Blood glucose management in the patient undergoing cardiac surgery: A review

Both diabetes mellitus and hyperglycemia per se are associated with negative outcomes after cardiac surgery. In this article, we review these associations, the possible mechanisms that lead to adverse outcomes, and the epidemiology of diabetes focusing on those patients requiring cardiac surgery. We also examine outpatient and perioperative management of diabetes with the same focus. Finally, we discuss our own efforts to improve glycemic management of patients undergoing cardiac surgery at our institution, including keys to success, results of implementation, and patient safety concerns.

Balancing act:The dilemma of rapid hyperglycemia correction in diabetes management

The global diabetes surge poses a critical public health challenge,emphasizing the need for effective glycemic control.However,rapid correction of chronic hyperglycemia can unexpectedly trigger microvascular complications,necessitating a reevaluation of the speed and intensity of glycemic correction.Theories suggest swift blood sugar reductions may cause inflammation,oxidative stress,and neurovascular changes,resulting in complications.Healthcare providers should cautiously approach aggressive glycemic control,especially in long-standing,poorly controlled diabetes.Preventing and managing these complications requires a personalized,comprehensive approach with education,monitoring,and interdisciplinary care.Diabetes management must balance short and longterm goals,prioritizing overall well-being.This editorial underscores the need for a personalized,nuanced approach,focusing on equilibrium between glycemic control and avoiding overcorrection.

Diagnosis and management of insulinoma

Insulinomas,the most common cause of hypoglycemia related to endogenous hyperinsulinism,occur in 1-4 people per million of the general population.Common autonomic symptoms of insulinoma include diaphroresis,tremor,and palpitations,whereas neuroglycopenenic symptoms include confusion,behavioural changes,personality changes,visual disturbances,seizure,and coma.Diagnosis of suspected cases is based on standard endocrine tests,especially the prolonged fasting test.Non-invasive imaging procedures,such as computed tomography and magnetic resonance imaging,are used when a diagnosis of insulinoma has been made to localize the source of pathological insulin secretion.Invasive modalities,such as endoscopic ultrasonography and arterial stimulation venous sampling,are highly accurate in the preoperative localization of insulinomas and have frequently been shown to be superior to noninvasive localization techniques.The range of techniques available for the localization of insulinomas means thatblind resection can be avoided.Intraoperative manual palpation of the pancreas by an experienced surgeon and intraoperative ultrasonography are both sensitive methods with which to finalize the location of insulinomas.A high proportion of patients with insulinomas can be cured with surgery.In patients with malignant insulinomas,an aggressive medical approach,including extended pancreatic resection,liver resection,liver transplantation,chemoembolization,or radiofrequency ablation,is recommended to improve both survival and quality of life.In patients with unresectable or uncontrollable insulinomas,such as malignant insulinoma of the pancreas,several techniques should be considered,including administration of ocreotide and/or continuous glucose monitoring,to prevent hypoglycemic episodes and to improve quality of life.

WJD 5^(th) Anniversary Special Issues(2): Type 2 diabetes Structured SMBG in early management of T2DM: Contributions from the St Carlos study

Diabetes mellitus type 2(T2DM)is a global pandemic that will affect 300 million people in the next decade.It has been shown that early and aggressive treatment of T2DM from the onset decreases complications,and the patient’s active role is necessary to achieve better glycemic control.In order to achieve glycemic control targets,an active attitude in patients is needed,and selfmonitoring of blood glucose(SMBG)plays a significant role.Nowadays,SMBG has become an important component of modern therapy for diabetes mellitus,and is even more useful if it is performed in a structured way.SMBG aids physicians and patients to achieve a specific level of glycemic control and to prevent hypoglycemia.In addition,SMBG empowers patients to achieve nutritional and physical activity goals,and helps physicians to optimize the different hypoglycemic therapies as demonstrated in the St Carlos study.This article describes the different ways of using this educational and therapeutic tool from the medical point of view as well as from the patient’s perspective.

