Glycemic control reduces postsurgery infection
While glycemic control is essential for all diabetic patients, researchers from Johns Hopkins Medical Institutions in Baltimore have found it becomes even more important after surgery.
Sherita Hill-Golden, MD, senior fellow in the division of endocrinology and metabolism at John Hopkins Medical School, recommends that clinicians consider more aggressive glycemic control for perioperative diabetic patients to reduce the rate of bacterial infections — a complication risk already elevated for patients with diabetes. "The data suggest that hyperglycemia is an independent predictor of the short-term risk of infections," she says.
Hill-Golden recommends reducing the risk of infection by bringing diabetic patients into the best possible glycemic control before they undergo elective surgery.
After surgery, she recommends maintaining blood glucose under 200 mg/dL, at which point laboratory studies have shown white blood cells begin to malfunction. She also suggests temporarily putting a patient on insulin therapy immediately after surgery. Intravenous glucose can be combined with an insulin drip, achieving a "perfect" balance. The patient can be re-introduced to oral agents as he transfers to a solid diet. The first 36 hours after surgery are critical, she says, with infection rates rising in tandem with rising blood sugars.
Hill-Golden’s team studied the records of 411 diabetic patients who underwent coronary artery bypass surgery at Johns Hopkins between 1990 and 1995. Subjects had a median blood glucose of 229 mg/dL as recorded in six fingersticks during the first 36 hours after surgery. Before surgery, 41.7% of the subjects were on insulin, 45.1% were maintained on oral agents, 11.7% were maintained by diet alone, and 1.5% were on combination therapy of oral agents and insulin.
One hundred patients (nearly 25%) developed one or more infections after surgery, and four died after surgery — three of them from infections of the leg wounds, urinary tract, sternal wound, and pneumonia.
Those with blood glucose between 207 mg/dl and 229 mg/dL were 17% more likely to get an infection than those with blood glucose at 206 or lower in those first 36 hours after surgery. Those with sugars between 230 and 252 were 86% more likely to get an infection, and those in the fourth quartile, with sugars 253-352, were 72% more likely to get an infection.
"In the hospital setting, clinicians often feel more comfortable letting diabetic patients run into the high 200s after surgery," says Hill-Golden. "We found that leads to far more short-term complications and indicates tighter glycemic control will give better outcomes."
Increasing blood glucose levels are common in perioperative patients, says Farah Parvez, MD, a medical epidemiologist in the Division of Hospital Infection at the Centers for Disease Control and Prevention in Atlanta.
She agrees that clinicians should strive for a perioperative goal of 200 ml/dL. "This will maximize the patients’ condition and ensure the best possible outcome."
[Contact Sherita Hill-Golden at (410) 955-3663 and Farah Parvez at (404) 639-6412.]
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