Preoperative Hyperglycemia Increases Length of Stay after Major Orthopedic Surgery
Boris Mraovic, M.D., Jeffery I. Joseph, D.O., Brian R. Hipszer, M.S., Edward C. Pequignot, M.S., Inna Chervoneva. Ph.D.
Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA
Background:
Methods:
Results and Discussion:
Reducing hospital length of stay (LOS) after major orthopedic surgery has gained popularity with surgeons,
hospital administrators and third party payers. Admission hyperglycemia prolongs LOS in trauma parients.
(1) Hyperglycemia has been reported to prolong LOS after ICU admission and CABG surgery.(2) However,
it is unknown if increased blood glucose (BG) prolongs LOS after hip and knee surgery.
After obtaining IRB approval, we retrospectively reviewed the medical records of patients undergoing
elective total hip or total knee replacement from January 2001 to April 2006. Patients with incomplete records
were excluded. Patients were divided into 3 groups based on preoperative BG levels: Normal <110 mg/dl,
High 110-199 mg/dl and Very High ≥200 mg/dl. Data are reported as geometric mean with 95% confidence
interval in parentheses unless otherwise noted. Effects of various risk factors on log transformed LOS were
evaluated using robust regression and robust ANOVA. A p value of < 0.05 was considered
statistically significant.
Data from 7282 patients were included in the study. The median LOS was 3 days (range 1-58). Patients with
Normal BG stayed on average 3.46 days (3.43, 3.49), High BG 3.62 days (3.56, 3.67) and Very High BG
4.05 days (3.80, 4.31). LOS was 8% (4, 12; p<0.001) longer in Very High group compared with Normal
group. An 8% increase from the median LOS of 3 days translates into 5.8 hours. Age increased LOS by 2%
(1, 2; p<0.001) per decade of life, BMI >40 kg/m2 by 4% (1, 6; p=0.002), duration of surgery >137 min
by 19% (12, 20; p<0.001), bilateral knee surgery by 28% (27, 30; p<0.001) compared with unilateral knee
surgery, knee surgery by 9% (8, 10; p<0.001) comparing with hip surgery. Patients with history of congestive
hear failure had 6% (2, 10; p=0,004) longer LOS on average. Diabetes increased LOS by 4% (2, 5; p<0.001).
Females had shorter LOS than males by 4% (3, 5; p<0.001) on average. Analysis confirms that the intention
to decrease LOS was successful in our hospital. Compared to 2001, LOS was on average 9% (7, 11) shorter
in 2002, 12% (10, 13) in 2003, 15% (14, 16) in 2004 and 16% (14, 17) in 2005/2006, p< 0.001.
We investigate whether preoperative hyperglycemia ≥200 mg/dL (11.1 mmol/L) was associated with
increased LOS after total hip and knee arthroplasty.
Univariate analysis of length of stay after hip and knee surgery
(n = 7282)
Geometric means
P values
Percent increase of legth of stay
(days)
Female n=4090 (56.2%)
3.42
Male
3.31
n=3192 (43.8%)
Age (yrs) (overall mean [SD])
63.7 [12.2]
<50 yrs
3.19
3.31
>60-70 yrs
3.39
>70-80 yrs
3.45
>80 yrs
3.56
Sex
0.96 (0.95, 0.97)
<0.001*
30.1 [6. 2]
Age per decade
1.01 (1.01, 1.01)
<0.001*
BMI
1.00 (1.00, 1.00)
0.311
ASA PS 2+4/1+2
1.01 (1.00, 1.02)
0.003*
Hip/Knee
0.97 (0.93, 1.01)
0.126
Primary/Revisions
0.96 (0.94, 0.97)
<0.001*
Bilateral/Unilateral Knee
1.15 (1.14, 1.17)
<0.001*
