Glucose Control Factsheet

AHRQ Safety Program for Surgery

Facts About Glucose Control and the Prevention of Surgical Site Infections

Definition of Tight Glucose Control

Tight glucose control refers to getting as close to a normal (nondiabetic) blood glucose level as you safely can. Ideally, this means levels between 70 and 130 mg/dL before meals, and less than 180 mg/dL 2 hours after starting a meal, with a glycated hemoglobin A1C level less than 7 percent. The target number for glycated hemoglobin will vary depending on the type of test doctor's laboratory uses.1

Glycemic Control for Prevention of Surgical Site Infections

A 2017 guideline from the Centers for Disease Control and Prevention recommends perioperative glycemic control using a target blood glucose level less than 200 mg/dL regardless of whether the patient has diabetes.2

  • The evidence review did not identify randomized controlled trials that evaluated lower target levels. It noted that some other organizations have published recommendations based on observational evidence.   

Glucose Control and Cardiac Surgery Complications

  • The Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) recommend focusing glucose control on patients undergoing cardiac surgery since most of the supporting literature involves this patient population. This also harmonizes with Surgical Care Improvement Project/National Quality Forum measures.3, 4
  • In one prospective cohort study, 6 percent of cardiothoracic surgery patients had evidence of undiagnosed diabetes. Their surgical site infection (SSI) rate equaled that of known diabetic patients.5
  • To be consistent with the Surgical Care Improvement Project measures, SHEA and IDSA suggest focusing postoperative glucose control on patients undergoing cardiac surgery. Consider specifying targets for glucose control (e.g., less than 200 mg/dL on postoperative days 1 and 2).3
  • Intraoperative and perioperative glycemic control guidelines recommend glucose control (180 mg/dL or lower) in cardiac surgery patients in the time frame of 18–24 hours after anesthesia end time.4,6-9

Evidence of an Association Between Hyperglycemia and Postoperative Complications

  • Although tight glucose control has not been studied rigorously in the general surgery population, studies have revealed an association between hyperglycemia and postoperative complications.10-14
  • In a study of general surgery patients, postoperative blood glucose was the only significant predictor of SSI after multivariate analysis.15
  • Poor long-term glucose control as evidenced by elevated hemoglobin A1C values are considered a predictor of SSI.16, 17

Need More Research To Confirm Significant Association Between Hyperglycemia and Postoperative Complications

  • Despite this research, evidence for tight glucose control is equivocal.18, 19  A recent Cochrane review found that there was insufficient evidence to support strict perioperative glycemic control for SSI prevention.20
  • Intensive postoperative glucose control (targeting levels less than 110 mg/dL) has not been shown to reduce the risk of SSI and may actually lead to higher rates of adverse outcomes, including stroke and death.21

How To Measure Compliance With Glucose Control?

Measure the percentage of procedures for which serum glucose meets the selected target, e.g., 180 mg/dL or lower within 18–24 hours, by using the following calculations:4,6-9

  • Numerator: number of patients with appropriately maintained serum glucose using the selected target (e.g., 180 mg/dL or lower) in the timeframe of 18–24 hours after anesthesia end time following cardiac surgery.
  • Denominator: total number of cardiac procedures performed.
  • Multiply by 100 so that the measure is expressed as a percentage after anesthesia end time for all cardiac surgery patients.

