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My Patient’s HgbA1c Is 8.6 but Trying to Get It Under Control

My Patient’s HgbA1c Is 8.6 but Trying to Get It Under Control. Michael A. Kelly, MD Chairman Orthopedic Surgery Hackensack University Medical Center Chairman and Professor Hackensack Meridian School of Medicine at Seton Hall. Disclosures. Zimmer Biomet: Royalties IP/Consultant

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My Patient’s HgbA1c Is 8.6 but Trying to Get It Under Control

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  1. My Patient’s HgbA1c Is 8.6 but Trying to Get It Under Control Michael A. Kelly, MD Chairman Orthopedic Surgery Hackensack University Medical Center Chairman and Professor Hackensack Meridian School of Medicine at Seton Hall

  2. Disclosures • Zimmer Biomet: Royalties IP/Consultant • Acuitive Technologies: Consultant/Stock • Flexion: Speakers Bureau • Sanofi: Scientic Advisory Board • Healthtrust: Consultant • Think Surgical: Board Member • Blue Horizon International: Scientific Advisory Board

  3. Diabetes Mellitus • Established risk factor for osteoarthritis • Prevalence 2x population w/ TJA • Undiagnosed DM, pre-diabetes common in TJA • Clear risk factor for SSI and PJI

  4. Pre-op TJA Assessment • ICM-PJI meeting Philadelphia-DM • 2018-96% agreement • Routine screening has potential to reduce risk of SSI/PJI • Consensus level of evidence • Allows early detection DM & optimization • Critical for CMS bundles performance Shohat, N et. al ICM 2018

  5. Laboratory Markers Assessing DM,GlycemicPeri-operative Control • Lack consensus-multiple studies,ICM 2018 • HgbA1c level – multiple studies • 7.5%-8% • Random glucose >200 mg/dL • Fasting glucose >126 mg/dL

  6. Increased Post-operative Glucose Variability Is Associated with Adverse Outcomes… • Increased risk of post op infections • Increased LOS, mortality • Markers assessing glycemic control – no consensus • Maintaining glucose control w/in narrow range benefits all TJA patients • Suggested range: 70 – 140 Shohat, N et. al JBJS Vol. 100 2018

  7. Biomarker: Fructosamine • Pre-op marker • Measures average glucose levels 14-21 days • Maybe better for fluctuations and rapid variations in glucose • Short term fluctuations in glucose may impair host defenses vs. infection • Suggested value 292mmol/L Shohat, N et. al ICM Phil 2018

  8. This Patient • No consensus for optimal level pre-op HgbA1c • Acceptable levels 7.5 – 8% • HUMC – 8.0% • Clearly at increased risk for SSI and PJI • Consult endocrine service DM

  9. This Patient • Additional markers • Random glucose (< 200 mg/dL) • Fasting glucose (<126 mg/dL) • Fructosamine (292 mmol/L)

  10. This Patient • Difficult to optimize HgbA1c • Hard stop < 7% only 45% patients achieved pre op- Gioriet al • Reasonable to proceed TJA after best optimization • Careful peri-op monitoring and glucose control with endocrine service • Manage co-morbid issues (obesity,hypertension) Giori, NJ et. al JBJS 2014

  11. Summary • Clear relationship of DM & peri-op glycemic control with increased risk of SSI / PJI • Routine pre-op screening recommended by many – large % of patients undiagnosed DM or pre-diabetic with similar risks • Endocrinology service with special interest in DM and PJI = valuable asset • No clear consensus on optimal biomarker levels – continue research necessary

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