Increased Preoperative Glucose Variability Is Associated with Adverse Perioperative Outcomes Following Orthopedic Surgery in Patients with Type 2 Diabetes Mellitus

Abstract

The association between glucose variability (GV) and adverse perioperative outcomes in type 2 diabetes mellitus (T2DM) patients undergoing orthopedic surgery was investigated. A retrospective cohort study was performed by analyzing data on T2DM patients receiving continuous blood glucose (BG) monitoring and continuous subcutaneous insulin infusion treatment due to poorly controlled preoperative BG prior to orthopedic surgery. GV was assessed with coefficient of variation (CV). Postoperative and perioperative CV, hypoglycemia cases, and other perioperative outcomes (diabetes preparation time [DPT], length of stay [LOS], and perioperative and infective complication cases) were analyzed. Results showed that a total of 168 patients were grouped into preoperative CV tertiles: 1st (n=56): 0–0.2921, 2nd (n=58): 0.2922–0.3779, and 3rd (n=54): 0.3780–0.5750. Fasting blood glucose (FBG), perioperative CV, rate of hypoglycemia cases (OR: 5.53, 95%CI: 2.43–12.59) (all P<0.001) and DPT (P=0.024) were higher in the 3rd than in the 1st tertile. After adjustments of covariates, regression analysis indicated that the 3rd tertile was associated with increased perioperative CV (adjusted coefficient=0.515, P<0.001), DPT (adjusted coefficient =0.169, P=0.073), rate of hypoglycemia cases (OR: 6.72, 95%CI: 2.69−16.82, P<0.001) and perioperative complication cases (OR: 2.50, 95%CI: 0.90−7.01, P=0.080). In conclusion, preoperative GV is associated with increased perioperative GV and adverse perioperative outcomes including longer DPT and higher rates of hypoglycemia and perioperative complications.

Keywords

glycemic variability / orthopedics / perioperative period / type 2 diabetes mellitus

References

[1] ClementS, BraithwaiteSS, MageeMF, et al.. Management of diabetes and hyperglycemia in hospitals. Diabetes Care, 2004, 27(2): 553-591

[2] BrowneJA, CookC, PietrobonR, et al.. Diabetes and early postoperative outcomes following lumbar fusion. Spine (Phila Pa 1976), 2007, 32(20): 2214-2219

[3] PopeD, ScaifeSL, TzengTH, et al.. Impact of diabetes on early postoperative outcomes after total elbow arthroplasty. J Shoulder Elbow Surg, 2015, 24(3): 348-352

[4] ToorAS, JiangJJ, ShiLL, et al.. Comparison of perioperative complications after total elbow arthro-plasty in patients with and without diabetes. J Shoulder Elbow Surg, 2014, 23(11): 1599-1606

[5] Berrios-TorresSI, UmscheidCA, BratzlerDW, et al.. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg, 2017, 152(8): 784-791

[6] LeaperDJ, EdmistonCE. World Health Organization: global guidelines for the prevention of surgical site infection. J Hosp Infect, 2017, 95(2): 135-136

[7] BrunkhorstFM, EngelC, BloosF, et al.. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med, 2008, 358(2): 125-139

[8] FinferS, ChittockDR, SuSY, et al.. Intensive versus conventional glucose control in critically ill patients. N Engl J Med, 2009, 360(13): 1283-1297

[9] HirschIB, BrownleeM. Should minimal blood glucose variability become the gold standard of glycemic control?. J Diabetes Complications, 2005, 19(3): 178-181

[10] ShohatN, FoltzC, RestrepoC, et al.. Increased postoperative glucose variability is associated with adverse outcomes following orthopaedic surgery. Bone Joint J, 2018, 100-B(8): 1125-1132

[11] ShohatN, RestrepoC, AllierezaieA, et al.. Increased Postoperative Glucose Variability Is Associated with Adverse Outcomes Following Total Joint Arthroplasty. J Bone Joint Surg Am, 2018, 100(13): 1110-1117

[12] SuhS, KimJH. Glycemic Variability: How Do We Measure It and Why Is It Important?. Diabetes Metab J, 2015, 39(4): 273-282

