Aims. Preoperative diabetic and glycemic screening may or may not be cost effective. Although hyperglycemia is known to compromise surgical outcomes, the effect of a diabetic diagnosis on outcomes is poorly known. We examine the effect of diabetes on outcomes for general and vascular surgery patients. Methods. Data were collected from the Michigan Surgical Quality Collaborative for general or vascular surgery patients who had diabetes. Primary and secondary outcomes were 30-day mortality and 30-day overall morbidity, respectively. Binary logistic regression analysis was used to identify risk factors. Results. We identified 177,430 (89.9%) general surgery and 34,006 (16.1%) vascular surgery patients. Insulin and noninsulin diabetics accounted for 7.1% and 9.8%, respectively. Insulin and noninsulin dependent diabetics were not at increased risk for mortality. Diabetics are at a slight increased odds than non-diabetics for overall morbidity, and insulin dependent diabetics more so than non-insulin dependent. Ventilator dependence, 10% weight loss, emergent case, and ASA class were most predictive. Conclusions. Diabetics were not at increased risk for postoperative mortality. Insulin-dependent diabetics undergoing general or vascular surgery were at increased risk of overall 30-day morbidity. These data provide insight towards mitigating poor surgical outcomes in diabetic patients and the cost effectiveness of preoperative diabetic screening. 1. Introduction The national diabetes epidemic continues to expand, with about 1.6 million new cases each year and an overall prevalence of 23.6 million people. Additional 57 million American adults are at high risk for type 2 diabetes mellitus (T2DM) [1]. The annual diagnosed diabetes incidence is projected to almost double from 8 cases per 1,000 in 2008 to about 15 in 1,000 by 2050, with a potential total prevalence projected to increase one-fifth of the US population by 2050 [2]. Currently, 10% of Americans have T2DM, and 20% to 25% are considered prediabetic with impaired glucose tolerance and elevated fasting glucose measurements [3]. The long-term complications of uncontrolled hyperglycemia in diabetics include neuropathy, nephropathy, retinopathy, and other chronic issues. The in-hospital morbidity of diabetics and new-onset hyperglycemics is well documented. Umpierrez et al. showed that for inpatients with new hyperglycemia or known diabetes there was a higher in-hospital mortality, increased length of stay, increased intensive care unit (ICU) stay, increased transitional or nursing home care, a higher rate of
References
[1]
Centers for Disease and Control Prevention, National Diabetes Fact Sheet: General Information and National Estimates on Diabetes in the United States, 2007, Department of Health and Human Services, Centers for Disease Control and Prevention, Atlanta, Ga, USA, 2008.
[2]
J. P. Boyle, T. J. Thompson, E. W. Gregg, L. E. Barker, and D. F. Williamson, “Projection of the year 2050 burden of diabetes in the US adult population: dynamic modeling of incidence, mortality, and prediabetes prevalence,” Population Health Metrics, vol. 8, article 29, 2010.
[3]
C. C. Cowie, K. F. Rust, D. D. Byrd-Holt et al., “Prevalence of diabetes and impaired fasting glucose in adults in the U.S. population: national health and nutrition examination survey 1999–2002,” Diabetes Care, vol. 29, no. 6, pp. 1263–1268, 2006.
[4]
G. E. Umpierrez, S. D. Isaacs, N. Bazargan, X. You, L. M. Thaler, and A. E. Kitabchi, “Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes,” Journal of Clinical Endocrinology and Metabolism, vol. 87, no. 3, pp. 978–982, 2002.
[5]
S. E. Capes, D. Hunt, K. Malmberg, and H. C. Gerstein, “Stress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview,” The Lancet, vol. 355, no. 9206, pp. 773–778, 2000.
[6]
J. Bolk, T. van der Ploeg, J. H. Cornel, A. E. R. Arnold, J. Sepers, and V. A. W. M. Umans, “Impaired glucose metabolism predicts mortality after a myocardial infarction,” International Journal of Cardiology, vol. 79, no. 2-3, pp. 207–214, 2001.
