Risk factors for perioperative hyperglycemia in primary hip and knee replacements

Postoperative hyperglycemia among adult non-diabetic surgical patients at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia

BACKGROUND

Postoperative hyperglycemia is associated with morbidity and mortality in non-diabetic surgical patients. However, there is limited information on the extent and factors associated with postoperative hyperglycemia. This study assessed the magnitude and associated factors of postoperative hyperglycemia among non-diabetic adult patients who underwent elective surgery at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia.

METHODS

A facility-based cross-sectional study was conducted among 412 adult patients who underwent elective surgery at University of Gondar Comprehensive Specialized Hospital from April 14 to June 30, 2022 All consecutive postoperative non-diabetic elective surgical patients who were admitted to PACU during the data collection period and who fulfilled inclusion criteria were included in the study until the intended minimum sample size was achieved. And data were collected through interviews using a pretested semi-structured questionnaire. Postoperative hyperglycemia was defined as a blood glucose level of ≥ 140 mg/dl. Multivariable logistic regression was performed to identify the association between postoperative hyperglycemia and independent variables. Variables with a p-value less than 0.05 and a 95% confidence interval (CI) were considered statistically significant.

RESULTS

A total of 405 patients' data were evaluated with a response rate of 98.3%. The median (IQR) age was 40 (28-52) years. The prevalence of postoperative hyperglycemia was 34.1% (95% CI: 29.4-39.0). Factors significantly associated with postoperative hyperglycemia included being overweight (AOR = 5.45, 95% CI: 2.46-12.0), American Society of Anesthesiologists (ASA) classification II and III (AOR = 2.37, 95% CI: 1.17-4.79), postoperative low body temperature (AOR = 0.18, 95% CI: 0.069-0.48), blood loss ≥ 500 ml (AOR = 2.33, 95% CI: 1.27-4.27), long duration of surgery, mild pain (AOR = 5.17, 95% CI: 1.32-20.4), and moderate pain (AOR = 7.63, 95% CI: 1.811-32.20).

CONCLUSION AND RECOMMENDATION

One-third of the study participants had postoperative hyperglycemia. Weight, ASA classification, postoperative body temperature, duration of surgery, intraoperative blood loss, and postoperative pain were identified as a modifiable risk factors. Maintaining normal body temperature throughout the procedure, treating postoperative pain, and monitoring and controlling blood glucose level in patients at risk of hyperglycemia is crucial.

Inpatient or outpatient total elbow arthroplasty: a comparison of patient populations and 30-day surgical outcomes from the American College of Surgeons National Surgical Quality Improvement Program

BACKGROUND

Total elbow arthroplasty (TEA) is uncommon, but growing in incidence. Traditionally an inpatient operation, a growing number are performed outpatient, consistent with general trends in orthopedic surgery. The aim of this study was to compare TEA outcomes between inpatient and outpatient surgical settings. Secondarily, we sought to identify patient characteristics that predict the operative setting.

METHODS

Patient data were collected from the American College of Surgeons National Quality Improvement Program. Preoperative variables, including patient demographics and comorbidities, were recorded, and baseline differences were assessed via multivariate regression to predict operative setting. Multivariate regression was also used to compare postoperative complications within 30 days.

RESULTS

A total of 468 patients, 303 inpatient and 165 outpatient procedures, were identified for inclusion. Hypoalbuminemia (odds ratio [OR], 2.5; P=0.029), history of chronic obstructive pulmonary disorder or pneumonia (OR, 2.4; P=0.029), and diabetes mellitus (OR, 2.5; P=0.001) were significantly associated with inpatient TEA, as were greater odds of any complication (OR, 4.1; P<0.001) or adverse discharge (OR, 4.5; P<0.001) and decreased odds of reoperation (OR, 0.4; P=0.037).

CONCLUSIONS

Patients undergoing inpatient TEA are generally more comorbid, and inpatient surgery is associated with greater odds of complications and adverse discharge. However, we found higher rates of reoperation in outpatient TEA. Our findings suggest outpatient TEA is safe, although patients with a higher comorbidity burden may require inpatient surgery. Level of evidence: III.

Preventing the Impact of Hyperglycemia and Diabetes on Patients Undergoing Total Joint Arthroplasty

Primary and revision total joint arthroplasty (TJA) procedures have become increasingly popular worldwide. At the same time, a growing number of patients undergoing TJA are either known diabetics or exhibit evidence of hyperglycemia preoperatively. Based on extensive data, it is well-established that poor glycemic control in TJA patients is an independent risk factor for several complications, including periprosthetic joint infection and death. This article will serve as an overview of currently available evidence on how to prevent the impact of hyperglycemia and diabetes mellitus on patients undergoing TJA.

