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Evaluation of the Effect of Perioperative Blood Sugar Level on Surgical Site Infections in Patients Undergoing Total Mastectomy

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Int J Cancer Manag. In Press(In Press):e88551.
Published online 2019 December 7.
doi: 10.5812/ijcm.88551.
Research Article
Evaluation of the Effect of Perioperative Blood Sugar Level on Surgical
Site Infections in Patients Undergoing Total Mastectomy
Dawood Mafinezhad 1, Reza Taheri1, Seyed Esmaeil Nezhad Hoseini 1and Mohammadreza Motie
1, 2, *
1Surgical Oncology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
2Surgery Department, Surgery Imam Reza Hospital, Mashhad, Iran
*Corresponding author: Surgery Department, Surgery Imam Reza Hospital, Mashhad, Iran. Tel: +98-5138022677, Fax: +98-5138525255, Email: motiem@mums.ac.ir
Received 2019 January 01; Revised 2019 August 22; Accepted 2019 August 31.
Abstract
Background: Stress hyperglycemia during surgeries has been reported to increase the possibility of surgical site infections (SSIs)
and worsen the patient’s prognosis.
Objectives: The aim of the present study was to evaluate the correlation between perioperative blood sugar level and SSIs in patients
undergoing mastectomy.
Methods: In this prospective case-control study, 158 female patients undergoing mastectomy were included with diabetes as an
exclusion criterion. Blood glucose levels were measured in 5 phases for each patient.
Results: Among 158 studied patients, 8 (5.5%) developed SSIs. Four patients (2.74%) in the control group and 4 patients (50%) in
the case group had hyperglycemia in at least one of the stages. Logistic regression analysis demonstrated associations between SSI
development and any blood glucose value of more than 150 mg/dL. It seems that age, medical history, current smoking, tumor char-
acteristics, previous chemoradiotherapy, surgical duration, administration of prophylactic antibiotics, and other surgical factors
have not been significantly correlated with SSI.
Conclusions: As hyperglycemia is an easily controllable factor, the control of blood sugar levels during the perioperative period is
recommended in patients undergoing breast surgeries to decrease SSI rates.
Keywords: Blood Sugar Level, Mastectomy, Surgical Site Infection
1. Background
Surgical site infections (SSIs) are among the common
causes of postoperative morbidity, which also increase
mortality, hospital re-admission, and hospitalization dura-
tion in patients undergoing surgery (1,2). Hyperglycemia
during hospitalization, especially in traumas and surg-
eries, occurs approximately in one-third of patients. Acute
transient (stress) hyperglycemia during surgeries has been
reported to increase the possibility of SSIs and worsen the
patient prognosis as well (1,3-5). Previous studies have re-
ported that regardless of the history of diabetes, higher
blood glucose values are associated with higher risks of
SSIs and glycemic control has been shown to reduce the
risk of SSIs in various types of surgeries (6,7). However,
glycemic control is not well established in postoperative
care strategies (8). Although mastectomies, which are the
most common oncologic surgeries, are considered clean
surgeries and low rates of SSIs are expected in these pro-
cedures, SSI rates for mastectomies are quite significant.
The growing incidence of resistant bacterial strains in
hospital-acquired infections is also a matter of concern in
this regard (9-11).
2. Objectives
The aim of the present study was to evaluate the associ-
ation between perioperative blood glucose levels and SSIs
in patients undergoing mastectomy.
3. Methods
3.1. Study Population
In this prospective case-control study, 158 female pa-
tients with the diagnosis of breast cancer, who were candi-
dates for a total mastectomy, were included. This investiga-
tion was conducted at the general surgery department of
Imam Reza Hospital of Mashhad, Mashhad, Iran, between
March 2013 and March 2016. The study protocol was ap-
proved by the Ethics Committee of Mashhad University of
Copyright © 2019, Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License
(http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly
cited.
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Mafinezhad D et al.
Medical Sciences (code number: 900850). All participants
gave full informed written consent prior to inclusion in
the study. Patients with a previously-diagnosed diabetes
mellitus, a history of antibiotic use within the previous 30
days, under treatment with corticosteroids, and those who
were reluctant to participate in the study, were excluded.
The demographic data, including age and a full history of
medical conditions consisting of hypertension, hyperlipi-
demia, ischemic heart disease (IHD), previous chemother-
apy or radiotherapy, previous breast surgery, other phar-
macologic cancer therapies (steroids, etc.), current smok-
ing, alcohol use, and American Society of Anesthesiolo-
gists (ASA) score, were provided for each patient. Patients
with SSIs were considered as cases and patients, who were
infection-free by the 30th postoperative day, were consid-
ered as controls.
3.2. Patient Management
Blood glucose levels were measured in 5 phases for
each patient. (1) before entering the operating room; (2)
at the time of anesthesia induction; (3) during the surgery;
(4) in the recovery room; (5) 24 hours postoperatively by
capillary glucometer. The patients would be categorized
in the hyperglycemic group if they had any glucose value
of more than 150 mg/dL. Otherwise, the patients were in-
cluded in the normo-glycemic group. The patients were
randomly selected by each surgical team to be operated on.
