Percentage of adult patients with a perioperative glucose >200 mg/dL with administration of insulin (IV or SubQ) or a glucose recheck within 90 minutes and documented glucose < 200 mg/dL.

Surgical and anesthetic stress increases hyperglycemia incidence in both diabetics and non-diabetics.^3,22 Perioperative hyperglycemia is mediated by the release of proinflammatory cytokines (e.g., TNF-alpha and IL-6) and elevated concentrations of catecholamines, growth hormone, glucagon, and glucocorticoids.⁴ These mediators induce metabolic alterations in carbohydrate balance that alter peripheral glucose uptake and utilization, increase gluconeogenesis, depress glycogenesis, and induce glucose intolerance and insulin resistance.  Hyperglycemia can also be drug induced (administration of steroids).

Acute hyperglycemia in the perioperative period is known to increase the incidence of wound infections, overall mortality, length of stay, acute kidney injury, and delayed wound healing. ^{2,5,7, 8-12} Use of insulin to correct perioperative hyperglycemia decreases the risk of hospital complications and mortality in cardiac and general surgery patients.^{6, 12} The American Association of Clinical Endocrinologists and American Diabetes Association recommend a treatment threshold of 180 mg/dL in critically ill hospitalized patients and a preprandial blood glucose goal of 140 mg/dL in non-critically hospitalized ill patients.¹³ The Society for Ambulatory Anesthesia, American Association of Clinical Endocrinologists, The Society for Thoracic Surgery, and the Joint British Diabetes Society also recommend blood glucose management <180 mg/dL.^{14, 15,16, 17, 18} The ADA 2019 guidelines call for perioperative blood glucose ranges from 80-180mg/dL..¹⁹ Patients undergoing anesthesia are at risk of hypoglycemia as the effects of anesthesia can mask the symptoms of hypoglycemia; however, conventional glucose targets of <180 mg/dL have not been associated with significant risk of hypoglycemia.^1,20,21 Frequent blood glucose monitoring after insulin administration is recommended. Intraoperative glucose levels should be checked every 2 hours or more frequent and insulin infusions should be monitored at least hourly.³ A relatively high threshold glucose level (greater than 200 mg/dL) is used for this measure to alleviate concerns that patients undergoing general anesthetics are at risk of overtreatment and hypoglycemia.¹

Preop start to PACU end

• All patients with a documented blood glucose level greater than 200 mg/dL between Preop Start and PACU End.
• Patients with and without diagnosis of diabetes.

• Age < 12 years
• ASA 5 & 6 including Organ Procurement (CPT: 01990)
• Cases with measure duration (Preop Start to PACU End) ≤ 30 minutes
• Cesarean Delivery Cases (determined by Obstetric Anesthesia Type value codes: 1, 2, 7)
• Documented blood glucose <200 within 90 minutes of a blood glucose >200 mg/dL excludes the glucose >200mg/dL
• Glucose measurements > 200 mg/dL within 90 minutes before measure end
• Labor Epidurals (determined by Obstetric Anesthesia Type value codes: 3 & 6 including obstetric non-operative procedures - CPT: 01958)
• Outpatient cases with Anesthesia Duration <4 hours long

Administration of insulin within 90 minutes of blood glucose >200 mg/dL

• Each blood glucose is evaluated separately.  
• The measure evaluates the following conditions for each high glucose, prioritized in this order. If *none* of the conditions are true for a given high glucose, the case is marked as flagged
  1. Glucose value resulted within 90 minutes of measure end = value excluded
  2. An insulin administration was given within 90 minutes of the high glucose = value passes
  3. An insulin infusion is active when the high glucose was resulted = value passes (Note: If no end time is available for an insulin infusion, the ‘measure end time’ will be considered the insulin infusion end time.)
  4. Another glucose value < 200 was resulted within 90 minutes of the high glucose = value passes
  5. Insulin SQ adjustment: Insulin SQ was administered within 120 minutes before high glucose value = value excluded
• If any of the values for a case are considered flagged, the case is flagged. If all values are excluded for a case, case is excluded from the measure. 
• Insulin doses sent to MPOG outside the measure time period will be included for evaluation.

*This measure will include valid MPOG cases defined by the Is Valid Case phenotype.

Not applicable

Preop start to Anesthesia Start: The first anesthesia provider(s) signed into the case

Anesthesia Start to Anesthesia End: The provider(s) signed in at the first glucose recheck or first administration of insulin. If neither occurred, then the responsible provider is the one signed in 90 minutes after the high glucose measurement.

Anesthesia End to PACU End: The last anesthesia provider(s) signed into the case.

1. Akhtar, Shamsuddin, Paul G. Barash, and Silvio E. Inzucchi. 2010. “Scientific Principles and Clinical Implications of Perioperative Glucose Regulation and Control.” Anesthesia and Analgesia 110 (2): 478–97.
2. Bellusse, Gislaine Cristhina, Julio Cesar Ribeiro, Isabel Cristina Martins de Freitas, and Cristina Maria Galvão. 2019. “Effect of Perioperative Hyperglycemia on Surgical Site Infection in Abdominal Surgery: A Prospective Cohort Study.” American Journal of Infection Control, December. https://doi.org/10.1016/j.ajic.2019.11.009.
3. Duggan, Elizabeth W., Karen Carlson, and Guillermo E. Umpierrez. 2017. “Perioperative Hyperglycemia Management: An Update.” Anesthesiology 126 (3): 547–60.
4. Esposito, Katherine, Francesco Nappo, Raffaele Marfella, Giovanni Giugliano, Francesco Giugliano, Myriam Ciotola, Lisa Quagliaro, Antonio Ceriello, and Dario Giugliano. 2002. “Inflammatory Cytokine Concentrations Are Acutely Increased by Hyperglycemia in Humans: Role of Oxidative Stress.” Circulation 106 (16): 2067–72.
5. Frisch, Anna, Prakash Chandra, Dawn Smiley, Limin Peng, Monica Rizzo, Chelsea Gatcliffe, Megan Hudson, et al. 2010. “Prevalence and Clinical Outcome of Hyperglycemia in the Perioperative Period in Noncardiac Surgery.” Diabetes Care 33 (8): 1783–88.
6. Furnary, Anthony P., Guangqiang Gao, Gary L. Grunkemeier, Yingxing Wu, Kathryn J. Zerr, Stephen O. Bookin, H. Storm Floten, and Albert Starr. 2003. “Continuous Insulin Infusion Reduces Mortality in Patients with Diabetes Undergoing Coronary Artery Bypass Grafting.” The Journal of Thoracic and Cardiovascular Surgery 125 (5): 1007–21.
7. Gandhi, Gunjan Y., Gregory A. Nuttall, Martin D. Abel, Charles J. Mullany, Hartzell V. Schaff, Brent A. Williams, Lisa M. Schrader, Robert A. Rizza, and M. Molly McMahon. 2005. “Intraoperative Hyperglycemia and Perioperative Outcomes in Cardiac Surgery Patients.” Mayo Clinic Proceedings. Mayo Clinic 80 (7): 862–66.
8. Kotagal, Meera, Rebecca G. Symons, Irl B. Hirsch, Guillermo E. Umpierrez, E. Patchen Dellinger, Ellen T. Farrokhi, David R. Flum, and SCOAP-CERTAIN Collaborative. 2015. “Perioperative Hyperglycemia and Risk of Adverse Events among Patients with and without Diabetes.” Annals of Surgery 261 (1): 97–103.
9. Kwon, Steve, Rachel Thompson, Patchen Dellinger, David Yanez, Ellen Farrohki, and David Flum. 2013. “Importance of Perioperative Glycemic Control in General Surgery: A Report from the Surgical Care and Outcomes Assessment Program.” Annals of Surgery 257 (1): 8–14.
10. Mendez, Carlos E., Paul J. Der Mesropian, Roy O. Mathew, and Barbara Slawski. 2016. “Hyperglycemia and Acute Kidney Injury During the Perioperative Period.” Current Diabetes Reports 16 (1): 10.
11. Ramos, Margarita, Zain Khalpey, Stuart Lipsitz, Jill Steinberg, Maria Theresa Panizales, Michael Zinner, and Selwyn O. Rogers. 2008. “Relationship of Perioperative Hyperglycemia and Postoperative Infections in Patients Who Undergo General and Vascular Surgery.” Annals of Surgery 248 (4): 585–91.
12. Umpierrez, Guillermo E., Scott D. Isaacs, Niloofar Bazargan, Xiangdong You, Leonard M. Thaler, and Abbas E. Kitabchi. 2002. “Hyperglycemia: An Independent Marker of in-Hospital Mortality in Patients with Undiagnosed Diabetes.” The Journal of Clinical Endocrinology and Metabolism 87 (3): 978–82.
13. Moghissi, Etie S., Mary T. Korytkowski, Monica DiNardo, Daniel Einhorn, Richard Hellman, Irl B. Hirsch, Silvio E. Inzucchi, et al. 2009. “American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient Glycemic Control.” Diabetes Care 32 (6): 1119–31.
14. Joshi, Girish P., Frances Chung, Mary Ann Vann, Shireen Ahmad, Tong J. Gan, Daniel T. Goulson, Douglas G. Merrill, Rebecca Twersky, and Society for Ambulatory Anesthesia. 2010. “Society for Ambulatory Anesthesia Consensus Statement on Perioperative Blood Glucose Management in Diabetic Patients Undergoing Ambulatory Surgery.” Anesthesia and Analgesia 111 (6): 1378–87.
15. Moghissi, Etie S., Mary T. Korytkowski, Monica DiNardo, Daniel Einhorn, Richard Hellman, Irl B. Hirsch, Silvio E. Inzucchi, et al. 2009. “American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient Glycemic Control.” Diabetes Care 32 (6): 1119–31.
16. Lazar, Harold L., Marie McDonnell, Stuart R. Chipkin, Anthony P. Furnary, Richard M. Engelman, Archana R. Sadhu, Charles R. Bridges, et al. 2009. “The Society of Thoracic Surgeons Practice Guideline Series: Blood Glucose Management during Adult Cardiac Surgery.” The Annals of Thoracic Surgery 87 (2): 663–69.
17. Dhatariya, K., N. Levy, A. Kilvert, B. Watson, D. Cousins, D. Flanagan, L. Hilton, et al. 2012. “NHS Diabetes Guideline for the Perioperative Management of the Adult Patient with Diabetes.” Diabetic Medicine: A Journal of the British Diabetic Association 29 (4): 420–33.
18. Duggan, Elizabeth, and York Chen. 2019. “Glycemic Management in the Operating Room: Screening, Monitoring, Oral Hypoglycemics, and Insulin Therapy.” Current Diabetes Reports 19 (11): 134.
19. American Diabetes Association. 2019. “15. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes-2019.” Diabetes Care 42 (Suppl 1): S173–81.
20. NICE-SUGAR Study Investigators, Simon Finfer, Dean R. Chittock, Steve Yu-Shuo Su, Deborah Blair, Denise Foster, Vinay Dhingra, et al. 2009. “Intensive versus Conventional Glucose Control in Critically Ill Patients.” The New England Journal of Medicine 360 (13): 1283–97.
21. NICE-SUGAR Study Investigators, Simon Finfer, Bette Liu, Dean R. Chittock, Robyn Norton, John A. Myburgh, Colin McArthur, et al. 2012. “Hypoglycemia and Risk of Death in Critically Ill Patients.” The New England Journal of Medicine 367 (12): 1108–18.
22. Dungan, Kathleen M., Susan S. Braithwaite, and Jean-Charles Preiser. 2009. “Stress Hyperglycaemia.” The Lancet 373 (9677): 1798–1807.