Doctor-reported hospital management of acute coronary syndrome in China: A nationwide survey of 1029 hospitals in 30 provinces

Background: Despite recent improvements in the hospital treatment of ACS, little is known about current cardiological practice in China or use of evidence-based approach in Chinese hospitals. Methods: A questionnaire about doctor-reported hospital management of ACS was posted to the head of the cardiology department of 1397 hospitals across 30 provinces of China. Reported use of various clinical procedures and treatments were analysed and compared between different types of hospital. Results: Of the 1029 (74%) hospitals that responded, 43% were tier III (tertiary) hospitals. For STEMI, primary PCI was used as the main reperfusion therapy by 50.2% of tier III and 9.3% of tier II/I (secondary) hospitals. Most of hospitals also used various proven therapy routinely for STEMI and NSTEMI/UA, including anti-platelet therapy (98% and 93%), anticoagulant (96% and 90%), statin (97% and 94%), oral β-blockers (87% and 86%) and ACE-I (88% and 83%). However, certain therapies with little or no proven value (eg, G.I.K., magnesium and Chinese tradition medicine) remained used routinely by 25% - 40% of tier II/I hospitals. After discharge, statin, antiplatelet, β-blockers and ACE-I were reportedly used routinely by 85% - 95% of the responders for secondary prevention. Conclusions: With a few exceptions, doctor-reported hospital management of ACS in China is largely consistent with that recommended by current guidelines. Large nationwide registries are needed to assess long-term adherence to treatments after hospital discharge.

Intrapartum application of the continuous glucose monitoring system in pregnancies complicated with diabetes: A review and feasibility study

Intrapartum maternal normoglycemia seems to play an important role in the prevention of adverse perinatal, maternal and neonatal outcomes. Several glucose monitoring protocols have been developed, aiming to achieve a tight glucose monitoring and control. Depending on the type of diabetes and the optimal or suboptimal glycemic control, the treatment options include fasting status of the parturient, frequent monitoring of capillary blood glucose, intravenous dextrose infusion and subcutaneous or intravenous use of insulin. Continuous glucose monitoring system(CGMS) is a relatively new technology that measures interstitial glucose at very short time intervals over a specifi c period of time. The resulting profi le provides a more comprehensive measure of glycemic excursions than intermittent home blood glucose monitoring. Results of studies applying the CGMS technology in patients with or without diabetes mellitus(DM) have revealed new insights in glucose metabolism. Moreover, CGMS have a potential role in the improvement of glycemic control during pregnancy and labor, which may lead to a decrease in perinatal morbidity and mortality. In conclusion, the use of CGMS, with its important technical advantages compared to the conventional way of monitoring, may lead into a more etiological intrapartum management of both the mother and her fetus/infant in pregnancies complicated with DM.

Effectiveness of Clinical Pharmacist Directed-Diabetes Management

Objective: The main aim of the study is predominately utilizing clinical pharmacist in the provision of continuing diabetic education programs to emphasize and re-emphasize the importance of risk factors, prevention, adherence to medication and behavioral changes to prevent recurrences of the disease, their progression, and ultimately minimize hospitalization. Specific goals are to improve clinical outcomes for patients with diabetes—to maintain optimal plasma glucose concentrations Fasting, Postprandial Plasma Glucose, and Glycated Hemoglobin. Study design: A prospective interventional study in the Outpatient General Medicine Department, for a period of six months from October 2018 to March 2019. Results: HbA1c levels were reduced from baseline by −1.107 ± 0.8634, Fasting Plasma Glucose levels and Postprandial blood glucose levels were reduced from baseline by −24.2218 ± 5.70352 and −30.1891 ± 1.40592 respectively. Conclusion: A trained clinical pharmacist by providing diabetes education and care can significantly reduce hyperglycemia, thereby improving the quality of life in diabetes patients and ultimately reducing health care costs associated with these morbidities.

