Archive September 2013 XIV, No. 9

Infection Prevention: Reducing SSIs in Diabetics

Glucose control is just one part of a much bigger picture.

Ron Olson, MD

glucose levels BALANCING ACT Using insulin to lower glucose levels can decrease some risks while simultaneously increasing others.

We know surgical site infections are common in diabetic patients, and even more common in patients (known diabetics and others) with higher pre-operative glucose and hemoglobin A1C levels. Insulin normalizes glucose and also has anti-inflammatory benefits that are known to reduce SSIs in diabetics and non-diabetics. So you'd probably assume that using pre-operative insulin infusions to reduce glucose levels would reduce the risk of SSIs and overall morbidity.

Not necessarily.

While it's true that high glucose produces an environment that interferes with healing and predisposes patients to infections, it's likely that many of the SSIs suffered by diabetics come from secondary conditions, such as neuropathy and microcirculatory deficits. And those are conditions that can't be changed quickly. In addition, stress increases glucose levels, so high glucose may be as much a marker of increased perioperative risk as a cause of it. Complicating matters further is the fact that while high glucose is bad, so is low glucose. You may reduce some risks by lowering glucose levels, but you also might increase others.

It's easy to say that patients with poor glucose control simply shouldn't have elective surgery, but unfortunately, some patients are unlikely to ever achieve great control. In some cases, the reason for surgery — for example, infection or inflammation — is contributing to the poor glucose control. So postponing surgery probably won't provide a significant short-term net benefit. All of which begs the question: What's the best way to deal with the propensity of diabetic patients to develop surgical site infections?

Control glucose with caution
Use the pre-operative assessment as an opportunity to optimize glucose control. Tight glucose control is a noble goal — but only if you're also adequately monitoring to detect and treat hypoglycemia. Ultimately, you need to balance how much control you can safely achieve. It may be safer and more practical to accept "loose" control of hyperglycemia, as the benefits of tighter control may not warrant what it takes to avoid the dangers of hypoglycemia.

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