 17 years old in 15 public schools, 5 municipal schools, and 10 private schools. Asthma data were ascertained by the International Study of Asthma and Allergies in Childhood (ISAAC) written questionnaire. Sex-, age-, and height-specific percentile levels were used to define prehypertension (90-94th percentile) and hypertension (>= 95(th) percentile). Results. the prevalence of asthma was 20.6% in boys and 27.7% in girls. Among boys, the prevalence rates of prehypertension and hypertension were 26.7% and 17.0%, respectively. Among girls, the rates of prehypertension and hypertension were 14.3% and 12.9%, respectively. There were no statistically significant associations between asthma and prehypertension, and hypertension, even after adjusting for age, social economic status, physical activity, and body mass index (BMI) in both boys (prehypertension: odds ratio [OR] = 1.35, 95% confidence interval [CI]: 0.80-2.27; hypertension: OR = 0.60, 95% CI: 0.29-1.23) and girls (prehypertension: OR = 0.71, 95% CI: 0.40-1.28; hypertension: OR = 1.07, 95% CI: 0.60-1.94). Conclusions. These results suggest no association between asthma and high blood pressure in adolescents. More prospective studies are needed to establish whether hypertension becomes more pronounced at a specific age in asthmatics, and if so, the possible factors that may contribute to this.Univ Amsterdam, Acad Med Ctr, Dept Publ Hlth, NL-1105 AZ Amsterdam, NetherlandsUniv Fed Sergipe, Dept Med & Post Grad Nucleus Med, Aracaju, BrazilUniv Fed Sergipe, Univ Hosp, Aracaju, BrazilUniversidade Federal de São Paulo, Dept Paediat, São Paulo, BrazilUniversidade Federal de São Paulo, Dept Paediat, São Paulo, BrazilWeb of Scienc

Comparison of perioperative glucose regulation in patients with type 1 vs type 2 diabetes mellitus: A retrospective cross-sectional study

Background: Most perioperative diabetes mellitus (DM) guidelines do not distinguish between patients with type 1 (DM1) and type 2 (DM2). We hypothesised that similar treatment of DM1 and DM2 patients leads to differences in their perioperative glucose control. Methods: We performed a retrospective cross-sectional study, of all DM patients undergoing surgery between May 2013 and November 2015 in a Dutch university hospital. We compared DM1 with DM2 patients, treated according to the same perioperative glucose protocol. Our primary outcome was the incidence of hyperglycaemia (glucose ≥10 mmol/L). Secondary outcomes were short-term glycaemic control (glucose before surgery and peak glucose perioperatively), long-term glycaemic control (HbA1c in 90 days before and after surgery) and the incidence of hypoglycaemia (glucose <4 mmol/L). Results: We included 2259 patients with DM, 216 (10%) of which had DM1. The calculated incidences in our population were 7 out of 1000 patients with DM1 and 69 out of 1000 patients with DM2. Compared to those with DM2, patients with DM1 were younger, had a lower BMI, a higher glucose concentration before surgery, and a higher perioperative peak glucose concentration (11.0 [8.2-14.7] vs 9.4 [7.7-11.7], P < 0.001). The incidence of the primary endpoint, perioperative hyperglycaemia, was significantly higher in DM1 compared to DM2 patients (63% vs 43%, P < 0.001). Hypoglycaemia occurred more often in the DM1 population (7.1% vs 1.3%, P < 0.001). Conclusion: Providing similar perioperative treatment to patients with DM1 and DM2 is associated with poorer short-term and long-term glycaemic control in DM1 throughout the perioperative period as well as an increased risk of hypoglycaemia

Blood pressure and BMI in adolescents in Aracaju, Brazil

Objective: To assess the prevalence of high blood pressure (BP) and the association of overweight and obesity with high BP among adolescents in Aracaju, Brazil. Design: Cross-sectional study. The main outcome measure was the proportion of adolescents with high BP (sex-, age- and height-specific >= 95th percentile). The main predictor variables were overweight and obesity defined according to the criteria of the International Obesity Task Force. Other covariates included age, socio-economic status and leisure-time physical activity. Setting: Aracaju, Brazil, capital city of Sergipe State, north-eastern Brazil. Subjects: A random sample of 1002 adolescents (442 boys and 560 girls) aged 12-17 years selected from twenty public schools and ten private schools were studied. Results: The prevalence of high BP was 16.9% (95% CI 13.1, 21.7) in boys and 12.9% (95% CI 9.0, 18.0) in girls. After adjusting for age, socio-economic status and leisure-time physical activity in both boys and girls, overweight (prevalence ratio (PR) 51.93, 95% CI 1.08, 3.48; PR = 4.34, 95% CI 2.58, 7.30, respectively) and obesity (PR = 4.87, 95% CI 2.35, 10.11; PR = 5.18, 95% CI 2.67, 10.06, respectively) were found to be associated with high BP. Conclusions: These findings indicate a high prevalence of high BP in both boys and girls in Aracaju, Brazil. Overweight and obesity were strongly associated with high BP. These findings underscore the urgent need for public health measures to prevent increasing high BP in adolescents in Brazil. Targeting intervention in adolescence may be a critical method for preventing high BP in later lif