An uncommon complication of laparoscopic live donor nephrectomy.

Chylous ascites is an uncommon complication of laparoscopic live donor nephrectomy, occurring when milky chyle from the lymphatic system leaks into the peritoneal cavity. This can occur after trauma or be caused by obstruction of the lymphatic system. Treatment may include a fat-free diet, total parenteral nutrition, subcutaneous somatostatin, lymphangiography, and/or surgical closure of the leaking lymph vessel.

Transitioning insulin pump therapy from the outpatient to the inpatient setting: a review of 6 years' experience with 253 cases.

BACKGROUND: We reviewed the care of a large cohort of patients with diabetes mellitus on insulin pump therapy who required an inpatient stay. METHODS: Records were reviewed of patients hospitalized between January 1, 2006, and December 31, 2011. RESULTS: A total of 136 patients using insulin pumps had 253 hospitalizations. Mean (standard deviation) patient age was 55 (16) years, diabetes duration was 29 (15) years, and pump duration was 6 (5) years. Insulin pump therapy was continued in 164 (65%) hospitalizations. Adherence to core process measures improved over time: by 2011, 100% of cases had an endocrinology consultation, 100% had the required insulin pump order set completed, and 94% had documentation of the signed agreement specifying patient responsibilities for continued use of the technology while hospitalized. Documentation of the insulin pump flow sheet also increased but could still be located in only 64% of cases by the end of 2011. Mean glucose was not significantly different among patients who remained on insulin pump therapy compared to those for whom it was discontinued (p > .1), but episodes of severe hyperglycemia (>300 mg/dl) and hypoglycemia (<40 mg/dl) were significantly less common among pump users. No pump site infections, mechanical pump failures, or episodes of diabetic ketoacidosis were observed among patients remaining on therapy. CONCLUSIONS: With appropriate patient selection and usage guidelines, most patients using insulin pumps can safely have their therapy transitioned to the inpatient setting. Further study is needed to determine whether this approach can be translated to other hospital settings.

Insulin pump therapy in the perioperative period: a review of care after implementation of institutional guidelines.

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.

Guidelines for application of continuous subcutaneous insulin infusion (insulin pump) therapy in the perioperative period.

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 in patients with diabetes undergoing surgery.

OBJECTIVE: To assess perioperative management of patients with diabetes mellitus who were being treated with insulin pump therapy. METHODS: We reviewed records for documentation of insulin pump status and glucose monitoring during preoperative, intraoperative, and postanesthesia care unit (PACU) phases of surgery. RESULTS: 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. CONCLUSIONS: 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.

Temporal and geographic patterns of hypoglycemia among hospitalized patients with diabetes mellitus.

BACKGROUND: Hypoglycemia is often cited as a barrier to achieving inpatient glycemic targets. We sought to characterize hypoglycemic events in our institution by work-shift cycle and by specific treatment area. METHODS: Capillary (bedside) and blood (laboratory) glucose values of <70 mg/dl for patients with either a known diagnosis of diabetes or with evidence of hyperglycemia were abstracted from our laboratory database for hospitalizations between October 1, 2007, and February 3, 2008. Hypoglycemic events were analyzed by 12 h nursing work-shift cycles (day shift, 07:00 to 18:59; night shift, 19:00 to 06:59) and by the six medical, surgical, and intensive care areas in the hospital (designated areas 1 to 6). RESULTS: We identified 206 individual patients with either diabetes or hyperglycemia (mean age, 67 years; 56% men; 83% white) who had 423 hypoglycemic events. There were 78% more hypoglycemic events during the night shift (n = 271 events in 128 individual patients) than during the day shift (n = 152 events in 96 individual patients). Most of the night-shift hypoglycemic measurements were detected between 04:00 and 04:59 or 06:00 and 06:59. The mean hypoglycemic level was comparable between shifts (p = .79) and across the six inpatient areas. The number of hypoglycemic events per person increased with lengths of hospital stay >5 days. The prevalence of hypoglycemia varied across patient care areas within the hospital, with most (28%) detected in one area of the hospital. CONCLUSION: There are temporal and geographic patterns in the occurrence of hypoglycemia among patients with diabetes or hyperglycemia in our hospital. Further study should focus on the reasons underlying these variations so that specific interventions can address the risk of hypoglycemia during peak times and places.

Beliefs about hospital diabetes and perceived barriers to glucose management among inpatient midlevel practitioners.

PURPOSE: The purpose of this study is to explore attitudes among inpatient midlevel practitioners about hospital hyperglycemia and to identify perceived barriers to care. METHODS: A questionnaire previously applied to resident physicians was administered to midlevel providers (physician assistants and nurse practitioners) to determine their beliefs about the importance of inpatient glucose control, their perceptions about what glucose ranges were desirable, and the problems they encountered when trying to manage hyperglycemia in the hospital. Barriers to care reported in this study were also combined with responses from the prior resident survey. RESULTS: Most respondents indicated that glucose control was very important in critically ill, noncritically ill, and perioperative patients. However, most felt only somewhat comfortable treating hyperglycemia and hypoglycemia and with using subcutaneous insulin; respondents expressed the least amount of confidence with using insulin infusions and insulin pumps. Respondents were not familiar with existing institutional polices and preprinted order sets relating to glucose management. The most commonly reported barrier to hyperglycemia management in the hospital was lack of familiarity with how to useinsulin, a finding that persisted after analyzing composite resident and midlevel responses. CONCLUSIONS: Most midlevel providers acknowledged the importance of good glucose control in the hospital. Lack of familiarity with how to use insulin in the hospital was the most commonly cited barrier to care. Educational programs should heavily emphasize inpatient treatment strategies.

Use of continuous subcutaneous insulin infusion (insulin pump) therapy in the hospital: a review of one institution's experience.

BACKGROUND: This article reviews the performance of our hospital's inpatient insulin pump policy. METHODS: Twenty-five hospital admissions of 21 unique patients receiving outpatient insulin pump therapy were reviewed. RESULTS: 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. CONCLUSIONS: 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.