Preoperative and Perioperative Management of Diabetics Undergoing Elective Foot and Ankle Surgery

Diabetics are a highly comorbid population with an elevated risk profile when undergoing surgery. Proper preparation and management of modifiable risk factors can optimize outcomes in diabetics. A multidisciplinary approach to preoperative optimization, including surgeons, primary care providers, and anesthesiologists, ensures diabetic patients receive comprehensive evaluation before elective surgery. Orthopedic surgeons must understand preoperative optimization goals as they pertain to nutrition, glycemic control, and cardiovascular disease in diabetic patients.

Comparison of spinal versus general anesthesia on the perioperative blood glucose levels in patients undergoing lower abdominal and pelvic surgery: a prospective cohort study, Ethiopia

Surgery is linked with fear and stress that disrupt metabolic and neuroendocrine activities, which impair normal maintained glucose metabolism that leads to stress hyperglycaemia. This study aimed to compare the effect of general and spinal anaesthesia on perioperative blood glucose levels in patients undergoing lower abdominal and pelvic surgery.

Methods

This prospective observational cohort study recruits 70 adult patients who underwent lower abdominal and pelvic surgery under general and spinal anaesthesia; 35 in each group. A systematic random sampling technique was used to select study participants. Capillary blood glucose was measured at four perioperative times. An independent t-test, dependent t-test, and Manny-Whitney U test were used for statistical analysis, as appropriate. P values less than 0.05 were considered statistically significant.

Results

No statistically significant difference was observed in mean blood glucose levels at baseline and 5 min after induction of general anaesthesia and complete blocks of spinal anaesthesia. But at the end of surgery and 60 min after the end of surgery the mean blood glucose levels were statistically significantly higher in the general anaesthesia group compared with the spinal anaesthesia group (P<0.05). And the blood glucose level was significantly increased from baseline compared with the different time intervals in the general anaesthesia group.

Conclusion

The mean blood glucose levels were lower in patients undergoing surgery under spinal anaesthesia compared with general anaesthesia. The authors recommend spinal over general anaesthesia whenever possible for patients undergoing lower abdominal and pelvic surgery.

Perioperative Identification and Management of Hyperglycemia in Orthopaedic Surgery

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The consequences of undermanaged perioperative hyperglycemia are notable and can have a serious impact on adverse postoperative outcomes, especially surgical site infections and periprosthetic joint infections (PJIs).

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Preoperative screening of hemoglobin A1c with a goal threshold of <7.45% is ideal.

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There are a variety of risk factors that contribute to hyperglycemia that should be considered in the perioperative period, including glucocorticoid use, nutritional factors, patient-specific factors, anesthesia, and surgery.

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There are expected trends in the rise, peak, and fall of postoperative blood glucose levels, and identifying and treating hyperglycemia as swiftly as possible are the fundamental aims of treatment and improved glucose control. Performing frequent postoperative blood glucose monitoring (in the post-anesthesia care unit, on the day of surgery at 1700 and 2100 hours, and in the morning of postoperative day 1) should be considered to allow for the early detection of alterations in glucose metabolism. In addition, instituting a postoperative dietary restriction of carbohydrates should be considered.

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The use of insulin as a hypoglycemic agent in orthopaedic patients is relatively safe and is an effective means of controlling fluctuating blood glucose levels. Insulin therapy should be administered to treat hyperglycemia at ≥140 mg/dL when fasting and ≥180 mg/dL postprandially. Insulin therapy should be ceased at blood glucose levels of <110 mg/dL; however, monitoring for glycemic dysregulation should be continued. In all cases of complex diabetes, consultation with diabetes specialty services should be considered.

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The emerging use of technology, including continuous subcutaneous insulin pump therapy and continuous glucose monitoring, is an exciting area of further research and development as such technology can more immediately detect and correct aberrations in blood glucose levels.

Association between glycosylated hemoglobin, diabetes mellitus, and preoperative deep vein thrombosis in patients undergoing total joint arthroplasty: a retrospective study

Background

To investigate the association between the level of glycosylated hemoglobin (HbA1c) and preoperative deep vein thrombosis (DVT) and that between diabetes mellitus (DM) and preoperative DVT in patient undergoing total joint arthroplasty (TJA).

