Perioperative Hyperglycemia and Risk of Adverse Events Among Patients With and Without Diabetes

Abstract

Objective To study the association between diabetes status, perioperative hyperglycemia, and adverse events in a statewide surgical cohort. Background Perioperative hyperglycemia may increase the risk of adverse events more significantly in patients without diabetes (NDM) than in those with diabetes (DM). Methods Using data from the Surgical Care and Outcomes Assessment Program, a cohort study (2010–2012) evaluated diabetes status, perioperative hyperglycemia, and composite adverse events in abdominal, vascular, and spine surgery at 53 hospitals in Washington State. Results Among 40,836 patients (mean age, 54 years; 53.6% women), 19% had diabetes; 47% underwent a perioperative blood glucose (BG) test, and of those, 18% had BG ≥180 mg/dL. DM patients had a higher rate of adverse events (12% vs 9%, P < 0.001) than NDM patients. After adjustment, among NDM patients, those with hyperglycemia had an increased risk of adverse events compared with those with normal BG. Among NDM patients, there was a dose-response relationship between the level of BG and composite adverse events [odds ratio (OR), 1.3 for BG 125–180 (95% confidence interval (CI), 1.1–1.5); OR, 1.6 for BG ≥180 (95% CI, 1.3–2.1)]. Conversely, hyperglycemic DM patients did not have an increased risk of adverse events, including those with a BG 180 or more (OR, 0.8; 95% CI, 0.6–1.0). NDM patients were less likely to receive insulin at each BG level. Conclusions For NDM patients, but not DM patients, the risk of adverse events was linked to hyperglycemia. Underlying this paradoxical effect may be the underuse of insulin, but also that hyperglycemia indicates higher levels of stress in NDM patients than in DM patients.

Strict glycemic control to prevent surgical site infections in gastroenterological surgery

“…In contrast, Kotagal et al 17. reported that the risk of complications was linked to hyperglycemia for non‐DM patients but not for DM patients, which is consistent with our results.…”

“…There are currently several debates regarding the benefits of strict glucose control in less critically ill patients undergoing elective surgery as opposed to critically ill (medical) patients12, 13, 14, 15, 16, 17, 18 (Table 2). Although the recommended target BG is 140–180 mg/dL for most ICU patients,27 a recent meta‐analysis23 comparing the efficacy between an intensive and a conventional protocol in patients undergoing surgery showed a significant benefit for the intensive protocol in reducing SSI.…”

“…Although non‐DM patients had a lower incidence and decreased severity of hyperglycemia compared with DM patients, hyperglycemia was also associated with adverse outcomes in non‐DM patients 13, 16, 17. In the assessment of operative‐day BG in non‐DM patients who underwent colectomy, normoglycemia (≤120 mg/dL) endured in 26.2%, whereas 53.6% had BG of 121–160 mg/dL, 15.1% had 161–200 mg/dL, and 4.5% >200 mg/dL 18.…”

“…A single initial or maximal postoperative elevated BG was evaluated in several studies including by us, and corrected BG by insulin therapy was not taken into account. Kotagal et al 17. reported that DM patients were significantly more likely to receive insulin than non‐DM patients at each level of hyperglycemia.…”

“…The Surgical Care Improvement Project5 (SCIP) developed a quality performance measure to maintain the 6 a.m. controlled blood glucose level (BG) at <200 mg/dL in cardiac surgery (<180 mg/dL in the updated version11). This recommendation has been challenged by recent studies suggesting that an even lower target BG is required to prevent SSI 12, 13, 14, 15, 16, 17, 18. The intensive insulin administration protocol (intensive protocol), however, leads to an increased risk of hypoglycemia, which, in turn, is associated with increased morbidity and mortality 19, 20.…”