SLR - February 2022 - Fernando Ramirez II
Reference: Anderson, Braden M. BS; Wise, Brent T. MD; Joshi, Manjari MBBS; Castillo, Renan PhD; O'Toole, Robert V. MD, Richards, Justin E. MD Admission Hyperglycemia Is a Risk Factor for Deep Surgical-Site Infection in Orthopaedic Trauma Patients, Journal of Orthopaedic Trauma: December 2021 - Volume 35 - Issue 12
Level of Evidence: Prognostic Level III
Scientific Literature Review
Reviewed By: Fernando Ramirez II, DPM
Residency Program: Kaiser San Francisco Bay Area Foot and Ankle Residency Program – Oakland, CA
Podiatric Relevance: The increased risk of surgical site infections (SSI) in patients with diabetes is well documented. However, nondiabetic patients with hyperglycemia are also at increased risk for acute complications, even greater than hyperglycemic patients with a history of diabetes mellitus. Post traumatic hyperglycemia has a negative effect on the biochemical and immunologic response to operative stress and injury. The negative impact of hyperglycemia following orthopaedic trauma in the nondiabetic population is not well documented. SSI are one of the most daunting complications for any orthopaedic surgery. Being able to identify patients at higher risk for infection and to effectively optimize the patient is critical. This research can enhance the way trauma patients are managed preoperatively.
Methods: A level III retrospective review from December 1, 2006 to December 31, 2015 was performed for nondiabetic patients, noncritically ill suffering an extremity, pelvic or acetabular fracture which required open reduction and internal fixation or intramedullary nailing. Two cohorts were collected during that time period. Patients which sustained a deep SSI within 90-days of the initial operation and a control group collected from randomly selected convenience sample of noninfected patients in a 2:1 ratio. Patients in both the infected and noninfected cohorts were required to have a serum blood glucose value collected on admission to the trauma center. Admission hyperglycemia was considered if the first obtained blood glucose was > 200 mg/dL. Univariate analysis was conducted to compare cases with a 90-day deep SSI with the control group that did not experience an infection. The association of admission hyperglycemia and 90-day deep SSI was further assessed using a multivariable logistic regression model.
Results: The final study population consisted of 465 patients. Data were collected for 128 (27.5 percent) patients with a deep SSI and 337 (72.5 percent) patients without a deep SSI. There was no significant difference in age, race, smoking status, body mass index, ASA physical classification score, and 90-day deep SSI. However, male patients were more likely to be infected (100/329, 30.4 percent vs. 28/136, 20.6 percent; P = 0.03). In addition, patients with a history of drug or alcohol abuse were more likely to develop a 90-day deep SSI (17/42, 40.5 percent vs. 113/423, 26.2 percent; P = 0.049). Anatomic region of injury and open fractures were also associated with the infection status on univariate analysis. The mean admission glucose was 127.4 mg/dL (SD: 30.9). Admission blood glucose > 200 mg/dL occurred in 14/ 465 (3.0 percent). Admission hyperglycemia was significantly associated with deep SSI (8/128, 6.3 percent vs. 6/337, 1.8 percent; P = 0.01). Multivariable logistic regression model demonstrated that admission hyperglycemia remained significantly associated with 90-day deep SSI after controlling for male gender, prior drug or alcohol abuse, open fracture and anatomic region.
Conclusions: An admission blood glucose of > 200 mg/dL represents a significant association with 90-day SSI in nondiabetic patients undergoing posttraumatic orthopaedic surgery. Presurgical BG normalization in patients without diabetes should be considered to decrease chances of SSI. Further studies in this patient population are needed to determine definitive guidelines.