[13] Smith-PalmerJ, BrandleM, TrevisanR, et al.. Assessment of the association between glycemic variability and diabetes-related complications in type 1 and type 2 diabetes. Diabetes Res Clin Pract, 2014, 105(3): 273-284

[14] MoghissiES, KorytkowskiMT, DiNardoM, et al.. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Endocr Pract, 2009, 15(4): 353-369

[15] SiegelaarSE, HollemanF, HoekstraJB, et al.. Glucose variability; does it matter?. Endocr Rev, 2010, 31(2): 171-182

[16] No Authors Listed. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-ICD-9-CM).Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/icd/icd9cm.htm (date last accessed 08 June 2019)

[17] No Authors Listed. International statistical classification of diseases and related health problems Tenth Revision (ICD-10). World Health Organization (WHO). http://www.who.int/classifications/icd/ICD-10_2nd_ed_volume2.pdf (date last accessed 08 June 2019)

[18] RodbardD. Clinical interpretation of indices of quality of glycemic control and glycemic variability. Postgrad Med, 2011, 123(4): 107-118

[19] BragdJ, AdamsonU, BacklundLB, et al.. Can glycaemic variability, as calculated from blood glucose self-monitoring, predict the development of complications in type 1 diabetes over a decade?. Diabetes Metab, 2008, 34(6): 612-616 Pt 1

[20] BaghurstPA. Calculating the mean amplitude of glycemic excursion from continuous glucose monitoring data: an automated algorithm. Diabetes Technol Ther, 2011, 13(3): 296-302

[21] FritzscheG, KohnertKD, HeinkeP, et al.. The use of a computer program to calculate the mean amplitude of glycemic excursions. Diabetes Technol Ther, 2011, 13(3): 319-325

[22] RodbardD, BaileyT, JovanovicL, et al.. Improved quality of glycemic control and reduced glycemic variability with use of continuous glucose monitoring. Diabetes Technol Ther, 2009, 11(11): 717-723

[23] RodbardD, JovanovicL, GargSK. Responses to continuous glucose monitoring in subjects with type 1 diabetes using continuous subcutaneous insulin infusion or multiple daily injections. Diabetes Technol Ther, 2009, 11(12): 757-765

[24] MonnierL, ColetteC, OwensDR. Glycemic variability: the third component of the dysglycemia in diabetes. Is it important? How to measure it?. J Diabetes Sci Technol, 2008, 2(6): 1094-1100

[25] MonnierL, WojtusciszynA, ColetteC, et al.. The contribution of glucose variability to asymptomatic hypoglycemia in persons with type 2 diabetes. Diabetes Technol Ther, 2011, 13(8): 813-818

[26] AkirovA, Diker-CohenT, Masri-IraqiH, et al.. High Glucose Variability Increases Mortality Risk in Hospitalized Patients. J Clin Endocrinol Metab, 2017, 102(7): 2230-2241

[27] CerielloA, IhnatMA. ’Glycaemic variability’: a new therapeutic challenge in diabetes and the critical care setting. Diabet Med, 2010, 27(8): 862-867

[28] MendezCE, MokKT, AtaA, et al.. Increased glycemic variability is independently associated with length of stay and mortality in noncritically ill hospitalized patients. Diabetes Care, 2013, 36(12): 4091-4097

[29] SubramaniamB, LernerA, NovackV, et al.. Increased glycemic variability in patients with elevated preo-perative HbA1C predicts adverse outcomes following coronary artery bypass grafting surgery. Anesth Analg, 2014, 118(2): 277-287

[30] MonnierL, MasE, GinetC, et al.. Activation of oxidative stress by acute glucose fluctuations compared with sustained chronic hyperglycemia in patients with type 2 diabetes. JAMA, 2006, 295(14): 1681-1687

[31] QuagliaroL, PiconiL, AssaloniR, et al.. Intermittent high glucose enhances ICAM-1, VCAM-1 and E-selectin expression in human umbilical vein endothelial cells in culture: the distinct role of protein kinase C and mitochondrial superoxide production. Atherosclerosis, 2005, 183(2): 259-267