Lamanna Daniel L, McDonnell Marie E, Chen Antonia F, Gallagher John M
Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Boston, Massachusetts.
J Bone Joint Surg Am. 2022 Dec 7;104(23):2117-2126. doi: 10.2106/JBJS.22.00149. Epub 2022 Aug 24.
➤: The consequences of undermanaged perioperative hyperglycemia are notable and can have a serious impact on adverse postoperative outcomes, especially surgical site infections and periprosthetic joint infections (PJIs).
➤: Preoperative screening of hemoglobin A1c with a goal threshold of <7.45% is ideal.
➤: There are a variety of risk factors that contribute to hyperglycemia that should be considered in the perioperative period, including glucocorticoid use, nutritional factors, patient-specific factors, anesthesia, and surgery.
➤: There are expected trends in the rise, peak, and fall of postoperative blood glucose levels, and identifying and treating hyperglycemia as swiftly as possible are the fundamental aims of treatment and improved glucose control. Performing frequent postoperative blood glucose monitoring (in the post-anesthesia care unit, on the day of surgery at 1700 and 2100 hours, and in the morning of postoperative day 1) should be considered to allow for the early detection of alterations in glucose metabolism. In addition, instituting a postoperative dietary restriction of carbohydrates should be considered.
➤: The use of insulin as a hypoglycemic agent in orthopaedic patients is relatively safe and is an effective means of controlling fluctuating blood glucose levels. Insulin therapy should be administered to treat hyperglycemia at ≥140 mg/dL when fasting and ≥180 mg/dL postprandially. Insulin therapy should be ceased at blood glucose levels of <110 mg/dL; however, monitoring for glycemic dysregulation should be continued. In all cases of complex diabetes, consultation with diabetes specialty services should be considered.
➤: The emerging use of technology, including continuous subcutaneous insulin pump therapy and continuous glucose monitoring, is an exciting area of further research and development as such technology can more immediately detect and correct aberrations in blood glucose levels.
➤：围手术期高血糖管理不当的后果显著，会对术后不良结局产生严重影响，尤其是手术部位感染和人工关节周围感染（PJI）。
➤：术前筛查糖化血红蛋白，目标阈值<7.45%是理想的。
➤：围手术期应考虑多种导致高血糖的危险因素，包括糖皮质激素的使用、营养因素、患者特异性因素、麻醉和手术。
➤：术后血糖水平有上升、峰值和下降的预期趋势，尽快识别和治疗高血糖是治疗和改善血糖控制的基本目标。应考虑进行频繁的术后血糖监测（在麻醉后护理单元、手术当天17:00和21:00以及术后第1天上午），以便早期发现糖代谢变化。此外，应考虑在术后限制碳水化合物饮食。
➤：在骨科患者中使用胰岛素作为降血糖药物相对安全，是控制血糖波动的有效手段。空腹血糖≥140mg/dL和餐后血糖≥180mg/dL时，应给予胰岛素治疗以治疗高血糖。血糖水平<110mg/dL时应停止胰岛素治疗；然而，应继续监测血糖失调情况。对于所有复杂糖尿病病例，应考虑咨询糖尿病专科服务。
➤：包括持续皮下胰岛素泵治疗和持续血糖监测在内的技术的新应用是一个令人兴奋的进一步研究和开发领域，因为此类技术可以更即时地检测和纠正血糖水平异常。
