Early Postoperative Hyperglycemia Research Articles

Early postoperative hyperglycemia as a predictor of postoperative infectious complications and overall survival in non-diabetic patients with esophageal cancer

BackgroundDiabetes mellitus (DM) is known to be a risk factor for postoperative infectious complications (PICs). However, the significance of postoperative hyperglycemia in non-DM cases has not been well investigated. We sought to establish whether postoperative hyperglycemia is associated with PICs and survival among patients with esophageal cancer, with a focus on non-DM cases. MethodsA total of 430 patients who underwent subtotal esophagectomy for esophageal cancer between 2014 and 2018 were enrolled. Postoperative blood glucose was measured by arterial blood gas test every 8 h from postoperative day (POD) 1 to POD4. The association between hyperglycemia (mean ≥ 200 mg/dl) and PICs or long-term outcomes on each POD was investigated. ResultsThere were 53 DM and 377 non-DM cases. PICs occurred in 127 patients. In the multivariate analysis of all cases, PICs were associated with hyperglycemia on POD1 or -2 (odds ratio [OR] = 1.69, 95% CI, 1.05–2.73, P = 0.031 for POD1; OR = 2.55, 95% CI, 1.10–5.93, P = 0.029 for POD 2). Among non-DM cases, the association was more evident, and persisted until POD4 (OR = 1.94, 95% CI, 1.16–3.24, P = 0.012 for POD1; OR = 3.68, 95% CI, 1.28–10.6, P = 0.016 for POD2; OR = 3.07, 95% CI, 1.11–8.51, P = 0.031 for POD4). Survival analyses limited to R0 cases revealed hyperglycemia on POD2 as an independent prognostic factor in all cases (N = 412) [hazard ratio (HR) = 2.61, 95%CI, 1.21–5.63, P = 0.014], with the prognostic impact more evident among non-DM cases (N = 360) (HR = 4.38, 95% CI, 1.82–10.57, P = 0.0010). ConclusionPostoperative hyperglycemia is associated with PICs and worse survival after esophagectomy, particularly in patients without DM.

Hyperglycemia is associated with worse 3-year survival in older patients admitted to the intensive care unit after non-cardiac surgery: Post hoc analysis of a randomized trial.

Hyperglycemia is common in critically ill patients after surgery and is associated with worse perioperative outcomes. Yet, the impact of postoperative hyperglycemia on long-term outcomes remains unclear. We therefore analyzed the association between early postoperative hyperglycemia and 3-year overall survival in older patients who were admitted to the intensive care unit after surgery. This was a post hoc analysis of database obtained from a previous randomized trial and 3-year follow-up. The underlying trial enrolled 700 patients aged 65 years or older who were admitted to the intensive care unit after elective non-cardiac surgery. Early postoperative time-weighted average blood glucose was calculated and was divided into three levels, i.e., <8.0 mmol/L, from 8.0 to 10.0 mmol/L, and >10.0 mmol/L. The primary outcome was 3-year overall survival. The association between time-weighted average blood glucose level and 3-year overall survival was analyzed with Cox proportional hazard regression models. Subgroup analyses were also performed in patients with or without diabetes, and in patients following cancer or non-cancer surgery. A total of 677 patients (mean age 74 years, 60% male sex) were included in the final analysis. Within 3 years after surgery, deaths occurred in 22.1% (30/136) of patients with time-weighted average blood glucose <8.0 mmol/L, compared with 35.7% (81/227) of those from 8.0 to 10.0 mmol/L (unadjusted hazard ratio 1.75, 95% CI 1.15 to 2.67, P = 0.009), and 36.9% (116/314) of those >10.0 mmol/L (unadjusted hazard ratio 1.91, 95% CI 1.28 to 2.85, P = 0.002). After adjustment for confounding factors, the risk of 3-year mortality remained higher in patients with time-weighted average blood glucose from 8.0 to 10.0 mmol/L (adjusted hazard ratio 2.28, 95% CI 1.47 to 3.54, P < 0.001) and in those >10.0 mmol/L (adjusted hazard ratio 2.00, 95% CI 1.29 to 3.10, P = 0.002). Similar results were obtained in the subgroups of patients without diabetes and patients following cancer surgery. For older patients admitted to the intensive care unit after elective non-cardiac surgery, high early blood glucose (time-weighted average blood glucose ≥ 8.0 mmol/L) was associated with poor 3-year overall survival. The impact of moderate glycemic control on long-term survival deserves further investigation.

Perioperative management of diabetes in patients undergoing bariatric and metabolic surgery: a narrative review and the Cleveland Clinic practical recommendations.

Bariatric and metabolic surgery is an effective treatment for patients with severe obesity and obesity-related diseases. In patients with type 2 diabetes, it provides marked improvement in glycemic control and even remission of diabetes. In patients with type 1 diabetes, bariatric surgery may offer improvement in insulin sensitivity and other cardiometabolic risk factors, as well as amelioration of the mechanical complications of obesity. Because of these positive outcomes, there are increasing numbers of patients with diabetes who undergo bariatric surgical procedures each year. Prior to surgery, efforts should be made to optimize glycemic control. However, there is no need to delay or withhold bariatric surgery until a specific glycosylated hemoglobin target is reached. Instead, treatment should focus on avoidance of early postoperative hyperglycemia. In general, oral glucose-lowering medications and noninsulin injectables are not favored to control hyperglycemia in the inpatient setting. Hyperglycemia in the hospital is managed with insulin, aiming for perioperative blood glucose concentrations between 80 and 180 mg/dL. Following surgery, substantial changes of the antidiabetic medication regimens are common. Patients should have a clear understanding of the modifications made to their treatment and should be followed closely thereafter. In this review article, we describe practical recommendations for the perioperative management of diabetes in patients with type 2 or type 1 diabetes undergoing bariatric surgery. Specific recommendations are delineated based on the different treatments that are currently available for glycemic control, including oral glucose-lowering medications, noninsulin injectables, and a variety of insulin regimens.

Impact of Postoperative Glycemic Control on Postoperative Morbidity in Patients Undergoing Open Pancreaticoduodenectomy.

To evaluate the impact of postoperative glycemic control on postoperative morbidity in patients undergoing a pancreaticoduodenectomy. A retrospective study was performed on patients at The Johns Hopkins Hospital between April 2015 and April 2016. Data were collected on postoperative insulin regimens, blood glucose, rates of hyperglycemia and hypoglycemia, and postoperative complications and were evaluated. Out of 244 patients, 114 (46.7%) experienced at least 1 hyperglycemic (>180 mg/dL) episode and 16 (6.6%) experienced at least 1 hypoglycemic episode (<70 mg/dL) during the first postoperative 24 hours. Early postoperative hyperglycemia (>180 mg/dL) was associated with a significantly higher rate of surgical site infections (15.7% vs 7%; P = 0.031). Late postoperative hyperglycemia (>180 mg/dL) was associated with a significantly higher rate of fistulas (4.3% vs 14.6%; P = 0.021). Early hyperglycemia (>180 mg/dL) is associated with a higher risk of surgical site infections while late hyperglycemia is associated with a higher risk of fistulas. Intensive glucose control (<150 mg/dL) was not demonstrated to decrease the risk of postoperative complications. Similar to other critically ill populations, targeting a glucose goal of <180 mg/dL may be an appropriate target to reduce morbidity without increasing the risk of hypoglycemia.

Relationship between pancreatic parenchyma loss and early postoperative hyperglycemia in patients with benign pancreatic diseases

ObjectiveTo evaluate the relationship between pancreatic parenchyma loss and early postoperative hyperglycemia in patients with benign pancreatic diseases.MethodsA total of 171 patients with benign pancreatic tumors or chronic pancreatitis, whose preoperative fasting blood glucose (FBG) was normal and who underwent partial pancreatectomy were reviewed. The pancreatic volume was measured by CT imaging before and after the operation. According to their different pancreatic resection volume (PRV), 171 patients were divided into five groups: < 30%, 30%–39%, 40%–49%, 50%–59%, and ≥ 60%. The correlation between the PRV and postoperative FBG was investigated. According to the postoperative FBG value, the patients were divided into a hyperglycemia group (HG) and nonhyperglycemia group (non-HG) to explore the best cutoff value of the PRV between the two groups.ResultsThere were significant differences in the postoperative FBG among the five groups (PRV < 30%, 30%–39%, 40%–49%, 50%–59%, and ≥ 60%). The PRV was positively correlated with postoperative FBG in the benign tumor group and chronic pancreatitis group (R = 0.727 and 0.651, respectively). ROC curve analysis showed that the best cutoff value of the PRV between the HG (n = 84) and non-HG (n = 87) was 39.95% with an AUC = 0.898; the sensitivity was 89.29%, and the specificity was 82.76%.ConclusionThere was a linear positive correlation between the postoperative FBG level and PRV. Patients with a PRV ≥ 40% are more likely to develop early postoperative hyperglycemia.

