1. Safety and efficacy of insulin guideline for controlling perioperative hyperglycemia
Marwa Amer PharmD Candidate1, Mark Shelly MD2, Dianne Lee PharmD Candidate1, Judianne C. Slish PharmD, BCPS1,2
1St. John Fisher College, Wegmans School of Pharmacy, 2Highland Hospital, Rochester, NY
Objectives and Purposes
Results
Multivariate Analysis for hyperglycemia risk factors
Primary Objective:
Assess the efficacy and safety of preoperative and postoperative glucose control guideline at UR Medicine at Highland Hospital
Secondary Objectives:
Evaluate the strength of risk factors for hyperglycemia (e.g. Diabetes, BMI, Hemoglobin A1C, preoperative glucose, and use of perioperative corticosteroids).
Evaluate the safety and efficacy of IV regular insulin in the immediate perioperative setting.
Study Population
Variables
LogWorth Value
P value
Perioperative glucose
17.9
<0.0001
Diabetes
8.6
Perioperative steroid
6.5
• procedures on 5338 patients screened.
• 808 patients met inclusion criteria.  
• 208 of the patients evaluated received LAI and 600 did not.
180
Baseline Characteristics & Demographics
140
Variables
% (N)
Diabetes mellitus
67.7% (547)
Type 2 DM
95.0% (519)
Surgery type
Orthopedics (mostly arthroplasty)
30.8% (249)
General (mostly bariatric surgery)
29.5% (238)
Gynecological
12.1% (98)
Neurological
9.8% (79)
Others ( no cardiac)
17.8% (144)
Background  
180
Maximum Glucose in the postoperative 24 hours
Postoperative hyperglycemia was common ( 57.4%, 464/808) . As expected, it was more common in diabetic patients.
The negative consequences of postoperative hyperglycemia are documented in cardiac and non-cardiac surgery. Glucose control strategies are a crucial aspect for surgical patients.
Some clinical trials suggest that intensive glucose control (target level of mg/dL) is associated with more hypoglycemia and mortality when compared with moderate targets mg/dL.
The Society of Thoracic Surgery recommends maintaining perioperative glucose levels <180 mg/dL in cardiac surgery patients.
Hyperglycemia with LAI % (n)
Normal BL
Hyperglycemia
Yes
3.4% (7)
32.7% (68)
63.9% (133) No
13.0% (78)
31.8% (191)
55.2% (331)
Hyperglycemia with IV insulin % (n)
0.6% (2)
26.4% (92)
73.1% (255)
18.1% (83)
36.4% (167)
45.5% (209)
Outcomes: Hypoglycemia
Hypoglycemia (blood glucose level < 70 mg/dl )
occurred in 6.4% (52 / 808) occurred most often in patients who did not receive insulin
Red Dots are diabetics, Black dots not known diabetic
Perioperative glucose measures correlate with postoperative maximum glucose as expected
Hypoglycemia blood glucose level < 70 mg/dl
n/Total %
P value
LAI
Yes
15/208
7.2 %
0.41 No
36/600
6.0 %
Received IV regular insulin
13/349
3.7%
0.006*
39/459
8.5 %
Methods
Discussion and Conclusion
IV insulin given almost exclusively to these pts total 349
Study Design:
Previous quality improvement work designed a protocol aimed at reducing perioperative glucose. This included the use of long acting insulin (LAI) given preoperatively and doses of IV regular insulin to correct documented hyperglycemia.
We retrospectively reviewed the records between 9/2013 to 2/2014 to compare patients who were given LAI preoperatively versus those treated with usual care
Setting: UR Medicine Highland Hospital, Rochester NY.
Patients Selection:
Inclusion criteria: Patients with ≥ 3 glucose measures in the 24 hours following the surgery.
Exclusion Criteria: Patients < 18 year old and glucose not measured at least 3 times postoperatively.