Methods

A total of 1386 patients were enrolled. We created the receiver operating characteristic (ROC) curve of HbA1c, and based on the cutoff value, patients were divided into two groups. Risk factors were subsequently examined. Chi-square test or Fisher’s exact test was adopted for enumeration data. The results were expressed in percentages (%), and DVT-related variates were analyzed. We included the variates that were statistically significant in the univariate analysis in the multivariate binary logistic regression analysis and calculated the adjusted odds ratio (OR) and 95% confidence interval (95% CI).

Results

Preoperative DVT was 100 cases (7.22%) and DM in 301 cases (21.7%). We determined the cutoff value of HbA1c of 6.15% using the ROC curve as the area under the curve (AUC) was 0.548. Univariate logistic regression revealed that the risk of preoperative DVT in TJA patients with HbA1c ≥ 6.15%, HbA1c between 7 and 7.9%, HbA1c ≥ 8%, DM, female, and major surgery in the last 12 months increased by 1.84 (P = 0.005; 95% CI [1.20–2.80]), 2.22 (P = 0.028, 95% CI [1.09–4.52]), 2.47 (P = 0.013, 95% CI [1.21–5.04]), 2.03 (P = 0.004, 95% CI [1.25–3.30]); 1.85 (P = 0.010, 95% CI [1.16–2.95]); and 2.86 times (P = 0.006, 95% CI [1.35–6.05]), respectively. And multivariate logistic regression revealed that the risk of preoperative DVT in TJA patients with HbA1c ≥ 6.15%, HbA1c between 7 and 7.9%, HbA1c ≥ 8%, DM patients, female patients, and major surgery in the last 12 months increased by 1.77 (P = 0.009, 95% CI [1.16–2.72]); 2.10 (P = 0.043, 95% CI [1.02–4.30]); 2.50 (P = 0.013, 95% CI [1.22–5.14]); 2.01 (P = 0.005, 95% CI [1.23–3.28]); 1.80 (P = 0.014, 95% CI [1.13–2.89]); and 3.04 times (P = 0.004, 95% CI [1.42–6.49]), respectively.

Conclusion

We conclude that HbA1c ≥ 6.15%, DM, female and major surgery in the last 12 months are the independent risk factors for preoperative DVT in patients undergoing TJA. And patients with a higher HbA1c level are at an increased risk of preoperative DVT.

Trial registration: ChiCRT2100054844.

Correlation between the Control of Blood Glucose Level and HbA1C and the Incidence of Surgical Site Infection after Emergent Surgery for the Lower Limb Fracture among Type II DM Patients Aged More Than 50 Years Old

This is the first study focusing on perioperative blood glycemic monitoring for the incidence of surgical site infection (SSI) among patients with type II DM (T2DM) during the 1-year follow-up after emergent orthopedic surgery. We retrospectively collected the data of 604 patients who had received surgery for unilateral lower limb traumatic fracture from January 2011 to January 2021, including 215 men and 389 women with a mean age of 71.21 and a mean BMI of 25.26. In total, 84 (13.9%) of them developed SSI during the 1-year follow-up. Higher preoperative and postoperative -3-month hemoglobin A1c (HbA1c) and AC blood glucose and the presence of rheumatoid arthritis were all associated with increased rates of SSI. The thresholds for predicting SSI were the following: (1) preoperative HbA1c > 7.850% (area under curve [AUC] = 0.793); (2) postoperative HbA1c > 6.650% (AUC = 0.648); (3) preoperative AC blood glucose > 130.50 mg/dL (AUC = 0.773); and (4) postoperative AC blood glucose > 148.5 mg/dL (AUC = 0.709) by receiver-operating characteristic curve method. These findings may provide a useful control guideline for patients with T2DM older than 50 years old and who received surgery for a lower limb fracture in the prevention of postoperative SSI.

Effect of Intraoperative Magnesium Sulfate Administration on Blood Glucose Control following Total Joint Arthroplasty in Patients with Diabetes

Magnesium deficiency, which is known to be highly prevalent among patients with diabetes, has been associated with insulin resistance and poor glucose control. Here, we aimed to investigate the effects of intraoperative magnesium administration on postoperative glucose control in patients with diabetes. We retrospectively reviewed the medical records of patients with type 2 diabetes who had undergone total joint arthroplasty at a tertiary hospital, where intraoperative magnesium sulfate injections were frequently performed for postoperative analgesia. The patients were grouped based on whether treated with magnesium or not (magnesium vs. control groups). We investigated postoperative blood glucose levels and sliding scale insulin requirements. After propensity matching, 170 patients were allotted to each group. Both the mean glucose level and the incidence of a mean glucose level of >200mg/dL were significantly lower in the magnesium group than in the control group (p = 0.040 and 0.013, respectively). There was also a lower insulin requirement in the magnesium group (p = 0.043). Multivariate logistic regression revealed that magnesium treatment was significantly related to a less frequent incidence of a mean blood glucose level of >200 mg/dL (p = 0.047). This study demonstrated that magnesium sulfate infusion was associated with an improved postoperative blood glucose profile in patients with diabetes.

