Thurs., 10/13/11 Polytrauma, Paper #28, 3:08 pm OTA-2011
Stress–Induced Hyperglycemia Is a Risk Factor for Surgical–Site Infection in Nondiabetic Orthopaedic Trauma Patients
Justin E. Richards, MD1; Rondi M. Kauffmann, MD, MPH2;
William T. Obremskey, MD, MPH1; Addison K. May, MD2;
1Div. of Orthopaedic Trauma,
2Div. of Emergency Surgery and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee, USA
Purpose: The purpose of this investigation was to evaluate the effect of stress-induced hyperglycemia on infectious complications in a population of orthopaedic trauma patients.
Methods: This is a retrospective study of isolated orthopaedic trauma patients admitted to an academic Level 1 trauma center from January 2004 to October 2009. Inclusion criteria were age ≥18 years, ICU stay ≥1 day, orthopaedic injury requiring operative intervention, and more than 1 documented blood glucose (BG) value. Patients with a history of diabetes mellitus, corticosteroid use, immunologic disease, or Abbreviated Injury Scale scores other than extremity were excluded. Demographics, injury severity, units of red blood cell transfusion, BG, and infectious complication data were obtained. Infections considered were pneumonia, urinary tract infection (UTI), surgical-site infection (SSI), and bacteremia. The Hyperglycemic Index (HGI) was calculated for each patient and reflects the mean BG level above 108 mg/dL. HGI was determined from BG values obtained prior to the diagnosis of infection. HGI was considered separately as a continuous variable and a dichotomous variable >1.72 (equivalent to BG of 139 mg/dL).
Results: 187 patients were identified. All were managed with a tight glycemic protocol (target BG: 80-110 mg/dL). Mean age was 47.7 ± 23.2 years and 121 of 187 patients (64.7%) were male. Mean ICU and hospital length of stay was 4.0 ± 4.9 and 10.0 ± 8.1 days, respectively. ISS was higher in patients with an infection (10.6 ± 3.7 vs 9.5 ± 2.8; P = 0.03), but not clinically significant. Infections were recorded in 43 of 187 patients (23.0%) and SSIs specifically documented in 16 patients (8.6%). Open fractures were not associated with SSI (8 of 83 [9.6%] vs 8 of 104 [7.7%]; P = 0.64). By univariate analysis there was no difference in admission BG or HGI and infection. However, there was a significant difference in HGI when considering SSI alone (2.1 ± 1.7 vs 1.2 ± 1.1; P = 0.003). HGI >1.72 was associated with SSIs (8 of 16 [50.0%] vs 33 of 171 [19.3%]; P = 0.005). Patients with an SSI received a greater amount of blood transfusions (14.9 ± 12.1 vs 4.9 ± 7.6; P <0.001). No patient was diagnosed with a separate infection (ie, pneumonia, UTI, bacteremia) prior to SSI. There was no difference in ISS among patients with an SSI (11.1 ± 4.0 vs 9.6 ± 3.0; P = 0.06). Multivariable regression testing HGI as a continuous variable demonstrated a significant relationship (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.2-2.6) with SSI after adjusting for blood transfusions (OR, 1.1; 95% CI, 1.1-1.2).
Conclusions: Stress-induced hyperglycemia may represent a significant risk factor for SSIs in nondiabetic trauma patients with isolated orthopaedic injuries.
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• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant.