Perioperative challenges in management of diabetic patients undergoing non-cardiac surgery

Prediabetes and diabetes are important disease processes which have several perioperative implications.About one third of the United States population is considered to have prediabetes.The prevalence in surgical patients is even higher.This is due to the associated micro and macrovascular complications of diabetes that result in the need for subsequent surgical procedures.A careful preoperative evaluation of diabetic patients and patients at risk for prediabetes is essential to reduce perioperative mortality and morbidity.This preoperative evaluation involves an optimization of preoperative comorbidities.It also includes optimization of antidiabetic medication regimens,as the avoidance of unintentional hypoglycemic and hyperglycemic episodes during the perioperative period is crucial.The focus of the perioperative management is to ensure euglycemia and thus improve postoperative outcomes.Therefore,prolonged preoperative fasting should be avoided and close monitoring of blood glucose should be initiated and continued throughout surgery.This can be accomplished with either analysis in blood gas samples,venous phlebotomy or point-of-care testing.Although capillary and arterial whole blood glucose do not meet standard guidelines for glucose testing,they can still be used to guide insulin dosing in the operating room.Intraoperative glycemic control goals may vary slightly in different protocols but overall the guidelines suggest a glucose range in the operating room should be between 140 mg/dL to 180 mg/dL.When hyperglycemia is detected in the operating room,blood glucose management may be initiated with subcutaneous rapid-acting insulin,with intravenous infusion or boluses of regular insulin.Fluid and electrolyte management are other perioperative challenges.Notably diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic state are the two most serious acute metabolic complications of diabetes that must be recognized early and treated.

A longitudinal study of SARS-CoV-2-infected patients reveals a high correlation between neutralizing antibodies and COVID-19 severity

Understanding the immune responses elicited by SARS-CoV-2 infection is critical in terms of protection against reinfection and,thus,for public health policy and vaccine development for COVID-19.In this study,using either live SARS-CoV-2 particles or retroviruses pseudotyped with the SARS-CoV-2 S viral surface protein(Spike),we studied the neutralizing antibody(nAb)response in serum samples from a cohort of 140 SARS-CoV-2 qPCR-confirmed infections,including patients with mild symptoms and also more severe forms,including those that required intensive care.We show that nAb titers correlated strongly with disease severity and with anti-spike IgG levels.Indeed,patients from intensive care units exhibited high nAb titers;conversely,patients with milder disease symptoms had heterogeneous nAb titers,and asymptomatic or exclusive outpatient-care patients had no or low nAbs.We found that nAb activity in SARS-CoV-2-infected patients displayed a relatively rapid decline after recovery compared to individuals infected with other coronaviruses.Moreover,we found an absence of cross-neutralization between endemic coronaviruses and SARS-CoV-2,indicating that previous infection by human coronaviruses may not generate protective nAbs against SARS-CoV-2.Finally,we found that the D614G mutation in the spike protein,which has recently been identified as the current major variant in Europe,does not allow neutralization escape.Altogether,our results contribute to our understanding of the immune correlates of SARS-CoV-2-induced disease,and rapid evaluation of the role of the humoral response in the pathogenesis of SARS-CoV-2 is warranted.