Decisional practices and patterns of intraoperative glucose management in an academic medical center

• Published in: Journal of clinical anesthesia 2016-08, Vol.32, p.214-223
• Main Authors: Grunzweig, Katherine, BA, Nair, Bala G., PhD, Peterson, Gene N., MD, PhD, Horibe, Mayumi, MD, Neradilek, Moni B., MS, Newman, Shu-Fang, MS, Van Norman, Gail, MD, Schwid, Howard A., MD, Hao, Wei, MD, PhD, Dellinger, E. Patchen, MD, Hirsch, Irl B., MD
• Format: Article
• Language: English
• Subjects: Academic Medical Centers; Aged; Anesthesia; Anesthesia & Perioperative Care; Blood glucose; Blood Glucose - analysis; Blood Glucose - drug effects; Clinical Decision-Making - methods; Cohort Studies; Compliance; Diabetes; Female; Glucose; Humans; Hyperglycemia - blood; Hyperglycemia - prevention & control; Hypoglycemia - blood; Hypoglycemia - prevention & control; Information management; Institutional protocol; Insulin; Insulin - blood; Insulin - therapeutic use; Intraoperative Care - methods; Intraoperative glucose; Laboratories; Liver; Male; Middle Aged; Pain Medicine; Patients; Practice Guidelines as Topic; Retrospective Studies; Surgery
• ISSN: 0952-8180; 1873-4529
• DOI: 10.1016/j.jclinane.2016.02.027

Abstract Objective To understand the decisional practices of anesthesia providers in managing intraoperative glucose levels. Design This is a retrospective cohort study. Setting Operating rooms in an academic medical center. Patients Adult patients undergoing surgery. Intervention Intraoperative blood glucose management based on an institutional protocol. Measurements Glucose management data was extracted from electronic medical records to determine compliance to institutional glucose management protocol that prescribes hourly glucose measurements and insulin doses to maintain glucose levels between 100 to 140 mg/dL. Effect of patient and surgery specific factors on compliance to glucose management protocol was explored. Main results In 1903 adult patients compliances to hourly glucose measurements was 72.5% and correct insulin adjustments was 12.4%. Insulin was under-dosed compared to the prescribed value by a mean of 0.85 U/h (95% CI 0.76-0.95). Multivariate analysis showed that compliance to hourly glucose measurements decreased with increasing length of the procedure (OR = 0.92 per hour, 95% CI 0.89-0.95) but increased with ASA status codes (OR = 1.25 per ASA unit, 95% CI = 1.06-1.49). Greater compliance to correct insulin adjustment was found in diabetic patients compared with non-diabetic patients (OR = 1.31, 95% CI 1.09-1.55). On average, providers administered progressively more insulin with an additional 0.11 U/h (95% CI = 0.00-0.21] for every additional 10 kg/m2 of BMI and 0.20 U/h (95% CI = 0.01-0.39) less in diabetic patients than in non-diabetic patients. With the above practice pattern, the mean ± SD of glucose level was 158 ± 36 mg/dL. Hypoglycemic (< 60 mg/dL) incident rate was 0.1% (9/8301 measurements) while hyperglycemic (> 180 mg/dL) incident rate was 28%. Glucose levels were within the target range (100-140 mg/dL) only 28% of the time. Conclusions Low compliance and considerable variability in initiating and following institutional glucose management protocol were observed.