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Cover of Evidence review for blood glucose control management

Evidence review for blood glucose control management

Perioperative care in adults

Evidence review K

NICE Guideline, No. 180

.

London: National Institute for Health and Care Excellence (NICE); .
ISBN-13: 978-1-4731-3827-8

1. Blood glucose control management

1.1. Review question: What is the clinical and cost effectiveness of blood glucose control management in adults undergoing surgery?

1.2. Introduction

The prevalence of diabetes in the general UK population is thought to be about 6.5% but data from the 2017 National Diabetes Inpatient Audit (NaDIA) suggests that on average across the UK 18% of all inpatients have diabetes, and for people presenting for surgery this figure is probably higher. As well as having increased length of stay, as a result of complications, surgical patients with diabetes have increased mortality. Complications not only cause immediate patient harm, but patients who have suffered perioperative complications continue to experience increased morbidity for several years. It is therefore necessary to prevent perioperative complications. Non-diabetic patients are also a risk of complication from hyperglycemia.

NaDIA 2017 identified that harm to inpatients with diabetes has multiple causes including hypoglycaemia, hospital acquired diabetic ketoacidosis, medication errors and inappropriate use of insulin infusions. There has been much debate on whether the benefits of tight glycaemic control with insulin outweigh the risk of harm from hypoglycaemia caused by intensive insulin therapy with intravenous insulin infusions.

Current NICE recommendations suggest that adults with type1 diabetes should aim for a fasting plasma glucose level of 5–7mmol/litre in the community and 5–8mmol/ litre during surgery or acute illness. The purpose of this review is to determine whether these recommendations are applicable to people with type 2 diabetes and non-diabetic people.

1.3. PICO table

For full details see the review protocol in appendix A.

Table 1. PICO characteristics of review question.

Table 1

PICO characteristics of review question.

1.4. Clinical evidence

1.4.1. Included studies

Thirty randomised controlled trials were included in the review;1, 5, 9, 26, 27, 31, 32, 39–43, 52, 55, 59, 60, 74, 77, 78, 113, 114, 120, 137, 142, 143, 146, 153, 157, 159, 162, 166, 169, 170 these are summarised in Table 2 below. Evidence from these studies is summarised in the clinical evidence summary below (Table 3).

See also the study selection flow chart in appendix C, study evidence tables in appendix D, forest plots in appendix E and GRADE tables in appendix F.

1.4.2. Excluded studies

See the excluded studies list in appendix I.

1.4.3. Summary of clinical studies included in the evidence review

Table 2. Summary of studies included in the evidence review.

Table 2

Summary of studies included in the evidence review.

See appendix D for full evidence tables.

1.4.4. Quality assessment of clinical studies included in the evidence review

Table 3. Clinical evidence summary: Glucose control versus standard care.

Table 3

Clinical evidence summary: Glucose control versus standard care.

Table 4. Evidence not suitable for GRADE analysis: Glucose control versus standard care.

Table 4

Evidence not suitable for GRADE analysis: Glucose control versus standard care.

See appendix F for full GRADE tables.

1.5. Economic evidence

1.5.1. Included studies

No health economic studies were included.

1.5.2. Excluded studies

No relevant health economic studies were excluded due to assessment of limited applicability or methodological limitations.

See also the health economic study selection flow chart in Appendix G:.

1.6. Evidence statements

1.6.1. Clinical evidence statements

No evidence was identified for health-related quality of life or unplanned ICU admission.

Glucose control versus standard care
Mortality

Twenty one studies demonstrated a clinically important benefit of glucose control in 30-day mortality compared to and standard care (21 studies, n=5623, moderate quality evidence).

Five studies showed no clinically important difference in mortality after 1 year between glucose control and standard care (5 studies, n=3087, moderate quality evidence).

Adverse events

Three studies found a clinically important benefit of glucose control for the number of post-operative complications compared to standard care (3 studies, n=298, moderate quality evidence).

Seven studies showed no clinically important difference in pulmonary complications between glucose control and standard care (7 studies, n=1138, low quality evidence).

Twelve studies showed no clinically important difference in cardiovascular complications between glucose control and standard care (12 studies, n=3868, high quality evidence).

Two studies showed no clinically important difference in cardiovascular complications (cardiac complications) between glucose control and standard care (2 studies, n=306, low quality evidence).

Four studies showed no clinically important difference in cardiovascular complications (cardiac arrest) between glucose control and standard care (4 studies, n=1332, moderate quality evidence).

