Assessing the Effectiveness of Continuous Glucose Monitoring in Enhancing Surgical Outcomes for Diabetic Patients

Assessing the Effectiveness of Continuous Glucose Monitoring Compared With Conventional Monitoring in Enhancing Surgical Outcomes for Diabetic Patients: A Multi-center, Pragmatic, Randomized Controlled Trial in China

The goal of this multi-center, pragmatic, randomized controlled trial is to assess the effectiveness of continuous glucose monitoring (CGM) compared with conventional monitoring in enhancing surgical outcomes for diabetic patients. The main questions it aims to answer are:

• To assess the effectiveness of CGM compared with conventional monitoring in reducing the comprehensive complication index (CCI) for patients with diabetes or impaired glucose tolerance (IGT) within 30 days after surgery.
• To analyze the impact of different age groups, types of surgery, preoperative levels of HbA1c, and preoperative 24h glycemic variations on the improvement of surgical outcomes under the CGM model.

Participants will receive CGM prescribed by the attending physician for at least 6 hours before surgery. Glucose monitoring should be continued until the 7th day after surgery or discharge.

The investigators will compare conventional monitoring group to see if CGM could reduce the CCIs for patients with diabetes or impaired glucose tolerance within 30 days after surgery.

Study Overview

• Status: Recruiting
• Conditions: Comprehensive Complication Index
• Intervention / Treatment: Device: Continuous glucose monitoring (CGM) device

Detailed Description

Abstract: Postoperative complications are important factors in reducing surgical quality and increasing healthcare costs. The CCI is an internationally recognized index to quantify postoperative complications. Patients with diabetes mellitus (DM) or IGT are more prone to developing dysglycemia during the perioperative period, which in turn leads to various types of complications and increased mortality, as evidenced by a significant increase in CCI. Our previous study confirmed that strict glucose management in the perioperative period can help reduce the incidence of postoperative complications such as surgical site infections (SSIs), but this strategy has not been replicated in the perioperative period due to the disadvantages of heavy and complex operations and the possible increased risk of concomitant hypoglycemia. CGM, with its advantages of portability, accuracy, real-time, and information-richness, has been used for precise glucose management in chronic diseases. A small number of prospective randomized controlled studies have previously demonstrated the existence of an improved effect of CGM on intraoperative glycemic management in major surgery. However, there are no real-world studies with large sample sizes to clarify the efficacy and safety of CGM in reducing CCI in patients with DM or IGT. This is where our research comes in. In this real-world study, we aim to clarify the role of perioperative CGM in improving both prognosis and efficacy of surgery.

This is an investigator-initiated, multi-center, pragmatic,1:1ratio randomized, parallel-group, controlled trial which consisted of a 1 to 3-day screening period, and a 7-day(at least 3-day) intervention period, with a final evaluation at day 30. A total of approximately 10168 patients (≥ 18 years of age) with DM or IGT undergoing elective surgeries (including major thoracoabdominal surgery [excluding cardiac surgery], open orthopedic surgery, or neurosurgery) will be enrolled. Patients fulfilling all of the inclusion criteria and none of the exclusion criteria will be randomized into two groups (CGM group versus C group) according to the 1:1 ratio after offering informed content.

Glucose monitoring models:

1. CGM group: A CGM prescription will be issued by the attending physician at least 6 hours before surgery. The primary nurse in charge will educate the participant and their family members on the proper wearing and connection of the CGM device. The calibration frequency and interval of preoperative and postoperative glucose monitoring devices will be determined based on institutional diagnostic and treatment guidelines and the requirements of the monitoring device used. Intraoperative glucose calibration will be performed immediately upon admission, immediately after surgical incision, every 2 hours after surgical incision, and at the completion of wound closure.
2. C group: Perioperative glucose monitoring will be conducted based on institutional diagnostic and treatment guidelines.
3. Glucose/blood glucose monitoring will be continued for both groups of patients until postoperative day 7 or discharge.

