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Insulin Pump Therapy in the Perioperative Period: A Review of Care after Implementation of Institutional Guidelines
Abstract and Figures
Background:
An institutional policy was previously established for patients with diabetes on insulin pump therapy undergoing elective surgical procedures.
Method:
Electronic medical records were reviewed to assess documentation of insulin pump status and glucose monitoring during preoperative, intraoperative, and postanesthesia care unit (PACU) phases of care.
Results:
Twenty patients with insulin pumps underwent 23 procedures from March 1 to December 31, 2011. Mean (standard deviation) age was 58 (13) years, mean diabetes duration was 28 (17) years, and mean duration of insulin pump therapy was 7 (6) years. Nearly all cases (86%) during the preoperative phase had the presence of the device documented--an improvement over the 64% noted in data collected before the policy. Intraoperatively, 13 cases (61%) had the presence of the pump documented, which was higher than the 28% before implementation of the policy. However, documentation of pump status was found in only 38% in the PACU and was actually less than the 60% documented previously. Over 90% of cases had glucose checked in the preoperative area and the PACU, and only 60% had it checked intraoperatively, which was nearly identical to the percentages seen before policy implementation. No adverse events occurred when insulin pump therapy was continued.
Conclusions:
Although some processes still require improvement, preliminary data suggest that the policy for perioperative management of insulin pumps has provided useful structure for care of these cases. The data thus far indicate that insulin pump therapy can be continued safely during the perioperative period.
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... However, to date, there is no public consensus or guideline on perioperative insulin pump use in diabetic patients requiring surgical procedures. 20 The insulin pump cannot control the patients' blood glucose well in the face of major hemodynamic changes. Therefore, for patients who require longer surgery, have a large amount of fluid loss during surgery, and require emergency surgery, consideration should be given to withdrawing the insulin pump and changing to intravenous insulin to better control blood glucose. ...
Diabetes mellitus is a common chronic disease. With the improvement of living standards, the prevalence of diabetes mellitus in China is increasing. There are now more people with diabetes in China (>100 million) than in any other country. About half of these people with diabetes need to undergo at least one procedure in their lifetime. Diabetic patients have a much higher probability of perioperative dysglycemia than the normal population, which has a great impact on their prognosis. In addition, non-diabetic patients may also have abnormal blood glucose levels due to various reasons during the perioperative period, which will also lead to a series of adverse consequences. This article reviews the perioperative blood glucose management of patients to provide a reference for improving their health status.
... Perhaps even more importantly, the postoperative management of the CSII pump can become problematic due to glycaemic dysregulation or the patient's inability to correctly operate the pump. Finally, the pump should be removed during radiological procedures such as CT, MRI and cardiac catheterisation, and the pump should be placed away from the electrical arc when using (monopolar) electrocautery [42,48]. ...
Diabetes mellitus is often treated as a uniform disease in the perioperative period. Type 2 diabetes is most commonly encountered, and only a minority of surgical patients have been diagnosed with another type of diabetes. Patients with a specific type of diabetes can be particularly prone to perioperative glycaemic dysregulation. In addition, certain type-related features and pitfalls should be taken into account in the operating theatre. In this narrative review, we discuss characteristics of types of diabetes other than type 2 diabetes relevant to the anaesthetist, based on available literature and data from our clinic.
... In general, insulin pumps can be left in place for shorter elective procedures. They have been shown to be safe in several studies [28][29][30][31][32] If the patient demonstrates decompensated metabolic control, the patient should be started on an insulin infusion and the pump be removed. In general, the infusion should be in place for ½ hour before the pump is discontinued. ...
... There are no generalized guidelines for insulin pump use in the inpatient setting. It has been shown that hospitals with well-designed diabetes treatment protocols can efficiently manage insulin pump therapy [13][14][15][16][17][18]; however, such protocols do not exist for all inpatient care facilities. The 2016 ESG state that the decision to continue the insulin pump therapy in the inpatient setting should be evaluated thoroughly, preferably by an endocrinologist experienced in pump therapy, for potential risk factors such as the extent of medical illness, impact of co-medications, the degree of insulin resistance, and mental capacity of the patient. ...