Two studies showed no clinically important difference in cardiovascular complications (myocardial infarction) between glucose control and standard care (2 studies, n=469, low quality evidence).

Seven studies showed no clinically important difference in cardiovascular complications (atrial fibrillation) between glucose control and standard care (7 studies, n=2305, high quality evidence).

One study showed no clinically important difference in cardiovascular complications (arrhythmia) between glucose control and standard care (1 study, n=381, low quality evidence).

One study showed no clinically important difference in cardiovascular complications (sternal instability) between glucose control and standard care (1 study, n=75, low quality evidence).

Five studies showed no clinically important difference in neurological complications (neurological deficit) between glucose control and standard care (5 studies, n=1726, high quality evidence).

Five studies showed no clinically important difference in neurological complications (stroke) between glucose control and standard care (5 studies, n=1521, low quality evidence).

Infection

Seventeen studies showed no clinically important difference for infections between glucose control and standard care (17 studies, n=3948, high quality evidence).

Hypoglycaemic events

Twenty two studies showed no clinically important difference for hypoglycaemic events between glucose control and standard care (21 studies, n=5665, high quality evidence).

Length of hospital stay

Ten studies showed no clinically important difference in length of hospital stay between glucose control and standard care (10 studies, n=1081, moderate quality evidence).

Length of ICU stay

Eleven studies showed no clinically important difference in length of ICU stay between glucose control and standard care (11 studies, n=1145, low quality evidence).

Readmissions

Two studies showed no clinically important difference in hospital readmissions between glucose control and standard care (2 studies, n=478, moderate quality evidence).

Evidence not suitable for GRADE analysis

Two studies found no statistically significant difference in quality of life between glucose control and standard care (2 studies, n=644, high risk of bias).

Seven studies showed no statistically significant difference in length of hospital stay between glucose control and standard care (7 studies, n=2865, low risk of bias).

Five studies showed no statistically significant difference in length of ICU stay between glucose control and standard care (5 studies, n=2668, high risk of bias).

Three studies showed a trend to harm with glucose control for hypoglycaemic events compared to standard care.

Two studies showed a statistically significant benefit with tight glucose control for risk of infection compared to standard care (2 studies, n=149, very high risk of bias).

1.6.2. Health economic evidence statements

  • No relevant economic evaluations were identified.

1.7. The committee’s discussion of the evidence

Please see recommendations 1.4.6 – 1.4.7 in the guideline.

1.7.1. Interpreting the evidence

1.7.1.1. The outcomes that matter most

The committee highlighted that inadequate glucose control is associated with risk of increased length of stay as a result of complications and even increased mortality. There has also been debate as to whether the benefits of tight glycaemic control with insulin outweighs the risk of harm from hypoglycaemia caused by intensive insulin therapy with intravenous insulin infusions. As such, the committee considered critical outcomes for decision making to be health-related quality of life, mortality, adverse events and complications, infections and hypoglycaemia, and important outcomes to be length of hospital stay, unplanned ICU admission, ICU length of stay and hospital readmission

No evidence was identified for health-related quality of life or unplanned ICU admission.

1.7.1.2. The quality of the evidence

The quality of evidence that was suitable for GRADE analysis ranged from low to high. The majority of the evidence was graded at moderate quality. This was mostly due to imprecision of data, reducing the certainty with which the committee could make conclusions from the evidence. The committee felt that the evidence presented was of sufficient quality and quantity to support the recommendations made.

1.7.1.3. Benefits and harms

The committee reviewed the body of evidence comparing tight glucose control to standard care.

Across most of the outcomes there was little evidence of clinically important difference between the two glucose control methods.

There was a visible trend of more hypoglycaemic events with tight glucose control, although this difference did not meet the threshold of clinically important difference. The committee felt that this was still a significant observation, given the significance of hypoglycaemic events and the efforts that should be made to avoid such outcomes.

Evidence showed a slight increase in risk in mortality at 30 days, although this difference was not seen at 1 year post-operatively. The committee considered that across all of the evidence from mortality, there was little to suggest a significant impact from glucose control.

Evidence from three studies showed a lower risk of post-operative complications with tight glucose control. However, evidence from seven studies showed no difference in pulmonary complications, evidence from 13 studies showed no difference in cardiovascular complications, and evidence from 10 studies showed no difference in neurological complications. There was also no evidence of difference in rate of infections, length of hospital stay, length of ICU stay or hospital readmissions.

