Danger: High Blood Sugar and the Ortho OR

A study published in the July 2012 issue of the Journal of Bone and Joint Surgery (JBJS) has found that high blood sugar is a concern during the post-traumatic and post-operative period. The authors of the study, “Relationship of Hyperglycemia and Surgical-Site Infection in Orthopaedic Surgery, ” found that it may help to preoperatively identify those patients with musculoskeletal injuries who are at significant risk for infectious complications.

The authors reviewed data on patients 18 years or older who had orthopedic injuries requiring acute operative intervention. Of 790 patients, there were 268 open fractures and 21 surgical-site infections (SSIs) at 30-day follow-up. Age, race, comorbidities, injury severity, and blood transfusion were not associated with SSI at 30 days. SSIs developed in 13 of 294 patients who had more than one glucose value greater than or equal to 200 mg/dL and 8 of 496 patients without more than one glucose value greater than or equal to 200 mg/dL. The authors concluded that hyperglycemia was an independent risk factor for 30-day SSI in orthopedic trauma patients without a history of diabetes.

The lead author on the study was Justin E. Richards, M.D. with Vanderbilt Orthopaedic Institute. Asked what might be the best way to manage these orthopedic patients postop,  Dr. Richards told OTW,

Unfortunately, we still don’t have a great answer on how to manage hyperglycemia in orthopedic trauma patients without a history of diabetes and who are not in the intensive care unit. What has immediately changed our practice is now knowing that a portion of these orthopedic trauma patients who were without a history of diabetes actually have hyperglycemia, and that some of these patients may be occult, or previously undiagnosed, diabetics. We now routinely check blood glucose on all our orthopedic trauma patients in the perioperative period and for those patients who are hyperglycemic we obtain a Hemoglobin A1C level to identify potential occult diabetes and refer them for appropriate diabetic management. It is important to keep in mind that our data was unable to evaluate if patients who were hyperglycemic were administered insulin and whether or not this affected outcome. What we also do not know yet is if hyperglycemia is in some way a causation of surgical-site infections (SSIs) or just an association in patients who respond poorly to surgery or trauma and have metabolic anomalies that manifest in hyperglycemia and increased risk for SSIs. Hopefully future prospective, randomized studies will be able to answer these questions.