Stress Hyperglycemia and Complications Following Traumatic Injuries in Individuals With/Without Diabetes: The Case of Orthopedic Surgery

Figures & data

Table 1 Baseline Demographic and Clinical Data from Patients of the Total Cohort. The Age-Adjusted Charlson Comorbidity Index Was Calculated on the Basis of Medical History¹⁹

Clinical Characteristics	All Patients (n=202)
Age (years)	74.4 ± 12.4
Weight (kg)	76.4 ± 15.2
Height (cm)	165.1 ± 9.8
Body Mass Index (kg/m^2)	27.9 ± 4.5
Glycosylated A1c hemoglobin (%)	7.08 ± 1.00
Blood glucose (mg/dL)	164.7 ± 59.8
Serum hemoglobin (g/dL)	12.6 ± 1.8
Serum potassium (mEq/L)	4.43 ± 0.54
Serum creatinine (mg/dL)	1.00 ± 0.47
Age-adjCharlson Comorbidity Index	5.21 ± 2.12
Major surgery (%)*	85.6 (79.9–89.6)
Comorbidities (%)
Arterial hypertension (%)	76.7 (70.2–81.8)
Dyslipidemia (%)	37.1 (30.5–43.7)
Coronary artery disease (%)	17.3 (12.5–22.9)
Peripheral vascular disease (%)	15.8 (11.2–21.2)
Chronic kidney disease (%)^#	10.9 (7.1–15.7)
Retinopathy (%)	6.4 (3.6–10.4)
Previous cancer (last 5 years)(%)	12.9 (8.7–17.9)
Liver disease (%)	9.4 (5.9–13.9)
Previously diagnosed diabetes (N=183)(%)*	90.6 (85.5–93.7)
Newly-detected diabetes (N=13)(%)	6.4 (2.8–13.2)
Diabetes treatment
Diet only (N=18)(%)°	9.8 (6.1–14.6)
Metformin (N=63)(%)°	34.4 (27.7–41.3)
Any additional non-insulin drug (N=55)(%)°	29.9 (23.5–36.6)
Insulin + any non-insulin treatment (N=21)(%)°	11.4 (7.4–16.5)
Insulin alone (N=26)(%)°	14.1 (9.8–19.6)
Relative hyperglycemia (SHR)	1.06 ± 0.34
Stress hyperglycemia (SHR >1.14)(N=58)(%)*	28.9 (22.8–35.2)

Notes: Data are presented as means ± standard deviation. *Percent (95% confidence interval). ^#Estimated glomerular filtration rate <60mL/min/1.73m² (with/without albuminuria). °Percent within diabetes cohort (95% confidence interval).

Figure 1 Diagnostic algorithm for the evaluation of patients with in-hospital hyperglycemia at admission (number of cases are reported in parenthesis).

Abbreviations: DM, diabetes mellitus; HbA1c, glycosylated hemoglobin; SH, stress hyperglycemia (SHR >1.14); SHR, stress hyperglycemia ratio.

Table 2 Principal Characteristics and Adverse Events or Complications in Relation to the Presence of Diabetes and Stress Hyperglycemia

