Magnitude and associated factors of postoperative hyperglycemia among an adult nondiabetic patient who underwent surgery at 2 tertiary hospitals in Ethiopia : IJS Global Health

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Magnitude and associated factors of postoperative hyperglycemia among an adult nondiabetic patient who underwent surgery at 2 tertiary hospitals in Ethiopia

Desalegn, Mitiku MSca,; Shitemaw, Tewoderos MSc, MPHb; Sitot, Mulualem MScc; Getachew, Lemlem MScc

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International Journal of Surgery: Global Health 5(5):p e86, September 2022. | DOI: 10.1097/GH9.0000000000000086
  • Open

Abstract

Hyperglycemia is common after acute trauma, injury, and illness in both diabetic and nondiabetic patients1. Surgical trauma commonly results in postoperative insulin resistance2, this exerts altered insulin and glucose metabolism3. Perioperative hyperglycemia is a common outcome with a reported prevalence of between 20% and 40% of patients undergoing general surgery4. The American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA) have developed a consensus statement on inpatient glycemic control that defines hyperglycemia as any blood glucose (BG) value >140 mg/dL without evidence of previous diabetes5.

Elevated intraoperative BG levels are associated with increased patient morbidity and mortality4. There is a clear association between inpatient hyperglycemia (>180 mg/dL, 10 mmol/L) and adverse clinical outcomes, including surgical site infections, delayed wound healing, and increased length of stay6. Review of this study shows perioperative hyperglycemia is associated with wound infection, skin infection, urinary tract infection, myocardial infarction, pneumonia, and acute renal failure in noncardiac surgery4,6.

There are a variety of protocols used to control BG levels in different hospital settings. Infusion of insulin in the postoperative period for the hyperglycemic patients was effective7. A study demonstrated that a bolus of subcutaneous insulin is effective in reducing the BG level, but tight glycemic control in the recovery room results in hypoglycemia in some patients8. This study aims to determine the magnitude and contributing risk factors of postoperative hyperglycemia, thus allowing targeted steps to be taken to improve the quality of care delivered to postsurgical patients.

Materials and methods

Study design and settings

An institutional-based cross-sectional study was conducted in 2 public specialized hospitals from January 1 to March 30, 2021. Tikur Anbessa specialized Hospital (TASH) is located in Addis Ababa, the capital city of Ethiopia, and Nigist Elleni Mohamed Memorial specialized Hospital (NEMMSH) is located in Hossana town, the capital of Hadya zone.

Population

All adult nondiabetic patients who underwent elective surgery were the source population and all eligible nondiabetic adult patients who fulfilled the inclusion criteria during the data collection period were the study population. During the preoperative period, patients with the diagnosis of diabetes mellitus (fasting plasma glucose 126 mg/dL)9 and patients with confirmed pregnancy were excluded from the study.

Sample size determination and sampling technique

The sample size was determined using the single population proportion method for the first objective, which is the magnitude of postoperative hyperglycemia after elective surgery.

Since no related study was found in Ethiopia or Africa, P=0.5 was used for calculation to get the maximum sample size, 95% level of significance, 5% margin of error, and 10% for incomplete or as contingency data was used as parameters. The sample size was 384 and, adding 10% for nonresponse rate, the final sample was 424.

A systematic random sampling method was used. Potential study subjects were all patients scheduled for elective surgery and their names were selected and included in the surgery list. A list of all adult patients scheduled for elective surgery was collected from the theater lists and submitted to the operating theater by different surgical specialties a day before the scheduled surgical procedures.

After situational analysis was done for 3 months before the start of the study, an average of 1260 elective surgery cases (842 in TASH and 418 in NEMMSH) are found to be done in 3 months in both hospitals. After proportional allocation, 284 elective surgical cases from TASH and 140 elective surgical cases from NEMMSH were taken. K was determined using the formula: K=N/n, where n=total sample size and N=population. Therefore, the sampling interval was 3 and the first study participant (random start) was selected using a lottery method from each surgical specialty. Each day before elective surgery begins, patients are selected by a systematic random sampling technique from each group of surgical specialities.