Incidence, risk factors, and outcomes of early postoperative hyperglycemia in surgical patients: a protocol for a systematic review and meta-analysis

BackgroundEarly postoperative hyperglycemia (POHG) is common and associated with poor postoperative outcomes. Currently, there is no systematic review and meta-analysis that addresses the knowledge gap of the incidence of POHG in surgical patients and that explores the associated risk factors and complications. The objective of this study will be to estimate the pooled incidence, risk factors, and clinical outcomes of early postoperative hyperglycemia in men and women globally.MethodsWe designed and registered a study protocol for a systematic review and meta-analysis of studies reporting the incidence of postoperative hyperglycemia (POHG). We will search PubMed (MEDLINE), Scopus, Web of Science, EMBASE, Cochrane Library, OVID (HEALTH STAR), OVID (MEDLINE), and Joana Briggs Institute EBF Database (from inception onwards). Randomized controlled trials and observational cohort studies reporting the incidence of POHG and conducted in surgical patients will be included. No age, geographical location, study design, or language limits will be applied. The primary outcome will be the incidence of POHG. Secondary outcomes will be risk factors and clinical outcomes of POHG. Two reviewers will independently screen citations, full text articles, and abstract data, extract data, and evaluate the quality and bias of included studies. Discrepancies will be resolved through discussion or consultation with a third researcher. The risk of bias and study methodological quality of included studies will be evaluated by the appropriate Cochrane risk of bias tool for randomized trials and Newcastle-Ottawa Scale for cohort studies. If feasible, we will conduct random effects meta-analysis with a logit transformation of proportions. We will report the probability of postoperative hyperglycemia as a measure of incidence rate, relative risk ratios (RR), and 95% confidence intervals to report the effects of the risk factors and postoperative outcomes. Additional analyses will be conducted to explore the potential sources of heterogeneity (e.g., age, gender, geographical location, publication year, comorbidities, type of surgical procedure). The Egger test and funnel plots will be used to assess small study effects (publication bias).DiscussionThis systematic review and meta-analysis will identify, evaluate, and integrate the evidence on the incidence, risk factors, and outcomes of early POHG in surgical patients. The results of this study can be used to identify populations which may be at particular risk for POHG. Future studies which use this information to better guide post-operative glycemic control in surgical patients could be considered.Systematic review registrationPROSPERO registration number CRD42020167138

Hyperglycemia and risk of adverse outcomes following microvascular reconstruction of oncologic head and neck defects

IntroductionOur aim is to examine the correlation between perioperative hyperglycemia and post-operative outcomes following microvascular reconstruction of head and neck defects. Patients and methodsRetrospective review of a prospectively collected database of 350 consecutive patients who underwent microvascular reconstruction of malignant head and neck defects over a 2 year period. The relationship between perioperative hyperglycemia (≥ 180 mg/dL) and the incidence of the following complications was evaluated: flap loss, flap-related complications and surgical site infections (SSI). Sub-group analysis based on timing of hyperglycemia was also performed. ResultsWe identified 313 patients (89.4%) in the normoglycemic group and 37 patients (10.6%) in the hyperglycemic group. Baseline demographics, tumor stage, operative variable were comparable. There were no significant differences in flap-related complications and overall mortality. SSI were significantly higher in the hyperglycemic cohort (48% vs. 28%, p = 0.01). On multivariate analysis, hyperglycemia [OR 2.07; 95% CI, 1.87–4.89], perioperative insulin administration [OR 4.805; 95% CI, 2.18–10.60], prolonged operative time [OR 1.003; 95% CI, 1.002–1.025] and higher Charlson co-morbidity indices [II: OR 2.286 & III: OR 2.284] were independent predictors of SSI. On sub-group analysis, only patients with early (POD 1) post-operative hyperglycemia had a significant OR for SSI (OR 1.88; 95% CI, 1.07–3.29). ConclusionOur findings suggest that perioperative hyperglycemia, specifically during the first 24 h post-operatively, is associated with SSI in microvascular head and neck reconstruction. This association highlights the need for strict screening of head and neck patients for hyperglycemia especially in the immediate post-operative period.

