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Part III
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Surgical Specialties
Chapter 10
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Risk Reduction inDiabetic Patients
Undergoing Orthopaedic Surgery
MichaelS.Pinzur
Introduction
Most experts herald the 1999 publication from the Institute of Medicine, “To Err is
Human”, as the beginning of the “Patient Safety Movement” [1]. This seminal report
estimated that up to 98,000 deaths occurred yearly in the United States due to preventable errors occurring during the delivery of health care. Avoiding error became
the focus during the early phase of this paradigm shift. Early adopters borrowed on
the concepts of entropy that we learned in high school physics, appreciating that a
system left to its own devices, would revert to disorder. It was felt that this systemic
disorder was responsible for the errors that led to patient harm. Patient care pathways and clinical algorithms evolved as the methodology to standardize clinical
care and counteract these error-producing forces. They borrowed the principles of
decision support from the business world to develop clinical systems that were
designed to lessen the risk for deviation and error.
The by-product of this thinking was likely a strong motivating force that led to
the development of Hospitalist-Orthopaedic co-management programs. Introducing
internal medicine principles led to the development of clinical algorithms designed
to not only decrease the risk for error, but also decrease the risks of co-morbidity
disease-impact on clinical care. The nal step leading to the most forward thinking
delivery of health care was the asking the question when performing elective surgery … If we make sick patients less sick, will their clinical outcomes be improved?
This evolution in thinking allowed the Patient Safety Movement to evolve from the
simple avoidance of treatment errors, to the current approach that medically
M. S. Pinzur (*)
Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center,
Maywood, IL, USA
e-mail: mpinzu1@lumc.edu
Switzerland AG 2024
J. Faintuch, S. Faintuch (eds.), Recent Strategies in High Risk Surgery,
https://doi.org/10.1007/978-3-031-56270-9_10
161© The Author(s), under exclusive license to Springer Nature
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M. S. Pinzur
optimizes patients’ co-morbidities, thus allowing sick patients to take advantage of
modern clinical innovations at a reasonable risk tolerance.
The United States Centers for Disease Control currently estimates that there
are over 30 million diabetes in the United States, a number approaching 10% of
our population, with an estimated over 80 million additional individuals over 18
years of age being pre-diabetic [2]. This objective of this chapter to provide physicians the clinical tools to employ the modern methods of medical optimization for
complex diabetic patients undergoing emergent, urgent and elective Orthopaedic
Surgery [3].
Diabetic Organ System Disease
The primary initiator of diabetic organ system disease is the presence of elevated
blood sugar over time. Elevated blood sugar binds with hemoglobin within red
blood cells to form glycosylated hemoglobin, which is clinically measured as
hemoglobin A1C.This glycosylated hemoglobin leads to a release of free radicals, which damages the basement membrane of all vessels in the arterial tree,
leading to a similar level of disease expression in all key organ systems [4, 5]. We
have long viewed the presence of peripheral neuropathy, as measured by insensitivity to the Semmes- Weinstein 5.07 monolament, as an important risk factor in
diabetics (Fig.10.1). Instead of viewing insensitivity to the monolament as a risk
Fig. 10.1 Semmes-Weinstein 5.07 monolament. This monolament imparts 10 g of pressure to
the tuft of the hallux. When patients cannot, perceive this amount of pressure, they exhibit a level
of sensory peripheral neuropathy that is associated with other diabetic organ system disease. Long
thought of as a risk factor for associated organ system disease, this level of peripheral neuropathy
should be considered as a disease marker, as patients with peripheral neuropathy also have a level
of cardiac, pulmonary, renal disease and osteoporosis
10 Risk Reduction inDiabetic Patients Undergoing Orthopaedic Surgery
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factor, we should view the presence of peripheral neuropathy as a measure of
disease expression.
When caring for patients, we view the serum level of hemoglobin A1C, as a
measure of estimated serum glucose levels over the past 3 months. We use the measurement of serum glucose as a temporal measure of real-time blood sugar. It is this
measurement that allows the poorly controlled diabetic to develop both the acute
and chronic consequences of life-threatening ketoacidosis. Management of serum
glucose will be expanded when we discuss the hard stops of care for diabetic
patients.
163
Hospitalist Co-management
The increasing complexities associated with the delivery of complex medical
care led to the development of the Hospitalist, as a medical specialty. First
described by Wachter in 1996, the care of hospitalized medical patients has been
assumed by physicians who could focus on inpatient medical care, without the
associated stresses of an outpatient medical practice [6, 7]. Early adopters to the
Hospitalist patient care model expanded this concept to develop co-management
partnerships with Orthopaedic and other surgical colleagues. Patients could
then have the added advantage of medical expertise when clinical care could be
managed as a team effort. While these programs were not initially able to
improve the metrics of health care, experience has led to improved clinical outcomes, decreased rates of complications and hospital re-admissions, and substantial cost savings [8–11].
Most musculoskeletal care is currently provided in the ambulatory setting. Total
hip and knee arthroplasty is increasingly being performed on healthy individuals
without hospital admission. Therefore, virtually all patients undergoing inpatient
urgent or elective Orthopaedic surgery have sufcient medical co-morbidities to
warrant the routine utilization of a Hospitalist-Orthopaedic co-management patient
care model [12].
The Hard Stops
There are four medical co-morbidities that have clearly been associated with
increased rates of death, poor clinical outcomes, surgical site infections, perioperative complications, hospital re-admission and impaired metrics of health care [3,
13]. Glucose management in both diabetics and non-diabetics, cardio-pulmonary
function, anemia and hypertension, are the critical medical co-morbidities that must
be addressed, regardless of the nature of surgery. We call these four medical comorbidities hard stops, as they must be addressed when both performing emergent
or urgent surgery, and have the potential to be optimized prior to elective surgery.
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