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BRIEF COMMUNICATION
Year : 2016  |  Volume : 60  |  Issue : 2  |  Page : 135-137  

Screening for inpatient hyperglycaemia in surgical patients under 40 years at the time of securing intravenous access on the operative table


Department of Anaesthesia, King Edward Memorial Hospital, Mumbai, Maharashtra, India

Date of Web Publication12-Feb-2016

Correspondence Address:
Anjana Sagar Wajekar
“Shri Niwas”, Plot No. 62/7, Sector 28, Vashi, Navi Mumbai - 400 703, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5049.176272

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How to cite this article:
Wajekar AS. Screening for inpatient hyperglycaemia in surgical patients under 40 years at the time of securing intravenous access on the operative table. Indian J Anaesth 2016;60:135-7

How to cite this URL:
Wajekar AS. Screening for inpatient hyperglycaemia in surgical patients under 40 years at the time of securing intravenous access on the operative table. Indian J Anaesth [serial online] 2016 [cited 2020 Feb 18];60:135-7. Available from: http://www.ijaweb.org/text.asp?2016/60/2/135/176272


   Introduction Top


Traditionally, Type 2 diabetes is considered as a disease afflicting older population, but due to modern lifestyles, increasingly younger people are being diagnosed as diabetics. 8–45% of newly diagnosed patients include paediatric and young adults, depending on the geographical location.[1] Fasting blood sugar levels (BSLs) are not done routinely in this population presenting for surgery.[2],[3] Thus, hyperglycaemia may be missed in many of them during hospital admission. Inpatient hyperglycaemia can produce several adverse outcomes.[3] The venous blood residue from the intravenous cannula can easily be measured, thus serving as an effective bedside screening tool for hyperglycaemia, bringing a large patient population in the purview of diabetes screening at the time of securing an intravenous access on the operating table.


   Methods Top


After institutional ethical committee approval and written informed patient consent, 135 fasting patients belonging to American Society of Anesthesiologists physical status I and II, aged 1–40 years, non-diabetic on history, scheduled for elective surgeries were included. Starvation status of all the patients (30 paediatric patients and 105 adults) was confirmed. Diabetes was clinically ruled out at the time of the pre-anaesthesia checkup. After instituting standard anaesthesia monitoring, 22G or 20G intravenous (IV) cannula was inserted in the vein on the dorsum of the hand of the patients. Correct placement of cannula was checked by collection of blood in the flashback chamber at the top of the catheter needle. The residue of blood left in the IV catheter needle was pushed out of the tip of the needle by removing and forcefully reapplying the stopper at the top of the needle. This blood was then collected on the glucometer strip and utilised for checking the venous sugar level with the help of Contour TS ® glucometer (Bayer Healthcare LLC, USA). Repeat testing intraoperatively was advised if the glucose was above >125 mg%. According to the World Health Organisation (WHO), fasting plasma glucose >110 mg% is considered as impaired fasting glucose level (IFG) (pre-diabetes state) and >125 mg% as diabetes mellitus.[4] And venous plasma glucose should be the standard method for measuring glucose concentrations in blood. Unlike the laboratory testing, glucometer provides a point of care measurement of the BSLs, which has been found to be similar or slightly higher than laboratory values.


   Results Top


30 paediatric and 105 adult patients were tested. [Table 1] Of the 30 paediatric patients, 3 patients had BSL between 110 and 125 mg%, and only one child had a BSL of 200 mg%. Of 105 adult patients, 10 patients were found to have BSL between 110 and 125 mg%, and 7 patients had BSL above 125 mg%, the highest being 230 mg%.
Table 1: Pre-operative venous glucose values of the patients

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   Discussion Top


India ranks the highest globally for the number of diabetes mellitus patients.[4] As high as 50–70% patients remain undiagnosed, presenting directly with diabetic complications.[4] The incidence and prevalence of diabetes mellitus Type 2 are as high as 8–45% in various populations.[1]

The spectrum of inpatient hyperglycaemia includes (a) undiagnosed diabetes, (b) stress-induced hyperglycaemia (SIH) and (c) IFG and impaired glucose tolerance (pre-diabetes stage).[5] Undiagnosed diabetics are patients in whom hyperglycaemia persists even after discharge from hospital.[5] Persistent hyperglycaemia may lead to many complications such as exacerbated inflammation, delayed wound healing, infection and cardiovascular complications.[3],[5] SIH has been defined as transient hyperglycaemia occurring only during times of stress such as surgery and anaesthesia, due to excessive secretion of hormones such as glucagon, corticosteroids, epinephrine and pro-inflammatory mediators, such as cytokines; with no prior history of diabetes.[3],[5] Not only adults but also infants and paediatric patients can have hyperglycaemia in response to perioperative stress.[6],[7],[8] Egi et al. have found an increased mortality in hyperglycaemia requiring insulin in critical care setting in patients without diabetes as compared to those with diabetes inspite of lower average blood sugar values.[9] It has been postulated that undiagnosed diabetes and SIH both act through different pathological pathways to produce adverse effects.[9]

Fasting BSLs are not done routinely as a part of pre-anaesthetic checkup in younger patients.[2] Thus, diabetes may be missed in many of them inspite of a hospital admission. Two most commonly used tests for diabetes screening are fasting and post-prandial BSLs.[4] In the immediate pre-anaesthetic period, these patients are already fasting for 8–10 h. Without giving an additional prick to the patient, venous sugar levels can easily be checked in these patients.