Optimal time period for blood glucose level evaluation after total knee arthroplasty in patients without diabetes: a prospective, observational study

Background

Postoperative hyperglycemia has been reported to be a risk factor for postoperative infection even in patients without diabetes mellitus (DM). However, there is no standard for how long blood glucose level (BGL) monitoring should be performed after total knee arthroplasty (TKA). The purpose of this study was to determine the optimal time period for BGL evaluation after TKA in patients without DM.

Methods

This prospective study included 132 knees of 110 patients who underwent TKA between March 2018 and July 2021 in our hospital. Fasting BGLs were measured preoperatively, at 9:00 PM on the day of surgery (DOS), and at 7:00 AM on postoperative days (PODs) 1, 2, and 3. Patients were divided into two groups with a preoperative hemoglobin A1c (HbA1c) cut-off value of 5.9%, and the BGLs on POD 1 were compared between the two groups.

Results

The BGLs were significantly higher on the DOS, POD 1, and POD 2 than preoperative levels. The BGL was significantly higher on POD 1 than at any other time point. Patients with an HbA1c ≥ 5.9% had significantly higher BGLs than those with an HbA1c < 5.9% on POD 1.

Conclusions

The optimal time period for BGL evaluation after TKA in patients without DM was considered to be from postoperative to POD 2. Patients with an HbA1c ≥ 5.9% may require careful perioperative glycemic control.

Postoperative Hyperglycemia in Patients with and without Diabetes After Major Joint Replacement: The Impact of an Enhanced Glucose Management Program

Background:

Perioperative hyperglycemia can have an even more detrimental effect on postoperative outcomes in patients without diabetes than in patients with diabetes, but it has not been established if the treatment of patients without diabetes is safe and effective. We hypothesized that sliding-scale insulin for severe postoperative hyperglycemia (glucose ≥180 mg/dL) could lower mean postoperative glucose levels and minimize short-term complications in patients without diabetes undergoing major joint replacement.

Methods:

In a prospective study group, 1,398 consecutive patients, with and without diabetes, undergoing joint replacement were monitored and treated for hyperglycemia and were compared with 886 historical, less frequently monitored controls. The primary outcome was the mean glucose level in patients with and without diabetes within 48 hours after the surgical procedure. Two secondary outcomes could be examined only in the prospective study group, which, by design, had much more frequent glucose sampling and insulin use than the historical controls. First, the contribution of comorbidities and procedural factors to postoperative hyperglycemia in patients without diabetes was assessed with multivariable linear regression. Second, the ability of insulin treatment to reduce complications in patients without diabetes who developed hyperglycemia was evaluated.

Results:

In comparison with 886 historical controls, enhanced glucose management lowered the mean glucose (and standard deviation) from 129 ± 28 mg/dL to 123 ± 23 mg/dL for patients without diabetes (p = 0.041). Multivariable linear regression revealed factors that contributed to elevated mean glucose in patients without diabetes: preoperative fasting glucose (p < 0.001), perioperative steroid use (p < 0.001), general anesthesia (p < 0.001), procedure duration (p = 0.003), and transfusion (p 0.008). Of 968 patients without diabetes, 203 developed severe hyperglycemia. The recommended insulin coverage was given to 129 of these patients, and 74 patients did not receive it for various clinical reasons. Insulin treatment reduced the frequency of positive cultures from any site (p = 0.025) and a composite of positive cultures and readmissions (p = 0.006) in comparison with no insulin treatment. No patient without diabetes who received insulin experienced mild or severe hypoglycemia.

Conclusions:

Postoperative hyperglycemia is frequent in patients without diabetes after orthopaedic surgery, but an enhanced glucose management program can lower mean postoperative glucose levels. The treatment of hyperglycemia in patients without diabetes reduced short-term complications and was associated with minimal side effects.

Level of Evidence:

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Suprascapular Nerve Block Is an Effective Pain Control Method in Patients Undergoing Arthroscopic Rotator Cuff Repair: A Randomized Controlled Trial

Background

Effective pain control in patients who have undergone arthroscopic rotator cuff surgery improves functional recovery and early mobilization. Interscalene blocks (ISBs), a widely used approach, are safe and provide fast pain relief; however, they are associated with complications. Another pain management strategy is the use of a suprascapular nerve block (SSNB).