All patients were managed by the standard protocol and
the routine surgical procedure. Antibiotic prophylaxis was
used. At the end of the surgery, the wound was closed and
a drain was placed at the anterior chest wall and axilla as
needed. Wound care strategies were done after surgery. Af-
ter discharge, patients were educated to wash the wound
every 24 hours with soap and water and covered it by sterile
gauze pads. They were also trained to measure the amount
of the drain. Intraoperative variables, including duration
of surgery, type of mastectomy (radical vs. modified rad-
ical mastectomy), prophylactic and postoperative antibi-
otics, estimated blood loss, drains used, and lymph node
dissection were recorded as well.
Postoperatively, the patients were visited daily in the
hospital ward and, then, followed up by phone calls or
direct observation in the outpatient clinic for at least 30
days. They were followed with the cancer staging re-
ports, postoperative antibiotics, and other wound compli-
cations, such as flap necrosis, dehiscence, hematoma, and
seroma formation. An SSI would be diagnosed clinically if
any sign of SSI occurred, including pain or tenderness, lo-
calized swelling, redness or heat, purulent drainage from
the superficial or deep incision, and fever more than 38ºC.
3.3. Statistical Analysis
All statistical analyses were performed, using SPSS 19
statistical software. Continuous variables were reported
as mean ±SD. Categorical variables were reported as ab-
solute numbers and percentages. Analysis of the data
distribution was assessed by the Kolmogorov-Smirnov
test. Normally-distributed continuous variables were com-
pared, using the unpaired t-test. The Mann-Whitney U test
was used for those variables that were not normally dis-
tributed. Categorical variables were analyzed, using either
the chi-square test or Fisher’s exact test. Logistic regres-
sion analysis was conducted to obtain adjusted estimates
of the odds ratio and to identify the association between
blood glucose level and SSIs, using SPSS. Two-sided P values
of less than 0.05 were considered to indicate statistical sig-
nificance for all statistical tests.
4. Results
Among 158 studied patients, 8 (5.5%) developed SSIs.
The mean ±SD age of the patients was 48.2 ±11.9 years,
53.75 ±11.61 years for cases, and 48.12 ±11.75 for the con-
trol group; 5 patients were current smokers and 8 were ad-
dicted to some kinds of opiate. Ninety patients (56.96%)
denied the history of medical conditions, 36 had a history
of hypertension, 17 had dyslipidemia, and 13 had a positive
history of IHD. The detailed characteristics of patients are
presented in Table 1.
Among the patients, 5.1% (8 patients) had a history of
breast cancer in the contralateral breast, 152 (96.2%) were
presented as primary tumors, and 6 (3.8%) had the recur-
rence of a primary tumor. A total of 39 of 158 patients
(25.3%) had preoperative chemoradiotherapy. According to
the ASA physical status classification system, 142 of the pa-
tients (89.9%) were categorized as ASA I and 16 (10.1%) as ASA
II (Table 2).
Prophylactic antibiotics were prescribed for 12 patients
(7.6%). All patients took cefazolin and cephalexin postop-
eratively; 55 of the patients (34.8%) underwent total mas-
tectomy and 103 (65.2%) had modified radical mastectomy.
The mean ±SD duration of surgery was 2.92 ±0.65 hours
overall, 3.25 ±0.65 hours in the case group, and 2.89 ±
0.64 in the control group. In 55 of the patients (34.8%),
axillary lymph node dissection (ALND) accompanied mas-
tectomy. No patient underwent sentinel lymph node dis-
section. Pectoral surgical drains were inserted in 27 pa-
tients (17.1%) and combined pectoral and axillary drains
were placed in 131 patients (82.9%) (Table 3).
A total of 36 of the patients (22.8%) had at least one
blood glucose value over 150 mg/dL and were considered as
hyperglycemic; the other 122 patients (77.2%) were included
in the normo-glycemic group. Four patients (2.74%) in the
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Mafinezhad D et al.
Table1. Detailed Characteristics of Patients in the Case and Control Groupsa
Values Control Group CaseGroup P Value (Fisher’s Exact Test)
Smoking 5 (3.16) 5 0 1.000
Addiction 8 (5.06) 6 2 0.057
No previous medical disease 93 (58.9) 87 3 0.278
Hypertension 36 (22.78) 34 2 1.000
Hyperlipidemia 17 (10.76) 14 3 0.054
Ischemic heart disease 13 (8.23) 11 2 0.138
aValues are expressed as No. (%).
Table2. Presentation and ASA Classification in the Control and Case Groupsa
Values ControlGroup Case Group P Value (Fisher’s Exact Test)
Presentation 0.138
Primary tumor 152 (96.2) 145 7
Recurrence 6 (3.8) 5 1
Previous chemoradiotherapy 39 (25.3) 35 4 0.191
ASA classification 0.568
ASA I 142 (89.9) 135 7
ASA II 16 (10.1) 15 1
aValues are expressed as No. (%).
