Risk factors for perioperative hyperglycemia in primary hip and knee replacements

Figures & data

Figure 1. Collection of patients.

Table 1. Patient demographics, medical status, and operative data

Patient demographics and comorbidity
Median age at surgery (range), years	66 (43–89)
Sex, no.
Female	124 (65%)
Male	67 (35%)
Median body mass index (range), kg/m^2	30 (21–50)
ASA risk score, no.
I	16 (8%)
II	92 (48%)
III	82 (43%)
IV	1 (1%)
Self-reported comorbidities, n
Hypertension	106 (55%)
Cardiovascular disease	42 (22%)
Pulmonary disease	31 (16%)
Dermatological disease	28 (15%)
Gastrointestinal disease	22 (12%)
Genitourinary disease	17 (9%)
Cancer or history of cancer	14 (7%)
Neurological disease	6 (3%)
Smoking, n	22 (12%)
Earlier joint replacements, n
None	150 (79%)
Any	41 (21%)
Clinical evaluation in this study
State of glucose metabolism, n
Normal	91 (48%)
IFG and/or IGT (“pre-diabetes”)	47 (24%)
Newly diagnosed diabetes	17 (9%)
Previously diagnosed diabetes	36 (19%)
Metabolic syndrome, n	85 (45%)
Preoperative anemia, n	10 (5%)
Renal function, n^a
Normal	100 (52%)
Mild insufficiency	74 (39%)
Moderate insufficiency	17 (9%)
Severe insufficiency	0
Operative data
Simultaneous bilateral surgery, no.	21 (11%)
Total joint replacement, no.	182 (95%)
Prosthesis fixation, no.
Cemented	101 (53%)
Hybrid	7 (4%)
Cementless	83 (43%)
Median duration of surgery (range), min	85 (44–225)
Median tourniquet time (range), min	50 (0–129)
Median blood loss (range), mL	150 (5–3100)
Blood transfusions, n	24 (13%)
Closed suction drains, n	114 (60%)

^a Estimated, based on preoperative creatinine according to the Cockcroft-Gault formula.

SD: standard deviation; ASA: American Society of Anesthesiologists; IFG: increased fasting glucose; IGT: impaired glucose tolerance.

Figure 2. Mean glucose (with 95% CIs) following primary hip and knee replacement in patients with osteoarthritis.

Table 2. The effects of different patient- and operation-related factors on the incidence of hyperglycemia and severe hyperglycemia. The odds ratios (ORs) were adjusted for age, sex, operated joint (hip or knee), and the American Society of Anesthesiologists risk score