Hypothesis

We hypothesized that indwelling SSNB catheters are a more effective pain control method than single-shot ISBs. We also hypothesized that indwelling SSNB catheters will reduce the level of rebound pain and the demand for opioid analgesics.

Study Design

Randomized controlled trial; Level of evidence, 1.

Methods

Included in this study were 93 patients who underwent arthroscopic rotator cuff surgery between May 2012 and January 2019. These patients were assigned to either the indwelling SSNB catheter group, the single-shot ISB group, or the control (sham/placebo) group (31 patients per group). Level of pain was measured with a visual analog scale (VAS; 0 to 10 [worst pain]) on the day of the operation. The preoperative VAS score was recorded at 6 AM on the day of operation, and the postoperative scores were recorded at 1, 8, and 16 hours after surgery and then every 8 hours until postoperative day 3.

Results

The VAS pain scores were lower in the SSNB and ISB groups than in the control group up to postoperative hour (POH) 8, with the most significant difference at POH 8. At POH 1 and POH 8, the mean VAS scores for each group were 2.29 and 1.74 (SSNB), 2.59 and 2.50 (ISB), and 3.42 and 4.48 (control), respectively. VAS scores in the SSNB and ISB groups were consistently <3, compared with a mean VAS score of 3.1 ± 1.58 in the control group (P < .001). Compared with the ISB group, the SSNB group had significantly fewer side effects such as rebound pain duration as well as lower VAS scores (P < .001).

Conclusion

VAS scores were the lowest in the indwelling SSNB catheter group, with the most pronounced between-group difference in VAS scores at POH 8. Severity and recurring frequency of pain were lower in the indwelling SSNB catheter group than in the single-shot ISB group.

Preoperative Carbohydrate Drinks Do Not Decrease Postoperative Nausea and Vomiting in Type 2 Diabetic Patients Undergoing Total Knee Arthroplasty-A Randomized Controlled Trial

INTRODUCTION

We evaluated whether preoperative carbohydrate drink would be able to decrease postoperative nausea and vomiting (PONV) and improve the quality of recovery (QoR) in diabetic patients undergoing total knee arthroplasty (TKA).

METHODS

Eighty-two patients were randomized to either the intravenous (IV) Dextrose group (n = 41) or Oral carbohydrate (CHO) group (n = 41). The IV Dextrose group received dextrose solution mixed with insulin while fasting, and the Oral CHO group received carbohydrate drinks preoperatively. PONV was assessed up to postoperative 36 hours, and QoR was assessed before surgery and on postoperative day (POD) 1. Blood glucose was measured from the morning of surgery until POD 1.

RESULTS

PONV scores were not different between the groups. Postoperative QoR scores were significantly higher in the Oral CHO group (median [interquartile range]; 160 [153 to 167]) than the IV Dextrose group (155 [147 to 159]) (P = 0.009), but the difference did not meet the minimal clinically important difference. Blood glucose was comparable between the groups.

DISCUSSION

Preoperative CHO drink did not reduce PONV in diabetic patients after total knee arthroplasty. A statistically significant but clinically questionable improvement in the QoR was seen in the Oral CHO group. However, preoperative CHO drink did not increase hyperglycemia, which suggests that it may be a safe component of perioperative care in diabetic patients.

Perioperative hyperglycaemia in elective arthroplasties. Should we do better?

BACKGROUND

Perioperative dysglycaemia is associated with deleterious outcomes but guidelines to improve glucose management are poorly or inconsistently adhered to. We evaluated glucose management among diabetic and non-diabetic patients undergoing elective hip or knee arthroplasty.

METHODS

Capillary plasma glucose (CPG) was measured prospectively four times daily of 209 patients undergoing elective hip or knee surgery. Actions of the attending teams to CPG values and detection of patients at risk were analysed.

RESULTS

A total of 209 patients were enrolled. All diabetic patients on insulin (6/6) had hyperglycaemia (≥7.8 mmol/l) more than twice and severe hyperglycaemia (>10 mmol/l) at least once. Of the 27 diabetic patients not on insulin 26 (96.3%) had CPG ≥ 7.8 mmol/l ≥ 2 times and 17 (63%) >10 mmol/l. The corresponding figures of the 176 non-diabetic patients were 137 (77.8%) and 61 (34.7%). Severe hyperglycaemia occurred in 54/176 (30.1%) of the non-diabetic patients with pre-operative HbA1c < 42 mmol/mol and random plasma glucose < 7.8 mmol/l. Of the 84 hyperglycaemic episodes > 10 mmol/l, none was treated. Patients with a FINDRISC score ≥ 12 (corresponding to moderate to high risk of diabetes) and hyperglycaemia went unnoticed.