The committee agreed that people undergoing surgery may require some blood glucose control to reduce the risk of infections, but also that healthcare professionals should endeavour to avoid the adverse events such as hypoglycaemic events from lowering a patient’s blood sugar too much in an attempt to achieve a tight blood glucose control due to the serious health implications. The committee added that a more liberal blood glucose control may allow planned surgery to go ahead even if the person undergoing surgery’s blood sugar is outside of the optimum range, where this surgery may have otherwise been unnecessarily cancelled.

1.7.2. Cost effectiveness and resource use

No economic evaluations were identified for this question.

The clinical review showed that there was little evidence of an important difference between the two blood glucose control methods. The committee highlighted that both forms of blood glucose control would require monitoring the patient during surgery, which requires nurse time. The amount of insulin required to maintain the adequate blood glucose level varies between people, but with tight glucose control it may require more insulin and additional staff time as the patients are being monitored more strictly. Conclusions could not be made regarding the cost effectiveness of tight blood glucose control during surgery due to the clinical evidence not showing a benefit, and that it may lead to an increase in resource use.

The committee acknowledged that the recommendation would not lead to a substantial resource impact as current practice across most centres is to not routinely aim for tight blood glucose control.

1.7.3. Other factors the committee took into account

The committee recognised the importance of consulting with an inpatient specialist diabetes team before decisions around blood glucose monitoring and diabetes management are made during perioperative surgery.

The committee discussed that the range for blood glucose could be 6–10 mmol/L was desirable but this was not the focus of the evidence review.

The committee noted that patients who undergo surgery often develop a hypermetabolic stress response, which is characterised by hyperglycaemia and insulin resistance. The committee suggested that hyperglycaemia can often be an index of the stress the patient is undergoing perioperatively. The aim of intensive or tight glucose control is to achieve normoglycemia, although the evidence showed no overall clinical benefit to this strategy.

The committee were aware of a large body of research conducted in ICU medical patients reviewing the efficacy of tight glucose control. The committee noted that this evidence suggested an increased risk of hypoglycaemic events with tight glucose control. The committee considered this evidence when making a recommendation for patients undergoing surgery.

The recommendation will prevent surgical cancellations if a patient does not have optimised glucose control.

The committee were aware of the recommendations on target blood glucose in the NICE guideline of type 2 diabetes (NG28)

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Appendices

Appendix B. Literature search strategies

The literature searches for this review are detailed below and complied with the methodology outlined in Developing NICE guidelines: the manual 2014, updated 2018.108

For more detailed information, please see the Methodology Review.

B.1. Clinical search literature search strategy

Searches were constructed using a PICO framework where population (P) terms were combined with Intervention (I) and in some cases Comparison (C) terms. Outcomes (O) are rarely used in search strategies for interventions as these concepts may not be well described in title, abstract or indexes and therefore difficult to retrieve. Search filters were applied to the search where appropriate.

Table 7. Database date parameters and filters used

Medline (Ovid) search terms

Embase (Ovid) search terms

Cochrane Library (Wiley) search terms

Epistemonikos (Epistemonikos Foundation) search terms

B.2. Health Economics literature search strategy

Health economic evidence was identified by conducting a broad search relating to the perioperative care population in NHS Economic Evaluation Database (NHS EED – this ceased to be updated after March 2015) and the Health Technology Assessment database (HTA) with no date restrictions. NHS EED and HTA databases are hosted by the Centre for Research and Dissemination (CRD). Additional health economics searches were run on Medline and Embase.

Table 8. Database date parameters and filters used

Medline (Ovid) search terms

Embase (Ovid) search terms

NHS EED and HTA (CRD) search terms

Appendix D. Clinical evidence tables

Download PDF (760K)

Appendix H. Health economic evidence tables

None.

Appendix I. Excluded studies

I.2. Excluded health economic studies

Published health economic studies that met the inclusion criteria (relevant population, comparators, economic study design, published 2003 or later and not from non-OECD country or USA) but that were excluded following appraisal of applicability and methodological quality are listed below. See the health economic protocol for more details.

Table 11. Studies excluded from the health economic review

Final

Evidence reviews underpinning recommendations 1.4.6 and 1.4.7 in the NICE guideline

This evidence review was developed by the National Guideline Centre

Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and, where appropriate, their carer or guardian.

Local commissioners and providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.

Copyright © NICE 2020.
Bookshelf ID: NBK561962PMID: 32931169

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