Division of Vascular Surgery, Department of Surgery, University of Missouri, School of Medicine, Columbia, Mo.
Department of Family and Community Medicine, University of Missouri, School of Medicine, Columbia, Mo.
J Vasc Surg. 2019 Mar;69(3):763-773.e3. doi: 10.1016/j.jvs.2018.05.240. Epub 2018 Aug 25.
We evaluated the association between postoperative hyperglycemia and outcomes after abdominal aortic aneurysm (AAA) repair.
We used diagnosis and procedure codes (International Classification of Diseases, Ninth Revision, Clinical Modification) to identify patients who underwent open or endovascular repair of a nonruptured AAA from September 2008 to March 2014 from the Cerner Health Facts database (Cerner Corporation, North Kansas City, Mo). We evaluated the association between postoperative hyperglycemia (glucose concentration >180 mg/dL) and infections, in-hospital mortality, readmission, patients' characteristics, length of hospital stay, and medications. Multivariable logistic models examined the association of postoperative hyperglycemia with in-hospital infection and mortality.
Of 2478 patients, 2071 (83.5%) had good postoperative glucose control (80-180 mg/dL), and 407 (16.5%) had suboptimal control (hyperglycemia). Patients who had postoperative hyperglycemia experienced longer hospital stays (9.5 vs 4.7 days; P < .0001), higher infection rates (18% vs 8%; P < .0001), higher in-hospital mortality (8.4 vs 1.2%; P <.0001), and more acute complications (ie, acute renal failure, fluid and electrolyte disorders, respiratory complications). After adjusting for patients' characteristics and medications, multivariable logistic regression models demonstrated that patients receiving postoperative insulin had nearly 1.6 times the odds of having an infectious complication (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.12-2.2; P = .007) than those who did not. Hyperglycemic patients had 3.5 times the odds of in-hospital mortality (OR, 3.48; 95% CI, 1.78-6.80 [P = .0003]; 2.3% vs 1.2%; P < .001). When stratified by procedure type, patients with hyperglycemia who underwent endovascular repair had nearly 2 times the odds of an infectious complication (OR, 1.85; 95% CI, 0.98-3.51; P = .05) and 7.5 times the odds of in-hospital mortality (OR, 7.54; 95% CI, 1.95-29.1; P = .003). Patients who underwent an open AAA repair and who had hyperglycemia had three times the odds of dying in the hospital (OR, 3.05; 95% CI, 1.29-7.21; P = .01).
Among patients undergoing elective AAA repair, approximately one in six had postoperative hyperglycemia. After AAA repair in patients with and without diabetes, postoperative hyperglycemia was associated with adverse events, including in-hospital mortality and infections. Compared with those who had open surgery, patients undergoing endovascular repair who had postoperative hyperglycemia had greater risk of infection and death. After controlling for insulin administration and postoperative hyperglycemia, a diabetes diagnosis was associated with lower odds of both infection and in-hospital mortality. Our study suggests that hyperglycemia may be used as a clinical marker as it was found to be significantly associated with inferior outcomes after elective AAA repair. This retrospective study, however, cannot imply causation; further study using prospective methods is needed to elucidate the relationship between postoperative hyperglycemia and patient outcomes.
评估腹主动脉瘤（AAA）修复术后高血糖与结局之间的关系。
我们使用诊断和手术代码（国际疾病分类，第九修订版，临床修正）从 2008 年 9 月至 2014 年 3 月从 Cerner Health Facts 数据库（堪萨斯城北部的 Cerner 公司）中确定接受非破裂性 AAA 开放或血管内修复的患者。我们评估了术后高血糖（葡萄糖浓度>180mg/dL）与感染、院内死亡率、再入院、患者特征、住院时间和药物之间的关系。多变量逻辑模型检查了术后高血糖与院内感染和死亡率的关联。
在 2478 名患者中，2071 名（83.5%）有良好的术后血糖控制（80-180mg/dL），407 名（16.5%）控制不佳（高血糖）。术后发生高血糖的患者住院时间较长（9.5 天比 4.7 天；P<0.0001），感染率较高（18%比 8%；P<0.0001），院内死亡率较高（8.4%比 1.2%；P<.0001），急性并发症较多（即急性肾衰竭、液体和电解质紊乱、呼吸并发症）。在调整了患者特征和药物治疗后，多变量逻辑回归模型表明，接受术后胰岛素治疗的患者发生感染性并发症的几率几乎是未接受胰岛素治疗的患者的 1.6 倍（比值比[OR]，1.6；95%置信区间[CI]，1.12-2.2；P=0.007）。高血糖患者的院内死亡率是 3.5 倍（OR，3.48；95%CI，1.78-6.80[P=0.0003]；2.3%比 1.2%；P<.001）。按手术类型分层时，接受血管内修复的高血糖患者发生感染性并发症的几率几乎是前者的 2 倍（OR，1.85；95%CI，0.98-3.51；P=0.05），院内死亡率是前者的 7.5 倍（OR，7.54；95%CI，1.95-29.1；P=0.003）。接受开放 AAA 修复且高血糖的患者住院死亡的几率是前者的 3 倍（OR，3.05；95%CI，1.29-7.21；P=0.01）。
在接受择期 AAA 修复的患者中，大约有六分之一的患者术后出现高血糖。在有和没有糖尿病的 AAA 修复患者中，术后高血糖与不良事件有关，包括院内死亡率和感染。与接受开放性手术的患者相比，接受血管内修复且术后发生高血糖的患者感染和死亡的风险更高。在控制了胰岛素的使用和术后高血糖后，糖尿病的诊断与感染和院内死亡率较低的几率相关。我们的研究表明，高血糖可能被用作临床标志物，因为它与择期 AAA 修复后的不良结局有显著的相关性。然而，这项回顾性研究不能暗示因果关系；需要使用前瞻性方法进一步研究，以阐明术后高血糖与患者结局之间的关系。