CONCLUSIONS

Hyperglycaemia is common among elective orthopaedic surgery patients with or without diabetes. More than 80% of the 209 patients had hyperglycaemia and 40% had severe hyperglycaemia. None of the patients was treated according to guidelines and none of the patients at risk of hyperglycaemia or diabetes was noticed. There is an obvious need for further education and support by diabetes specialists.

CLINICAL TRIAL REGISTRATION

Clinical trials, gov. NCT03306810.

No association between preoperative impaired glucose control and postoperative adverse events following hip fracture surgery - A single-centre observational cohort study

RATIONALE

Observational studies have shown an association between hyperglycaemia and increased complications in orthopaedic patients. The aim of the study was to investigate if impaired preoperative glycaemic control, reflected by elevated HbA1c, was associated with adverse postoperative events in hip fracture patients.

METHODS

160 patients (116 women and 44 men; age 80 ± 10 and BMI 24 ± 4; mean ± SD) with hip fractures were included in a prospective observational cohort study. The patients were divided into two groups, normal glycaemic control (NGC) and impaired glycaemic control (IGC) HbA1c ≥ 42 mmol/mol. The patients were also characterized according to BMI and nutritional status using MNA-SF (Minimal Nutritional Assessment Short Form). Complications within 30 days of surgery were classified according to Clavien-Dindo and 1-year mortality was compared between the groups.

RESULTS

Out of 160 patients, 18 had diabetes and 4 more had likely occult diabetes (HbA1c ≥ 48). Impaired glycaemic control (IGC) was seen in 29 patients (18.1%) and normal glycaemic control (NGC) in 131 (81.9%). In patients with NGC and IGC, no postoperative complications (Clavien-Dindo Grade 0) were seen in 64/131 vs. 14/29 (48.9 vs. 48.3%), Grade 1-3a in 54/131 vs. 14/29 (41.2 vs. 48.3%) and Grade 3b-5 in 13/131 vs. 1/29 (9.9 vs. 3.4%) respectively, p = NS. There were no differences in 30-day complications (p = 0.55) or 1-year mortality (p = 0.35) between the groups.

CONCLUSION

Elevated HbA1c at admission is not associated with increased complications or mortality after hip fracture surgery.

Risk factors and impact of postoperative hyperglycemia in nondiabetic patients after cardiac surgery: A prospective study

Cardiac surgery induces a significant inflammatory hypermetabolic stress response, resulting in postoperative hyperglycemia in both preoperatively diabetic and nondiabetic patients. Such postoperative hyperglycemia has been associated with adverse outcomes in surgery and postsurgical recovery. Yet, while diabetes is a known risk factor for postoperative hyperglycemia, predictors of postoperative hyperglycemia among nondiabetics in the local Southeast Asian population remain unknown.We aim to investigate the predictors and outcomes associated with hyperglycemia after cardiac surgery among nondiabetics in the local Southeast Asian population. We analyzed data from 1602 nondiabetic adult patients undergoing elective cardiac surgery, from 2008 to 2010 at the 2 main heart centers in Singapore.Nondiabetic patients who developed postoperative hyperglycemia tended to be women, older, more obese, and hypertensive. Higher body mass index (BMI), age, aortic cross-clamp time, and blood transfusion were identified as independent risk factors of postoperative hyperglycemia. Postoperative hyperglycemia was also significantly associated with postoperative cardiac arrhythmias (26.9% vs 15.0%, P < .001), acute kidney injury (30.0% vs 20.1%, P < .001), longer intensive care unit (ICU) stay (46.7 ± 104.1 vs 37.2 ± 76.6 hours, P = .044) and longer hospitalization (11.5 ± 12.2 vs 9.6 ± 8.0 days, P < .001).Our study identified aortic cross-clamp time and blood transfusion as independent risk factors of postoperative hyperglycemia after cardiac surgery in nondiabetics. Similar to other studies, higher BMI and age were independent risk factors for postoperative hyperglycemia. Postoperative hyperglycemia was also associated with adverse perioperative outcomes and should thereby be avoided by treating modifiable risk factors identified in this study including reducing blood transfusion and aortic cross-clamp time. Our findings contribute to early risk stratification of nondiabetic patients who are at increased risk of postoperative hyperglycemia.