Table3. Type of Surgery and Surgical Drains in the Control and Case Groupsa
Values Control Group Case Group P Value (Fisher’s Exact Test)
Typeof surgery 0.051
Total mastectomy 55(34.8) 55 0
MRM 103 (65.2) 95 8
ALND 55 (34.8) 55 0 0.051
Surgical drains 0.352
Pectoral 27 (17.1) 27 0
Pectoral + axillary 131 (82.9) 119 8
aValues are expressed as No. (%).
control group and 4 (50%) in the case group had hyper-
glycemia during at least one stage. The mean glucose levels
in every 5 phases of measurement in the case and control
groups are summarized in Table 4.
Table4. Blood Glucose in the Control and Case Groupsa
Total Control Group Case Group
BG1 107.91 ±35.33 106.12±32.72 150.5 ±58.45
BG2 117.86 ±43.68 115.5 ±36.54 179.12 ±99.00
BG3 120.75 ±45.54 117.93 ±38.08 184.88 ±105.77
BG4 120.97 ±34.75 119.27 ±32.45 163.00 ±53.67
BG5 114.49 ±39.09 111.94 ±34.76 145.88 ±60.35
aValues are expressed as mean ±SD.
A comparison of the mean age of cases and con-
trols showed no statistically significant difference between
these groups (independent sample t-test: P = 0.220). There
was no significant difference between the case and control
groups considering the history of smoking, addiction, his-
tory of hypertension, IHD, and dyslipidemia.
Variables associated with tumor characteristics, in-
cluding primary tumor versus the recurrence of a primary
tumor, ASA score, and previous chemoradiotherapy were
similar in the case and groups. There was no significant dif-
ference between groups regarding the history of cancer in
the contralateral breast. Factors regarding surgical proce-
dure, which included the mean duration of surgery (Mann-
Whitney U test; P = 0.183), prescription of prophylactic an-
tibiotics (Fisher’s exact test: P = 0.647), type of surgery,
ALND, and type of the used surgical drains, did not have sig-
nificant association with the development of SSI.
Logistic regression analysis demonstrated associa-
tions between SSI development and any blood glucose
Int J Cancer Manag. In Press(In Press):e88551. 3
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Mafinezhad D et al.
value of more than 150 mg/dL (Table 5).
Table5. AssociationsBetween SSI Development and any Blood Glucose Value of More
Than 150 mg/dL
Odd Ratio 95% Confidence Interval P Value
BG1 6.32 1.35 - 29.5 0.019
BG2 5.81 1.35 - 25 0.018
BG3 3.68 0.82 - 16.6 0.089
BG4 5.81 1.35 - 25 0.018
BG5 2.60 0.49 - 13.9 0.26
5. Discussion
Several studies have demonstrated a significant associ-
ation between perioperative blood glucose level and SSI de-
velopment in different eras, including cardiovascular and
general surgery, ICU, and trauma patients, regardless of
the history of diabetes (8,12-16). These studies are limited
among patients undergoing mastectomy. Vilar-Compte
et al. (1) in 2008 indicated that in patients undergoing
mastectomy, elevated blood glucose values during surgery
and/or the immediate postoperative period correlate with
the increased risk of SSI. They showed that any blood glu-
cose of more than 150 mg/dL increases the risk of devel-
oping postoperative SSIs (1). In the present study, logistic
regression analysis demonstrated an association between
SSI development and any blood glucose value of more than
150 mg/dL as well. In Ruiz-Tovar’s study, a cut-off point of
128 mg/dL was established with patients, whose glucose
exceeded this having a 4.7-fold higher risk of SSI (6). The
analysis of the quantitative correlation between the blood
glucose levels and infection rate has also been established
in some studies (1,8,14). This issue was not concerned in
our study. In the current study, age, medical history, cur-
rent smoking, tumor characteristics, previous chemora-
diotherapy, duration of surgery, and other surgical factors,
as well as prophylactic antibiotic did not seem to have a
significant association with the SSI post-surgically. Vilar-
Compte et al. reported different results; age more than 50
and preoperative chemoradiotherapy were risk factors for
infection occurrence (1,11). They explained the role of ad-
vanced age with the progressive incidence of medical con-
ditions, especially diabetes and hypertension, in older pa-
tients. Advanced age, chemoradiotherapy, and duration of
surgery have been mentioned as risk factors for infection
in other studies (15,17). The effect of solo radiotherapy and
chemotherapy was not explored in our analysis. Davis re-
ported ASA score of 3 or higher, surgical time of 2 hours or
longer, and current smoking status as significant risk fac-
tors (18). In our study, we found no association between
ASA score and SSI development, although no patient had
ASA score of 3 or higher. As shown in previous articles (18),
ALND was not a risk factor for SSI occurrence.