Grek et al. proved this to be cost-effective and easily implemented screening test for pre-operative hyperglycaemia.[10] Comparison of blood sugar values obtained from the glucometer have been compared with laboratory values, with different glucometers, different sites and both capillary and venous blood, and have been found to be similar or slightly higher than the reference laboratory values.[11],[12],[13],[14] Only those paediatric patients whose veins could be cannulated with 22G IV cannula were included as it is very difficult to collect the blood residue from IV cannulas of 24G and below.

The main limitation of this study was the lack of post-operative follow-up. Estimation of HbA1c postoperatively can be used for further screening of inpatient diabetes, which we did not do.[3]


   Conclusion Top


Pre-operative screening on the operating table, especially in patients under 40 years age, can be effective and useful in bringing a large patient population in the purview of hyperglycaemia screening. Any patient with high perioperative blood glucose levels needs to undergo further evaluation later in an unstressed ambulatory setting.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Alberti G, Zimmet P, Shaw J, Bloomgarden Z, Kaufman F, Silink M; Consensus Workshop Group. Type 2 diabetes in the young: The evolving epidemic: The international diabetes federation consensus workshop. Diabetes Care 2004;27:1798-811.  Back to cited text no. 1
    
2.
Committee on Standards and Practice Parameters, Apfelbaum JL, Connis RT, Nickinovich DG; American Society of Anesthesiologists Task Force on Preanesthesia Evaluation, Pasternak LR, Arens JF, et al. Practice advisory for preanesthesia evaluation: An updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology 2012;116:522-38.  Back to cited text no. 2
    
3.
Lena D, Kalfon P, Preiser JC, Ichai C. Glycemic control in the intensive care unit and during the postoperative period. Anesthesiology 2011;114:438-44.  Back to cited text no. 3
    
4.
Somannavar S, Ganesan A, Deepa M, Datta M, Mohan V. Random capillary blood glucose cut points for diabetes and pre-diabetes derived from community-based opportunistic screening in India. Diabetes Care 2009;32:641-3.  Back to cited text no. 4
    
5.
Sheehy AM, Gabbay RA. An overview of preoperative glucose evaluation, management, and perioperative impact. J Diabetes Sci Technol 2009;3:1261-9.  Back to cited text no. 5
    
6.
Wolf AR. Effects of regional analgesia on stress responses to pediatric surgery. Paediatr Anaesth 2012;22:19-24.  Back to cited text no. 6
    
7.
Yang LQ, Li JJ, Chen SQ, Wang YW. Effect of different depths of anesthesia on perioperative stress response in children undergoing adenoidectomy and tonsillectomy. CNS Neurosci Ther 2013;19:134-5.  Back to cited text no. 7
    
8.
Chorney JM, Kain ZN. Behavioral analysis of children's response to induction of anesthesia. Anesth Analg 2009;109:1434-40.  Back to cited text no. 8
    
9.
Egi M, Bellomo R, Stachowski E, French CJ, Hart GK, Hegarty C, et al. Blood glucose concentration and outcome of critical illness: The impact of diabetes. Crit Care Med 2008;36:2249-55.  Back to cited text no. 9
    
10.
Grek S, Gravenstein N, Morey TE, Rice MJ. A cost-effective screening method for preoperative hyperglycemia. Anesth Analg 2009;109:1622-4.  Back to cited text no. 10
    
11.
Ullal A, Parmar GM, Chauhan PH. Comparison of glucometers used in hospitals and in outpatient settings with the laboratory reference method in a tertiary care hospital in Mumbai. Indian J Endocrinol Metab 2013;17 Suppl 3:S688-93.  Back to cited text no. 11
    
12.
Kumar G, Sng BL, Kumar S. Correlation of capillary and venous blood glucometry with laboratory determination. Prehosp Emerg Care 2004;8:378-83.  Back to cited text no. 12
    
13.
Agarwal MM, Dhatt GS, Safraou MF. Gestational diabetes: Using a portable glucometer to simplify the approach to screening. Gynecol Obstet Invest 2008;66:178-83.  Back to cited text no. 13
    
14.
Marley JV, Davis S, Coleman K, Hayhow BD, Brennan G, Mein JK, et al. Point-of-care testing of capillary glucose in the exclusion and diagnosis of diabetes in remote Australia. Med J Aust 2007;186:500-3.  Back to cited text no. 14
    



 
 
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