Effect of Surgical-Site, Multimodal Drug Injection on Pain and Stress Biomarkers in Patients Undergoing Plate Fixation for Clavicular Fractures

Background

Surgical-site, multimodal drug injection has recently evolved to be a safe and useful method for multimodal pain management even in patients with musculoskeletal trauma.

Methods

Fifty consecutive patients who underwent plating for mid-shaft and distal clavicular fractures were included in the study. To evaluate whether surgical-site injections (SIs) have pain management benefits, the patients were divided into two groups (SI and no-SI groups). The injection was administered between the deep and superficial tissues prior to wound closure. The mixture of anesthetics consisted of epinephrine hydrochloride (HCL), morphine sulfate, ropivacaine HCL, and normal saline. The visual analogue scale (VAS) pain scores were measured at 6-hour intervals until postoperative hour (POH) 72; stress biomarkers (dehydroepiandrosterone sulfate [DHEA-S], insulin, and fibrinogen) were measured preoperatively and at POH 24, 48, and 72. In patients who wanted further pain control or had a VAS pain score of 7 points until POH 72, 75 mg of intravenous tramadol was administered, and the intravenous tramadol requirements were also recorded. Other medications were not used for pain management.

Results

The SI group showed significantly lower VAS pain scores until POH 24, except for POH 18. Tramadol requirement was significantly lower in the SI group until POH 24, except for POH 12 and 18. The mean DHEA-S level significantly decreased in the no-SI group (74.2 ± 47.0 µg/dL) at POH 72 compared to that in the SI group (110.1 ± 87.1 µg/dL; p = 0.046). There was no significant difference in the insulin and fibrinogen levels between the groups. The correlation values between all the biomarkers and VAS pain scores were not significantly different between the two groups (p > 0.05).

Conclusions

After internal fixation of the clavicular fracture, the surgical-site, multimodal drug injection effectively relieved pain on the day of the surgery without any complications. Therefore, we believe that SI is a safe and effective method for pain management after internal fixation of a clavicular fracture.

The Utility of Basic Metabolic Panel Tests After Total Joint Arthroplasty

INTRODUCTION

Routine laboratory studies are often obtained daily after total joint arthroplasty (TJA) regardless of medical management. The purpose of this study was to investigate the utility of routine basic metabolic panel (BMP) tests after TJA. Furthermore, the goal was to identify factors that may predispose patients to abnormal laboratory values that require medical intervention.

METHODS

A retrospective review was performed on 767 patients who underwent primary TJA at a single institution. Preoperative and postoperative potassium, sodium, creatinine, and glucose values were collected along with demographic data, comorbidities, and procedural characteristics. Multivariable logistic regression models were used to determine independent risk factors for abnormal postoperative laboratory values.

RESULTS

Diabetes was associated with abnormal glucose (odds ratio [OR] 23.4, 95% confidence interval [CI] 10.7-51.0, P < .001), while chronic kidney disease was associated with abnormal creatinine (OR 3.1, 95% CI 1.7-5.8, P < .001) and potassium (OR 1.8, 95% CI 1.1-2.8, P = .014) requiring medical intervention. An abnormal preoperative laboratory value was also associated with medical treatment for each of sodium, potassium, and creatinine (all P < .001). Average number of BMP tests collected for patients who did not receive medical intervention was 2.8. This equated to $472,372.56 in total hospital charges.

CONCLUSION

Cost containment while maintaining high-quality patient care is critical. Routine postoperative BMP tests in patients with normal preoperative values without major medical comorbidities do not contribute to actionable information. Patients with diabetes, chronic kidney disease, or with abnormal preoperative values should obtain a BMP after TJA.

Effects of a Single-Dose Interscalene Block on Pain and Stress Biomarkers in Patients Undergoing Arthroscopic Rotator Cuff Repair: A Randomized Controlled Trial

PURPOSE

To compare the effects of a single-dose interscalene block and general anesthesia (SISB/GA) with the effects of GA only in the early postoperative period after arthroscopic rotator cuff repair by evaluating subjective pain visual analog scale scores and objective pain-related stress biomarkers.

METHODS

Patients refractory to conservative treatment of the affected shoulder were enrolled in this prospective, randomized endpoint study. Patients diagnosed with a rotator cuff tear (1-4 cm) based on magnetic resonance imaging were included. Exclusion criteria were small (<1 cm) and massive (>4 cm) rotator cuff tears. Thirty-one patients each were randomized into the SISB/GA and GA treatment groups. Preoperative pain scores were measured at 6:00 AM on the day of surgery, measured again at 1 and 6 hours postoperatively, and then every 6 hours until 3 days postoperatively. Blood sampling was performed to evaluate the stress biomarkers insulin, dehydroepiandrosterone sulfate, and fibrinogen preoperatively at 6:00 AM on the day of surgery and postoperatively at 18, 42, and 66 hours (6:00 AM on postoperative days 1-3).