[7]
G. C. K. W. Koh, A. P. J. Vlaar, J. J. Hofstra et al., “In the critically ill patient, diabetes predicts mortality independent of statin therapy but is not associated with acute lung injury: a cohort study,” Critical Care Medicine, vol. 40, no. 6, pp. 1835–1843, 2012.
[8]
B. B. Graham, A. Keniston, O. Gajic, C. A. Trillo Alvarez, S. Medvedev, and I. S. Douglas, “Diabetes mellitus does not adversely affect outcomes from a critical illness,” Critical Care Medicine, vol. 38, no. 1, pp. 16–24, 2010.
[9]
J.-L. Vincent, J.-C. Preiser, C. L. Sprung, R. Moreno, and Y. Sakr, “Insulin-treated diabetes is not associated with increased mortality in critically ill patients,” Critical Care, vol. 14, no. 1, article R12, 2010.
[10]
A. T. Schlussel, D. B. Holt, E. A. Crawley, M. B. Lustik, C. E. Wade, and C. F. Uyehara, “Effect of diabetes mellitus on outcomes of hyperglycemia in a mixed medical surgical intensive care unit,” Journal of Diabetes Science and Technology, vol. 5, no. 3, pp. 731–740, 2011.
[11]
W. B. Kannel, “Lipids, diabetes, and coronary heart disease: insights from the Framingham study,” The American Heart Journal, vol. 110, no. 5, pp. 1100–1107, 1985.
[12]
J. T. King Jr., J. L. Goulet, M. F. Perkal, and R. A. Rosenthal, “Glycemic control and infections in patients with diabetes undergoing noncardiac surgery,” Annals of Surgery, vol. 253, no. 1, pp. 158–165, 2011.
[13]
W. F. Bower, L. Jin, M. J. Underwood et al., “Overt diabetes mellitus adversely affects surgical outcomes of noncardiovascular patients,” Surgery, vol. 147, no. 5, pp. 670–675, 2010.
[14]
T. Schricker, R. Lattermann, M. Schreiber, W. Geisser, M. Georgieff, and P. Radermacher, “The hyperglycaemic response to surgery: pathophysiology, clinical implications and modification by the anaesthetic technique,” Clinical Intensive Care, vol. 9, no. 3, pp. 118–128, 1998.
[15]
G. P. Joshi, F. Chung, M. A. Vann et al., “Society for ambulatory anesthesia consensus statement on perioperative blood glucose management in diabetic patients undergoing ambulatory surgery,” Anesthesia and Analgesia, vol. 111, no. 6, pp. 1378–1387, 2010.
[16]
T. S. J. Shine, M. Uchikado, C. C. Crawford, and M. J. Murray, “Importance of perioperative blood glucose management in cardiac surgical patients,” Asian Cardiovascular and Thoracic Annals, vol. 15, no. 6, pp. 534–538, 2007.
[17]
H. L. Lazar, S. R. Chipkin, C. A. Fitzgerald, Y. Bao, H. Cabral, and C. S. Apstein, “Tight glycemic control in diabetic coronary artery bypass graft patients improves perioperative outcomes and decreases recurrent ischemic events,” Circulation, vol. 109, no. 12, pp. 1497–1502, 2004.
[18]
C. J. O'Sullivan, N. Hynes, B. Mahendran et al., “Haemoglobin A1c (HbA1C) in non-diabetic and diabetic vascular patients. Is HbA1C an independent risk factor and predictor of adverse outcome?” European Journal of Vascular and Endovascular Surgery, vol. 32, no. 2, pp. 188–197, 2006.
[19]
S. Takahashi, A. Suzuki, H. Toyoda, et al., “Characteristics of diabetes associated with poor improvements in clinical outcomes following lumbar spine surgery,” Spine, vol. 38, no. 6, pp. 516–522, 2013.
[20]
J. H. Atkins and D. S. Smith, “A review of perioperative glucose control in the neurosurgical population,” Journal of Diabetes Science and Technology, vol. 3, no. 6, pp. 1352–1364, 2009.
[21]
G. F. Woodworth, K. L. Chaichana, M. J. McGirt et al., “Predictors of ambulatory function after surgical resection of intramedullary spinal cord tumors,” Neurosurgery, vol. 61, no. 1, pp. 99–105, 2007.