Perioperative Hyperglycemia and Postoperative Outcomes in Patients Undergoing Resection of Colorectal Liver Metastases

IntroductionThere is limited evidence characterizing the impact of glycemic alterations on short-term outcomes among patients undergoing resection of colorectal liver metastases (CRLM). MethodsHyperglycemia was defined as a glucose value >125 mg/dl according to WHO definition. The impact of early postoperative hyperglycemia on short-term postoperative outcomes was assessed. ResultsThe mean postoperative glucose value was 128 mg/dl; 30 (9.8 %) patients had normal fasting glucose (<100 mg/dl), 106 patients had glucose intolerance (100–125 mg/dl), and 170 (55.5 %) patients had hyperglycemia (>125 mg/dl). A postoperative complication occurred in 101 patients (morbidity, 33.1 %); among patients who experienced a complication, an infectious complication was most common (38.6 %). After controlling for clinical factors, patients with hyperglycemia had an increased risk of overall complications [odds ratio (OR) 4.11; 95 % confidence interval (CI) 1.96–8.62, P < 0.001]. This was the case for both patients with and without diabetes (P < 0.05). Patients with hyperglycemia on the day of surgery were also at an increased risk of infections [OR 9.17; 95 % CI 2.26–37.13, P = 0.002] and had a longer hospital stay (normal glucose, 4 days vs. glucose 100–125 mg/dl, 4 days vs. glucose >125 mg/dl, 5 days, P < 0.001). ConclusionsEarly postoperative hyperglycemia was associated with adverse outcomes in patients with and without diabetes who underwent resection of CRLM. Perioperative glucose evaluation may be an important quality target.

Mo1574 Impact of Early Postoperative Hyperglycemia on Short-Term Outcomes After Resection of Colorectal Liver Metastases

Mo1574 Impact of Early Postoperative Hyperglycemia on Short-Term Outcomes After Resection of Colorectal Liver Metastases

Association of postoperative hyperglycemia with outcomes among patients with complex ventral hernia repair.

Patients with medically complex conditions undergoing repair of large or recurrent hernia of the abdominal wall are at risk for early postoperative hyperglycemia, which may serve as an early warning for delays in recovery and for adverse outcomes. To evaluate postoperative serum glucose level as a predictor of outcome after open ventral hernia repair in patients with major medical comorbidities. We performed a retrospective medical record review of 172 consecutive patients who underwent open ventral hernia repair at Penn State Milton S. Hershey Medical Center, an academic tertiary referral center, from May 1, 2011, through November 30, 2013. We initially identified patients by medical complexity and repair requiring a length of stay of longer than 1 day. Postoperative recovery variables, including time to the first solid meal, length of stay, total costs of hospitalization, and surgical site occurrence. Postoperative serum glucose values were available for 136 patients (79.1%), with 130 (95.6%) obtained within 48 hours of surgery. Among these patients, Ventral Hernia Working Group grade distributions included 8 patients with grade 1, 79 with grade 2, 41 with grade 3, and 8 with grade 4. Fifty-four patients (39.7%) had a postoperative glucose level of at least 140 mg/dL, and 69 patients (50.7%) required insulin administration. Both outcomes were associated with delays in the interval to the first solid meal (glucose level, ≥140 vs <140 mg/dL: mean [SD] delay, 6.4 [5.3] vs 5.6 [8.2] days; P = .01; ≥2 insulin events vs <2: 6.5 [5.5] vs 5.4 [8.4] days; P = .02); increased length of stay (glucose level, ≥140 vs <140 mg/dL: mean [SD], 8.0 [6.0] vs 6.9 [8.2] days; P = .008; ≥2 insulin events vs <2: 8.3 [6.1] vs 6.5 [8.4] days; P < .001); increased costs of hospitalization (glucose level, ≥140 vs <140 mg/dL: mean [SD], $31 307 [$20 875] vs $22 508 [$22 531]; P < .001; ≥2 insulin events vs <2: $31 943 [$22 224] vs $20 651 [$20 917]; P < .001); and possibly increased likelihood of surgical site occurrence (glucose level, ≥140 vs <140 mg/dL: 37.5% [21 of 56 patients] vs 22.5% [18 of 80 patients]; P = .06; ≥2 insulin events vs <2: 36.4% [24 of 66 patients] vs 21.4% [15 of 70 patients]; P = .06). Not all patients with diabetes mellitus developed postoperative hyperglycemia or needed more intense insulin therapy; however, 46.4% of the patients who developed postoperative hyperglycemia were not previously known to have diabetes mellitus, although most had at least 1 clinical risk factor for a prediabetic condition. Postoperative hyperglycemia was associated with outcomes in patients in this study who underwent complex ventral hernia repair and may serve as a suitable target for screening, benchmarking, and intervention in patient groups with major comorbidities.