Purpose of review:
Decades after the invention of insulin pump, diabetes management has encountered a technology revolution with the introduction of continuous glucose monitoring, sensor-augmented insulin pump therapy and closed-loop/artificial pancreas systems. In this review, we discuss the significance of the 2016 Endocrine Society Guidelines for insulin pump therapy and continuous glucose monitoring and summarize findings from relevant diabetes technology studies that were conducted after the publication of the 2016 Endocrine Society Guidelines.
Recent findings:
The 2016 Endocrine Society Guidelines have been a great resource for clinicians managing diabetes in this new era of diabetes technology. There is good body of evidence indicating that using diabetes technology systems safely tightens glycemic control while managing both type 1 and type 2 diabetes. The first-generation diabetes technology systems will evolve as we gain more experience and collaboratively work to improve them with an ultimate goal of keeping people with diabetes complication and burden-free until the cure for diabetes becomes a reality.
Objective To evaluate the impact of temporary insulin pump use during hospitalization on glycemia, postoperative complications, and cost/utilization in perioperative patients with diabetes.
Methods Patients (n=159) with type 2 diabetes and hospitalized for elective surgery were recruited from three hospitals. Subjects were categorized into the insulin pump group and the multiple daily subcutaneous insulin injection group according to their treatment therapy. Data were collected at admission, discharge, and 3 months post-discharge.
Results Subjects in the CSII group who were still on insulin therapy transitioned from CSII to MDII; however, their daily insulin dosages were lower than those in the MDII group (15.31±10.98 U/d vs. 23.48±17.02 U/d, P=0.015) after discharge. In terms of medical costs, the CSII group had significantly higher hospitalization costs than the MDII group (112.36±103.43 thousand RMB vs. 82.65±77.98 thousand RMB, P=0.043). After 3 months, the CSII group had significantly lower outpatient costs than the MDII group (3.17±0.94 thousand RMB vs. 3.98±1.76 thousand RMB, P ˂ 0.001). In the MDII group, 10 patients reported severe postoperative complications requiring re-hospitalization; there were no similar reports in the CSII group.
Conclusion Temporary use of insulin pump therapy for perioperative patients with diabetes results in a reduction in blood glucose and blood glucose fluctuation during hospitalization, HbA1c, and the risk of postoperative complication and readmission, thus significantly decreasing costs in this complex patient cohort. Further work is needed to better understand indications for utilizing pump therapy based on diabetes phenotype and the complexity of planned surgical intervention.
Objective: The goal of this quality initiative was to develop consensus standards for glycemic management of patients with diabetes who undergo surgical procedures in Canada.
Methods
A modified Delphi methodology was used to gather broad stakeholder input and arrive at a consensus for perioperative/periprocedure diabetes management.
Results
Glycemic management standards were developed for the following categories: Organization of Care, Preoperative Assessment, Immediate Preoperative and Intraoperative, Post Anesthesia Care Unit (PACU) or Recovery Room, Postoperative Period, and Transition to Outpatient Care.
Conclusions
It is anticipated these standards will serve as a basis to develop clinical tools to support the recommendations.
Background:
Perioperative hyperglycemia was associated with postoperative infection, and proper management of perioperative glucose has become critical in improving the prognosis of patients.
Methods:
1015 diabetic patients who underwent surgery and received insulin treatment for their hyperglycemia in our hospital were retrospectively reviewed. According to propensity matching, we obtained 253 pairs of patients from group received continuous subcutaneous insulin infusion therapy (CSII group) and the group received insulin injection therapy (non-CSII group). Perioperative glucose levels and corresponding outcomes were compared between the two groups.
Results:
Compared with non-CSII group, CSII group had lower fasting and mean glucose levels, lower incidence of fever (operation day: 18.6% vs 10.2%; P = 0.014; first postoperative day: 55.1% vs 34.7%; P<0.001) and positive rate of postoperative secretion culture (6.3% vs 1.2%; P = 0.004), shorter time of antibiotics use (total antibiotics use: P = 0.002; postoperative antibiotics use: P<0.001) and hospital stays (P<0.001). However, there was no difference in the total medical expenditure between the two groups (P = 0.499). Further analysis showed that CSII therapy was superior to multiple daily insulin injection therapy (MDI) therapy in its effect on infection and other postoperative outcomes when 64 pairs of patients from the CSII group and MDI group of non-CSII group were compared.