Variable	Diabetes, No SH (N=143)	Diabetes, SH+ (N=53)	No Diabetes, SH+ (N=6)	P value^^ DM (No SH vs. SH+)	P value^^ SH+ vs No SH
Admission glucose (mg/dL)	140.6 ± 34.5	230.1 ± 68.0	159.8 ± 7.8	<0.001	<0.001
HbA1c (mmol/mol)	7.11 ± 1.01	7.09 ± 0.97	6.10 ± 0.38^	0.887	0.425
Relative hyperglycemia	0.90 ± 0.17	1.47 ± 0.37	1.26 ± 0.13	<0.001	<0.001
Age (years)	73.5 ± 12.7	76.0 ± 11.6	83.3 ± 7.7	0.136	0.085
Age-adjCharlson Index	5.08 ± 2.17	5.55 ± 2.01	5.50 ± 1.76	0.171	0.156
Type of surgery (Major)	120 (83.9, 76.6–88.7)	47 (88.7, 76.3–94.1)	6 (100.0, 51.7–100.0)	0.500	0.378
Cases with events	33 (23.1, 16.6–30.3)	29 (54.7, 40.6–66.5)	5 (83.3, 36.6–94.0)	<0.001	<0.001
Cardiovascular events	6 (4.2, 1.7–8.4)	10 (18.9, 9.9–30.3)	4 (66.7, 24.1–86.1	<0.001	<0.001
AMI/angina	2 (1.4, 0.2–4.4)	2 (3.8, 0.7–11.4)	1 (16.7, 0.9–48.3)	0.296	0.150
Stroke/TIA	0 (0.0–1.9)	1 (1.9, 0.1–8.4)	0 (0.0–27.3)	0.270	0.292
Heart failure	1 (0.7, 0.0–3.3)	5 (9.4, 3.5–19.1)	1 (16.7, 0.9–48.3)	0.006	0.003
Arrhythmias	4 (2.5, 0.4–7.7)	5 (9.4, 3.5–19.1)	2 (33.3, 6.0–63.5)	0.062	0.016
Local infections	3 (2.1, 0.5–5.5)	2 (3.8, 0.7–11.4)	0 (0.0–27.3)	0.613	0.630
Systemic infections	21 (14.7, 9.5–21.0)	22 (41.5, 28.4–54.0)	3 (50.0, 13.9–75.9)	<0.001	<0.001
Other complications	3 (2.1, 0.5–5.5)	6 (11.3, 4.7–21.4)	1 (16.7, 0.9–48.3)	0.013	0.007
ICU admission	6 (4.2, 1.7–8.4)	4 (7.5, 2.4–16.6)	1 (16.7, 0.9–48.3)	0.464	0.304
Reintervention	0 (0.0–1.9)	3 (5.7, 1.5–14.1)	1 (16.7, 0.9–48.3)	0.117	0.007

Notes: Data are presented as means ± SD or as number of cases (%, 95% confidence interval). ^{^}Student t-test, Chi² test or Fisher exact test, as appropriate).

Abbreviations: AMI, acute myocardial infarction; ICU, intensive care unit; TIA, transient ischemic attack; SH, stress hyperglycemia.

Table 3 Association of Hyperglycemia Categories with Adverse Events in Subjects with/Without a History of Diabetes

Hyperglycemia Categories	All Adverse Events (N=68)	Odds Ratio (95% Confidence Intervals)
		CV Events* (N=19)	Systemic Infections (N=46)	Local Infections (N=5)	Admission to ICU (N=10)	Other Events° (N=10)
1. Diabetes, no SH (reference) (n = 154)	–	–	–	–	–	–
2. Diabetes, SH+ (n = 42)	4.03 (1.95–8.32)	5.51 (1.83–18.80)	4.32 (1.94–9.62)	2.19 (0.55–8.68)	1.95 (0.44–8.66)	6.62 (1.37–31.95)
3. No diabetes, SH+ (n = 6)	13.08 (1.25–100.3)	44.52 (4.70–422.1)	3.78 (0.63–22.63)	na	4.13 (0.34–50.01)	11.18 (0.50–249.3)
8. Stress hyperglycemia (all cases: 2+3)(n = 48)	4.43 (2.11–9.30)	7.09 (2.47–19.91)	4.21 (1.97–9.03)	3.40 (0.46–24.95)	2.37 (0.65–8.55)	6.30 (1.41–28.03)

Notes: All data are adjusted for age, sex, body mass index, Charlson’s index and type of surgery. Statistically significant results are presented in bold characters. *CV complications include acute myocardial infarction, arrhythmias, left bundle branch block, transient ischemic cerebral attack, stroke. °Other events include pulmonary, neurological and hepatic complications.

Abbreviations: SH, Stress hyperglycemia; CV, cardiovascular; ICU, intensive care unit; na, data not calculated because of lack of events.

Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–383. doi:10.1016/0021-9681(87)90171-8

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