Does Stress-Induced Hyperglycemia Increase the Risk of Perioperative Infectious Complications in Orthopaedic Trauma Patients?

ArticleinJournal of orthopaedic trauma 24(12):752-6 · December 2010with9 Reads
Impact Factor: 1.80 · DOI: 10.1097/BOT.0b013e3181d7aba5 · Source: PubMed
Abstract

To determine if hyperglycemia in postoperative orthopaedic trauma patients with no known history of diabetes mellitus is associated with an increased rate of infectious complications. Retrospective review. University Level I trauma center. One hundred ten consecutive orthopaedic trauma patients, Perioperative pneumonia, urinary tract infection, sepsis, or wound infection. Patients were divided into two subgroups based on mean serum glucose greater than 220 mg/dL (hyperglycemic index [HGI] 3.0 or greater). The incidence of infections was calculated for the following factors: age, medical comorbidities, Injury Severity Score, body mass index, HGI, sex, transfusions, tobacco use, and presence of open fracture. Means were compared using two-sample t tests (with or without adjustment for unequal variances as necessary), and percentages were compared using either chi square or Fisher exact tests. If the data were not normally distributed or measured on the ordinal scale, then the Wilcoxon rank sum test was used. A multivariate analysis using logistic regression was performed with the presence or absence of an infection as the dependent variable. A two-tailed P value < 0.05 was considered significant. SAS, Version 9.1 (SAS Institute Inc, Cary, NC), was used for all analyses. Forty-six infections occurred in 28 patients, including 11 wound infections, 17 pneumonia, 11 urinary tract infections, and seven sepsis or bacteremia. The overall infection rate for the study cohort was 28 of 110 (25%). No significant associations were identified among age, comorbidities, transfusions, tobacco use, open fracture, sex, body mass index, Injury Severity Score, and the presence of any infection. Ninety nine patients had an HGI less than 3.0 and 21 (21%) of these had a perioperative infection. Eleven patients had an HGI 3.0 or greater and seven (64%) of these had a perioperative infection. This difference was significant (P = 0.0056). Mean perioperative glucose levels greater than 220 mg/dL (HGI greater than 3.0) were associated with a seven times higher risk of infection in orthopaedic trauma patients with no known history of diabetes mellitus. Further prospective studies are needed to study the effects of stress-induced hyperglycemia and to determine whether this physiological response is protective or detrimental to the postoperative trauma patient.

    • "Similar to diabetic patients who underwent cardiothoracic surgeries, these patients had increased odds of specific perioperative complications such as pneumonia and need for transfusion, and experienced greater incidence of stroke, urinary tract infection, and ileus (p>.001), as well as a number of other perioperative complications [36]. Hyperglycemia is associated with increased risk of infectious complications in nondiabetic hyperglycemic trauma patients [37, 38]. In a large retrospective review of adults (mean age 47.7 years) without diabetes and requiring acute orthopedic intervention, hyperglycemia (serum glucose ≥140 mg/dL) was an independent predictor of 30-day SSI [39]. "
    [Show abstract] [Hide abstract] ABSTRACT: The aging of the U.S. population is leading to an increasing number of surgical procedures performed on older adults. At the same time, the quality of medical care is being more closely scrutinized. Surgical site infection is a widely-assessed outcome. Evidence suggests that strict perioperative serum glucose control among patients with or without diabetes can lower the risk of these infections, but it is unclear whether this control should be applied to older surgical patients. In this clinical review, we discuss current research on perioperative serum glucose management for cardiothoracic, orthopedic, and general/colorectal surgery. In addition, we summarize clinical recommendations and quality-of-care process indicators provided by surgical, diabetes, and geriatric medical organizations.
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  • [Show abstract] [Hide abstract] ABSTRACT: Some nondiabetic trauma patients with hyperglycemia have been found to have occult diabetes mellitus (ODM). We studied whether glycated albumin (GA) was an effective tool for detecting ODM in orthopedic trauma patients with elevated glucose levels. A cross-sectional, sequential case series study of adult patients presenting to the Orthopedic Trauma Center between September 2009 and March 2010 with new limb fractures was performed. Hemoglobin A1c (HbA1c) and GA levels were measured in hyperglycemic patients with no prior diabetes mellitus. A receiver operating characteristic curve was plotted to examine the sensitivity, specificity, and positive and negative predictive values of GA in identifying occult diabetes in hospitalized patients with acute hyperglycemia. A total of 2,058 trauma patients were screened and 399 patients (19.4%) with no known diabetes mellitus were noted to be hyperglycemic. Of these 399 patients, 38.3% (n = 153) had ODM according to the HbA1c diagnosis cutoff point. GA level was strongly correlated with HbA1c using Pearson's correlation analysis (r = 0.887, p < 0.01). Using logistic regression analysis, GA (odds ratio [OR] = 1.60, p < 0.001) and fasting plasma glucose (OR = 1.974, p < 0.001) were identified as significant risk factors for the diagnosis of ODM. Receiver operating characteristic curve analysis showed that a GA value of 17.5% gave an optimal sensitivity of 73.20% and specificity of 99.12% for distinguishing ODM from stress-induced hyperglycemia. Almost 40% of nondiabetic orthopedic trauma patients presenting with hyperglycemia were found to have ODM. A GA value of 17.5%, the optimal cutoff point, could distinguish between ODM and stress-induced hyperglycemia in Chinese orthopedic trauma subjects. II, diagnostic study.
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