The rate of SSIs in this study was 5.8%, which is ratio-
nal considering the clean base of this kind of surgery (1).
Some studies have reported a higher incidence of postop-
erative wound infections (1,11), which could not be com-
pared due to the lack of firm criteria for diagnosis or could
show a high prevalence of hospital-acquired infections in
their settings.
In the present study, hyperglycemia was associated
with an increased rate of SSIs in each of the 5 levels of mea-
surement. The results of the timing of hyperglycemia in
the literature are inconstant (8,14,19). It seems that hyper-
glycemia during the perioperative period is a consequence
of the stress-induced increase in counter-regulatory hor-
mones, which diminishes immune response as in patients
with diabetes (1). Regarding the role of diabetes as a risk
factor of postoperative infection, 4 types of comparison
have been made in the literature:
1) In some studies, the association between hyper-
glycemia and SSI has been investigated in patients with
diabetes (14,15). Actually, in these studies, the effect of
glycemic control in patients with diabetes was concerned;
the results showed an increased risk of infection in pa-
tients with diabetes, experiencing hyperglycemia in the
perioperative period (20).
2) In some other studies, the comparison has been
made between patients with newly-diagnosed hyper-
glycemia and hyperglycemia in patients with a known
history of diabetes, which have shown a more adverse
outcome in the newly-diagnosed patients (8,21).
3) Diabetes had also been investigated as an indepen-
dent risk factor post-surgically in patients with and with-
out SSIs (1).
4) In our study, diabetes was an exclusion criterion in
order to investigate the net effect of stress-induced hyper-
glycemia. No advantage of perioperative antibiotic pro-
phylaxis has (PAP) been reported in mastectomies (22).
Vilar-Compte et al. (1) found no difference in SSI rates or
other important outcomes associated with PAP in patients
undergoing mastectomy and concluded that not prescrib-
ing PAP is permitted in this group of patients. Similarly,
in our study, the prescription of prophylactic antibiotics
(Fisher’s exact test: P = 0.647) did not have a significant as-
sociation with the development of SSIs. Other wound com-
plications, including necrosis, hematoma, and seroma for-
mation in association with perioperative hyperglycemia
have been concerned in other studies (11), but we did not
discuss this matter. This study was limited by the low num-
ber of participants, which necessitates larger studies in
this matter in the future. Obesity was investigated by most
of the similar articles, which were not probed in our anal-
4Int J Cancer Manag. In Press(In Press):e88551.
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Mafinezhad D et al.
ysis because of too missing data. Another missing aspect
of our study is the microbiology of SSIs, which is recom-
mended to be approached in the future.
5.1. Conclusions
Conclusively, our analysis demonstrated a significant
association between perioperative blood glucose level and
SSI development in all 5 steps of measurement. As hyper-
glycemia is an easily modifiable factor, glycemic control
during the perioperative period is recommended in pa-
tients undergoing breast surgeries to lower SSI rates.
Footnotes
Authors’ Contribution: Project implementation: Da-
wood Mafinezhad, Reza Taheri, and Seyed Esmaeil Nezhad
Hoseini. Idea and project manager; Mohammadreza
Motie.
Conflict of Interests: The authors declare no conflict of
interest.
Funding/Support: This study was funded by Vice-
Chancellor of Research of Mashhad University of Med-
ical Sciences as a grant attributed to a general surgery
graduation thesis of the third author (code: 900850).
References
1. Vilar-Compte D, Alvarez de Iturbe I, Martin-Onraet A, Perez-Amador
M, Sanchez-Hernandez C, Volkow P. Hyperglycemia as a risk fac-
tor for surgical site infections in patients undergoing mastectomy.
Am J Infect Control. 2008;36(3):192–8. doi: 10.1016/j.ajic.2007.06.003.
[PubMed: 18371515].
2. Klevens RM, Edwards JR, Richards CJ, Horan TC, Gaynes RP, Pollock
DA, et al. Estimating health care-associated infections and deaths
in U.S. hospitals, 2002. Public Health Rep. 2007;122(2):160–6. doi:
10.1177/003335490712200205. [PubMed: 17357358]. [PubMed Central:
PMC1820440].
3. Kao LS, Phatak UR. Glycemic control and prevention of surgi-
cal site infection. Surg Infect (Larchmt). 2013;14(5):437–44. doi:
10.1089/sur.2013.008. [PubMed: 24111757].
4. Bochicchio GV, Laura S, Manjari J, Kelly B, Scalea TM. Admission pre-
operative glucose is predictive of morbidity and mortality in trauma
patients who require immediate operative intervention. Am Surg.
2005;71(2):171–4.
5. Krinsley J. Perioperative glucose control. Curr Opin Anaesthesiol.
2006;19(2):111–6. doi: 10.1097/01.aco.0000192767.12206.ec. [PubMed:
16552215].