Conclusions:
CSII therapy provide better perioperative glucose control and lower risk of postoperative infection, without increasing the total medical expenditure. This article is protected by copyright. All rights reserved.
Objective
Perioperative handling of insulin pumps (CSII) is inconsistent. The aims of this study were a literature search addressing this clinical question, analysis of data found and a proposal for perioperative management recommendations for clinical practice.
Methods
A systematic search was conducted in PubMed and Clinical Research Network.
Results and discussion
A total of 11 publications on CSII in perioperative medicine were identified. According to the evidence CSII guarantees perioperative glycemic stability under certain clinical situations. The use of CSII could be continued in patients undergoing elective non-cardiac minor surgery with fasting for up to one meal only. International guidelines on surgery in diabetes do not address the use of perioperative CSII. There is no nationwide register data for CSII, the use of which could be around 18%. Based on the search results, a hospital internal protocol for perioperative management with CSII and patient information material were designed.
Conclusion
Growing evidence for improved patient outcome with perioperative CSII usage warrants interdisciplinary transfer of knowledge and experiences on intensified insulin therapy and patient empowerment.
Hyperglycemia is associated with adverse outcomes in patients who are candidates for or underwent neurosurgical procedures. Specific concerns and settings that relate to these patients are preoperative glycemic control, intraoperative control, management in the neurological intensive care unit (NICU), and postoperative control. In each of these settings, physicians have to ensure appropriate glycemic control to prevent or minimize adverse events. The glycemic control is usually managed by a neurohospitalist in co-management with the neurosurgery team pre- and post-operatively, and by the neurocritical care team in the setting of NICU. In this review article, we outline current standards of care for neurosurgery patients with diabetes mellitus and/or and hyperglycemia and discuss results of most recent clinical trials. We highlight specific concerns with regards to glycemic controls in these patients including enteral tube feeding and parenteral nutrition, the issues of the transition to the outpatient care, and management of steroid-induced hyperglycemia. We also note lack of evidence in some important areas, and the need for more research addressing these gaps. Where possible, we provide suggestions how to manage these patients when there is no underlying guideline.
Objective:
To formulate clinical practice guidelines for the use of continuous glucose monitoring and continuous subcutaneous insulin infusion in adults with diabetes.
Participants:
The participants include an Endocrine Society-appointed Task Force of seven experts, a methodologist, and a medical writer. The American Association for Clinical Chemistry, the American Association of Diabetes Educators, and the European Society of Endocrinology co-sponsored this guideline.
Evidence:
The Task Force developed this evidence-based guideline using the Grading of Recommendations, Assessment, Development, and Evaluation system to describe the strength of recommendations and the quality of evidence. The Task Force commissioned one systematic review and used the best available evidence from other published systematic reviews and individual studies.
Consensus process:
One group meeting, several conference calls, and e-mail communications enabled consensus. Committees and members of the Endocrine Society, the American Association for Clinical Chemistry, the American Association of Diabetes Educators, and the European Society of Endocrinology reviewed and commented on preliminary drafts of these guidelines.
Conclusions:
Continuous subcutaneous insulin infusion and continuous glucose monitoring have an important role in the treatment of diabetes. Data from randomized controlled trials are limited on the use of medical devices, but existing studies support the use of diabetes technology for a wide variety of indications. This guideline presents a review of the literature and practice recommendations for appropriate device use.
Case reports indicate that diabetes patients receiving outpatient insulin pump therapy have been allowed to continue treatment during surgical procedures. Although allowed during surgery, there is actually little information in the medical literature on how to manage patients receiving insulin pump therapy during a planned surgical procedure. A multidisciplinary work group reviewed current information regarding the use of insulin pumps in the perioperative period. Although the work group identified safety issues specific to surgical scenarios, it believed that with the use of standardized guidelines and a checklist, continuation of insulin pump therapy during the perioperative period is feasible. A sample set of protocols have been developed and are summarized. A policy outlining clear procedures should be established at the institutional level to guide physicians and other staff if the devices are to be employed during the perioperative period. Additional clinical experience with the technology in surgical scenarios is needed, and consensus should be developed for insulin pump use in the perioperative phases of care.