Perioperative glucose management:

1. Preoperatively: For elective surgery, preoperative fasting blood glucose/glucose ≤10 mmol/L and HbA1c≤7.0%. For emergency surgery, the decision whether the participant's current blood glucose level is acceptable for surgical treatment is based on institutional practice and the experience of the physician in charge.
2. Intraoperatively: Blood glucose level will be set at 4.5-10mmol/L. Participants in both groups will be given glucose to elevate blood glucose when blood glucose was found to be≤4.5 mmol/L, or insulin when blood glucose was found to be ≥10 mmol/L. Drug dosages and administration methods will follow the medical practice of the institution and the anaesthesiologist in charge. In the CGM group, if mean amplitude of glycemic excursions (MAGE) ≥3.9 mmol/L or largest amplitude of glycemic excursions (LAGE)≥4.4 mmol/L was found in the last 2 h, the dose or rate of glucose/insulin administration will be adjusted as appropriate.
3. Postoperatively: The target of blood glucose management in the early postoperative period is 4.5-7.8 mmol/L. According to the institutional practice and the supervising physician's experience, participants in both groups will be treated with glucose to elevate blood glucose when blood glucose was found to be ≤4.5 mmol/L, and will be treated with insulin to lower blood glucose when blood glucose was found to be ≥7.8 mmol/L.In the CGM group, if excessive blood glucose variability was found, including coefficient of variation (CV)≥36%, LAGE≥4.4 mmol/L, postprandial glucose excursions of three dinners (PPGE)≥2.2mmol/L, standard deviation of blood glucose (SDBG)≥2.0 mmol/L or time in range (TIR)≤70%, an endocrinologist will aid in adjusting the blood glucose management programme.

The primary objective is to observe the improvement of CGM on the surgical outcomes of participants with DM or IGT, including a reduction in the CCI, overall postoperative infection rate, major adverse cardiovascular events (MACE) rate, and shortened postoperative hospital stay within 30 days after surgery.

The study consists of 9 visits including the day of screening and randomization,1,2,3,4,5,6,7 and 30-day follow-up postoperatively.

Demographic information, symptoms and signs, laboratory test, auxiliary examinations, CCIs will be recorded during the program. The trial is anticipated to last from April 2024 to December 2025 with 10168 subjects recruited from 50 centers in China. All the related investigative organization and individuals will obey the Declaration of Helsinki and Chinese Good Clinical Practice standard. A Data and Safety Monitoring Board (DSMB) will regularly monitor safety during the study. The trial has been approved by the ethics committee of Beijing Tsinghua Chang Gung Hospital and corresponding branch centers.

• Study Type: Interventional
• Enrollment (Estimated): 10168
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Zhi F Gao, M.D.; Phone Number: +86 15801249466; Email: btchgzf@hotmail.com

Study Locations

• China
  • Beijing
    • Beijing, Beijing, China, 102218
      • Recruiting
      • Zhifeng Gao
      • Contact: Zhifeng Gao, MD; Phone Number: 18756235568; Email: btchgzf@hotmail.com

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

1. Patients aged above 18 years;
2. Patients with diabetes mellitus or impaired glucose tolerance;
3. Expected major thoracic and abdominal surgery (except cardiac surgery; including endoscopic surgery and robotic surgery), open orthopedic surgery, neurosurgery;
4. Volunteered for this study and written informed consent.

Exclusion Criteria:

1. The patient refused;
2. The time between wearing CGM sensor and surgical skin incision cannot meet 6 hours or more;
3. Expected monitoring time less than 72 hours in CGM group;
4. Patients had comorbidities that affected the evaluation of endpoints;
5. The attending physician thought that the patient had inappropriate indications for enrollment;
6. Participants were involved in other studies that interfered with the evaluation of the results of this study.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: CGM group; Participants who receive continuous glucose monitoring (CGM) during the perioperative period. Glucose monitoring should be continued until the 7th day after surgery or discharge.	Device: Continuous glucose monitoring (CGM) device; Continuous glucose monitoring (CGM) will be prescribed by the attending physician for at least 6 hours before surgery. The supervising nurse will educate the patient and their family on the correct wearing and connection of the CGM device. The calibration frequency and interval of glucose monitoring devices before and after surgery should be determined according to institutional treatment guidelines and the requirements of the monitoring device used. Intraoperative glucose calibration should be done immediately upon entering the operating room, immediately after skin incision, every 2 hours after skin incision, and at the end of wound closure. Glucose monitoring should be continued until the 7th day after surgery or discharge.
No Intervention: Control group; Perioperative blood glucose monitoring was performed according to institutional treatment guidelines.Glucose monitoring should be continued until the 7th day after surgery or discharge.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Comprehensive complication index	The investigators will use the online tool（www.assesssurgery.com）to calculate every participant's cumulative comprehensive complication index (CCI) at 30-day follow-up. CCI is a validated prognostic assessment tool that calculates the total score of all complications weighted by severity, ranging from 0 (no complications) to 100 (death) for each patient. Higher values represent a worse outcome.	At 30-day follow-up

