Increased preoperative glucose levels are associated with perioperative mortality in patients undergoing noncardiac, nonvascular surgery

Abstract

Objective: To determine the relationship between preoperative glucose levels and perioperative mortality in noncardiac, nonvascular surgery. Research design and methods: We performed a case-control study in a cohort of 108 593 patients who underwent noncardiac surgery at the Erasmus MC during 1991-2001. Cases were 989 patients who underwent elective noncardiac, nonvascular surgery and died within 30 days during hospital stay. From the remaining patients, 1879 matched controls (age, sex, calendar year, and type of surgery) were selected. Information was obtained regarding the presence of cardiac risk factors, medication, and preoperative laboratory results. Preoperative random glucose levels !5.6 mmol/l (110 mg/dl) were normal. Impaired glucose levels in the range of 5.6-11.1 mmol/l were prediabetes. Glucose levels R11.1 mmol/l (200 mg/dl) were diabetes. Results: Preoperative glucose levels were available in 904 cases and 1247 controls. A cardiovascular complication was the primary cause of death in 207 (23%) cases. Prediabetes glucose levels were associated with a 1.7-fold increased mortality risk compared with normoglycemic levels (adjusted odds ratio (OR) 1.7 and 95% confidence interval (CI) 1.4-2.1; P!0.001). Diabetes glucose levels were associated with a 2.1-fold increased risk (adjusted OR 2.1 and 95% CI 1.3-3.5; P!0.001). In cases with cardiovascular death, prediabetes glucose levels had a threefold increased cardiovascular mortality risk (adjusted OR 3.0 and 95% CI 1.7-5.1) and diabetes glucose levels had a fourfold increased cardiovascular mortality risk (OR 4.0 and 95% CI 1.3-12). Conclusions: Preoperative hyperglycemia is associated with increased (cardiovascular) mortality in patients undergoing noncardiac, nonvascular surgery.

Preoperative glucose as a screening tool in patients without diabetes

“…We advocate for a policy to routinely measure pre-operative glucose and identify patients with poor glucose control so that follow-up HbA1c testing and other interventions could be initiated prior to surgery as this practice is not yet a routine pre-operative screening tool at many hospitals. In patients with a diagnosis of diabetes, studies have been mixed, showing that pre-operative hyperglycemia is not associated with mortality or infection rates in non-cardiac surgery, 9,17 but also that increased pre-operative glucose is associated with higher mortality in patients undergoing non-cardiac non-vascular surgery, 11 and that operative day hyperglycemia is associated with SSI after colectomy for cancer. 33 Our study had several limitations.…”

“…4,[10][11][12] Possible mechanisms linking hyperglycemia with worse outcomes (besides an undiagnosed illness causing physiologic stress) include derangements in leukocyte function, glycosylation and inactivation of immunoglobulins (leading to immune dysfunction), and collagen glycosylation (leading to poor healing from wounds and organ damage). [13][14][15][16] However, since there are likely many confounding factors contributing to the relationship between pre-operative hyperglycemia and post-operative complications, we sought to assess preoperative glucose as a marker, not as a causal determinant, of post-operative complications.…”

“…Pre-operative hyperglycemia was shown to be associated with increased hospital mortality in diabetic and non-diabetic patients. 11,17 However, a study of surgical patients with aneurysmal subarachnoid hemorrhage showed that admission hyperglycemia was not associated with worse outcomes. 18 Our study assesses pre-operative glucose as a marker for post-operative complications in a cohort of patients without known diabetes admitted for non-emergent non-cardiac surgery, which represents a unique chance to evaluate pre-operative screening for hyperglycemia in patients with lower levels of physiologic stress than previous study populations.…”

Perioperative catabolism

“…[45][46][47][48] In non-cardiac non-vascular patients, preoperative blood glucose levels [ 11.1 mmolÁL -1 were associated with a 2.1-fold higher risk in 30-day all-cause mortality and a four-fold higher risk of 30-day cardiovascular mortality. 49 In a large cohort of 61,536 consecutive elective noncardiac surgery patients, poor preoperative glycemic control was related to adverse in-hospital outcomes and one-year mortality. 50 …”

The relationship between glycosylated hemoglobin and perioperative glucose control in patients with diabetes

“…4 Several studies show that perioperative hyperglycemia is associated with morbidity. 5,6 An association between baseline glucose regulation and hyperglycemia in critically ill patients has been reported. 7 In trauma patients, there is a relationship between HbA 1c and hyperglycemia after a stress response.…”