Then, every third case from the daily surgical procedures was included in the study during the study period. The intention of including them in the study, the aim and benefits of the study, and the data collection procedures were explained. A preliminary assessment of whether the patient fulfils the inclusion criteria was made, and those who met the inclusion criteria are included. This procedure was repeated on each day of data collection until the required sample size was attained.

Operational definition

  • Hyperglycemia: fasting blood sugar ≥140 mg/dL for nondiabetic and ≥200 mg/dL for diabetic patients10.
  • Adult: age 18 years and above.
  • Baseline value: measurements taken before induction of anesthesia.
  • Postoperative: period after the patient is transferred to post anesthesia care unit (PACU).
  • Perioperative: the period comprises all 3 periods (preoperative, intraoperative, and postoperative).
  • Body mass index: a measure of body fat based on weight and height that applies to adult men and women.
  • Immediate postoperative period: the time that extends from patient admission to PACU until the first vital sign and BG level is taken by a nurse.
  • Confirmed pregnancy: pregnancy confirmed by pregnancy tests.

Data collection tools, methods and procedures

Data was collected using a structured pretested questionnaire by data collectors from January 1 to March 30, 2021. Questions in the questioner include sociodemographic data, clinical patient characteristics, and different surgical and anesthetic variables. Patients are allocated proportionally to each surgical type. Sociodemographic and preoperative clinical data were extracted from the patient’s records on the morning of surgery. Intraoperative anesthetic and surgical data were collected from the intraoperative anesthesia charts. Data was collected by 4 trained anesthetists; this was done on the morning of surgery, in the intraoperative period and immediately after surgery at PACU, and this continued until the desired number of patients is achieved for each surgical type.

Immediately after the patient was transferred to PACU, the nurse took and recorded the patient’s vital signs and fasting BG level on the chart. The assigned data collector records the fasting BG level from the PACU follow-up chart within 30 minutes of the patient’s arrival at PACU. The glucometer used at PACU to check for capillary BG by nurses was a hemocue201 glucose analyzer, which is based on the glucose dehydrogenase method. The completeness of the data was checked by the principal investigator every day.

Data quality control

To assure the quality of the data, training on the objectives and relevance of the study and brief orientations on the assessment tools were provided for the data collectors. The questionnaires were prepared in English and pretested on 5% of the study population. The results of the pretest were not included in the final analysis. During data collection, each question was revised by the investigator to be complete and appropriate. In the event of missed measurements during the intraoperative period, the electronic data stores of the monitoring equipment were recalled and back traced, and the data was filled.

Data analysis

Data were coded, edited, entered, and cleaned in Epi Info version 7 before being exported to the Statistical Package for Social Sciences (SPSS) software version 20.0. Bivariate and multivariate logistic regression analyses were done to determine the presence of associations between dependent and independent variables, and the odds ratio with 95% CIs was used to determine the degree of association between dependent and independent variables. The prevalence was calculated as the proportion of patients with postoperative hyperglycemia with a 95% CI. Variables with a P-value <0.25 in the bivariate logistic regression analysis were considered for multivariable analysis. After checking for multicollinearity, multivariable analysis was performed to adjust for possible confounders and come up with significant predictors. The statistical tests were performed at a 5% significance level. The results were presented by using text, tables, charts, and graphs.

Ethical considerations

Ethical approval and clearance were obtained from the ethical review committee of Addis Abeba and Wachemo University, College of Medicine and Health Sciences. Written informed consent was obtained from each patient and confidentiality was maintained by making the data collectors aware not to record any identification information found.

Results

Socio, demographic, and preoperative clinical characteristics of patients

Four hundred twenty-four patients were enrolled in the study. Thirty-two subjects’ preoperative fasting BG levels were above 126 mg/dL on the day of surgery and were removed before data analysis. Twenty-one patients who had missing glucose values and another 12 patients’ documents with incomplete records were also excluded. The results presented are for the remaining 359 patients. The mean age of the patients was 47.5 with a 16 SD. The total number of female participants was 167 (46.5%) and the number of male participants was 192 (53.5%). The majority (40.4%) of the patient’s age was found in the 18–40 age group, followed by the age group 41–60 (32.6%), and the rest are above 60 years. Regarding American Society of Anesthesiologists (ASA) status, most of the patients were under ASA class II (58.5%), the rest were under class I (Table 1).