6. Ruiz-Tovar J, Oller I, Llavero C, Arroyo A, Munoz JL, Calero A, et al.
Pre-operative and early post-operative factors associated with sur-
gical site infection after laparoscopic sleeve gastrectomy. Surg In-
fect (Larchmt). 2013;14(4):369–73. doi: 10.1089/sur.2012.114. [PubMed:
23718274].
7. Richards JE, Kauffmann RM, Obremskey WT, May AK. Stress-induced
hyperglycemia as a risk factor for surgical-site infection in nondia-
betic orthopedic trauma patients admitted to the intensive care unit.
J Orthop Trauma. 2013;27(1):16–21. doi: 10.1097/BOT.0b013e31825d60e5.
[PubMed: 22588532]. [PubMed Central: PMC3507335].
8. Kwon S, Thompson R, Dellinger P, Yanez D, Farrohki E, Flum D. Im-
portance of perioperative glycemic control in general surgery: A re-
port from the Surgical Care and Outcomes Assessment Program. Ann
Surg. 2013;257(1):8–14. doi: 10.1097/SLA.0b013e31827b6bbc. [PubMed:
23235393]. [PubMed Central: PMC4208433].
9. Throckmorton AD, Boughey JC, Boostrom SY, Holifield AC, Stobbs
MM, Hoskin T, et al. Postoperative prophylactic antibiotics and
surgical site infection rates in breast surgery patients. Ann Surg
Oncol. 2009;16(9):2464–9. doi: 10.1245/s10434-009-0542-1. [PubMed:
19506959].
10. Habermann EB, Abbott A, Parsons HM, Virnig BA, Al-Refaie WB, Tuttle
TM. Are mastectomy rates really increasing in the United States? J Clin
Oncol. 2010;28(21):3437–41. doi: 10.1200/JCO.2009.27.6774. [PubMed:
20548000].
11. Vilar-Compte D, Jacquemin B, Robles-Vidal C, Volkow P. Surgi-
cal site infections in breast surgery: Case-control study. World
J Surg. 2004;28(3):242–6. doi: 10.1007/s00268-003-7193-3. [PubMed:
14961196].
12. Latham R, Lancaster AD, Covington JF, Pirolo JS, Thomas CJ. The asso-
ciation of diabetes and glucose control with surgical-site infections
among cardiothoracic surgery patients. Infect Control Hosp Epidemiol.
2001;22(10):607–12. doi: 10.1086/501830. [PubMed: 11776345].
13. Grey NJ, Perdrizet GA. Reduction of nosocomial infections in the
surgical intensive-care unit by strict glycemic control. Endocr Pract.
2004;10 Suppl 2:46–52. doi: 10.4158/EP.10.S2.46. [PubMed: 15251640].
14. Gandhi GY, Nuttall GA, Abel MD, Mullany CJ, Schaff HV, Williams
BA, et al. Intraoperative hyperglycemia and perioperative outcomes
in cardiac surgery patients. Mayo Clin Proc. 2005;80(7):862–6. doi:
10.4065/80.7.862. [PubMed: 16007890].
15. Vriesendorp TM, Morelis QJ, Devries JH, Legemate DA, Hoekstra JB.
Early post-operative glucose levels are an independent risk factor for
infection after peripheral vascular surgery. A retrospective study. Eur
J Vasc Endovasc Surg. 2004;28(5):520–5. doi: 10.1016/j.ejvs.2004.08.006.
[PubMed: 15465374].
16. Laird AM, Miller PR, Kilgo PD, Meredith JW, Chang MC. Relationship
of early hyperglycemia to mortality in trauma patients. J Trauma.
2004;56(5):1058–62. doi: 10.1097/01.ta.0000123267.39011.9f. [PubMed:
15179246].
17. Ruvalcaba-Limon E, Robles-Vidal C, Poitevin-Chacon A, Chavez-
Macgregor M, Gamboa-Vignolle C, Vilar-Compte D. Complications
after breast cancer surgery in patients treated with concomitant pre-
operative chemoradiation: A case-control analysis. Breast Cancer Res
Treat. 2006;95(2):147–52. doi: 10.1007/s10549-005-9058-y. [PubMed:
16319989].
18. Davis GB, Peric M, Chan LS, Wong AK, Sener SF. Identifying risk
factors for surgical site infections in mastectomy patients using
the National Surgical Quality Improvement Program database. Am J
Surg. 2013;205(2):194–9. doi: 10.1016/j.amjsurg.2012.05.007. [PubMed:
22944390].
19. Ramos M, Khalpey Z, Lipsitz S, Steinberg J, Panizales MT, Zinner M,
et al. Relationship of perioperative hyperglycemia and postopera-
tive infections in patients who undergo general and vascular surgery.
Ann Surg. 2008;248(4):585–91. doi: 10.1097/SLA.0b013e31818990d1.
[PubMed: 18936571].
20. Shah BR, Hux JE. Quantifying the risk of infectious diseases for peo-
ple with diabetes. Diabetes Care. 2003;26(2):510–3. doi: 10.2337/di-
acare.26.2.510. [PubMed: 12547890].
21. Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi
AE. Hyperglycemia: An independent marker of in-hospital mortal-
ity in patients with undiagnosed diabetes. J Clin Endocrinol Metab.
2002;87(3):978–82. doi: 10.1210/jcem.87.3.8341. [PubMed: 11889147].
22. Gupta R, Sinnett D, Carpenter R, Preece PE, Royle GT. Antibi-
otic prophylaxis for post-operative wound infection in clean
elective breast surgery. Eur J Surg Oncol. 2000;26(4):363–6. doi:
10.1053/ejso.1999.0899. [PubMed: 10873356].
Int J Cancer Manag. In Press(In Press):e88551. 5
Article
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After the National Institutes of Health Consensus Statement in 1990, breast-conserving surgery (BCS) became more common while mastectomy rates decreased. However, several recently published single-institution studies have reported an increase in mastectomy rates in the past decade. We conducted a population-based study to evaluate national trends in the surgical treatment of breast cancer from 2000 through 2006. Using the Surveillance, Epidemiology, and End Results database, we conducted a retrospective cohort analysis of women undergoing surgical treatment for breast cancer. We evaluated variation in mastectomy rates by demographic and tumor factors and calculated differences in mastectomy rates across time. We utilized logistic regression to identify time trends and patient and tumor factors associated with mastectomy, testing for significance using two-sided methods. We identified 233,754 patients diagnosed with ductal carcinoma in situ or stage I to III unilateral breast cancer from 2000 to 2006. The proportion of women treated with mastectomy decreased from 40.8% in 2000 to 37.0% in 2006 (P < .001). These patterns were maintained across patient and tumor factors. Although the unilateral mastectomy rate decreased during the study period, the contralateral prophylactic mastectomy rate increased. Women were less likely to receive mastectomy over time (odds ratio, 1.18 for 2000 v 2006; 95% CI, 1.14 to 1.23; P < .0001), after adjusting for patient and tumor factors. In contrast to single-institution studies, our population-based analysis found a decrease in unilateral mastectomy rates from 2000 to 2006 in the United States. Variations in referral patterns and patient selection are potential explanations for these differences between single institutions and national trends.
Article
Introduction: Recent randomized prospective data suggest that early hyperglycemia is associated with excess mortality in critically ill patients, and tight glucose control leads to improved outcome. This concept has not been carefully examined in trauma patients, and the relationship of early hyperglycemia to mortality from sepsis in this population is unclear. The objective of this study was to determine the relationship different levels of early blood glucose elevation to outcome in a trauma ICU population. Methods: The records of all patients admitted to the ICU over a 2-year period at a Level I trauma center were reviewed for age, injury severity scores (ISS), admission Glasgow Coma Scale (GCS) score, base deficit (BD), blood glucose, and mortality. Three possible cutoffs in defining hyperglycemia were examined (glucose ≥110 mg/dL, ≥150 mg/dL, ≥200 mg/dL) in relation to infection and mortality. Early hyperglycemia was defined as elevated blood glucose on hospital days 1 or 2. Those with diabetes mellitus were excluded. Results: From 1/00-12/01, 516 eligible patients were admitted to the ICU after injury. Early hyperglycemia occurred in 483 at the ≥110 mg/dL level, 311 at the ≥150 mg/dL level, and 90 patients at the ≥200 mg/dL level. Univariate logistic regression demonstrated a significant relationship between ISS and subsequent infection (p = 0.02) and a trend toward such a relationship in GCS score, glucose ≥150 mg/dL, and glucose ≥200 mg/dL (p = 0.06, 0.12, and 0.06). A similar analysis for the relationship of these variables to eventual mortality showed a significant correlation with all examined variables except glucose ≥110 mg/dL. Multiple logistic regression to control for the effect of age, ISS, GCS score, and BD found early glucose ≥200 mg/dL to be an independent predictor of both infection and mortality while no such relationship was found with ≥110 mg/dL or ≥150 mg/dL. Conclusions: Early hyperglycemia as defined by glucose ≥200 mg/dL is associated with significantly higher infection and mortality rates in trauma patients independent of injury characteristics. This was not true at the cutoffs of ≥110 mg/dL or ≥150 mg/dL. These data support the need for a prospective analysis of tight glucose control, keeping serum glucose <200 mg/dL in critically ill trauma patients. However, aggressive maintenance of levels <110 mg/dL as reported by others may not be necessary.
