Investigating Glycemic Control in Patients Undergoing Lower Extremity Bypass Within an Enhanced Recovery Pathway at a Single Institution

Enhanced recovery pathways (ERPs) have been used with success in several surgical subspecialties including colorectal surgery and cardiovascular surgery. Vascular ERPs for lower extremity bypass also associated improved patient outcomes regarding length of stay after index operation. The primary goal is to reduce perioperative physiological stress. This achieved a multimodal fashion by limiting preoperative fasting, optimizing pain control, early initiation postoperative nutrition, involvement physical rehabilitation. In ERPs, as part limited duration fast, patients are recommended glucose load via clear carbohydrate drink up 2 hours before unless contraindicated comorbidities. Preoperative loading has shown decrease metabolic stress return bowel function, hospital However, there paucity research the management diabetic within vascular glycemic control postoperatively. Poor period an increased rate site infection worse overall outcomes. Given high prevalence diabetes among patients, we sought determine effects on operative We performed retrospective review undergoing infrainguinal at our institution from January 2016 July 2022; ERP was implemented May 2018. Patient data implementation prospectively collected since this time. Patients were stratified diagnosis hemoglobin A1C (HbA1C) levels. Perioperative then compared between (GL) non-GL (NGL) groups. Early hyperglycemia (EPH) designated blood (BG) >180 mg/dL first 24 Average values each day GL NGL addition, indication revascularization (claudication, rest pain, or tissue loss), compared. Finally, such infection, readmission, reinterventions, complications χ2 tests categorical variable comparison 2-sided t-tests continuous variables. cohort consisted 393 identified electronic health record 161 pre-ERP group 232 group. There no demographic differences Overall, 42% diabetics, 44.5% these GL. All ERP. Regarding demographics contained more non-White (44.8% vs 34.7%; P = .041) had number (36.9% 48.9%; .016). Otherwise, similar average age 64.7 ± 9.4 63.5 9.7 Evaluating revealed that 72.6% GL-diabetic experienced EPH 44.0% (95% confidence interval [CI]; ≤ .001). Although trend toward greater rates seen all glucose-loaded groups, when HbA1C, significantly higher only HbA1c >8 90.3% 59.3% CI; .006) (Table). Looking beyond immediate period, median BG levels averaged different groups trends across days Fig. statistically significant difference observed (POD) 1, 66.1% above threshold 180 29.3% NGL-diabetic (P .001) (Fig). dissipates POD 3. 2, 3 206 65 mg/dL, 226 89 194 72 176 56 166 61 170 58 respectively. To assess sensitivity using daily levels, repeated analysis maximum values. yielded results postoperatively well throughout stay. Hypoglycemic events (BG <70 mg/dL) cohorts explored. one experiencing hypoglycemic Beyond hours, less than three per hypoglycemia cohort. Interestingly, further claudication, loss if procedural indication, particularly wound presence, confounding factor EPH. follow demonstrated Fig regardless indication. Within postoperatively, 69.2% claudication 87% 64.9% .168). 35% 45% 48% .633). did not affect control. Despite reintervention, 30 days. percentage experience (9.3% 14%; .474) (26.7% 34.4%; .316) likely due fact exclusively potentially benefited additional enhanced components routine care poor perioperatively. severe, uncontrolled HbA1C appear be risk Nondiabetic however, comparable low hyperglycemia. GL, clinical 30-day infections may directly attributed presence absence principles oral intake regimens hold potential associations later phases course during hospitalization. given current study, it benefit poorly controlled withhold ERPs.TablePatients perioperatively comparing nonglucose (HbA1C)Nonglucose loadersGlucose loadersP valueHbA1C <6.417.5% (n 10)24.5% 24).314 6.5-845.8% 11)61.8% 23).23 >859.3% 11)90.3% 28).006Diabetic (DM) Non-DM6.2% 6)22.5% 28).001 DM44.0% 40)72.6% 53)<.001DM, Diabetes mellitus. Open table new tab