Preoperative Hyperglycemia Imperils Orthopedic Surgery Outcome

Dr. Boris Mraovic stated that, "We have good data regarding diabetes and hyperglycemia in heart surgery patients and patients cared for in the intensive care units, but we have no data regarding patients undergoing major orthopedic surgery."

Dr. Mraovic and his associates obtained medical records of 6538 patients admitted to Thomas Jefferson Medical College in Philadelphia for a total hip or total knee replacement between 2003 and 2005. The investigators identified 38 patients whose preoperative blood glucose level exceeded 250 mg/dL.

Control group data were taken from the Pennsylvania Health Care Cost Containment Council data base, which included all patients who underwent total hip and knee replacement at their hospital in 2002. In this control group, 1.7% of patients developed deep vein thrombosis or pulmonary embolism.

In contrast, among the hyperglycemic patients, the incidence of pulmonary embolism was 10.5% (p< 0.001).

"Every physician who is involved in perioperative care -- anesthesiologists, surgeons, endocrinologists, or primary care physicians -- needs to be aware of the increased risk" associated with very high blood glucose levels, Dr. Mraovic advises. He recommends that insulin infusions be used to reduce blood glucose levels to normal, prior to surgery.

"This is a fascinating study," said Dr. Samuel Goldhaber, a cardiologist at Brigham and Women's Hospital in Boston, who was not part of the study. "I'm not aware of previous studies linking poor glucose control with pulmonary embolism in patients undergoing surgery. So, this is the first one."

As an example, he discussed one patient with a blood glucose level of 350 mg/dL. "We started an insulin infusion, and within 4 hours, we had gotten the glucose level below 200 mg/dL," after which surgery was performed.

Dr. Mraovic pointed out that there are no guidelines on how to manage hyperglycemic patients prior to major orthopedic surgery. Before these can be developed, "a prospective, controlled study is needed to determine whether tight control of preoperative glucose levels could reduce the incidence of pulmonary embolism in this clinical setting." "The take-home message is that all patients should get their blood sugar under control before undergoing elective surgery," said the study's lead author, Dr. Boris Mraovic, an assistant professor of anesthesiology at Thomas Jefferson University in Philadelphia.

Presented last week at the American Society of Anesthesiologists meeting in Chicago.

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