An interdepartmental collaboration to improve preoperative glycemic control.

BACKGROUND: The Centers for Disease Control and Prevention estimates that 25.8 million adults in the United States have diabetes, and these patients experience higher rates of morbidity and mortality postoperatively than patients without diabetes. While several professional organizations have recommended tight glycemic control perioperatively, the data regarding preoperative glycemic control is only emerging. The hemoglobin A1c level, which reflects long-term glycemic control, has been shown to correlate with postoperative outcomes including length of stay, infections, and mortality. This relationship has implications for the preoperative surgical management of patients with diabetes. OBJECTIVES: Implemented in 2009, our interdepartmental initiative was designed to improve glycemic control within 5 to 7 days before surgery with a blood glucose target of 100 of 199 mg/dL the morning of surgery. An endocrinologist and a certified diabetes educator evaluate same-day urgent referrals from the anesthesia preoperative clinic, targeting high-risk patients with an HbA1c value of ≥ 9%, a random blood glucose level of ≥ 300 mg/dL, or a fasting blood glucose level of ≥ 240 mg/dL. Our team then creates an individualized preoperative treatment plan based on the patient's prior insulin regimen and diabetes self-management skills. Verbal and written instructions for insulin self-titration and guidance for insulin dose changes in preparation for a fasting state are included. DISCUSSION: : With this interdepartmental collaboration, as part of a larger institutional initiative, we hope to improve short- and long-term outcomes for surgical patients with uncontrolled diabetes, as well as improve costs and utilization of health care resources in our institution. Our glycemic control committee, which follows bimonthly metrics, including 90-day readmission rates for surgical patients, has noted a decline from 7.9% in 2009 to 4.5% in the 2012-2013 fiscal year. Our aggressive preoperative and postoperative blood glucose management has been a significant factor in this improvement.

Anesthetic Implications of Robotic Gynecologic Surgery.

Surgery using robotic techniques is becoming more and more common. One of the specialties at the fore-front of robotic surgery has been gynecology, much like it was at the fore-front a generation ago in bringing laparoscopy into the operating room. New considerations have been noted and new techniques have been learned on both sides of the drape in order to ensure a successful outcome for the patient undergoing robotic gynecologic surgery. The purpose of this article is to bring, to light the concerns facing the anesthesiologist in regards to robotic procedures. We discuss the problems facing anesthesiologists, when a patient is experiencing both intraabdominal insufflation and steep Trendelenburg position, and also the intraoperative management of such a patient.

Vagal nerve stimulation: overview and implications for anesthesiologists.

Vagal nerve stimulation is an important adjunctive therapy for medically refractory epilepsy and major depression. Additionally, it may prove effective in treating obesity, Alzheimer's disease, and some neuropsychiatic disorders. As the number of approved indications increases, more patients are becoming eligible for surgical placement of a commercial vagal nerve stimulator (VNS). Initial VNS placement typically requires general anesthesia, and patients with previously implanted devices may present for other surgical procedures requiring anesthetic management. In this review, we will focus on the indications for vagal nerve stimulation (both approved and experimental), proposed therapeutic mechanisms for vagal nerve stimulation, and potential perioperative complications during initial VNS placement. Anesthetic considerations during initial device placement, as well as anesthetic management issues for patients with a preexisting VNS, are reviewed.