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Postoperative complications	Postoperative complications will be diagnosed abased on signs, symptoms, laboratory and auxiliary examinations.	At 1-7 day postoperatively and 30-day follow-up
Morality	Morality will be expressed by the number and percentage of occurrences.	At 30-day follow-up
The length of the stay in the intensive care unit	The investigators will search the medical archives of participants.	The day when the subject is discharged from hospital.
The length of hospital stay	The investigators will search the medical archives of participants.	The day when the subject is discharged from hospital.
The overall hospitalization cost	The investigators will search the medical archives of participants.	The day when the subject is discharged from hospital.
Perioperative glucose level	CGM group: using CGM device; Control group: using conventional glucose monitoring, such as arterial blood gas, biochemistry examinations.	Perioperative glucose level will be monitored from the day of the enrollment to 7 days (at least 3 days) postoperatively.

Collaborators and Investigators

• Sponsor: Beijing Tsinghua Chang Gung Hospital
• Collaborators: The First Affiliated Hospital of Anhui Medical University; Beijing Tiantan Hospital; Peking University Shougang Hospital; Peking University International Hospital; Shanghai Tong Ren Hospital; Beijing Tongren Hospital; Beijing Chao Yang Hospital; Beijing Hospital; The First Affiliated Hospital of Zhengzhou University; Beijing Anzhen Hospital; Air Force Military Medical University, China; Tang-Du Hospital; First Affiliated Hospital of Xinjiang Medical University; Affiliated Hospital of Jiangsu University; Second Hospital of Shanxi Medical University; The First People's Hospital of Lianyungang; Wuhan Central Hospital; ZhuHai Hospital; Suzhou Municipal Hospital; The First People's Hospital of Changzhou; Liaocheng People's Hospital; Civil Aviation General Hospital; People's Hospital of Ningxia Hui Autonomous Region; Yueyang Central Hospital; Yiyang Central Hospital; Wang Jing Hospital; Emergency General Hospital; The Second Affiliated Hospital of Zhejiang Chinese Medical University; Henan Provincial Chest Hospital; Pinggu Hospital of Beijing Traditional Chinese Medicine Hospital; The First Affiliated Hospital of Anhui University of Chinese Medicine; Siyang County Hospital of Traditional Chinese Medicine; Fuzhou First Hospital; Mindong Hospital of Ningde; The Fifth Hospital of Xiamen; The Fifth hospital of Deyang; Peng Ding Shan Shi Zhong Yi Yi Yuan; Haimen District Traditional Chinese Medicine Hospital; The 910th Hospital; Jilin City Hospital of Chemical Industry; Creen Hospital-465; Chinese PLA Central Hospital
• Investigators: Principal Investigator: Lan Yao, Peking University International Hospital; Principal Investigator: Hui Q Xu, Wang Jing Hospital of CACMS; Principal Investigator: Yan Liu, ZhuHai Hospital; Principal Investigator: Qi Pan, Beijing Hospital; Principal Investigator: Jian H Jia, Siyang County Hospital of Traditional Chinese Medicine; Principal Investigator: Yi K Zhu, Second Hospital of Shanxi Medical University; Principal Investigator: Ke F Shi, Henan Provincial Chest Hospital; Principal Investigator: Fang F Zhang, Fuzhou First Hospital; Principal Investigator: Xiu Zh Wang, Pinggu District Hospital of Traditional Chinese Medicine; Principal Investigator: Feng Hong, The First Affiliated Hospital of Anhui University of Chinese Medicine; Principal Investigator: Ying J Hao, The First Affiliated Hospital of Zhengzhou University; Principal Investigator: Yi Q Cai, Mindong Hospital of Ningde; Principal Investigator: Lin Shen, Heze Hospital of Traditional Chinese Medicine; Principal Investigator: Jin L Liang, The Fifth Hospital of Xiamen; Principal Investigator: Zhen Wang, People's Hospital of Ningxia Hui Autonomous Region; Principal