OR Time (min)
1.00 (1.00, 1.00))
<0.001*
Year of surgery
0.96 (0.96, 0.96)
<0.001*
High/Normal
1.00 (0.99, 1.01)
0.593
Very High/Normal
1.03 (1.00, 1.07)
0.031 *
Arrhythmia
1.02 (1.00, 1.04)
0.024*
CAD
1.01 (1.00, 1.02)
0.032*
CHF
1.01 (0.98, 1.04)
0.537
Valve Disease
1.00 (0.98, 1.01)
0.683
Pulmonary
0.99 (0.98, 1.01)
0.316
Endocrinological
1.00 (0.99, 1.01)
0.665
Diabetes
0.96 (0.90, 1.02)
0.214
Hematological
1.01 (0.99, 1.02)
0.488
Sleep Apnea
1.01 (0.99, 1.03)
0.367
Stroke
1.00 (0.98, 1.02)
0.933
Hypertension
1.00 (0.99, 1.01)
0.741
Dislipidemia
1.00 (0.99, 1.01)
0.443
Malignancy
1.00 (0.98, 1.02)
0.930
BMI (kg/m ) (overall mean [SD])
<25 kg/m2
3.34
25-30 ≥ kg/m2
3.33
30-40 ≥ kg/m2
3.41
≥ 40 kg/m2
3.49
ASA PS
1+2
3.33
2+4
3.43
30
Knee
n=3203 (44.0%)
3.54
Hip
n=4079 (56.0%)
3.25
Revisions n=811 (11.1%)
3.56
Primary
3.36
n=6471 (88.9%)
Bilateral Knee
n=735 (10.1%)
Unilateral Knee n=2468 (33.9%)
OR Time (min) mean [SD]
4.14
25
0.026
<0.001*
<0.001*
<0.001*
117 [44]
3.17
86-107
3.21
108-136
3.38
>137
3.81
Year of surgery
<0.001*
2002
3.49
2003
3.37
2004
3.24
5
0
3.27
<0.001*
Normal (<110)
3.34
High (111-199)
3.44
Very High (≥200)
3.79
Arrhythmia
n=439 (6.0%)
3.53
0.112
CAD
n=1091 (15.0%)
3.49
0.014*
n=149 (2.1%)
3.91
0.004*
n= 677 (9.3%)
3.39
0.229
Pulmonary
n=1231 (16.9%)
3.43
0.249
Endocrinological
n=918 (12.6%)
3.48
0.004*
Diabetes
n= 862 (11.8%)
3.52
<0.001*
Hematological
n=390 (5.4%)
3.45
0.081
Sleep Apnea
n=392 (5.4%)
3.42
0.817
Stroke
n=299 (4.1%)
3.50
0.217
Hypertension
n=3874 (53.2%)
3.43
<0.001*
Dislipidemia
n=1370 (18.8%)
3.37
0.162
Malignancy
n=491 (6.7%)
3.44
0.040
GI
n=1944 (26.7%)
3.42
0.061
Liver disease
n=01 (2.8%)
3.39
0.980
Rheumatoid Art
n=210 (2.9%)
3.38
0.858
DVT
n=258 (3.5%)
3.47
0.040*
Renal
n= 23 (0.32%)
3.56
0.757
UTI
n=75 (1.03%)
3.37
0.531
Transfusions
n=1357 (18.6%)
3.74
<0.001*
* Statistically significant p<0.05
7 .7
3 .7
3 .5
3.78
Preoperative Glucose (mg/dL)
Dx
Preoperative Glucose
9 .3
5 .6
<0.001*
2005
15
10
Female/Male
Surgery:
1 8 .9
20
Bilateral
Knee
P values
(95% CI)
3.29
< 86
2001
Ratio of Geometric means
2 8 .2
<0.001*
Surgery:
CHF
Multivariate analysis of length of stay after hip and knee
<0.001*
>50-60 yrs
2
Valve
35
<0.001
Percentage (%)
Sex
OR Time
>137 min
Knee
Glucose
≥200 mg/dL
CHF
Diabetes
BMI≥40
kg/m2
* Statistically significant p<0.05
Conclusion:
References:
Our data suggests that history of CHF is an independent risk factor for developing PE after major
orthopedic surgery. Identifying patients with history of CHF could be helpful in the risk stratification for the
thromboprophylaxis after total hip and knee surgery.
1. Sung J et al. Admission Hyperglycemia Is Predictive of Outcome in Critically Ill Trauma Patients. J Trauma.
2005;59:80-83.
2. Lazar HL and al. Tight Glycemic Control in Diabetic Coronary Artery Bypass Graft Patients Improves
A prospective, randomized, controlled trial is required to determine whether optimizing CHF treatment
prior to surgery would decrease the incidence of PE in this clinical setting.
Perioperative Outcomes and Decreases Recurrent Ischemic Events.
Disclosure: This research was conducted with support from the Investigator-Initiated Study Program of LifeScan, Inc.