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Management of Diabetes Mellitus in preparation for surgery. Review of the evidence for A1c and blood glucose targets. Gregory Deines, D.O. SHMG Diabetes & Endocrinology PowerPoint 16:9 Screen Ratio Template 082308*

Disclosure Statement: No disclosures.

Overview and Objectives Diabetes-related statistics How big is the problem? Diabetes-related surgical complications What are the risks? Optimization of blood glucose levels and pre-op A1c Acute hyperglycemia vs. chronic hyperglycemia What is the evidence for management?

Diabetes Statistics CDC National Diabetes Statistics Report, 2017: In 2015, 30.3 million Americans, or 9.4% of the population, had diabetes. Approximately 1.25 million American children and adults have type 1 diabetes. Of the 30.3 million adults with diabetes, 23.1 million were diagnosed, and 7.2 million were undiagnosed.

Diabetes Statistics Economic Costs of Diabetes in the U.S. in 2017 Diabetes Care 2018 May; 41(5): 917-928. $327 billion: Total costs of diagnosed diabetes in the United States in 2017. $237 billion for direct medical costs. $90 billion in reduced productivity. People with diagnosed diabetes incur average medical expenditures of ∼$16,750 per year, of which ∼$9,600 is attributed to diabetes. People with diagnosed diabetes, on average, have medical expenditures ∼2.3 times higher than what expenditures would be in the absence of diabetes PowerPoint 16:9 Screen Ratio Template 082308*

What are the risks? People with Diabetes Mellitus are at higher risk for: ASVD including MI, silent ischemia, and CVA (2-3 fold risk CHD) Renal impairment Surgical Site Infection DKA (type 1 diabetes mellitus) Hypoglycemia Autonomic neuropathy

Pre-Operative Diabetes Management Acute Hyperglycemia: Hyperglycemia (BG = 200 mg/dl or greater) on day of surgery, within 24-48 hours of surgery, and during the entire hospital stay. Chronic Hyperglycemia: Hyperglycemia associated with elevated HbA1c values over the 90 to 120 days (or more) prior to surgery.

Chronic Hyperglycemia and Pre-Op A1c Value

Study Objective “To evaluate the relationship between preoperative A1c and clinical outcomes in individuals with diabetes mellitus undergoing non-cardiac surgery.”

Design and Methods Retrospective study using data from National Surgical Quality Improvement Program (NSQIP) database. Patients included were admitted to Brigham and Women’s Hospital between 2005 – 2010. Same-day surgeries were excluded. All people with diabetes had an A1c measurement within 90 days before surgery.

Design and Methods

Results and Outcomes

Results and Outcomes

Study Conclusions Results suggest that long-term glycemic control is a strong predictor of hospital LOS. A1c predictive effect is independent of blood glucose measurement on the day of surgery. A1c level >8% is associated with increased hospital LOS and increased morbidity and higher healthcare costs in individuals with diabetes who undergo non-cardiac surgery. Future studies are needed to determine if improving A1c prior to surgery will decrease LOS and improve outcomes.

Acute Hyperglycemia

Study Purpose: This study was conducted to evaluate the effect of preoperative diabetes management on glycemic control and clinical outcomes after major elective surgery.

Design and Methods: Location: Partners HealthCare System, an integrated healthcare delivery network in Eastern Massachusetts that includes Massachusetts General Hospital and Brigham and Women’s Hospital. Retrospective study design. Implemented as part of a quality improvement initiative. Data for all elective surgeries 2 years before and 2 years after program implementation were collected. Patients were seen at a preoperative evaluation center before major elective surgeries that would likely result in hospitalization for >24 hours.

Design and Methods: HbA1c values were obtained. If A1c< 8%= Diabetes management protocol followed by anesthesia with support/consultation from the Diabetes Management Team if needed. If A1c= 8% or greater, then patient was referred to the Diabetes Management Team. Goal of treatment: Improve blood glucose levels by the day of surgery so that blood glucose level is <200 mg/dl on the morning of surgery.

Design and Methods Study was not designed to evaluate effects of pre-op A1c value. No surgeries were cancelled or delayed to improve glycemic control unless requested by patient or surgeon.

Design and Methods:

Results of intervention:

Clinical Outcomes

Potential Cost Savings Reduced LOS was small but statistically significant. Estimated 1,000 surgeries performed on people with diabetes would result in ~200 less hospital days per year. Estimated cost of hospital day = $2,000/day could result in ~$400,000/year in cost savings for hospital.

Study Conclusions: Study suggests that optimizing diabetes treatment at the time of preoperative evaluation, results in: Improved glycemic control peri-operatively Decreased incidence of inpatient hypoglycemia Decreased LOS

Summary and Recommendations People with diabetes mellitus are at elevated risk for CAD and cardiovascular events compared to the general population. People with diabetes mellitus have increased morbidity associated with surgery. HbA1c> 8% is a strong predictor of prolonged hospital LOS. Counsel patients regarding risks at first pre-operative evaluation. It is unclear if delaying surgery to lower A1c is beneficial. Future prospective trials are needed.

Summary and Recommendations We recommend use of Pre-Operative Assessment Center for people with diabetes mellitus. Preoperative diabetes management results in improved peri-operative blood glucose levels and is associated with decreased LOS and improved morbidity. Use the Diabetes Management Service to assist with patients with A1c>8% or patients with complex diabetes management issues.

Spectrum Health Medical Group Diabetes & Endocrinology PowerPoint 16:9 Screen Ratio Template 082308*

PowerPoint 16:9 Screen Ratio Template 082308*