Table 1 - Socio, demographic, and preoperative characteristics of patients who underwent elective surgery at Tikur Anbessa specialized Hospital and Nigist Elleni Mohamed Memorial specialized Hospital from January 1 to March 30, 2021 (n=359).
Variables Category Frequency (%)
Sex Male 192 (53.5)
Female 167 (46.5)
Age 18–40 145 (40.4)
41–60 117 (32.6)
>60 97 (27)
ASA status Class I 149 (41.5)
Class II–III 210 (58.5)
BMI Nonobese 278 (77.4)
Obese 81 (22.6)
ASA indicates American Society of Anaesthesiologists; BMI, body mass index.

Anesthetic and surgical characteristics of patients

Of the total number of patients, the majority of patients underwent surgery under general anesthesia (42%), followed by regional anesthesia 116 (32%), and combined general-regional anesthesia 91 (26%). The majority of procedures took more than 60 minutes to complete (236, 65.7%). A numeric rating scale of pain was used to assess pain during the immediate postoperative period, of which 198 (55.2%) of the patients developed mild pain and the rest did not show any sign of pain (Table 2).

Table 2 - Anesthetic and surgical characteristics of patients who underwent elective surgery at Tikur Anbessa specialized Hospital and Nigist Elleni Mohamed Memorial specialized Hospital from January 1 to March 30, 2021 (n=359).
Variables Category Frequency (%)
Type of anesthesia Combined 91 (26)
Regional 116 (32)
General 152 (42)
Duration of surgery ≤60 min 123 (34.3)
>60 min 236 (65.7)
Intraoperative dexamethasone administered Yes 111 (30.9)
No 248 (69.1)
Immediate postoperative pain Yes 198 (55.2)
No 161 (44.8)

General surgery (50.6%) was the most frequently performed surgical procedure, followed by orthopedics (35%), neurosurgery (8%), and cardiothoracic (6.4%) (Fig. 1).

F1
Figure 1:
The type of elective surgery performed among adult patients at Tikur Anbessa specialized Hospital and Nigist Elleni Mohamed Memorial specialized Hospital from January 1 to March 30, 2021.

BG variable during preoperative and postoperative period

Out of 359 patients, 42% of the patients developed hyperglycemia during the postoperative period. Six patients developed immediate postoperative hypoglycemia (fasting BG ≤70 mg/dL) and were managed with a 40% dextrose IV bolus by PACU nurses (Table 3).

Table 3 - Fasting blood glucose level during the preoperative and postoperative periods of patients who underwent elective surgery at Tikur Anbessa specialized Hospital and Nigist Elleni Mohamed Memorial specialized Hospital from January 1 to March 30, 2021 (n=359).
Variables n Mean SD Median Range
Preoperative blood glucose (mg/dL) 359 94.3 23.57 88 44–124
Postoperative blood glucose (mg/dL) 359 145.67 64.59 130 44–391

Determinant factors of postoperative hyperglycemia

According to the results of bivariable binary logistic regression analysis, age, ASA class, administration of dexamethasone, type of procedure, type of anesthesia, and duration of surgery were associated with postoperative hyperglycemia.

In the final model (multivariable binary logistic regression analysis), after excluding variables which did not fit into the model using a P-value >0.25 in the likelihood ratio test, multivariate analysis was performed for those variables; age, type of procedure, type of anesthesia, administration of dexamethasone, and duration of surgery were associated with postoperative hyperglycemia.

Patients between the ages of 41 and 60 were 5 times more likely [adjusted odds ratio (AOR)=4.9; 95% CI: 2.5–9.7] and those over 60 were 5.3 times more likely (AOR=5.3; 95% CI: 2.36–11.8) likely to develop postoperative hyperglycemia than those between the ages of 18 and 40. Durations of surgery >1 hour were 3.9 times more likely to develop postoperative hyperglycemia than surgeries that took ≤1 hour.