[22]
M. J. McGirt, K. L. Chaichana, M. Gathinji et al., “Persistent outpatient hyperglycemia is independently associated with decreased survival after primary resection of malignant brain astrocytomas,” Neurosurgery, vol. 63, no. 2, pp. 286–291, 2008.
[23]
S. S. Serio, D. Grauf, J. C. Clements, and A. M. Merchant, “Analysis of outcomes of diabetic and nondiabetic general and vascular surgery patients oral presentation: clinical trials & outcomes global measures of quality,” in Proceedings of the Academic Surgical Congress on Results Previously Presented at Association of Academic Surgeons, New Orleans, La, USA, February 2013.
[24]
C. J. O'Sullivan, N. Hynes, B. Mahendran et al., “Haemoglobin A1c (HbA1C) in non-diabetic and diabetic vascular patients. Is HbA1C an independent risk factor and predictor of adverse outcome?” European Journal of Vascular and Endovascular Surgery, vol. 32, no. 2, pp. 188–197, 2006.
[25]
O. Guckelberger, A. Thelen, C. Benckert et al., “Diabetes mellitus is no independent risk factor for perioperative mortality following hepatic resection,” Experimental and Clinical Endocrinology and Diabetes, vol. 114, no. 5, pp. 257–261, 2006.
[26]
S. S. Rayan, A. D. Hamdan, D. R. Campbell et al., “Is diabetes a risk factor for patients undergoing open abdominal aortic aneurysm repair?” Vascular Surgery, vol. 36, no. 1, pp. 33–40, 2002.
[27]
L. Morricone, M. Ranucci, S. Denti et al., “Diabetes and complications after cardiac surgery: comparison with a non-diabetic population,” Acta Diabetologica, vol. 36, no. 1-2, pp. 77–84, 1999.
[28]
M. Krolikowska, M. Kataja, R. P？yhi？, J. Drzewoski, and M. Hynynen, “Mortality in diabetic patients undergoing non-cardiac surgery: a 7-year follow-up study,” Acta Anaesthesiologica Scandinavica, vol. 53, no. 6, pp. 749–758, 2009.
[29]
A. B. Juul, J. Wetterslevt, and A. Kofoed-Enevoldsen, “Long-term postoperative mortality in diabetic patients undergoing major non-cardiac surgery,” European Journal of Anaesthesiology, vol. 21, no. 7, pp. 523–529, 2004.
[30]
M. Hollenberg, D. T. Mangano, W. S. Browner, M. J. London, J. F. Tubau, and I. M. Tateo, “Predictors of postoperative myocardial ischemia in patients undergoing noncardiac surgery. The study of perioperative ischemia research group,” Journal of the American Medical Association, vol. 268, no. 2, pp. 205–209, 1992.
[31]
American Diabetes Association, “Standards of medical care in diabetes—2012,” Diabetes Care, vol. 35, supplement 1, pp. S11–S63.
[32]
N. Calonge, D. B. Petitti, T. G. DeWitt et al., “Screening for type 2 diabetes mellitus in adults: U.S. preventive services task force recommendation statement,” Annals of Internal Medicine, vol. 148, no. 11, pp. 846–854, 2008.
[33]
G. Van den Berghe, P. Wouters, F. Weekers et al., “Intensive insulin therapy in critically ill patients,” The New England Journal of Medicine, vol. 345, no. 19, pp. 1359–1367, 2001.
[34]
G. Van den Berghe, A. Wilmer, G. Hermans et al., “Intensive insulin therapy in the medical ICU,” The New England Journal of Medicine, vol. 354, no. 5, pp. 449–461, 2006.
[35]
M. E. Nunnally, “Con: tight perioperative glycemic control: poorly supported and risky,” Journal of Cardiothoracic and Vascular Anesthesia, vol. 19, no. 5, pp. 689–690, 2005.
[36]
G. Y. Ghandhi, G. A. Nuttall, M. D. Abel, et al., “Intraopertive hyperglycemia an perioperative outcomes in cardiac surgery patients,” Mayo Clinic Proceedings, vol. 80, pp. 862–866, 2005.
