What are the four most important red flags that a patient can present?
This talk, which is moderated by Giles R. Scuderi, M.D., was part of this past December’s 2018 Orthopaedic Summit in Las Vegas and the four participants, Michael A. Kelly, M.D., Peter K. Sculco, M.D., Edward MacPherson, M.D., and Adolph V. Lombardi, Jr., M.D., F.A.C.S., each identified the four top red flags that all orthopedic physicians should pay attention to.
Check them out and see if you agree.
RED FLAG #1: “My Patient’s HgbA1c is 8.6 but Trying to Get it Under Control.”
Michael A. Kelly, M.D.: Diabetes mellitus is an established risk factor for osteoarthritis. When you screen for it, you find that a large percentage of your patients are undiagnosed with diabetes or pre-diabetic.
About 96% of 500 surgeons from around the world attending International Consensus Meeting-Periprosthetic Joint Infection agreed that routine screening has the potential to reduce the risk of SSI or PJI. This allows early detection and optimization. It’s the only way we can risk-stratify the Medicare bundles and the various commercial bundles we’re going to be involved in. It’s crucial for successful CMS [Centers for Medicare and Medicaid Services] bundles, particularly now as we get to regional payments.
Laboratory markers assessing diabetes mellitus or glycemic peri-operative control.
Hemoglobin A1c levels lack consensus. Is there a number where above this number you have a high risk, below it you’re a little bit less risk, but at the same time you’re not just disallowing patients who would really have a successful total knee replacement change their life? That number is somewhere 7.5-8%. If you get too low you’re really keeping people away from an operation that may be very beneficial to them.
Random glucose—greater than or equal to 200 mg/dL. Fasting glucose is around 126 mg/dL.
Increased post-operative glucose variability is associated with adverse outcomes. If there is an increased risk of post-operative infection, there is an increased length of stay, as well as increased mortality. It is a benefit of maintaining glucose control within a narrow range in these total joint patients. Suggested range from 70-140 on random glucose variations.
- Parvizi published papers in the last year suggesting that this fluctuation in rapid variations in glucose is probably more important either than maintaining a level of glucose as well as higher levels of standard glucose and/or hemoglobin A1c and they look at a level of fructosamine—a preoperative marker that goes out over a longer period of time. It may be better for fluctuations in rapid variations and the value is 292 mmol/L.
Careful perioperative monitoring and glucose control using your endocrine service where indicated and manage your co-morbid issues.