Patients undergoing neurosurgery were 3.5 times more likely (AOR=3.5; 95% CI: 1.8–6.8) to develop postoperative hyperglycemia than patients undergoing orthopedic surgery. Patients who underwent general anesthesia were 5.8 times more likely (AOR=5.8; 95% CI: 2.5–13.59) to develop postoperative hyperglycemia than patients who underwent regional anaesthesia (AOR=4.8; 95% CI: 2.6–10.3). Patients who took dexamethasone were 2.65 times more likely to develop postoperative hyperglycemia than patients who did not (AOR=2.65; 95% CI: 1.1–5.9) (Table 4).

Table 4 - Determinants of postoperative hyperglycemia among adult patients who underwent elective surgery at Tikur Anbessa specialized Hospital and Nigist Elleni Mohamed Memorial specialized Hospital hospitals from January 1 to March 30, 2021 (n=359).
Variables Category COR 95% CI AOR 95% CI P
Sex Male 1 1
Female 0.67 [0.44–1.02] 1.1 [0.63–1.9] 0.7
Age 18–40 1
41–60 6.6 [3.8–11.4] 4.9 [2.486–9.7] 0.001
>60 3.7 [2.1–6.6] 5.29 [2.36–11.8] 0.001
ASA class Class I 1 1
Class II–III 2.17 [1.39–3.36] 1.81 [0.97–3.39] 0.062
BMI Nonobese 1 1
Obese 0.7 [0.4–1.17] 0.5 [0.254–1.3] 0.184
Dexamethasone No 1 1
Yes 2.2 [1.4–3.5] 2.65 [1.1–5.9] 0.018
Type of surgery Orthopedic 1 1
Neurosurgery 3 [1.844–4.9] 3.5 [1.8–6.8] 0.001
Cardiothoracic 2.57 [1.05–6.26] 1.3 [0.4–4.0] 0.58
General 0.7 [0.26–1.87] 0.58 [0.15–1.8] 0.3
Type of anesthesia Regional 1 1
General 13 [6.5–26] 5.88 [2.5–13.59] 0.001
Combined 6.9 [3.68–12.9] 4.8 [2.26–10.3] 0.001
Duration of surgery ≤60 min 1 1
>60 min 3.53 [2.1–5.7] 3.9 [1.9–8] 0.001
Immediate postoperative pain No 1 1
Yes 0.5 [0.36–1.84] 0.26 [0.135–1.5] 0.06
Statistically significant P<0.05.
AOR indicates adjusted odds ratio; ASA, American Society of Anaesthesiologists; COR, crude odds ratio.

Discussion

According to this study, there is a higher magnitude of postoperative hyperglycemia, 42% among adult nondiabetic patients who underwent elective surgery. Age, dexamethasone use, type of anesthesia, type of procedure, and duration of surgery were associated with postoperative hyperglycemia. The higher postoperative BG level may have been related to different factors in our study. This was an observational study with multiple variables included. The patient characteristics, the surgical-related variables, and the anesthetic management methods were not all controlled.

Our study found a high glucose level compared with a study conducted by Pereira et al11 (BG >120 mg/dL), 26.4%, according to Kwon et al12 (BG>180 mg/dL), 29.1% and a study reported by Jämsen et al13 (BG >140 mg/dL) 41%. The magnitude of the current findings is lower than the study reported by Ghildiyal et al14 (BG >140 mg/dL) 56.4% and at Singapore general hospital15 (BG >180 mg/dL) 56.1%. Tilak et al16 also described the prevalence of postoperative hyperglycemia as being 53%. These variations could be attributed to the size, setting, and variable cutoff points used to define hyperglycemia in different studies. Of course, genetic and behavioral factors (diet) as the result of differences in insulin resistance may have played a role in this disparity17,18.