Insulin pump therapy is a complex technology prone to errors when employed in the hospital setting. When patients on insulin pump therapy require hospitalization, practitioners caring for them must decide whether to allow continued pump use. We provide the largest review regarding transitioning insulin pump therapy from the outpatient to inpatient setting.
Records of inpatient insulin pump users were retrospectively analyzed at a metropolitan Phoenix hospital between January 2006 and December 2009. Adherence to institutional procedures on insulin pump use was assessed, glycemic control was determined, and adverse events were examined.
We examined records on 65 patients with insulin pumps, totaling 125 hospitalizations. Mean (standard deviation) patient age was 55 (17) years, diabetes duration was 27 (14) years, pump duration was 6 (5) years, length of hospital stay was 4.7 (6.3) days, hemoglobin A1c was 7.3 (1.3)%, 85% had type 1 diabetes mellitus, 57% were women, and 97% were white. Admissions involving insulin pumps increased (23 in 2006, 17 in 2007, 40 in 2008, and 45 in 2009). Insulin pump therapy was continued in 83 (66%) hospitalizations. Among these hospitalizations, endocrinology consultations were obtained in 89%, consent agreements were found in 83%, insulin pump order sets were completed in 89%, admission glucose was checked in 100%, and nursing assessments of pump insertion sites were documented in 89%, but bedside insulin pump flow sheets were found in only 55%. Mean glucose of 175 (57) mg/dl was not significantly different than that in hospitalizations where insulin pumps were discontinued [175 (42) mg/dl] or used intermittently [177 (7) mg/dl]. There was one instance of a pump catheter kinking; however, no other adverse events (pump site infections, mechanical pump failure, diabetic ketoacidosis) were observed, and there were no use-related fatalities.
Most patients using insulin pumps can safely have their therapy transitioned when hospitalized. A policy on inpatient continuous subcutaneous insulin infusion use can be successfully implemented. Compliance with required procedures can be achieved, although there was room to improve adherence with some process measures. Further study is needed to determine how to optimize glycemic control when pumps are allowed during hospitalization.
This article reviews the performance of our hospital's inpatient insulin pump policy.
Twenty-five hospital admissions of 21 unique patients receiving outpatient insulin pump therapy were reviewed.
Between November 1, 2005, and November 30, 2006, there were 25 hospital admissions involving 21 patients receiving outpatient insulin pump therapy. The average age and duration of diabetes among these 21 patients was 50 and 29 years, respectively; 67% were women, 90% had type 1 diabetes, and all were white. The mean length of hospital stay was 4 days, and the average reported length of insulin pump therapy was 4 years. Patients in 16 of the admissions were identified as candidates for continued use of the insulin pump during the hospital stay. Over 90% of patients remaining on the insulin pump had documentation by nursing of the presence of the pump at the time of admission; 100% of the patients had an admission glucose recorded; 88% had a record of signed patient consent; 81% had evidence of completed preprinted insulin pump orders; 75% received a required endocrine consultation; and 75% of cases had documentation of completed bedside flow sheet. A high frequency of both hypoglycemic and hyperglycemic events occurred in the patients; however, no adverse events were related directly to the insulin pump.
Insulin pump therapy can be safely continued in the hospital setting. While staff compliance with required procedures was high, there was still room for improvement. More data are needed, however, on whether this method of insulin delivery is effective for controlling hyperglycemia in hospitalized patients.
To assess perioperative management of patients with diabetes mellitus who were being treated with insulin pump therapy.
We reviewed records for documentation of insulin pump status and glucose monitoring during preoperative, intraoperative, and postanesthesia care unit (PACU) phases of surgery.
