FEBRUARY 2013
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Hyperglycemia Tied to Increased Orthopedic Surgery Infections Findings highlight role of anesthesiologists in controlling blood glucose
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wo recently published studies are the latest in a growing body of evidence emphasizing that one of the central roles of operating room anesthesiologists is to manage the patient’s blood sugar levels. The research found that hyperglycemia, even in the absence of diagnosed diabetes, increases the risk for surgical site infections (SSIs) by nearly five times in patients undergoing orthopedic and joint surgery. “The scope of our practice as true perioperative physicians is expanding and the postoperative consequences of uncontrolled hyperglycemia are one of a set of variables, including appropriate pain management and measures to reduce delirium, that lie within the realm of our care and have implications well beyond the operating room,” said Laura Clark, MD, director of acute pain and regional anesthesia and professor of anesthesia at the University of Louisville School of Medicine, in Kentucky. The two papers appeared in the Journal of Bone Joint Surgery of America. In one, researchers at Vanderbilt University, in Nashville, Tenn., retrospectively examined the incidence of SSIs within 30 days of orthopedic surgery as well as blood glucose levels in 790 surgery patients treated at the institution between 2004 and 2009 (2012;94:1181-1186). The patients did not have a history of diabetes, injuries to other body systems, corticosteroid use or admission to the ICU immediately following injury. More than 37% (294) of the patients in the study had glucose levels of 200 mg/dL or greater on at least two random glucose tests, the researchers found. Of these patients, 17% (134) met a separate criterion quantifying glucose control during an entire hospital stay as the area under the curve of all glucose values acquired during the patient’s hospitalization. An index score of at least 1.76 (≥140 mg/dL) is considered hyperglycemic. The researchers found 4.4% (13 of 294) of those with glucose at or above 200 mg/dL on at least two tests had an SSI within 30 days of surgery compared with 1.6% (eight of 496) of those who did not (P=0.02). Approximately 8% (10 of 134) of patients with hyperglycemia developed an SSI during that period compared with 1.7% (11 of 656) of those without elevated blood sugar (P<0.001).
Multivariable analyses controlling for the effects of open fractures confirmed the association, showing hyperglycemic patients were 3.2 to 4.9 times more likely than nonhyperglycemic patients to develop an SSI within 30 days, depending on the definition of hyperglycemia used.
“The link between hyperglycemia and postoperative complications has been established in other surgical disciplines, including general surgery, but ours is one of the first to look at non-diabetic, non-ICU patients,” said Justin Richards, MD, an anesthesia resident at Vanderbilt, who led the study.
“Given that up to one-third of patients admitted to hospital without a diagnosis of diabetes have hyperglycemia, these findings are very significant.” The increased risk for SSIs in patients without diabetes but who have high glucose levels was confirmed in the second see SSIs page 14
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Using NAROPIN beyond recommended doses to increase motor block or duration of sensory block may negate its favorable cardiovascular advantages, in the event that an inadvertent intravascular injection occurs.
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Important Safety Information There have been adverse event reports of chondrolysis in patients receiving intra-articular infusions of local anesthetics following arthroscopic and other surgical procedures. NAROPIN is not approved for this use. Please see dosage and administration details in Prescribing Information at www.naropin-us.com.
Like all amide-type local anesthetics, NAROPIN may be associated with adverse reactions. In clinical trials, side effects were mild and transient and may reflect the procedures, patient health status, and/or other medications used. Adverse events reported at a rate of ≥5%: hypotension, nausea, vomiting, bradycardia, fever, pain, postoperative complications, anemia, paresthesia, headache, pruritus, and back pain.
Please see accompanying brief summary of Prescribing Information. www.naropin-us.com NAROPIN is indicated for the production of regional or local anesthesia for surgery and for acute pain management. References: 1. Beaulieu P, Babin D, Hemmerling T. The pharmacodynamics of ropivacaine and bupivacaine in combined sciatic and femoral nerve blocks for total knee arthroplasty. Anesth Analg. 2006;103:768-774. 2. Morrison LM, Emanuelsson BM, McClure JH, et al. Efficacy and kinetics of extradural ropivacaine: comparison with bupivacaine. Br J Anaesth. 1994;72:164-169. Naropin® and logo are trademarks of Fresenius Kabi USA, LLC. APP ® and are trademarks of Fresenius Kabi USA, LLC. ©2012, Fresenius Kabi USA, LLC. All Rights Reserved. 0155-NAR-05-2/11
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