In this study, age was strongly associated with postoperative hyperglycemia. Patients with an age group between 41 and 60 were 5 times more likely to develop postoperative hyperglycemia compared with a patient whose age is between 18 and 40. This result is consistent with the retrospective study conducted on 837 patients at PACU by the University of Sao Paulo11 and the study reported by Moorthy et al15. In a retrospective study, Ata et al19 found that postoperative hyperglycemia was associated with increasing age. Another study conducted by Hu et al20 found the degree of postoperative hyperglycemia correlated with age. This might be explained by the fact that, with aging, there are changes in insulin secretion and peripheral resistance to its effect as a result of increased abdominal fat mass21–23.

It was also observed in this study that an increase in the duration of surgery was strongly associated with postoperative hyperglycemia. Procedures that took more than 1 hour were 3.9 times more likely to result in postoperative hyperglycemia than procedures that took less than 1 hour. This finding is in line with the prospective observational study described by Jämsen et al13, conducted on patients who underwent primary hip and knee replacement surgery. Prolonged surgery results in activation of endocrine response including increased release of catecholamines, cortisol, and glucagon and reduced glucose uptake capacity2. Persistence in release of cathecolamines during prolonged duration surgery elevates blood sugar level.

Patients who took general anesthesia were 5.8 times and combined general-regional anesthesia was 4.8 times more prone to hyperglycemia than patients who undertook regional anesthesia. This finding is in line with the study conducted to identify the effects of different types of anesthesia on BG levels; the combined general regional anesthesia has better BG levels than general anesthesia24. Another study conducted by El-Radaideh et al25 to compare the effects of general anesthesia and spinal anesthesia on changes in BG concentration in nondiabetic patients also supports our study results. This might also be related to volatile anesthetic agents that inhibit insulin production and increase hyperglycemic response to surgery26.

Administration of dexamethasone during the intraoperative period is another factor associated with the likelihood of exhibiting postoperative hyperglycemia. This finding is consistent with the study reported by Pereira et al11. The administration of 8 mg of dexamethasone between diabetic and nondiabetic patients who underwent laparoscopic surgery, the BG levels observed at the 30 and 120 minutes marks were statistically significant relative to the preinduction BG27. Another study predicted the maximum increase in 24-hour postoperative BG to be 1.9 mmol/L (95% CI: 1.0–2.9) was higher in patients receiving dexamethasone compared with patients receiving Ondasteron28. The likely explanation is the increased stimulation of the adrenal glands by steroids, which might result in increased sympathetic nervous system activation2,3.

Limitation of the study

Prediabetic patients have impaired fasting glucose and impaired glucose tolerance tests. The only way to identify this group of patients is to test for % HgbA1c, IGT test, and IFG test. These tests are expensive and are not done routinely in our setup. Some patients may have undiagnosed endocrine metabolic disorders (thyroid and liver disease), which will predispose patients to having altered glucose metabolism. Because these factors may have an effect on the outcome variable, the findings of this study should be interpreted with these limitations in mind.

Conclusion

Nearly half of the patients had postoperative hyperglycemia. Age, dexamethasone administration, type of anesthesia, type of procedure, and duration of surgery were predictors of postoperative hyperglycemia. The anesthetist’s and PACU staff’s understanding of these factors is important for close follow-up of this group of patients.

Ethical approval

Ethical approval was obtained from the ethical review committee of Addis Abeba and Wachemo University, College of Medicine and Health Sciences.

Sources of funding

Supported by the Addis Ababa University.

Authors’ contribution

M.D.: contributed to conception, design, and acquisition of data, analysis, and interpretation of data as well as on preparing the manuscript. T.S.: involved in analysis, interpretation of data and drafting the manuscript and revising it critically for important intellectual contents. M.S. and L.G.: contributed to design, analysis and critical review and editing of the manuscript drafts for scientific merit and depth.

Conflicts of interest disclosure

The authors declare that they have no financial conflict of interest with regard to the content of this report.

Research registration unique identifying number (UIN)

8233.

Guarantor

Mitiku Desalegn.

Acknowledgements

We would like to thank Addis Abeba University College of Medicine and Health Science for funding this research. Our gratitude goes to supervisors, data collectors and study respondents. Finally, we would like to thank all those, who in one way or another have contribute in this work.

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Keywords:

Postoperative hyperglycemia; Elective surgery; Associated factors; Nondiabetic

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