Thirty-five patients (21 men) with insulin pumps underwent surgical procedures between January 1, 2006, and December 31, 2010. Mean age was 56 years, mean diabetes duration was 31 years, and mean duration of insulin pump therapy was 7 years. All patients were white, and 29 had type 1 diabetes mellitus. Of the 50 surgical procedures performed during the study period, 16 were orthopedic, 9 were general surgical, 7 were urologic, and 7 were kidney transplant operations; the remaining 11 procedures were in other surgical specialties. The mean (± standard deviation) time in the preoperative area was 118 ± 75 minutes, mean intraoperative time was 177 ± 102 minutes, and mean PACU time was 170 ± 78 minutes. Of the 50 procedures, status of pump use was documented in 32 cases in the preoperative area, 14 cases intraoperatively, and 30 cases in the PACU. Glucose values were recorded in 47 cases preoperatively, 30 cases intraoperatively, and 48 cases in the PACU.
Results showed inconsistent documentation of pump use and glucose monitoring throughout the perioperative period, even for patients with prolonged anesthesia and recovery times. It was often unclear whether the pump was in place and operational during the intraoperative period. Guidelines should be developed for management of insulin pump-treated patients who are to undergo surgery.
To analyze data on inpatient insulin pump use and examine staff compliance with hospital procedures, glycemic control, and safety.
We conducted a retrospective review of charts and bedside glucose data for patients who had been receiving outpatient insulin pump therapy and were admitted to our teaching hospital between November 1, 2005, and February 8, 2008.
During the study period, there were 50 hospitalizations involving 35 patients who had been receiving outpatient insulin pump therapy. The mean age and duration of diabetes of the 35 patients was 55 years and 32 years, respectively. Sixty-six percent were women, and 91% had type 1 diabetes. Patients in 31 of the hospitalizations (62%) were deemed candidates for continued insulin pump therapy during their stay. Of the 31 hospitalizations, 80% had the presence of the pump documented at admission; 100% had an admission glucose value; 77% had documentation of signed patient consent; 81% had evidence of completed preprinted insulin pump orders; 77% received an endocrine consultation; and 68% had a completed bedside flow sheet. Patients continuing insulin pump therapy had mean bedside glucose levels similar to those whose pump therapy was discontinued (P = .11); however, the proportion of hypoglycemic events was lower among insulin pump users (P<.01) than among nonusers.
Insulin pump therapy is safe for select inpatients. Overall, staff compliance with procedures was high, although we identified areas for improvement. Continued study is needed on the effectiveness of insulin pump therapy in controlling inpatient hyperglycemia.
Clearly, perioperative management of diabetic patients requires thorough preoperative evaluation and planning whenever possible. A firm understanding of the pathophysiology of type 1 diabetes mellitus, the metabolic stress response, and the interactions between various forms of insulin and other variables such as supplemental nutrition and glucocorticoids can greatly assist in achieving a positive outcome. Consultation with an endocrinologist, internist, or other primary care provider comfortable with managing type 1 diabetes patients is strongly recommended to assist in the details of in-patient care and overseeing of proper ancillary support. It may also be helpful to allow the patient to function as an active decision-maker in the coordination of care, especially because a large percentage of type 1 diabetes patients (particularly those who are on insulin pumps) are well-educated about their disease process and their own physiologic idiosyncrasies. This knowledge can save valuable time and effort toward achieving the ultimate united goal of avoiding perioperative morbidity and mortality by maximizing glycemic control.
Care of the patient with diabetes mellitus presents numerous challenges to the anesthesia practitioner. There is no perfect way to care for these patients nor are any 2 patients with diabetes exactly alike. With the advent of subcutaneous insulin pumps, the anesthesia practitioner has another tool to assist him or her in giving high quality care. This case study describes the anesthesia care provided to a patient with type 1 diabetes who wore his continuous subcutaneous insulin infusion (CSII) pump during general anesthesia for surgical repair of a herniated lumbar disk. Importantly, the anesthesia plan involved a collaborative effort with the patient. Blood glucose levels were stable throughout the perioperative period. Little or no extra work was required of the CRNA. This case showed that the CSII could be used to minimize perioperative fluctuations in blood sugar. Postoperatively, the patient expressed a high degree of satisfaction with the anesthetic.
The past 20 yr have seen an explosion in advances for the management of Type I diabetes mellitus. Not only new delivery systems, such as the continuous subcutaneous insulin pump, but also better and more stable types of insulin with predictable pharmacokinetics and pharmacodynamics have been developed. An artificial pancreas is now on the horizon. This progress has had a significant impact on modern perioperative care of the diabetic patient.