A Study of Evaluation for the Management of Diabetes in Bangladesh

Diabetes Mellitus is a leading cause of death in present world. This study was carried out to evaluate the management, control, complication profile and treatment strategies in patients with diabetes and to determine what extent management of diabetes in a tertiary-care diabetic hospital in Bangladesh adhered to current guidelines. Total 140 diabetic pa- tients (type-1 = 3, type-2 = 137) were randomly selected from outpatient department of a tertiary care diabetic hospital in the Rajshahi city, Bangladesh, during the month of August to September. A standard questionnaire was constructed in local language and interview was administrated. The result was expressed as mean ± SD and the age was 53.2 ± 10.5 yr, duration of diabetes was 6.3 ± 5.6 yr and age at the onset of diabetes was 46.9 ± 9.9 yr. The study group comprised of about 43% male and 57% female with varying risk factors including family history (49%), smoking (11%) and both smoking and family history (4%). Results showed deteriorating glycemic control with mean FBG (fasting blood glucose) and PPG (postprandial blood glucose) level was 8.9 ± 3.6 mmol/L and 11.2 ± 4.7 mmol/L respectively. About 25% patients had FBG level < 6.1 mmol/L, 24% had FBG 6.1 - 7.8 mmol/L and rest 51% had FBG > 7.8 mmol/L. Of the 51% patients with hypertension, 94% were taking anti-hypertensive medicine and 21% patients with dyslipidemia, 59% were treated with lipid lowering agents. Micro-vascular and Macro-vascular complications were reported in 49% and 11% patients respectively. The rates of diabetic complications were cataract 19%, diabetic retinopathy 14%, neuropathy symptoms 35%, nephropathy 6%, MI 6%, cerebral stroke 4% and history of angina pectoris was 7%. Proportion of patients on diet control alone, oral hypoglycemic agent (OHA), insulin and combination of insulin & OHA was 10, 44, 25 and 21 percent respectively. Quality of life evaluation showed that about half of patients have poor quality of life as well as poor adherence to diet, exercise and self testing of blood glucose. In conclusion, majority of the patients were still not satisfactorily controlled. There is an urgent need for effective remedial measures to increase adherence to practice guidelines and to educate both patients and healthcare personnel on importance of achieving clinical targets for metabolic control.

Nurse Documentation in Deteriorating Patients Prior to In-hospital Cardiac Arrest--A Pilot Study in A Swedish University Hospital

Presence of abnormal vital signs prior to IHCA and consequently higher mortality has been found in numerous studies. It is unknown whether abnormal vital signs are acted upon or not and how this affects the outcome of the IHCA. Aim： Compare differences in journal notes regarding abnormal vital signs or worry by nurses up until 24 h between survivors and non-survivors after an in-hospital cardiac arrest （IHCA）. Design： Pragmatic retrospective case-control study in a Swedish university hospital. Methods： All IHCA during 2007-2011 was reviewed （n = 720）. Out of them, 20 （3%） fulfilled the inclusion criteria; survived 30 d, had their IHCA at a general ward, were aged 〉 18 years and had documented abnormal vital signs or nurse worries. Out of the non-survivors, two controls were after matching for age, sex and number of diseases randomly drawn for each case. Pearson＇s chi test was used to assess significance on the level of 0.05 in differences between survivors and non-survivors. Results： Of 20 survivors with preceding abnormal vital signs prior to IHCA, 15 patients （75%） had documented worries or action taken by a nurse compared to 23 patients （58%） among non-survivors （p-value： 0.258）. Conclusion： The journal documentation 24 h prior to a 1HCA was fairly equal in numbers between patients surviving at least 30 d afterwards compared to those not surviving, but the content of the journal notes had a slightly higher, but not statistical significant, frequency of worry or action taken by attending nurses in survivors.

Insulin Requirements and Management in Trans-Catheter vs. Surgical Aortic Valve Replacement

Objective: Trans-catheter Aortic Valve Replacement/Aortic Valve Implantation (TAVR) are increasingly performed today. We compared insulin requirements between TAVR and Surgical Aortic Valve Replacement (SAVR) patients with and without diabetes mellitus (DM) to determine optimal glucose management strategies during the perioperative period (POP). Methods: Charts of consecutive patients undergoing aortic procedures were retrospectively reviewed for glucose ranges, insulin requirements and routes of insulin administration (subcutaneous vs. intravenous) for patients with and without DM to maintain BG Results: Patients with SAVRs without DM and A1C Conclusions: TAVR patients have different insulin requirements compared to SAVRs (p < 0.05). This information helps build a glucose management algorithm for a procedure which is increasingly performed.

