Postoperative Hyperglycemia Can Be Safely and Effectively Controlled in Both Diabetic and Nondiabetic Patients with Use of a Subcutaneous Insulin Protocol

Abstract

Background:Postoperative hyperglycemia related to stress has been shown to be an independent risk factor for periprosthetic joint infection. In a non-intensive care, general-surgery setting, a standardized postoperative insulin protocol has been shown to decrease the rate of wound infections. We hypothesized that the use of a similar protocol is both safe and effective for controlling hyperglycemia in patients who have undergone total joint replacement.Methods:We performed a retrospective cohort study of 489 consecutive patients who underwent primary or revision total hip or knee arthroplasty between January 2008 and April 2013. All patients were tested with point-of-care (finger-stick) glucose determinations postoperatively and were started on a subcutaneous insulin protocol if they had postoperative stress hyperglycemia of >140 mg/dL when fasting or >180 mg/dL after meals. Insulin was discontinued when blood glucose decreased to <100 mg/dL.Results:Of the 489 patients, 301 (62%) qualified for the insulin protocol. Thirty-seven (17%) of the 220 patients for whom the hemoglobin A1c level was available were diabetic, and 21 (11%) of the 187 patients for whom body mass index data were available were morbidly obese (body mass index, ≥40 kg/m2). Diabetes (p < 0.001), revision surgery (p < 0.001), male sex (p = 0.0110), and obesity (including morbid obesity) (p = 0.0051) were independent factors resulting in significant glycemic elevation. A trend toward hyperglycemia occurred in younger patients but did not reach significance (p = 0.063). The glucose levels of patients in all of these groups responded well to insulin. None of the patients who were managed with the insulin experienced a periprosthetic joint infection. There were no injuries related to hypoglycemia.Conclusions:The findings of the present study suggest that hyperglycemia is a common link between seemingly disparate factors related to the increased prevalence of periprosthetic joint infection. The standardized subcutaneous insulin protocol was both safe and effective for the treatment of hyperglycemia for nondiabetic as well as diabetic patients. Patients who have undergone total joint replacement, especially those with revision procedures, male sex, morbid obesity, and diabetes, should be evaluated for hyperglycemia starting in the post-anesthesia care unit and should be managed with the insulin protocol when that risk is identified.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Fluctuation of fasting blood glucose in patients who underwent primary or revision total joint arthroplasty: a retrospective review

“…At POD1, FBG in many patients was beyond the cutoff values, which suggested an increased risk of postoperative complications based on previous evidence [ 4 , 13 , 16 , 19 , 21 ]. Notably, controlling and maintaining glucose levels under thresholds was likely to reduce complications, which was supported by previous studies [ 21 , 33 ]. Gallagher et al pointed out that subcutaneous insulin intervention was both effective and safe for the management of postoperative hyperglycemia in TJA patients with or without DM, and the rate of developing PJI was remarkedly low by controlling hyperglycemia in a timely manner [ 33 ].…”

“…Notably, controlling and maintaining glucose levels under thresholds was likely to reduce complications, which was supported by previous studies [ 21 , 33 ]. Gallagher et al pointed out that subcutaneous insulin intervention was both effective and safe for the management of postoperative hyperglycemia in TJA patients with or without DM, and the rate of developing PJI was remarkedly low by controlling hyperglycemia in a timely manner [ 33 ]. Besides investigations in the arthroplasty literature, a study regarding the general surgery as well verified the evidence that implementing insulin to lower blood glucose levels in hyperglycemic patients postoperatively ameliorates the risk of postoperative complications [ 21 ].…”

Postoperative Hyperglycemia in Patients with and without Diabetes After Major Joint Replacement

“…Glucose control in orthopaedic patients is challenging: a high percentage of patients have diabetes or prediabetes, resume an oral diet early after the surgical procedure, and are discharged from the hospital within 1 to 2 days. Short-acting insulin appears to be a suitable agent to treat the transient and unpredictable hyperglycemia in orthopaedic patients without diabetes, and its use might be less complex than other approaches to lowering glucose 15 .…”

Hemoglobin A1c as a marker to stratify diabetes risk following pancreaticoduodenectomy

“…Some previous studies failed to follow postoperative outcomes beyond 30 days, a major limitation considering that up to 45% of patients who develop endocrine insufficiency following pancreatic resection do so at least 90 days after surgery [ 22 ]. Immediate postoperative glucose was not included in this study, as many patients develop temporary hyperglycemia following surgery [ 18 , 23 ]. Further studies looking at the relationship of DM and pancreatic surgery should ensure that longer-term outcomes are available.…”