Preadmission Hyperglycemia is an Independent Risk Factor for In-Hospital Symptomatic Pulmonary Embolism After Major Orthopedic Surgery

doi:10.1016/j.arth.2008.10.002

The Journal of Arthroplasty

Volume 25, Issue 1, January 2010, Pages 64-70

https://doi.org/10.1016/j.arth.2008.10.002 Get rights and content

Abstract

We investigate whether preadmission hyperglycemia is a risk factor for developing in-hospital symptomatic pulmonary embolism after major orthopedic surgery. Medical records of patients undergoing total hip or total knee arthroplasty from January 2001 to April 2006 were reviewed. The incidence of PE was 1.47% (107/7282 patients). Multivariate analysis showed that preadmission blood glucose (BG) of at least 200 mg/dL independently increased the risk of pulmonary embolism by 3.19 times (P = .015), when compared with patients with BG of less than 110 mg/dL. Other significant risks factors were age (≥70 years old), body mass index of more than 30 kg/m², and congestive heart failure. Total knee had 2.19 times (P = .002) more risk than total hip arthroplasty and bilateral procedure increased the risk by 2.13 times (P = .015). Sex, American Society of Anesthesiologists status, duration of surgery, malignancy, pulmonary disease, hypertension, diabetes mellitus, dyslipidemia, sleep apnea, and stroke were not found to be significant risk factors for pulmonary embolism.

Section snippets

Materials and Methods

After obtaining institutional board review approval, we reviewed the medical records of patients undergoing total hip or total knee arthroplasty from January 1, 2001, to April 30, 2006. Data were collected from electronic medical records and included comorbidities recorded during the patients' preoperative clinic visits.

Results

Data from 11 283 patients who had hip or knee arthroplasty in the study period were reviewed. After excluding the patient records (total of 3347) with missing data (height and/or weight [3342 records], preoperative blood glucose values [912 records], American Society of Anesthesiologists [ASA] status and preoperative comorbidities [3330 records]), 7936 patient records were eligible for the study. In addition, the data from repeated admissions were excluded (654 records). After all exclusions, a

Discussion

Our retrospective study showed that in patients receiving warfarin for thromboprophylaxis preadmission BG of at least 200 mg/dL increases risk of in-hospital symptomatic pulmonary embolism after total hip and knee arthroplasty. A single, random preadmission BG of at least 200 mg/dL had the risk for in-hospital symptomatic PE of similar magnitude as the other recognized risk factors, such as BMI, age, knee surgery, and bilateral surgery, independently increasing the risk more than 3 times.

The

Acknowledgment

Contributing authors are as follows: Inna Chervoneva, PhD, data analysis and review of the manuscript; Zvi Grunwald, MD, review of the manuscript; and Luis Pulido, MD, data collection and review of the manuscript.