Effect of Case Management for Patients with Gestational Diabetes

Objective:To explore the effect of allocating case managers for gestational diabetes patients.Methods:200 patients with gestational diabetes mellitus from December 2021 to December 2022 were included in this study,and the collection period.They were divided into groups according to the interventions received.Each patient in the observation group was managed by a case manager,while the control group were managed with conventional methods without the supervision of a case manager.There were 100 cases in each group,and the curative effects of the two groups were compared.Results:The fasting blood glucose and 2-hour postprandial blood glucose in the observation group were significantly lower than those of the control group(P<0.05).The re-admission rate of patients due to poor blood sugar control in the observation group was lower than that in the control group(P<0.05).The pregnancy outcome of the observation group was better than that of the control group(P<0.05).Conclusion:Case management of gestational diabetes can not only control the blood glucose of pregnant women,but also improve pregnancy outcomes.

Unsatisfactory Glucose Management and Adverse Pregnancy Outcomes of Gestational Diabetes Mellitus in the Real World of Clinical Practice： A Retrospective Study

Background：Facing the increasing prevalence of gestational diabetes mellitus （GDM）,this study aimed to evaluate the management of GDM and its association with adverse pregnancy outcomes.Methods：The data of 996 inpatients with GDM who terminated pregnancies in our hospital from January 2011 to December 2015 were collected.Treatments during pregnancy and the last hospital admission before delivery were analyzed.Pregnancy outcomes of the GDM patients were compared with 996 nondiabetic subjects matched by delivery year and gestational age.The association between fasting plasma glucose （FPG） and adverse pregnancy outcomes was examined by logistic regression analyses.Results：The average prevalence of GDM over the 5 years was 4.4％ （1330/30,191）.Within the GDM patients,42.8％ （426/996） received dietary intervention,whereas 19.1％ （190/996） received insulin treatment.Adverse outcomes were more likely to occur in patients with unsatisfactory control of blood glucose such as respiratory distress syndrome （RDS,x2 =13.373,P ＜ 0.01）.Elevated FPG was identified as an independent risk factor for premature birth （odds ratio [OR] =1.460,P ＜ 0.001）,neonatal care unit admission （OR =1.284,P ＜ 0.001）,RDS （OR=1.322,P =0.001）,and stillbirth （OR =1.427,P ＜ 0.001）.Conclusions：Management of GDM in the real world of clinical practice was unsatisfactory,which might have contributed to adverse pregnancy outcomes.

互联网自我管理模式对2型糖尿病患者血糖控制和自我管理水平的影响

目的探讨基于互联网的自我管理模式对2型糖尿病(T2DM)患者血糖控制和自我管理水平的影响。方法选取我院2021年6月至2022年12月收治的138例T2DM患者,经随机数字表法分为试验组(n=69)及对照组(n=69),对照组予以常规健康管理,试验组予以基于互联网的自我管理模式。比较两组血糖、血压及体重控制情况、干预前后代谢指标、自我管理水平[采用中文版糖尿病自我管理活动问卷(SDSCA)]及生活质量[采用糖尿病生存质量量表(DSQL)]。结果干预后,两组糖化血红蛋白、空腹血糖(FPG)、餐后2 h血糖、舒张压、收缩压、体质量指数均低于干预前,且试验组低于对照组(P<0.05);两组低密度脂蛋白胆固醇、总胆固醇及甘油三酯均低于干预前,且试验组低于对照组(P<0.05);两组足部护理、血糖监测、运动及饮食等维度评分均高于干预前,且试验组高于对照组(P<0.05);两组治疗、社会关系、心理、生理功能等维度评分均低于干预前,且试验组低于对照组(P<0.05)。结论基于互联网的自我管理模式有利于T2DM患者控制血糖、血压及体重控制,能改善患者代谢指标,提高管理水平及生活质量。