		Hyperglycemia Adjusted		Severe hyperglycemia Adjusted
	n	n (%)	OR (95% CI)	n (%)	OR (95% CI)
Gender
Male	67	26 (39)	1	17 (25)	1
Female	124	50 (40)	1.4 (0.70–2.7)	31 (25)	1.3 (0.60–2.6)
Age ^a			1.0 (0.99–1.1)		1.0 (0.97–1.1)
< 55 years	20	5 (25)	1	4 (20)	1
55–64 years	68	20 (29)	0.7 (0.22–2.5)	10 (15)	0.4 (0.11–1.6)
65–74 years	72	32 (44)	1.0 (0.79–7.3)	20 (28)	0.7 (0.18–2.7)
≥ 75 years	31	19 (61)	1.7 (0.42–6.7)	14 (45)	1.2 (0.28–5.5)
ASA risk score
I	16	1 (6)	1	1 (6)	1
II	92	27 (29)	5.0 (0.61–41)	15 (16)	2.6 (0.31–22)
III	82	48 (59)	15 (1.8–125)	32 (39)	8.0 (0.93–69)
IV	1	0 (0)	-	0 (0)	-
Body mass index, kg/m^2^a			1.0 (0.94–1.1)		1.0 (0.95–1.1)
< 25.0	28	12 (43)	1	9 (32)	1
25.0–29.9	71	27 (38)	1.0 (0.37–2.5)	11 (16)	0.4 (0.14–1.2)
30.0–34.9	60	24 (40)	1.0 (0.36–2.6)	19 (32)	1.1 (0.39–3.0)
35.0–39.9	20	8 (40)	1.0 (0.28–3.7)	6 (30)	1.0 (0.26–3.9)
≥ 40.0	12	5 (42)	0.8 (0.19–3.8)	3 (25)	0.6 (0.12–3.3)
State of glucose metabolism
Normal	91	20 (22)	1	10 (11)	1
IFG and/or IGT	47	17 (36)	1.8 (0.79–4.1)	7 (15)	1.4 (0.48–4.2)
Newly diagnosed diabetes	17	8 (47)	2.4 (0.79–7.5)	3 (18)	1.5 (0.34–6.1)
Previously diagnosed diabetes	36	31 (86)	18 (5.7–59)	28 (78)	29 (9.1–97)
Metabolic syndrome
Without	106	31 (29)	1	18 (17)	1
With	85	45 (53)	2.2 (1.1–4.2)	30 (35)	2.1 (1.03–4.4)
Smoking
No	169	67 (40)	1	42 (25)	1
Yes	22	9 (41)	1.59 (0.52–4.83)	6 (27)	1.6 (0.52–4.8)
Preoperative anemia
Without	181	69 (38)	1	44 (24)	1
With	10	7 (70)	3.9 (0.91–17)	4 (40)	2.0 (0.50–8.1)
Renal function
Normal	100	39 (39)	1	26 (26)	1
Mild insufficiency	74	29 (39)	0.6 (0.28–1.2)	15 (20)	0.5 (0.22–1.2)
Moderate insufficiency	17	8 (47)	0.5 (0.12–1.6)	7 (41)	1.0 (0.27–3.7)
Operation-related data
Laterality
Unilateral	170	72 (42)	1	45 (27)	1
Bilateral	21	4 (19)	0.5 (0.14–1.5)	3 (14)	0.7 (0.17–2.5)
Time of induction of anesthesia
Before 10 am	95	41 (43)	1	25 (26)	1
After 10 am	96	35 (37)	0.7 (0.40–1.4)	23 (24)	0.9 (0.43–1.7)
Duration of surgery × 10 min ^a	191		0.95 (0.86–1.1)		1.03 (0.92–1.2)
Blood loss × 100 mL ^a	191		1.0 (0.88–1.1)		1.0 (0.90–1.2)
Tourniquet time × 10 min (incl. knees only) ^a	117		1.0 (0.84–1.2)		1.2 (0.99–1.5)
Cement used for fixation^b
None	83	36 (43)	1	21 (25)	1
Any	108	40 (37)	0.8 (0.37–1.6)	27 (25)	1.3 (0.56–2.9)
Blood transfusion
None	167	63 (38)	1	38 (23)	1
Any	24	13 (54)	1.3 (0.48–3.3)	10 (42)	1.8 (0.66–4.7)
Closed suction drains
None	77	31 (40)	1	21 (27)	1
Any	114	45 (40)	2.0 (0.67–5.8)	27 (24)	1.4 (0.44–4.2)

^a Continuous

^b Fully cementless vs. fully cemented and hybrid joint replacements.

ASA: American Society of Anesthesiologists; IFG: increased fasting glucose;

IGT: impaired glucose tolerance.

Table 3. Association of preoperative HbA1c and baseline glucose (on the day of operation) with occurrence of hyperglycemia in patients with and without a previous diagnosis of diabetes

	Patients with previously diagnosed diabetes Hyper-glycemia			Patients without a previous diagnosis of diabetes Hyper-glycemia
	n	n (%)	p^a	n	n (%)	p^a
HbA1c
≤ 6.0%	7	4 (57)	-	96	20 (21)	-
6.1–6.4%	7	6 (86)	0.3	49	19 (39)	0.01
≥ 6.5%	22	21 (95)	0.002	10	6 (60)	0.04
Baseline glucose
< 5.6 mmol/L	6	4 (67)	-	88	18 (20)	-
5.6–6.9 mmol/L	12	10 (83)	0.4	60	22 (37)	0.03
> 6.9 mmol/L	18	17 (94)	0.1	5	4 (80)	0.02

^a p-values are from pairwise univariate comparisons against the lowest HbA1c/glucose category.