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Morbidly obese (body mass index [BMI] >40 kg/m²) patients undergoing total joint arthroplasty (TJA) are at high risk for postoperative venous thromboembolism (VTE); however, there is debate surrounding the optimal pharmacologic agent for prevention of VTE after TJA in this patient subset. Current guidelines recommend against direct-acting oral anticoagulants (DOACs) in patients of BMI >40 kg/m² due to low quality evidence justifying their use. We evaluated whether patients of BMI >40 kg/m² undergoing primary unilateral TJA would have increased risk of postoperative VTE if prescribed DOACs compared to non-DOAC agents such as aspirin.
This retrospective study analyzed 897 patients of BMI >40 kg/m² undergoing primary unilateral TJA. Demographic and comorbidity-related variables were collected. The association between postoperative VTE and prophylactic pharmacologic agent prescribed was evaluated by multivariate logistic regression.
After controlling for comorbidities, we found that the sole use of DOACs, specifically apixaban, for VTE prophylaxis was associated with an increased risk of developing VTE compared to prophylaxis with aspirin alone in patients of BMI >40 kg/m² (odds ratio 2.962, P = .016). Regardless of VTE prophylactic agent, patients with BMI >40 kg/m² undergoing TKA had at least 4.5-fold increased odds of developing VTE compared to patients undergoing THA (OR 4.830, P = .019).
In our retrospective study of a large sample size of patients with BMI >40 kg/m², we found that the use of DOACs, specifically apixaban, for VTE prophylaxis following TJA was associated with increased odds of a VTE complication compared to the use of aspirin alone.
Suggested Canadian Standards for Perioperative/Periprocedure Glycemic Management in Patients With Type 1 and Type 2 Diabetes
2022, Canadian Journal of Diabetes
The goal of this quality initiative was to develop consensus standards for glycemic management of patients with diabetes who undergo surgical procedures in Canada.
A modified Delphi method was used to gather broad stakeholder input and arrive at a consensus for perioperative/periprocedure diabetes management.
Glycemic management standards were developed for the following categories: Organization of Care; Preoperative Assessment; Immediate Preoperative and Intraoperative; Postanesthesia Care Unit or Recovery Room; Postoperative Period; and Transition to Outpatient Care.
It is anticipated these standards will serve as a basis to develop clinical tools to support the recommendations.
L’objectif du projet sur la qualité était d’élaborer des normes consensuelles sur la prise en charge de la glycémie des patients diabétiques qui subissent des interventions chirurgicales au Canada.
Nous avons utilisé une méthode Delphi modifiée pour recueillir les commentaires d’un grand nombre de parties prenantes et parvenir à un consensus sur la prise en charge périopératoire/péri-interventionnelle du diabète.
Nous avons élaboré les normes sur la prise en charge de la glycémie pour les catégories suivantes : organisation des soins; évaluation préopératoire; préopératoire et intraopératoire immédiate; unité de soins post-anesthésie ou salle de réveil; période postopératoire; transition vers les soins en consultation externe.
On s’attend à ce que ces normes permettent l’élaboration d’outils cliniques pour étayer les recommandations.
Weight-Based Aspirin Dosing May Further Reduce the Incidence of Venous Thromboembolism Following Primary Total Joint Arthroplasty
2021, Journal of Arthroplasty
Citation Excerpt :
Significant predictors of VTE included history of diabetes, use of general anesthesia, and lower ASA score. Four previous studies have investigated diabetes in TJA and found no association with VTE [24–27]; however, preadmission hyperglycemia has been associated with PE after major orthopedic surgery [27]. Previous studies have demonstrated a greater risk of VTE with TKA compared to THA, possibly due to quicker mobility postoperatively; however, our analysis found that there was no significant difference in VTE rates between TKA and THA [27–29].
Obesity poses a challenge to thromboembolic prophylaxis following total joint arthroplasty (TJA). The purpose of this study is to evaluate a weight-based aspirin dosing regimen for prevention of venous thromboembolism (VTE) following TJA.
This is a retrospective observational study of 2403 patients who underwent primary total hip or knee arthroplasty at one institution. A weight-based aspirin dosing regimen for VTE prophylaxis was administered to 1247 patients: patients weighing ≥120 kg received 325 mg aspirin twice daily (BID) and those weighing <120 kg received 81 mg aspirin BID for 4 weeks. In total, 1156 patients in the comparison cohort received 81 mg aspirin BID. VTE and gastrointestinal bleeding events were identified through chart review at 42 days and 6 months postoperatively. A multivariable logistic regression was performed to adjust for covariates.
The weight-based aspirin cohort had a significantly lesser incidence of VTE at 42 days (P = .03, relative risk [RR] 0.31, 95% confidence interval 0.12-0.82) and 6 months (P = .03, RR 0.38, 95% confidence interval 0.18-0.80). There was no difference in VTE incidence between total hip arthroplasty and total knee arthroplasty cases (P = .8). There was no difference in gastrointestinal bleeding events between the cohorts at 42 days (P = .69) or 6 months (P = .92). Subanalysis of patients weighing ≥120 kg demonstrated a significant difference between the cohorts with a VTE incidence of 3.48% and 0% in the 81 mg and weight-based cohorts, respectively (P = .02).
Patients prescribed a weight-based aspirin regimen had significantly fewer VTEs after TJA compared to historical controls with an RR reduction of 69% at 6 weeks and 62% at 6 months postoperatively. This suggests the need to factor patient weight when determining postoperative VTE prophylaxis with aspirin.
Immediate preoperative hyperglycemia correlates with complications in non-cardiac surgical cases
2021, Journal of Clinical Anesthesia
Assess for a relationship between immediate preoperative glucose concentrations and postoperative complications.
Retrospective cohort study.
Single large, tertiary care academic medical center.
A five-year registry of all patients at our hospital who had a glucose concentration (plasma, serum, or venous/capillary/arterial whole blood) measured up to 6 h prior to a non-emergent surgery.
The glucose registry was cross-referenced with a database from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). We applied an outcomes review to the subset of patients for whom we had data from both registries (n = 1774).
Preoperative glucose concentration in the full population as well as the subgroups of patients with or without diabetes were correlated with adverse postsurgical outcomes using 1) univariable analysis and 2) full multivariable analysis correcting for 27 clinical factors available from the ACS NSQIP database. Logistic regression analysis was performed using glucose level either as a continuous variable or as a categorical variable according to the following classifications: mild (≥140 mg/dL; ≥7.8 mmol/L), moderate (≥180 mg/dL; ≥10 mmol/L), or severe (≥250 mg/dL; ≥13.9 mmol/L) hyperglycemia. A third analysis was performed correcting for 7 clinically important factors (age, BMI, predicted duration of procedure, sex, CKD stage, hypoalbuminemia, and diabetic status) identified by anesthesiologists and surgeons as immediately available and important for decision making.
Univariable analysis of all patients and the subgroups of patients without diabetes or with diabetes showed that immediate preoperative mild or moderate hyperglycemia correlates with postoperative complications. Statistical significance was lost in most groups using full multivariable analysis, but not when correcting for the 7 factors available immediately preoperatively. However, for all patients with diabetes, moderate hyperglycemia (≥180 mg/dL; ≥10 mmol/L) continued to significantly correlate with complications even in the full multivariable analysis [odds ratio (OR) 1.79; 95% Confidence Intervals (CI) 1.10, 2.92], and with readmission/reoperation within 30 days [OR 1.93; 95% CI 1.18, 3.13].
Preoperative hyperglycemia within 6 h of surgery is a marker of adverse postoperative outcomes. Among patients with diabetes in our study, a preoperative glucose level ≥ 180 mg/dL (≥10 mmol/L) independently correlates with risk of postoperative complications and readmission/reoperation. These results should encourage future work to determine whether addressing immediate preoperative hyperglycemia can improve complication rates, or simply serves as a marker of higher risk.
No association between preoperative impaired glucose control and postoperative adverse events following hip fracture surgery – A single-centre observational cohort study
2021, Clinical Nutrition
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.
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.
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.
Elevated HbA1c at admission is not associated with increased complications or mortality after hip fracture surgery.
Obstructive sleep apnea and venous thromboembolism: Overview of an emerging relationship
2020, Sleep Medicine Reviews
Obstructive sleep apnea (OSA) is a risk factor for cardiovascular syndromes. Venous thromboembolism (VTE) is a chronic disease, and pulmonary embolism (PE) is the major expression of VTE and the third most frequent cardiovascular disease. An increasing and emerging number of cross-sectional and longitudinal studies have linked OSA to VTE, and have postulated different putative pathways to explain how OSA might increase the risk of PE.
We aim to provide a critical overview of the existing evidence about the complex relationship between these two conditions, with some factors and confounding variables still to be clarified. A global interpretation of the studies shows OSA is highly prevalent in VTE patients. This association represents a major public health burden, given the high prevalence and the mortality rates of both disorders. Although still not proven, OSA may induce a persistent hypercoagulable state that may contribute to increase VTE rate and its recurrence. Coagulant activity, platelet function and fibrinolytic system may improve after continuous positive airway pressure (CPAP) in OSA. However, there is a still a lack of randomized controlled trials to evaluate the potential of CPAP and/or extend oral anticoagulation to reduce PE incidence, recurrence and mortality by PE in patients with OSA.