免疫检查点抑制剂诱导高血糖癌症患者血糖管理的最佳证据总结

目的总结免疫检查点抑制剂诱导高血糖癌症患者血糖管理的最佳证据,为临床管理此类患者提供依据。方法以循证“6S”证据模型自上而下系统检索中国知网、万方数据库、维普资讯、中华医学会网、中国生物医学文献数据库、BMJ最佳临床实践、Up To Date、PubMed、EBSCO、Web of Science、CINAHL、Embase、Cochrane Library、英国国家卫生与临床优化研究所网站、国际指南协作网、加拿大安大略省注册护士协会网站、苏格兰校际指南网络、澳大利亚乔安娜布里格斯研究所循证卫生保健中心数据库、美国国立综合癌症网络、美国临床肿瘤学会、美国国立实践技术指南库、国际内分泌学会、欧洲肿瘤内科学会、癌症免疫治疗学会、英国糖尿病协会联合住院治疗组、美国内分泌学会、英国内分泌学会等专业网站或数据库中关于免疫检查点抑制剂诱导高血糖管理的中文和英文文献,文献类型包括随机对照试验、临床决策、系统评价/Meta分析、专家共识、实践指南等,检索时间为建库至2024年6月30日。由2名接受过培训的研究者依据文献质量评价标准独立进行评价,对纳入的文献逐条提取证据并汇总。结果共纳入9篇文献,其中指南7篇、专家共识1篇、临床决策1篇。汇总了免疫检查点抑制剂诱导高血糖癌症患者血糖管理的32条最佳证据,包括监测与早期识别、治疗与护理、健康教育、血糖控制目标、内分泌专科团队管理等5个方面。结论本研究汇总了免疫检查点抑制剂诱导高血糖癌症患者血糖管理的32条最佳证据,在临床实践过程中,医护人员可根据患者的具体情况选择使用。

饮食营养健康管理对妊娠期糖尿病患者的产前血糖水平、自我管理行为的影响

目的探讨妊娠期糖尿病患者实施饮食营养健康管理对其血糖水平、自我管理行为的影响。方法回顾性选取2021年1月—2023年6月枣庄市妇幼保健院收治的86例妊娠期糖尿病患者的临床资料,按照护理方式的不同,分为观察组与对照组,各43例。对照组患者实施常规护理干预,观察组患者在对照组基础上进行饮食营养健康管理。干预后比较两组患者自我管理能力、血糖水平。结果干预后,观察组患者各维度糖尿病自我管理行为量表评分均高于对照组,差异有统计学意义(P均<0.05)。观察组餐后2 h血糖、空腹血糖、糖化血红蛋白水平低于对照组,差异有统计学意义(P均<0.05)。结论饮食营养健康管理用于妊娠期糖尿病患者护理中可改善妊娠期糖尿病患者自我管理行为,从而提升血糖控制效果。

基于赋权教育的自我管理干预对农村糖尿病患者的影响

目的探讨实施基于赋权教育的自我管理干预对农村糖尿病患者自我管理能力的效果。方法选取内分泌科住院的78例农村糖尿病患者为研究对象,按照入院时间顺序分成对照组(2022年6-10月)和观察组(2022年11月至2023年3月)各39例。观察组接受基于赋权教育模式的自我管理方案;对照组接受常规的糖尿病宣教方案。比较两组干预后血糖控制水平、自我管理能力和疾病态度。结果观察组34例、对照组35例完成研究。两组出院当日,出院后3、6个月患者自我管理能力、糖尿病态度得分显著高于对照组,空腹血糖值显著低于对照组(均P<0.05)。结论实施基于赋权教育的自我管理方案可改善农村糖尿病患者对疾病的态度和血糖控制水平,提高自我管理能力。

基于血糖优化的早期间断肠内营养在心脏瓣膜置换术后应激性高血糖患者中的应用

目的探讨基于血糖优化干预的早期间断肠内营养方案在心脏瓣膜置换术后合并应激性高血糖患者中的应用效果。方法构建血糖优化干预后的早期间断肠内营养方案,前瞻性分析2022年5月—2023年5月上海市某三级甲等医院心胸外科重症监护室心脏瓣膜置换术后合并应激性高血糖患者158例,按时间先后顺序分为对照组(n=78)和观察组(n=80),对照组采用常规肠内营养与血糖管理方案,观察组采用基于血糖优化干预的早期间断肠内营养方案。比较2组患者血糖管理质量指标及营养相关结局指标。结果实施基于血糖优化管理的早期间断肠内营养方案后,观察组最大血糖波动幅度、胰岛素使用时间及低血糖发生率明显低于对照组(P<0.05),葡萄糖目标范围内时间明显高于对照组,差异具有统计学意义(P<0.05);观察组患者营养相关指标(血清前清蛋白、血红蛋白、7 d热卡达标率)均高于对照组,差异均有统计学意义(P<0.05)。结论基于血糖优化干预的早期间断肠内营养方案可有效改善心脏瓣膜置换术后合并应激性高血糖患者的营养状态,减少血糖波动,提升血糖管理质量,具有一定的科学性和实用性。

