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Published on: June 11, 2012
Perioperative management of diabetes in elective patients: a region-wide audit
M J Jackson1, C Patvardhan2, F Wallace3
1Department of Anaesthesia and Intensive Care, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK m.j.jackson@doctors.org.uk.
Insights
Adherence to national diabetes surgery guidelines was poor in a regional audit. Many patients with diabetes undergoing elective surgery did not receive optimal perioperative care, increasing risks.
Area of Science:
- Perioperative Medicine
- Endocrinology
- Surgical Care
Background:
- Diabetes affects 10% of elective surgical patients, leading to increased perioperative risks.
- National guidelines for managing diabetes in surgical patients were published in 2011.
- A regional audit assessed adherence to these guidelines in the North Western Deanery.
Purpose of the Study:
- To audit adherence to national perioperative diabetes management guidelines.
- To identify areas of suboptimal care in diabetic patients undergoing elective surgery.
Main Methods:
- Prospective data collection from elective surgical patients with diabetes.
- Exclusion of pregnant, pediatric, and non-elective surgical patients.
- Analysis of patient characteristics and perioperative management against national recommendations.
Main Results:
- Audit included 247 diabetic patients; HbA1c recorded in 71%.
- 11% of patients did not receive indicated variable rate intravenous insulin infusions (VRIII).
- Only 8% received recommended fluid (5% glucose in 0.45% saline) with VRIII; 56% had hourly intraoperative capillary blood glucose monitoring.
Conclusions:
- Substantial non-adherence to national perioperative guidelines for diabetic patients was observed.
- The study highlights deficits in care, including insulin infusion and fluid management.
- This audit provides a template for future trainee-led network studies.
Background:
Ten percent of elective surgical patients have diabetes. These patients demonstrate excess perioperative morbidity and mortality. National guidance on the management of adults with diabetes undergoing surgery was published in 2011. We present a region-wide audit of adherence to this guidance across the North Western Deanery.
Methods:
Local teams prospectively collected data according to a locally approved protocol. Pregnant, paediatric and non-elective patients were excluded from this audit. Patient characteristics, type of surgery and aspects of perioperative management were collated and centrally analysed against audit criteria based upon national recommendations.
Results:
247 patients with diabetes were identified. HbA1c was recorded in 71% of patients preoperatively; 9% of patients with an abnormal HbA1c were not known by, or referred to, the diabetes team. 17% of patients were admitted the evening preceding surgery. The mean fasting time was 12:20(4) h. Variable rate i.v. insulin infusions (VRIII) were not used when indicated in 11%. Only 8% of patients received the recommended substrate fluid, along with the VRIII (5% glucose in 0.45% saline). Intra-operative capillary blood glucose (CBG) was measured hourly in 56% of patients. Intra-operative CBG was within the acceptable range (4-12 mmol.L(-1)) in 85% of patients. 73% of patients had a CBG measurement performed in recovery. The WHO checklist was used in 95% of patients.
Conclusions:
National perioperative guidelines were not adhered to in a substantial proportion of patients with diabetes undergoing elective surgery. This study represents a template for future trainee networks.
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