Paradoxical Association of Hyperglycemia and Surgical Complications Among Patients With and Without Diabetes

Abstract

IMPORTANCE Surgical complications associated with perioperative hyperglycemia are conventionally associated with diabetes, but, paradoxically, prior cohort studies have found that patients without diabetes have greater risk of complications at similar levels of hyperglycemia compared with patients with diabetes.OBJECTIVE To describe the association between perioperative hyperglycemia and surgical complications in a population of surgical patients without diabetes receiving routine blood glucose testing and insulin administration and to evaluate the potential correlation of perioperative hyperglycemia. DESIGN, SETTING, AND PARTICIPANTSThis retrospective cohort study of National Surgical Quality Improvement Program-defined complications after operation took place at a single academic medical center hospital from January 2013 to October 2016. Consecutive patients undergoing general, vascular, and gynecologic operations who were expected to have at least a 48-hour admission were included. Hyperglycemia was defined as blood glucose level of 140 mg/dL or higher within 24 hours after surgery. Multivariate regression was used to assess the association of hyperglycemia and complications, stratified by hyperglycemia severity and adjusted for diabetes status. Analysis began in February 2022.EXPOSURES Routine blood glucose testing and insulin administration. MAIN OUTCOMES AND MEASURESThe main outcomes are odds of experiencing perioperative hyperglycemia and postoperative complication, comparing patients with and without diabetes. RESULTSA total of 7634 patients (mean [SD] age, 53.5 [15.1] years; 6664 patients without diabetes [83.3%] and 970 patients with diabetes [17.7%]) underwent general (6204 [81.3%]), vascular (208 [2.7%]), and gynecologic (1222 [16%]) operations. Of these, 5868 (77%) had blood glucose testing (4899 individuals without diabetes [73.5%] and 969 [99.9%] with diabetes). Hyperglycemia occurred in 882 patients with diabetes (91%)and 2484 patients without diabetes (50.7%). Of those with blood glucose level more than 180 mg/dL, 1388 (72.7%) received insulin (658 patients with diabetes who had hyperglycemia [91%] and 680 patients without diabetes who had hyperglycemia [61%]). Adjusted odds of experiencing a complication were 83% greater for patients without vs with diabetes at blood glucose level of 140 to 179 mg/dL (odds ratio, 1.83 [95% CI, 0.93-3.6]), 49% greater for blood glucose level of 180 to 249 mg/dL (odds ratio, 1.49 [95% CI, 1.06-2.11]), and 88% greater for blood glucose level more than 250 mg/dL (odds ratio, 1.88 [95% CI, 1.11-3.17]). A similar trend was observed for serious complications. Insulin may mitigate the association of hyperglycemia and complications in patients without diabetes. CONCLUSIONS AND RELEVANCEIn this study, with near universal blood glucose testing and frequent insulin use, patients without diabetes paradoxically had worse outcomes than patients with diabetes at similar levels of hyperglycemia. Insulin may mitigate this effect and broader use may improve outcomes.

Hyperglycemia is associated with worse 3-year survival in older patients admitted to the intensive care unit after non-cardiac surgery: Post hoc analysis of a randomized trial

“…Yet hyperglycemia in patients without diabetes might be more harmful. For example, in a recent retrospective cohort study, patients without diabetes developed more postoperative complications than those with diabetes at similar levels of hyperglycemia ( 44 ). In another study of 3026 patients following minor stroke or transient ischemic accident, those without diabetes who developed stress hyperglycemia had a higher risk of stroke recurrence within 90 days ( 45 ).…”

Postoperative Length of Stay in Patients With Stress Hyperglycemia Compared to Patients With Diabetic Hyperglycemia: A Retrospective Cohort Study

“…Postoperative hyperglycemia occurs in 15% to 75% of surgical patients, approximately one third of whom have no history of diabetes mellitus. [1][2][3][4][5][6] Transient hyperglycemia in patients without diabetes is referred to as stress hyperglycemia (SH). Stress hyperglycemia is thought to be mediated by cytokines and counter-regulatory hormones, including glucagon, cortisol, catecholamines, and growth hormone released in response to physiologic stresses, such as illness or surgery.…”

What is the optimal range of glycemic control for non‐diabetic patients undergoing gastroenterological surgery? A single‐center randomized controlled trial using an artificial pancreas

“…Excessive hyperglycemia, even for a short period, causes organ damage via reactive oxygen species, 1 increased susceptibility to infection, 2 and impaired blood reperfusion 3 . In the postoperative setting, hyperglycemia is associated with serious complications in diabetic and non‐diabetic patients 4 . A pivotal study on hyperglycemia intervention was conducted by G van den Berghe et al, demonstrating that tight glycemic control (controlling the glucose level between 80 and 110 mg/dL) significantly improved the mortality rate among patients admitted to the surgical intensive care unit (ICU) 5 .…”

“…3 In the postoperative setting, hyperglycemia is associated with serious complications in diabetic and non-diabetic patients. 4 A pivotal study on hyperglycemia intervention was conducted by G van den Berghe et al, demonstrating that tight glycemic control (controlling the glucose level between 80 and 110 mg/dL) significantly improved the mortality rate among patients admitted to the surgical intensive care unit (ICU). 5 However, subsequent studies have reported contradictory results, [6][7][8] and a growing body of evidence has concluded that reducing glycemic variability and choking off severe hypoglycemia are more important factors in glycemic management than merely maintaining low glucose levels.…”