1例糖原累积病Ⅳ型合并急性肝衰竭患儿急性期的护理

总结2022年7月我科收治的1例糖原累积病Ⅳ型(glycogen storage disease typeⅣ,GSDⅣ)合并急性肝衰竭患儿急性期的护理经验。护理要点:监测血流动力学,积极抗休克;监测消化道出血量,实施止血治疗;开展人工肝治疗及预防相关并发症;连续监测血糖,根据病情与血糖动态调整营养治疗方案;开展远程探视和音乐治疗。经过6 d的救治和护理,患儿病情好转,顺利进行肝移植。术后18 d好转出院;随访1年,恢复良好。

基于IMB模型的运动干预对妊娠期糖尿病孕妇血糖控制、自我管理能力及妊娠结局的影响

目的:探讨基于信息-动机-行为技巧模型(IMB模型)的运动干预对妊娠期糖尿病(GDM)孕妇血糖控制、自我管理能力及妊娠结局的影响。方法:将100例GDM患者根据干预方式的不同分为两组,予以常规运动干预的为对照组(n=50);予以基于IMB模型运动干预的为观察组(n=50)。两组均干预4周。比较两组干预前后GDM运动知、信、行水平[GDM运动知识-态度-行为问卷]、自我管理能力[孕妇自我保健管理评定问卷]、血糖水平[空腹血糖(FPG)、糖化血红蛋白(HbAlc)水平,餐后2 h血糖(2 hPG)],随访至患者分娩,比较两组患者血糖控制不佳入院率、孕期体重增长超标、分娩后口服葡萄糖耐量试验(OGTT)不达标率及妊娠结局。结果:相较于对照组,干预后,观察组GDM运动知识、态度及行为评分均更高(P<0.05);孕妇自我保健管理评定问卷总分及各维度评分均更高(P<0.05);观察组FBG、2 hPG及HbA1c均更低(P<0.05),血糖控制不佳入院、孕期体重增长超标及分娩后OGTT不达标总发生率均更低(P<0.05)。观察组患者妊娠不良结局总发生率均低于对照组(P<0.05)。结论:基于IMB模型的运动干预可提高GDM患者运动知、信、行水平及自我管理能力,有效控制患者血糖,改善母婴结局。

持续性4C管理对孕早期糖耐量异常患者糖控制水平、健康行为、自我护理能力、心理状态、母婴妊娠结局的影响

目的探讨持续性4C管理对孕早期糖耐量异常(IGT)患者糖控制水平、健康行为、自我护理能力、心理状态、母婴妊娠结局的影响。方法选取郑州市妇幼保健院2021年01月~2022年12月收治的98例孕早期IGT患者,根据入院顺序分为常规组(49例)和4C管理组(49例)。常规组采用常规护理服务,4C管理组在常规基础护理服务基础上采用持续性4C管理服务。干预后,比较两组血糖控制水平[空腹血糖(FBG)、餐后2 h血糖(2hPG)、糖化血红蛋白(HbA1c)]、健康行为、自我护理能力、心理状态(焦虑、抑郁)、母婴妊娠结局。结果干预后,4C管理组FBG、2hPG、HbA1c水平均低于常规组(P<0.05);4C管理组HPLP-Ⅱ评分、ESCA评分均高于常规组、SAS评分、SDS评分均低于常规组(P<0.05);4C管理组早产、剖宫产、巨大儿发生率分别为6.12%、8.16%、4.08%,均低于常规组的22.45%、32.65%、20.41%(P<0.05)。结论持续性4C管理可有效调节孕早期IGT患者机体血糖水平,提升其健康行为及自护能力,缓解其焦虑、抑郁情绪,促进其妊娠结局改善。