Article
objective. The purpose of this study was to provide a national estimate of the number of healthcare-associated infections (HAI) and deaths in United States hospitals. Methods. No single source of nationally representative data on HAIs is currently available. The authors used a multi-step approach and three data sources. The main source of data was the National Nosocomial Infections Surveillance (NNIS) system, data from 1990-2002, conducted by the Centers for Disease Control and Prevention. Data from the National Hospital Discharge Survey (for 2002) and the American Hospital Association Survey (for 2000) were used to supplement NNIS data. The percentage of patients with an HAI whose death was determined to be caused or associated with the HAI from NNIS data was used to estimate the number of deaths. Results. In 2002, the estimated number of HAIs in U.S. hospitals, adjusted to include federal facilities, was approximately 1.7 million: 33,269 HAIs among newborns in high-risk nurseries, 19,059 among newborns in well-baby nurseries, 417,946 among adults and children in ICUs, and 1,266,851 among adults and children outside of ICUs. The estimated deaths associated with HAIs in U.S. hospitals were 98,987: of these, 35,967 were for pneumonia, 30,665 for bloodstream infections, 13,088 for urinary tract infections, 8,205 for surgical site infections, and 11,062 for infections of other sites. Conclusion. HAIs in hospitals are a significant cause of morbidity and mortality in the United States. The method described for estimating the number of HAIs makes the best use of existing data at the national level.
Article
Background: Stress hyperglycemia is associated with increased risk of surgical site infections (SSIs). Use of strict or tight glycemic control with intensive insulin therapy to prevent SSIs is controversial. Methods: Review of pertinent English-language literature. Results: There is a large body of literature supporting an association between stress hyperglycemia and SSIs. The quality of evidence from randomized controlled trials and meta-analyses that strict glycemic control reduces SSIs or any infections is low, and the strength of recommendation for strict glycemic control is weak due to the associated increase in moderate and severe hypoglycemia. Conclusion: Current recommendations for glycemic control in surgical patients are informed primarily by trials using intensive insulin therapy in critically ill patients. Further research is necessary to ascertain the optimal glycemic target for non-critically ill patients, to determine if subsets of patients may benefit from strict glycemic control, and to identify alternative methods for treating stress hyperglycemia and explaining the mechanisms by which it increases infectious risk.
Article
Background: Surgical procedures on obese patients are expected to have a high incidence of surgical site infection (SSI). The identification of pre-operative or early post-operative risk factors for SSI may help the surgeon to identify subjects in risk and adequately optimize their status. We conducted a study of the association of comorbidities and pre- and post-operative analytical variables with SSI following laparoscopic sleeve gastrectomy for the treatment of morbid obesity. Patients and methods: We performed a prospective study of all morbidly obese patients undergoing laparoscopic sleeve gastrectomy as a bariatric procedure between 2007 and 2011. An association of clinical and analytical variables with SSI was investigated. Results: The study included 40 patients with a mean pre-operative body mass index (BMI) of 51.2±7.9 kg/m(2). Surgical site infections appeared in three patients (7.5%), of whom two had an intra-abdominal abscess located in the left hypochondrium and the third had a superficial incisional SSI. Pre-operatively, a BMI >45 kg/m(2) (OR 8.7; p=0.008), restrictive disorders identified by pulmonary function tests (OR 10.0; p=0.012), a serum total protein concentration <5.3 g/dL (OR 13; p=0.003), a plasma cortisol >30 mcg/dL (OR 13.0; p=0.003), and a mean corpuscular volume (MCV) <82 fL (OR 1.6; p=0.04) were associated with post-operative SSI. Post-operatively, a serum glucose >128 mg/dL (OR 4.7; p=0.012) and hemoglobin <11g/dL (OR 7.5; p=0.002) were associated with SSI. Conclusions: The study supports the role of restrictive lung disorders and the values specified above for preoperative BMI, serum total protein and cortisol concentrations, and MCV, and of post-operative anemia and hyperglycemia as risk factors for SSI. In these situations, the surgeon must be aware of and seek to control these risk factors.
Article
: To determine the relationship of perioperative hyperglycemia and insulin administration on outcomes in elective colon/rectal and bariatric operations. : There is limited evidence to characterize the impact of perioperative hyperglycemia and insulin on adverse outcomes in patients, with and without diabetes, undergoing general surgical procedures. : The Surgical Care and Outcomes Assessment Program is a Washington State quality improvement benchmarking-based initiative. We evaluated the relationship of perioperative hyperglycemia (>180 mg/dL) and insulin administration on mortality, reoperative interventions, and infections for patients undergoing elective colorectal and bariatric surgery at 47 participating hospitals between fourth quarter of 2005 and fourth quarter of 2010. : Of the 11,633 patients (55.4 ± 15.3 years; 65.7% women) with a serum glucose determination on the day of surgery, postoperative day 1, or postoperative day 2, 29.1% of patients were hyperglycemic. After controlling for clinical factors, those with hyperglycemia had a significantly increased risk of infection [odds ratio (OR) 2.0; 95% confidence interval (CI), 1.63-2.44], reoperative interventions (OR, 1.8; 95% CI, 1.41-2.3), and death (OR, 2.71; 95% CI, 1.72-4.28). Increased risk of poor outcomes was observed both for patients with and without diabetes. Those with hyperglycemia on the day of surgery who received insulin had no significant increase in infections (OR, 1.01; 95% CI, 0.72-1.42), reoperative interventions (OR, 1.29; 95% CI, 0.89-1.89), or deaths (OR, 1.21; 95% CI, 0.61-2.42). A dose-effect relationship was found between the effectiveness of insulin-related glucose control (worst 180-250 mg/dL, best <130 mg/dL) and adverse outcomes. : Perioperative hyperglycemia was associated with adverse outcomes in general surgery patients with and without diabetes. However, patients with hyperglycemia who received insulin were at no greater risk than those with normal blood glucoses. Perioperative glucose evaluation and insulin administration in patients with hyperglycemia are important quality targets.