Statistical Analysis: Analysis will be performed using JMP statistical software (version 11, SAS, Cary, NC)
Patient characteristics (e.g. DM, BMI, HbA1C, preoperative glucose) were collected. Variables found to be correlated with hyperglycemia were examined for covariance and entered in a multivariate logistic regression to determine predictors of hyperglycemia.
Perioperative LAI at a dose of units was safe and did not result in significant hypoglycemia
The voluntary application of the current protocol did not reduce observed hyperglycemia postoperatively
In multivariate analysis, perioperative glucose, diabetes, and perioperative steroid use were associated with hyperglycemia
There were too few infections (10) to comment on the correlation with hyperglycemia
Limitations of our study included incomplete application of the protocol, retrospective analysis, single institution’s population, and difficulty in controlling confounding variables.
Hyperglycemia % (n)
Normal BL
Hyper-glycemia
P Value DM
Yes
5.3 % (29)
27.4 % (150)
67.3 % (368)
< No
21.5% (56)
41.8 % (109)
36.8% (96) *
Total
10.5% (85/808)
32.1% (259/808)
57.4% (464/808)
Perioperative Steroid
6.9% (27)
32.5% (128)
60.7% (239)
0.0031
14.2% (58)
31.5% (129)
54.4% (223)
10.6% (85/804)
32.0% (257/804)
57.5% (462/804)
* IV insulin given for hyperglycemia, this confounds the finding of less hypoglycemia with IV insulin
Hypoglycemia blood glucose level < 70 mg/dl
n/Total %
P Value DM
Yes
40 / 547
7.3 %
0.16 No
12/261
4.6 %
Total
52/808
6.4 %
Disclosure
A total of 52 patient had hypoglycemia of which 29 patients received IV insulin and LAI.
Low BMI was also associated with hypoglycemia (P=0.0006)
Authors of this presentation have nothing to disclose concerning possible financial or personal relationship with the commercial entities that may have a direct or indirect interest in the subject matter of this presentation
Diabetes is highly correlated to hyperglycemia, but
* % of the patients without a DM were hyperglycemic.
Hyperglycemia Tiers
Normal
< 140 mg/dl
Borderline hyperglycemia (BL)
≥140 - <180 mg/dl
Hyperglycemia
≥ 180 mg/dl
Preoperative glucose and Hemoglobin A1C and were associated with hyperglycemia (P < , P = ). HbA1C was available in only 173 mostly diabetic, and was not included in multivariate analysis.
References
Available upon request

2. This also correlate with DM BMI has less effect NS
Univariate Analysis
Univariate Analysis
Hypoglycemia blood glucose level < 70 mg/dl N %
P Value
Steroids
Yes
17/394
4.3%
0.02 No
35/410
8.5 %
BMI > 30
Less hypoglycemia with high BMI
0.006
Glucose pre Op
NS 0.26
OHG
YES (these are DM)
11/347
3.2 %
???? NO
29/211
13.7 %
Hyperglycemia % (n) 1 2
P Value
Pre-Op Steroid
Yes
6.9 (27)
32.5 (128)
60.7( 239) No
14.2 (58)
31.5 (129)
54.4 (223)
This also correlate with DM
BMI has less effect NS
Infection was not correlated bc insufficient #
Glucose max is not normally distributed
Log normal is closer but there is still sig skewed to high value
Log 10 glucose max help to eliminated this
Hypoglycemia distribution of BGL is closer to normal fits better as log normal ( log glucose min)
A1C n= 178 showed modest correlation
Those with higher BGL has higher A1C
50% 5.32
75% 7.6
90 % 9.8
Univariate Analysis Stratified by Diabetes
Hyperglycemia% (n)
None BL
Hyper
Total
P value
Steroid Pre-Op in non diabetic patients
Yes
14.8% (23)
44.5% (69)
40.7% (63)
105
0.0059 No
31.4% (33)
37.1% (39)
155
Total N
260
Steroid Pre-Op in diabetic patients
1.67% (4)
24.7% (59)
73.6% (176)
239
0.0007
8.2% (25)
29.5 % (90)
62.3% (190)
305
544