We just did a prospective study looking at the preoperative glycemic state in patients undergoing majorsurgery of the proximal femur. Hyperglycemic patients showed an impared clinical outcome. It would now be interesting to see, if normalizing the glycemic state pre-op and tight glycemic controll would leed to a better outcome. What are your views? How long would you administer tight glycemic control pre-op (1 week? 2 weeks?).
ABSTRACT: Background: Several clinical studies investigated the relationship between systemic glucose levels and clinical outcomes. It has been shown that high glucose levels during the hospital stay are associated with impaired outcomes. Effects of preexisting hyperglycemia on the hospital course in different patient populations have been discussed controversially. Hypothesis: The aim of this study was to test the predictive value of preoperative glucose measurements for clinical outcomes and complications. We hypothesize that hyperglycemia is associated with impaired outcomes.
Methods: A total of 336 patients undergoing major surgery of the proximal femur were prospectively enrolled in the study. Patients received prophylactic antibiotic treatment. Systemic glucose, bilirubin, kreatinin, CRP, leukocytes levels were measured preoperative and for up to 14 days post-surgery. Patients were grouped by glucose readings >120 (H) and
Certainly the literature shows that elevated glc pre-op leads to more infections, more adhesions, slower healing and worse outcomes. I have learned this the hard way as well, operating on patients who were suffering and could not get their glc under control. The answer is peri-operative clinics that understand this and get the tighter control.
The interesting part is the ROC-Analysis cut off at 111 mg/dl serum glucose. In clinical terms this would not be considered as a very high glucose-level and probably not be noticed as a riskfactor pre-op.
This is a great study: The best data I have come across is from Sheldon Lin - he did a rat study showing that normalizing sugars improved bone healing and growth factors. The only other surgical literature is the evidence from cardiac surgery. We published on failure of transmetarsal amputations and showed that the risk factor predicting conversion to below knee amputation was HBA1c. As a result our hospital now checks HBA1c preop in all patients with Diabetes to assist in the prediction of complications and assist in the management of sugar control
This is very interesting, thank you!
Have you had a chance to do the ROC analysis in different age subgroups? Given that age (along with comorbidities, nutrition, etc.) can also impact how a patient heals, I wonder if the healing of young patients may be less affected by high glucose level whereas for older patients it may be more affected.
Maybe it's a question to be answered in further studies! Thanks again for sharing your work!
It has been shown in some studies that patients with HbA1c of greater than 6.5 have poorer outcomes especially in knee arthroplasty. I remenber reading this article in 2008 but cannot recall the journal.
Dr Jensen:
I was thinking about your question of timing. I must admit most of my concern has been reducing complications - I am a foot and ankle surgeon! Our no 1. issue is wound healing which is a TKA problem but not so much a THA problem. Glycemic control from what i understand results in an almost instantaneous response in white cell function so from infection response good control will achieve this. The presence of insulin seems to be part of the healing response (in discussion with Sheldon Lin) and so increased insulin will result in better growth factors for skin and bone healing. I am not sure if it is cause or effect.
I have been asking for a normalized HBA1c as a preop parameter -my contract with patients is their HBA1c has to be under 7 if I am going to do a reconstructive procedure. So therefore Sugar control has to be achieved 3 months preop. This seems to be realistic as it takes a while for the endocrinologist to get them stable at a lower blood sugar (if the patient has one!) and the patient to change their habits. This is also part of what our hospital accreditation expects - improvement of overall patient health.
Don't get me started on BMI.....
Thank you all for some great answers.
Dr. Ng, we have been thinking about just that. In futur studies we must establish more subgroups!
Dr. Younger, it is very interesting to see how glycemic controll has taken its effect in everyday clinical practice. The timing is a crucial question, and I would love to see a study looking at a normalized serum glucose/and or HbA1c, for different periods of time pre-op. At the "end of the limb" you notice differences in the glycemic state first, I am sure :-)
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