RESULTS

Pain scores were significantly decreased in the SISB/GA group (2.50 ± 0.94) versus the GA group (3.82 ± 1.31) on the day of surgery (P < .001), and especially at 6 hours postoperatively (SISB/GA: 2.42 ± 1.43; GA: 4.23 ± 2.17; P < .001). Insulin was decreased significantly in the SISB/GA group (10.55 ± 7.92 μU/mL) versus the GA group (20.39 ± 25.60 μU/mL) at 42 hours postoperatively (P = .048). There was no significant change in dehydroepiandrosterone sulfate or fibrinogen over time (P > .05).

CONCLUSIONS

After arthroscopic rotator cuff repair, an SISB effectively relieved pain on the day of surgery without any complications. In addition, insulin levels were significantly reduced at 42 hours postoperatively.

LEVEL OF EVIDENCE

Level I, prospective randomized controlled trial.

Prevention of Infection in Orthopedic Prosthetic Surgery

Total joint arthroplasty is a generally safe orthopedic procedure; however, infection is a potentially devastating complication. Multiple risk factors have been identified for development of prosthetic joint infections. Identification of patients at risk and preoperative correction of known risk factors, such as smoking, diabetes mellitus, anemia, malnutrition, and decolonization of Staphylococcus carriers, represent well-established actions to decrease the infection risk. Careful operative technique, proper draping and skin preparation, and appropriate selection and dosing of antimicrobials for perioperative prophylaxis are also very important in prevention of infection.

Stress Hyperglycemia During Surgery and Anesthesia: Pathogenesis and Clinical Implications

Numerous studies have demonstrated an association between hyperglycemia in the perioperative period and adverse clinical outcomes. Many patients who experience hyperglycemia while hospitalized do not have a known history of diabetes and experience a transient phenomenon often described as "stress hyperglycemia" (SH). We discuss the epidemiology and pathogenesis of SH as well as evidence to date regarding predisposing factors and outcomes. Further research is needed to identify the long-term sequelae of SH as well as perioperative measures that may modulate glucose elevations and optimal treatment strategies.

The Effect of Diabetes Mellitus on Total Joint Arthroplasty Outcomes

Diabetes has negative effects on the outcomes of total joint arthroplasty, including increased numbers of complications, decreased function, early revision, and higher costs. The prevalence of diabetes is increasing rapidly worldwide; therefore, the orthopaedic surgeon should have an understanding of how diabetes affects surgical outcomes.

Diabetes is associated with persistent pain after hip and knee replacement

BACKGROUND AND PURPOSE

In some patients, for unknown reasons pain persists after joint replacement, especially in the knee. We determined the prevalence of persistent pain following primary hip or knee replacement and its association with disorders of glucose metabolism, metabolic syndrome (MetS), and obesity.

PATIENTS AND METHODS

The incidence of pain in the operated joint was surveyed 1-2 years after primary hip replacement (74 patients (4 bilateral)) or primary knee replacement (119 patients (19 bilateral)) in 193 osteoarthritis patients who had participated in a prospective study on perioperative hyperglycemia. Of the 155 patients who completed the survey, 21 had undergone further joint replacement surgery during the follow-up and were excluded, leaving 134 patients for analysis. Persistent pain was defined as daily pain in the operated joint that had lasted over 3 months. Factors associated with persistent pain were evaluated using binary logistic regression with adjustment for age, sex, and operated joint.

RESULTS

49 of the 134 patients (37%) had a painful joint and 18 of them (14%) had persistent pain. A greater proportion of knee patients than hip patients had a painful joint (46% vs. 24%; p = 0.01) and persistent pain (20% vs. 4%; p = 0.007). Previously diagnosed diabetes was strongly associated with persistent pain (5/19 vs. 13/115 in those without; adjusted OR = 8, 95% CI: 2-38) whereas MetS and obesity were not. However, severely obese patients (BMI ≥ 35) had a painful joint (but not persistent pain) more often than patients with BMI < 30 (14/21 vs. 18/71; adjusted OR = 5, 95% CI: 2-15).

INTERPRETATION

Previously diagnosed diabetes is a risk factor for persistent pain in the operated joint 1-2 years after primary hip or knee replacement.