Correlation of early postoperative blood glucose levels with postoperative complications, hospital costs, and length of hospital stay in patients with gastrointestinal malignancies.

Early postoperative hyperglycemia in non-diabetic patients is an important risk factor affecting postoperative complications and mortality. This study aimed at investigating the effects of early postoperative hyperglycemia on postoperative complications, hospital costs, and length of hospital stay in non-diabetic patients with gastrointestinal malignancies; data of 1,015 non-diabetic patients with gastrointestinal malignancies, who underwent surgical intervention between January 2010 and January 2012, were retrospectively evaluated. Records on fasting plasma glucose (FPG), liver function, and kidney function were collected before and one day after surgery. Correlation of early postoperative FPG levels with postoperative complications, hospital costs, and length of hospital stay was further assessed in non-diabetic patients with gastrointestinal malignancies. One day after surgery, FPG results were significantly increased compared to preoperative values. FPG levels greater than or equal to 9.13mmol/L (or 164.34mg/dL) were associated with significant increases in the incidence of postoperative complications, length of hospital stay, and hospital costs. An association is shown between FPG and postoperative hyperglycemia in non-diabetic patients undergoing surgery for gastrointestinal malignancies. Significant increases in postoperative complications among these patients suggest that measurement of early postoperative FPG levels is critical to identify patients with postoperative hyperglycemia.

Day 1 post-operative fasting hyperglycemia may affect graft survival in kidney transplantation

Early post-operative hyperglycemia is commonly encountered in patients without pre-existing diabetes mellitus who are undergoing kidney transplantation. The aim of this study was to determine the effect of early post-operative hyperglycemia on graft and patient survival after kidney transplantation in our center. This was a single-center retrospective review of solitary kidney recipients transplanted in our center between January 1998 and December 2007. Of a total of 432 patients, 377 were eligible for the study. Fasting plasma glucose (FPG) levels at day 1 (D1) and day 5 (D5) after transplantation were recorded. Hyperglycemia was defined as FPG ≥ 7.0 mmol/l. Outcome events recorded included deaths and graft failures. The mean age at transplantation was 43.2 ± 9.5 years and 50.4% were male. The mean FPG levels at D1 and D5 were 7.5 ± 1.3 mmol/L and 5.3 ± 1.3 mmol/L, respectively; 64.2% of recipients had FPG ≥ 7.0 mmol/L on D1 and this was reduced to 8.5% on D5. Recipients with D1 FPG ≥ 7.0 mmol/L had significantly poorer graft survival (39 events) compared to those without D1 hyperglycemia (6 events), with a hazard ratio of 3.708 (95% CI, 1.568-8.766, P=0.003). There was a trend towards better patients survival in recipients with D1 FPG <7.0 mmol/L (P=0.056). D1 post-transplantation hyperglycemia may be associated with increased risk of graft failure. It is thus important to closely monitor glucose levels during the early post-transplantation period so that high risk patients can be identified and appropriate measures can be implemented to improve the long-term outcome.