View all citing articles on Scopus

: This research was conducted with the support from the Investigator-Initiated Study Program of LifeScan Inc, 1000 Gibraltar Dr, MS 3I, Milpitas, CA 94040.

: Presented in part at CAS Annual Meeting, Calgary, Alberta, Canada, June 2007 and ASA annual meeting, San Francisco, CA, October 2007.

View full text

Preadmission Hyperglycemia is an Independent Risk Factor for In-Hospital Symptomatic Pulmonary Embolism After Major Orthopedic Surgery

Abstract

Section snippets

Materials and Methods

Results

Discussion

Acknowledgment

Effect of hyperglycemia and continuous intravenous insulin infusions on outcomes of cardiac surgical procedures: the Portland Diabetic Project

Endocr Pract

Intensive insulin therapy in the critically ill patients

N Engl J Med

Admission preoperative glucose is predictive of morbidity and mortality in trauma patients who require immediate operative intervention

Am Surg

Stress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview

Lancet

Admission glucose level and clinical outcomes in the NINDS rt-PA Stroke Trial

Neurology

Preoperative prediction of long-term outcome in poor-grade aneurysmal subarachnoid hemorrhage

Neurosurgery

Predictors of postoperative complications of Ilizarov external ring fixators in the foot and ankle

J Foot Ankle Surg

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

Eur J Endocrinol

A meta-analysis of thromboembolic prophylaxis in total knee arthroplasty

J Arthroplasty

Frequency and timing of clinical venous thromboembolism after major joint surgery

J Bone Joint Surg Br