Investigator: Hong W Ye, The First People's Hospital of Changzhou; Principal Investigator: Qin Wang, The Fifth hospital of Deyang; Principal Investigator: Jian P Qiu, Suzhou Municipal Hospital; Principal Investigator: Bo Liao, Tang-Du Hospital; Principal Investigator: Xin J Liu, Yiyang Central Hospital; Principal Investigator: Guo Sh Gu, Anhui No.2 Provincial People's Hospital; Principal Investigator: Li Quan, First Affiliated Hospital of Xinjiang Medical University; Principal Investigator: Li R Ma, Peng Ding Shan Shi Zhong Yi Yi Yuan; Principal Investigator: Zhi B Zhao, The First People's Hospital of Lianyungang; Principal Investigator: Xin Lu, Haimen District Traditional Chinese Medicine Hospital; Principal Investigator: Feng Zhou, Yueyang Central Hospital; Principal Investigator: Xiao D Yin, Zhe Cheng TCM Hospital; Principal Investigator: Li T Zhang, The 910th Hospital; Principal Investigator: Yu Zh He, The Second Affiliated Hospital of Zhejiang Chinese Medical University; Principal Investigator: Xiao M Zhang, The first People's Hospital of Zhengzhou; Principal Investigator: Yu H Jiang, Beijing Tiantan Hospital; Principal Investigator: Peng Jiang, Affiliated Hospital of Jiangsu University; Principal Investigator: Xiao Y Li, The First Affiliated Hospital of Zhengzhou University; Principal Investigator: Zhi H Liu, Liaocheng People's Hospital Zhiheng Liu; Principal Investigator: Jin C Yang, Beijing Chao Yang Hospital; Principal Investigator: Xue L Zhu, The People's Hospital of Nanchuan, Chongqing; Principal Investigator: Wen T Si, Zhengzhou Orthopaedic Hospital; Principal Investigator: Lei Ning, Jilin City Hospital of Chemical Industry; Principal Investigator: Li H Su, Creen Hospital-465; Principal Investigator: Zhong J Wang, Wuhan Central Hospital; Principal Investigator: Li P Ma, Beijing Anzhen Hospital; Principal Investigator: Yu H Xu, Air Force Military Medical University, China; Principal Investigator: Jiang M Yu, Tong Ren Hospital Shanghai Jiao Tong University school of medicine; Principal Investigator: Qing H Cheng, Emergency General Hospital; Principal Investigator: Hui J Wang, Beijing Tongren Hospital, Cmu; Principal Investigator: Jun Wu, Heilongjiang Provincial Hospital; Principal Investigator: Jun T Duan, Civil Aviation General Hospital; Principal Investigator: Zheng G Guo, Peking University Shougang Hospital; Principal Investigator: Xin Kuang, The People's Hospital of Longhua, Shenzhen; Principal Investigator: Chang J Yu, The First Affiliated Hospital of Anhui Medical University; Principal Investigator: Feng Liang, Chinese PLA Central Hospital

Study record dates

Study Major Dates

• Study Start (Actual): April 12, 2024
• Primary Completion (Estimated): October 31, 2025
• Study Completion (Estimated): December 31, 2025

Study Registration Dates

• First Submitted: March 18, 2024
• First Submitted That Met QC Criteria: March 24, 2024
• First Posted (Actual): March 26, 2024

Study Record Updates

• Last Update Posted (Actual): April 16, 2024
• Last Update Submitted That Met QC Criteria: April 13, 2024
• Last Verified: April 1, 2024

More Information

Terms related to this study

• Keywords: prognosis; continuous glucose monitoring; perioperative; comprehensive complication index
• Other Study ID Numbers: U1111-1305-0484

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: After publication, all the investigators, including statisticians, will have access to the final study database, and it will be up to the principal investigator to decide whether and how to share the raw data.
• IPD Sharing Time Frame: It will be up to the principal investigator.
• IPD Sharing Access Criteria: It will be up to the principal investigator to decide whether and how to share the raw data.
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; SAP; ICF; ANALYTIC_CODE; CSR

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No