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INFECTION PREVENTION
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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Set realistic goals
A pre-operative hemoglobin A1C of less than 7.5 and a glucose
level less than 120 mg/dl are practical goals for most facilities. How
far can you stray from those goals? It depends. The textbook answer
is that no surgery should be performed if hemoglobin A1C is greater
than 10 or blood glucose is greater than 250. But we all know patients
who live quite asymptomatically at much higher levels, and postponing surgery is not without risk, let alone inconvenience. It comes
down to a case-by-case determination. A skin graft warrants more
rigid standards for postponement than laparoscopy.
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