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Perioperative hyperglycemia risky for nondiabetics

NEW YORK 27/06 - The complication risk conferred by perioperative hyperglycemia is higher for patients without diabetes than it is for diabetics, a cohort study found.

The 5,868 patients - including 969 (17%) with diabetes - underwent either general (83.4%), vascular (2.6%), or gynecologic (14%) surgery with a planned admission at the University of Washington Medical Center.

The hospital employs an institution-wide perioperative glycemic monitoring and management protocol which tests and treats all patients regardless of diabetes status. Glucoses levels were measured on the day of surgery, intraoperatively at 60- to 90- minute intervals and then in the morning on postoperative days 1 and 2 (or more often, based on clinical management).

Hyperglycemia was considered to be mild (140-179 mg/dL), moderate (180-249 mg/dL), or severe (>250 mg/dL).

At each level of hyperglycemia, more patients without diabetes developed complications than did patients with diabetes, Dr. Judy Y. Chen and colleagues reported in JAMA Surgery.

Roughly 24% of patients without diabetes had a glycated hemoglobin A1c (HbA1c) test within 90 days before surgery; 78.7% were in the no-diabetes range, 13.1% had HbA1c levels of 6%-6.5%, and 8.2% had HbA1c levels >6.5%.

Overall, 91% of diabetics and 51% of nondiabetics had hyperglycemia within 24 hours after surgery.

Postoperative complications, as defined by the National Surgical Quality Improvement Program, occurred in 12% of diabetics and 14% of nondiabetics. Rates of severe complications were 9.2% with diabetes and 8% without it.

At each level of hyperglycemia, however, the proportion of patients who experienced any complication was higher in nondiabetics vs diabetics: mild, 13.3% vs 6.8%; moderate: 22% vs 14%; and severe, 38% vs 24%. The pattern was similar for serious complications.

After adjustment for confounders, the odds ratios for risk of any complication in nondiabetics were 1.83 with mild hyperglycemia; 1.49 with moderate hyperglycemia; and 1.88 with severe hyperglycemia. Respective odds ratios for serious complications were 1.57, 1.87 and 2.0.

Among patients with moderate or severe hyperglycemia, insulin was administered to 61% of nondiabetics and to 91% of diabetics.

Among nondiabetics with moderate or severe hyperglycemia, the adjusted odds of any complication or a severe complication based on the receipt of insulin were 0.79 (95% CI, 0.58-1.07) and 0.79 (95%, 0.57-11), respectively.

"The fact that our health care system has committed to a protocol of universal blood glucose testing and routine insulin administration, yet 30% of patients with hyperglycemia still did not receive insulin, suggests continued reluctance to treat hyperglycemia, especially among patients without diabetes who are likely insulin naïve," the authors wrote.

They concluded, "These findings suggest the importance of continued perioperative glycemic monitoring, especially in those patients without a known history of diabetes, and highlights areas for further inquiry."

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