Patients with diabetes are more likely to undergo surgery than nondiabetics, and maintaining glycemic control in subjects with diabetes can be challenging during the perioperative period. Surgery in diabetic patients is associated with longer hospital stay, higher health care resource utilization, and greater perioperative mortality. In addition, several observational and interventional studies have indicated that hyperglycemia is associated with adverse clinical outcomes in surgical and critically ill patients. This paper reviews the pathophysiology of hyperglycemia during trauma and surgical stress and will provide practical recommendations for the preoperative, intraoperative, and postoperative care of diabetic patients.
* The comprehensive operative risk assessment is an important step in the management of the diabetic patient before surgery.
* Surgery in diabetic patients is associated with longer hospital stay, higher health care resource utilization, and greater perioperative mortality than in nondiabetic subjects.
* Increasing evidence suggests that in hospitalized medical as well as surgical patients with and without diabetes, the presence of hyperglycemia is associated with poorer clinical outcomes and aggressive glycemic control positively impacts morbidity and mortality.
* Treatment recommendations are generally categorized based on the type of diabetes, nature and extent of the surgical procedure, antecedent pharmacological therapy, and state of metabolic control prior to surgery.
* All patients with diabetes should receive continued diabetes education and the outpatient treatment regimen should be reviewed prior to discharge.
1. Smiley DD, Umpierrez GE. Perioperative glucose control in the diabetic or nondiabetic patient. South Med J 2006;99:580–589.
2. Williams LS, Rotich J, Qi R, et al. Effects of admission hyperglycemia on mortality and costs in acute ischemic stroke. Neurology 2002;59:67–71.
3. Norhammar AM, Ryden L, Malmberg K. Admission plasma glucose. Independent risk factor for long-term prognosis after myocardial infarction even in nondiabetic patients. Diabetes Care 1999;22:1827–1831.
4. Capes SE, Hunt D, Malmberg K, et al. Stress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview. Lancet2000;355:773–778.
5. Golden SH, Peart-Vigilance C, Kao WH, et al. Perioperative glycemic control and the risk of infectious complications in a cohort of adults with diabetes. Diabetes Care 1999;22:1408–1414.
6. Krinsley JS. Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients. Mayo Clin Proc 2003;78:1471–1478.
7. Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients.N Engl J Med 2001;345:1359–1367.
8. Coursin DB, Connery LE, Ketzler JT. Perioperative diabetic and hyperglycemic management issues.Crit Care Med 2004;32 (Suppl 4):S116–S125.
9. Harris MI, Flegal KM, Cowie CC, et al. Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in U.S. adults. The Third National Health and Nutrition Examination Survey, 1988-1994. Diabetes Care 1998;21:518–524.
10. Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care 2004;27:553–591.
11. Furnary AP, Wu Y, Bookin SO. Effect of hyperglycemia and continuous intravenous insulin infusions on outcomes of cardiac surgical procedures: the Portland Diabetic Project. Endocr Pract 2004;10 (Suppl 2):21–33.
12. Harris MI, Eastman RC. Early detection of undiagnosed diabetes mellitus: a US perspective.Diabetes Metab Res Rev 2000;16:230–236.
13. Harris MI. Undiagnosed NIDDM: clinical and public health issues. Diabetes Care 1993;16:642–652.
14. Kosiborod M, Rathore SS, Inzucchi SE, et al. Admission glucose and mortality in elderly patients hospitalized with acute myocardial infarction: implications for patients with and without recognized diabetes. Circulation 2005;111:3078–3086.
15. Umpierrez GE, Isaacs SD, Bazargan N, et al. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab 2002;87:978–982.
16. Alberti KG, Zimmet PZ. Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: diagnosis and classification of diabetes mellitus provisional report of a WHO consultation. Diabet Med 1998;15:539–553.
17. Montori VM, Bistrian BR, McMahon MM. Hyperglycemia in acutely ill patients. JAMA2002;288:2167–2169.
18. Marik PE, Raghavan M. Stress-hyperglycemia, insulin and immunomodulation in sepsis. Intensive Care Med 2004;30:748–756.
19. Turina M, Fry DE, Polk HC. Acute hyperglycemia and the innate immune system: clinical, cellular, and molecular aspects. Crit Care Med 2005;33:1624–1633.
20. McCowen KC, Malhotra A, Bistrian BR. Stress-induced hyperglycemia. Crit Care Clin 2001;17:107–124.
21. Rady MY, Johnson DJ, Patel BM, et al. Influence of individual characteristics on outcome of glycemic control in intensive care unit patients with or without diabetes mellitus. Mayo Clin Proc2005;80:1558–1567.
22. Moghissi ES, Hirsch IB. Hospital management of diabetes. Endocrinol Metab Clin North Am2005;34:99–116.
23. Garber AJ, Moghissi ES, Bransome ED Jr, American College of Endocrinology position statement on inpatient diabetes and metabolic control. Endocrin Practice 2004;10:77–82.
24. Van den Berghe G, Wilmer A, Hermans G, et al. Intensive insulin therapy in the medical ICU. N Engl J Med 2006;354:449–461.
25. Genuth S, Alberti KG, Bennett P, et al., and the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Follow-up report on the diagnosis of diabetes mellitus. Diabetes Care 2003;26:3160–3167.
26. Tirosh A, Shai I, Tekes-Manova D, et al. Normal fasting plasma glucose levels and type 2 diabetes in young men. N Engl J Med 2005;353:1452–1464.
27. Bellomo R, Egi M. Glycemic control in the intensive care unit: why we should wait for NICE-SUGAR.Mayo Clin Proc 2005;80:1546–1548.