References

  1. American Diabetes Association. Tight Diabetes Control. May 13, 2015. www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/tight-diabetes-control.html. Accessed August 20, 2015.
  2. Berrios-Torres SI, Umscheid CA, Bratzler DW, et al.  Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017.  JAMA Surgery 2017;152(8):784-791.
  3. Society for Healthcare Epidemiology of America (SHEA) and Infectious Diseases Society of America (IDSA). Executive Summary Response to DHHS Action Plan to Prevent Healthcare-Associated Infections. www.shea-online.org/Assets/files/policy/SHEA_IDSA_HHS_HAI_Action_Plan_Comments_020609.pdf.
  4. National Quality Forum (NQF). Cardiac Surgery Patients with Controlled Postoperative Blood Glucose. Washington, DC: NQF, 2013. http://www.qualityforum.org/. Accessed January 6, 2013.
  5. Latham R, Lancaster AD, Covington JF, et al. The association of diabetes and glucose control with surgical-site infections among cardiothoracic surgery patients. Infect Control Hosp Epidemiol 2001 Oct;22(10):607-12. PMID: 11776345.
  6. Lazar HL, McDonnell M, Chipkin SR, et al. The Society of Thoracic Surgeons practice guideline series: Blood glucose management during adult cardiac surgery. Ann Thorac Surg 2009;87(2):663-9. PMID: 19161815.
  7. Jacobi J, Bircher N, Krinsley J, et al. Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. Crit Care Med 2012;40(12):3251–76. PMID: 23164767.
  8. Umpierrez GE, Hellman R, Korytkowski MT, et al. Management of hyperglycemia in hospitalized patients in non–critical care setting: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2012;97(1):16–38. PMID: 22223765.
  9. Anderson DJ, Kaye KS, Classen D, et al. Strategies to prevent surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;29 Suppl 1(2014):S51-S61. PMID: 18840089.
  10. Furnary AP, Cheek DB, Holmes SC, et al. Achieving tight glycemic control in the operating room: Lessons learned from 12 years in the trenches of a paradigm shift in anesthetic care. Semin Thorac Cardiovasc Surg 2006 Winter;18(4):339-45. PMID: 17395031.
  11. Presutti E, Millo J. Controlling blood glucose levels to reduce infection. Crit Care Nurs Q 2006 Apr-Jun;29(2):123-31. PMID: 16641648.
  12. Sehgal R, Berg A, Figueroa R, et al. Risk factors for surgical site infections after colorectal resection in diabetic patients. J Am Coll Surg 2011 Jan;212(1):29-34. PMID: 21123091.
  13. Serra-Aracil X, Garcia-Domingo MI, Pares D, et al. Surgical site infection in elective operations for colorectal cancer after the application of preventive measures. Arch Surg 2011 May;146(5):606-12. PMID: 21576613.
  14. Jackson RS, Amdur RL, White JC, et al. Hyperglycemia is associated with increased risk of morbidity and mortality after colectomy for cancer. J Am Coll Surg 2012 Jan;214(1):68-80. PMID: 22079879.
  15. Ata A, Lee J, Bestle SL, et al. Postoperative hyperglycemia and surgical site infection in general surgery patients. Arch Surg 2010 Sep;145(9):858-64. PMID: 20855756.
  16. Marchant MH, Viens NA, Cook C, et al. The Impact of Glycemic Control and Diabetes Mellitus on Perioperative Outcomes After Total Joint Arthroplasty. Bone Joint Surg Am 2009;91:1621-9. PMID: 19571084.
  17. Davis MC, Ziewacz JE, Sullivan SE, et al. Preoperative hyperglycemia and complication risk following neurosurgical intervention: A study of 918 consecutive cases. Surg Neurol Int 2012;3:49. PMID: 22629486.
  18. Serra-Aracil X, Garcia-Domingo MI, Pares D, et al. Surgical site infection in elective operations for colorectal cancer after the application of preventive measures. Arch Surg 2011 May;146(5):606-12. PMID: 21576613.
  19. Forbes SS, Stephen WJ, Harper WL, et al. Implementation of evidence-based practices for surgical site infection prophylaxis: Results of a pre- and postintervention study. J Am Coll Surg 2008 Sep;207(3):336-41. PMID: 18722937.
  20. Kao LS, Meeks D, Moyer VA, et al. Peri-operative glycaemic control regimens for preventing surgical site infections in adults. Cochrane Database Syst Rev 2009 Jul 8;(3):CD006806. PMID: 19588404.
  21. Gandhi GY, Nuttall GA, Abel MD, et al. Intensive intraoperative insulin therapy versus conventional glucose management during cardiac surgery: a randomized trial. Ann Intern Med 2007;146(4):233–43. PMID: 17310047.

 

Page last reviewed December 2017
Page originally created December 2017
Internet Citation: Glucose Control Factsheet. Content last reviewed December 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/hais/tools/surgery/tools/surgical-complication-prevention/glucose_control_factsheet.html