Perioperative hyperglycemia paradoxically tied to worse outcomes in patients without diabetes vs those with diabetes: JAMA
USA: Patients without diabetes were paradoxically shown to have worse outcomes than diabetes patients at similar levels of hyperglycemia, with frequent insulin use and near-universal blood glucose testing, a recent study has revealed. This effect may be mitigated by insulin and broader use may improve outcomes.
"Because neither underuse of insulin nor diabetes misclassification was responsible for perioperative hyperglycemia, consideration of the possibility of a biological mechanism should be made," Judy Y. Chen, Department of Surgery, University of Washington, Seattle, and colleagues wrote in their study published in JAMA Surgery.
Conventionally, surgical complications associated with perioperative hyperglycemia are associated with diabetes, but prior cohort studies have paradoxically found that patients without diabetes are at a greater complications risk at similar levels of hyperglycemia versus diabetes patients. Considering this, Dr. Chen and the team aimed to describe the association between perioperative hyperglycemia and surgical complications in a population of surgical patients without diabetes receiving routine blood glucose testing and insulin administration. They also evaluated the potential correlation of perioperative hyperglycemia.
For this purpose, the researchers conducted a retrospective cohort study of the National Surgical Quality Improvement Program–defined complications after operation took place at a single academic medical center hospital from January 2013 to October 2016. It included consecutive patients undergoing general, vascular, and gynecologic operations having at least a 48-hour admission.
Hyperglycemia was defined as a blood glucose level of 140 mg/dL or higher within 24 hours after surgery. The association of hyperglycemia and complications was assessed using multivariate regression, stratified by hyperglycemia severity and adjusted for diabetes status. Analysis began in February 2022.
The main outcomes are odds of experiencing perioperative hyperglycemia and postoperative complication, comparing patients with and without diabetes.
In total, 7634 patients (mean age, 53.5 years; 6664 patients without diabetes and 970 patients with diabetes) underwent general (81.3%), vascular (2.7%), and gynecologic (16%) operations. Of these, 77% had blood glucose testing (73.5% individuals with diabetes and 99.9% without diabetes).
The findings of the study were as follows:
- Hyperglycemia occurred in 91% of patients with diabetes and 50.7% of patients without diabetes.
- Of those with blood glucose levels more than 180 mg/dL, 72.7% received insulin (658 patients with diabetes who had hyperglycemia [91%] and 680 patients without diabetes who had hyperglycemia [61%]).
- Adjusted odds of experiencing a complication were 83% greater for patients without vs with diabetes at a blood glucose levels of 140 to 179 mg/dL, 49% greater for blood glucose levels of 180 to 249 mg/dL, and 88% greater for blood glucose level more than 250 mg/dL.
- A similar trend was observed for serious complications. Insulin may mitigate the association between hyperglycemia and complications in patients without diabetes.
"In this study, with near-universal blood glucose testing and frequent insulin use, patients without diabetes paradoxically had worse outcomes than diabetes patients at similar levels of hyperglycemia," the authors concluded. "Insulin may mitigate this effect and broader use may improve outcomes."
Reference:
Chen JY, Nassereldine H, Cook SB, Thornblade LW, Dellinger EP, Flum DR. Paradoxical Association of Hyperglycemia and Surgical Complications Among Patients With and Without Diabetes. JAMA Surg. Published online June 15, 2022. doi:10.1001/jamasurg.2021.5561
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