Tight glycemic control using an artificial endocrine pancreas may play an important role in preventing infection after pancreatic resection

It is well known that perioperative hyperglycemia is the main cause of infectious complications after surgery. To improve perioperative glycemic control, we wish to highlight and comment on an interesting paper published recently by the Annals of Surgery entitled: "Early postoperative hyperglycemia is associated with postoperative complications after pancreatoduodenectomy (PD)" by Eshuis et al. The authors concluded that early postoperative glucose levels more than 140 mg/dL was significantly associated with complications after PD. Since we recommend that perioperative tight glycemic control (TGC) is an effective method to prevent postoperative complications including surgical site infection after distal, proximal, and total pancreatic resection, we support strongly this conclusion drawn in this article. However, if early postoperative glucose control in patients undergoing PD was administrated by conventional method such as sliding scale approach as described in this article, it is difficult to maintain TGC. Therefore, we introduce a novel perioperative glycemic control using an artificial endocrine pancreas against pancreatogenic diabetes after pancreatic resection including PD.

Early Postoperative Hyperglycemia Is Associated With Postoperative Complications After Pancreatoduodenectomy

To investigate the relation between perioperative hyperglycemia and complications after pancreatoduodenectomy. Perioperative hyperglycemia is associated with complications after various types of surgery. This relation was never investigated for pancreatoduodenectomy. In a consecutive series of 330 patients undergoing pancreatoduodenectomy, glucose values were collected from the hospital information system during 3 periods: pre-, intra-, and early postoperative. The average glucose value per period was calculated for each patient and divided in duals according to the median group value. Odds ratios for complications were calculated for the upper versus lower dual, adjusted for age, sex, American Society of Anesthesiologists Classification, body mass index, diabetes mellitus, intraoperative blood transfusion, duration of surgery, intraoperative insulin administration, and octreotide use. The same procedures were carried out to assess the consequences of increased glucose variability, expressed by the standard deviation. Average glucose values were 135 (preoperative), 133 (intraoperative) and 142 mg/dL (early postoperative). Pre- and intraoperative glucose values were not associated with postoperative complications. Early postoperative hyperglycemia (≥140 mg/dL) was significantly associated with complications [odds ratio (OR) 2.9, 95% confidence interval (CI), 1.7-4.9]. Overall, high glucose variability was not significantly associated with postoperative complications, but early postoperative patients who had both high glucose values and high variability had an OR for complications of 3.6 (95% CI, 1.9-6.8) compared to the lower glucose dual. Early postoperative hyperglycemia is associated with postoperative complications after pancreatoduodenectomy. High glucose variability may enhance this risk. Future research must demonstrate whether strict glucose control in the early postoperative period prevents complications after pancreatoduodenectomy.

Hyperglycemia predicts mortality after CABG: postoperative hyperglycemia predicts dramatic increases in mortality after coronary artery bypass graft surgery

Objective Risk of morbidity and mortality after coronary artery bypass graft surgery (CABG) is higher in patients with clinical diabetes mellitus (DM). We evaluated whether outcomes are affected by postoperative hyperglycemia in CABG patients independent of preoperative DM diagnosis. Research Design and Methods A total of 2297 consecutive CABG patients were studied. The first glucose value after surgery completion (mean 15 min) was tested as a predictor of outcome. Primary outcome variables were prolonged ventilation (>24 h), deep sternal wound infection, renal failure, permanent stroke, any reoperation, length of stay (>14 days) and mortality. All outcomes except for prolonged ventilation and length of stay were tracked out to 30 days postoperatively. Patients were stratified by glycemic control: Low (glucose <80), normal (referent, glucose 80–110), high (glucose 111–200) and very high (glucose >200 mg/dl). Multivariable logistic regression was used to determine the independent predictive value of glycemic groups, adjusted for outcome specific risk scores from the Society of Thoracic Surgeons model. Results Patient distribution among groups low through very high were 44 (1.9%), 476 (20.7%), 1425 (62.0%) and 352 (15.3%). Greater complication rates were noted in the very high group when compared with the referent group: prolonged ventilation (adjusted odds ratio (OR)=2.66, P<.001), length of stay >14 days (adjusted OR=2.06, P=.004) and mortality (adjusted OR=7.71, P<.001). Conclusion Patients with blood glucose values >200 mg/dl immediately after CABG had an increased risk of complications, including mortality, independent of a clinical diagnosis of DM. This study documents the high risk associated with early postoperative hyperglycemia in this group, suggesting the need for prospective trials of glycemic control.