<p>Stress Hyperglycemia and Complications Following Traumatic Injuries in Individuals With/Without Diabetes: The Case of Orthopedic Surgery</p>

Abstract

Purpose: Hyperglycemia in trauma patients may stem from metabolic response to stress, both in the presence and the absence of underlying diabetes. We aimed to test the association of stress hyperglycemia with risks of adverse events subjects undergoing orthopedic surgery. Patients and Methods: In a prospective observational study, we enrolled 202 consecutive patients with hyperglycemia at hospital admission for trauma injuries requiring orthopedic surgery. Based on history, diabetes was present in 183, and 13 more were defined as unknown diabetes on the basis of HbA1c ≥48mmol/mol. Stress hyperglycemia was defined in subjects with/without diabetes by a stress hyperglycemia ratio (SHR) >1.14, calculated as admission glucose/average glucose, estimated from glycosylated hemoglobin. Logistic regression analysis was used to calculate the risk of post-surgery adverse events associated with different states of hyperglycemia, after correction for demographic and clinical confounders. Results: Stress hyperglycemia was diagnosed, either as superimposed to diabetes (54/196 cases, 27.6%) as well as in the 6 cases without diabetes. At least one complication was recorded in 68 cases (33.7%), the most common being systemic infection (22.8% of cases). In the total cohort, stress hyperglycemia, irrespective of the presence of diabetes, increased the risk of adverse events (any events, odds ratio [OR], 4.43; 95% confidence interval [CI], 2.11-9.30), cardiovascular events (OR, 7.09; 95% CI, 2.47-19.91), systemic infections (OR, 4.21; 95% CI, 1.97-9.03) and other adverse events (OR, 6.30; 95% CI, 1.41-28.03), after adjustment for confounders; hospital stay was much longer. The same was true when the analysis was limited to the diabetes cohort or by comparing pure stress hyperglycemia vs diabetes without stress hyperglycemia. Conclusion: The study highlights the importance of stress hyperglycemia for adverse events in the setting of orthopedic surgery following trauma injuries. This condition requires stricter management, considering the much longer length of hospital stay and higher costs.

Stress Hyperglycemia and Mortality in Subjects With Diabetes and Sepsis

“…By controlling for background blood glucose, SHR was reported to be a better biomarker than absolute hyperglycemia, although the cutoff value to define stress hyperglycemia has never been convincingly validated. The value of 1.14, used in the present study, has previously been used in subjects with diabetes submitted to orthopedic surgery, where it confirmed a prognostic value ( 16 ), but the critical value to define stress hyperglycemia remains poorly defined. In the original study by Roberts et al ( 14 ), a significant increase in mortality was specifically observed in the fourth and fifth SHR quintile, corresponding to average SHR values of 1.14 and 1.38, respectively.…”

“…A different prevalence of respiratory, genitourinary, and other infections (approximately 1.4–1.5×) and cardiovascular dysfunction (over 4×) were recorded among system of serious infection and clinical dysfunction diagnoses. The importance of stress hyperglycemia in the occurrence of cardiovascular events was recently confirmed in a surgical setting, where SHR was systematically associated with both infections and cardiovascular events in the presence of diabetes ( 16 ).…”

“…SHR was calculated by dividing the fasting glucose concentration by the estimated average glucose derived from HbA1c, assessed by the equation: estimated average glucose (mg/dL) = (28.7 × HbA1c [%])–46.7 ( 26 ). Stress hyperglycemia was defined by SHR greater than or equal to 1.14 ( 16 ).…”

“…As such, SHR, controlling for background glycemic control, proved valid to detect an abnormal response also in the presence of diabetes. The marker has been shown to be a better correlate of critical illness than absolute hyperglycemia ( 14 ), predicting negative outcomes in the elderly in several recent studies ( 12 , 15 , 16 ), particularly in the surgical setting ( 17 – 19 ).…”

The technique of simultaneous laparoscopic operations in the treatment of gallstone disease and hiatal hernia

“…Відомо, що маркером стресу є кортизол [7]. Спочатку цей компенсаторний механізм допомагає організму впоратися з пошкодженням [6], але згодом процеси набувають деструктивного характеру, тканини відчувають голодування як при діабеті [6], контрінсулярні властивості медіаторів запалення і кортизолу посилю-ють цей ефект [8,24]. Набряк, біль хоч і є результатом захисних механізмів, та все ж значно ускладнюють и пролонгують період реабілітації та загоєння [1,24].…”