Article
Background: The Centers for Disease Control and Prevention reported that surgical site infections (SSIs) create a significant hospital burden. To date, few multi-institutional studies have been performed to evaluate the risk factors for SSIs in mastectomy patients. Methods: By using the American College of Surgeons' National Surgical Quality Improvement Program database, all patients undergoing mastectomy from 2005 to 2009 were identified. The outcome was to determine the incidence rate and identify significant independent risk factors of SSIs. Results: The incidence of SSI was 2.3% (891 of 38,739; 95% confidence interval, 2.2%-2.5%) in patients undergoing mastectomy without reconstruction. Significant (P < .05) risk factors for SSI included a body mass index greater than 25, American Society of Anesthesiology classification of 3 or higher, diabetes mellitus, surgical time of 2 hours or longer (75th percentile), and current smoking status. Conclusions: Before this study, there was wide variation in the incidence rate of surgical site infections in this patient population. This was a large-scale study to address these inconsistencies.
Article
Objectives: The aim of this study was to evaluate the association between stress-induced hyperglycemia and infectious complications in nondiabetic orthopedic trauma patients admitted to the intensive care unit (ICU). Design: : This study was a retrospective review. Setting: The study was conducted at an academic level-1 trauma center. Patients: One hundred and eighty-seven consecutive trauma patients with isolated orthopedic injuries were studied. Intervention: : Blood glucose values during initial hospitalization were evaluated. The admission blood glucose (BG) and hyperglycemic index (HGI) were determined for each patient. Main outcome measures: Perioperative infectious complications: pneumonia, urinary tract infection (UTI), surgical-site infection (SSI), sepsis were the outcome measures. Results: An average of 21.5 BG values was obtained for each patient. The mean ICU and hospital length of stay was 4.0 ± 4.9 and 10.0 ± 8.1 days, respectively. Infections were recorded in 43 of 187 patients (23.0%) and SSIs specifically documented in 16 patients (8.6%). Open fractures were not associated with SSI (8/83, 9.6% vs. 8/104, 7.7%). There was no difference in admission BG or HGI and infection. However, there was a significant difference in HGI when considering SSI alone (2.1 ± 1.7 vs. 1.2 ± 1.1). Patients with an SSI received a greater amount of blood transfusions (14.9 ± 12.1 vs. 4.9 ± 7.6). No patient was diagnosed with a separate infection (ie, pneumonia, UTI, bacteremia) before SSI. There was no significant difference in injury severity score among patients with an SSI (11.1 ± 4.0 vs. 9.6 ± 3.0). Multivariable regression testing with HGI as a continuous variable demonstrated a significant relationship (odds ratio: 1.8, 95% confidence interval: 1.3-2.5) with SSI after adjusting for blood transfusions (odds ratio: 1.1, 95% confidence interval: 1.1-1.2). Conclusions: : Stress-induced hyperglycemia demonstrated a significant independent association with SSIs in nondiabetic orthopedic trauma patients who were admitted to the ICU. Level of evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Article
A single preoperative prophylactic dose of an intravenous antibiotic with antistaphylococcal activity is standard of care for breast and axillary surgical procedures. Some surgeons also prescribe postoperative prophylaxis for all patients with drains to prevent infection despite its lack of proven efficacy. A retrospective chart review of patients with breast and/or axillary surgical procedures between July 2004 and June 2006 were included. Data were collected on patient demographics, procedure types, and use of prophylactic antibiotics. Surgical site infection (SSI) was defined by means of Centers for Disease Control and Prevention criteria, including patients meeting the physician diagnosis criterion if an antibiotic was prescribed for a clinical diagnosis of cellulitis. chi(2) and Fisher's exact tests were used to compare SSI rates. Three hundred fifty-three patients with 436 surgical sites who received either preoperative or both pre- and postoperative antibiotic were analyzed. Overall, the SSI rate was 7.8% (34 of 436 surgical sites). Eighty-five patients (24%) with 127 surgical sites were provided both preoperative and postoperative prophylactic antibiotics. The SSI rates did not differ statistically (P = .67) for the groups that did (95% confidence interval, 4.8-15.0; 11 of 127 surgical sites, 8.7%) and did not receive postoperative antibiotic prophylaxis (95% confidence interval, 5.0-11.0; 23 of 309, 7.4%). Although the overall number of patients who developed SSI was relatively small, there was no reduction in the SSI rate among those who received postoperative antibiotic prophylaxis. Because of the potential adverse events associated with antibiotic use, further evaluation of this practice is required.