Perioperative Hyperglycemia and Control in Vascular Surgery

Introduction: Perioperative hyperglycemia occurs frequently and is associated withperioperative morbidity and mortality following vascular surgery. We sought to examine currentglycemic surveillance and control patterns at the McGill University Health Centre (MUHC) andthe impact of perioperative hyperglycemia on outcomes following vascular surgery. We alsoexamined the literature on the use of one glycemic control intervention, intensive insulin therapy,for pre-existing studies performing this intervention on patients undergoing lower extremityvascular surgery.Methods: Current glycemic control patterns at the MUHC were evaluated by retrospective datacollection on patients who underwent open infrainguinal vascular surgery. Patient baselinecharacteristics, intra-operative factors, efficacy of glycemic control, and post-operative outcomeswere assessed using univariate and multivariate analysis.A systematic review was then performed to determine the evidence for the use of intensiveinsulin therapy to reduce the risk of complications following open lower extremity vascularsurgery.Results: 38.9% of patients experienced perioperative hyperglycemia defined as glucose ³ 10mmol/L during their hospital admission. Only 3.9% of patients within the cohort underwent anyintraoperative glycemic surveillance, despite the fact that 43.9% of patients were diabetic. 16.8%patients remained hyperglycemic for at least 40% of their measurements during theirhospitalization. Multivariable logistic regression including the covariates of age, sex,hypertension, smoking status, diabetic status, presence of chronic kidney disease, dialysis,Rutherford stage, coronary artery disease and perioperative hyperglycemia demonstrated asignificant relationship between perioperative hyperglycemia and 30-day mortality (OR 25.00,595% CI 2.469 – 250.00, p = 0.006), major adverse cardiac events (OR 2.08, 95% CI 1.008 -4.292, p = 0.048), major adverse limb events (OR 2.24, 95% CI 1.020 – 4.950, p = 0.045), acutekidney injury (OR 7.58, 95% CI 3.021 – 19.231, p <0.001), reintervention (OR 2.06, 95% CI1.117 - 3.802, p = 0.021) and intensive care unit admission (OR 3.38, 95% CI 1.225 – 9.345, p =0.019).A systematic literature review identified two studies using intensive insulin therapy during andimmediately following vascular surgery. Protocols for insulin infusion varied significantly andmany patients did not achieve normoglycemia. Studies were also underpowered.Conclusion: Perioperative glycemic monitoring and control is sub-optimal following lowerextremity revascularization and is associated with significant morbidity and mortality in ourcohort. Pre-existing literature on the use of intensive insulin therapy in the perioperative periodin patients undergoing vascular surgery are underpowered and too variable to allow conclusionson the safety and efficacy of intensive insulin therapy to be drawn.More consistent monitoring and the use of more effective glycemic control protocols at theMcGill University Health Centre, such as the use of an intensive insulin protocol, might providea yet unexplored avenue for reducing patient morbidity and mortality following lower extremityopen vascular surgery. Further studies on the use of intensive insulin therapy in patientsundergoing lower extremity revascularization or major amputation are needed to properly assessthis intervention

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