Hostname: page-component-cd9895bd7-q99xh Total loading time: 0 Render date: 2024-12-26T16:50:57.608Z Has data issue: false hasContentIssue false
  • English
  • Français

Long-term postoperative mortality in diabetic patients undergoing major non-cardiac surgery

Published online by Cambridge University Press:  23 December 2004

A. B. Juul ,
J. Wetterslev  and
A. Kofoed-Enevoldsen
A. B. Juul
Affiliation:
Copenhagen University Hospital, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7102, Rigshospitalet, Copenhagen, Denmark
J. Wetterslev
Affiliation:
University Hospital of Copenhagen, Department of Anaesthesiology, Herlev, Denmark
A. Kofoed-Enevoldsen
Affiliation:
Esbjerg Varde Hospital, Department of Internal Medicine, Esbjerg, Denmark
Get access

Extract

Summary

Background and objective: The prognosis of diabetic patients after surgery remains controversial. Some suggest that the rates of death and complications today are almost identical in diabetic and non-diabetic patients within hospital stay or for 30 days postoperatively, whereas others suggest that diabetes still constitutes a major risk factor for both short-term (≤30 days) and long-term (>30 days) patients especially after major cardiac surgery. We examined the long-term postoperative mortality of diabetic patients undergoing major non-cardiac surgery to identify possible perioperative risk factors.

Methods: Data from 179 consecutive diabetic patients, who underwent major non-cardiac surgery at Herlev Hospital, Denmark, during a 12 month period, have been retrospectively analysed. Data were obtained from patient records and from The Danish National Health Register. The main outcome measure was postoperative mortality. Patients were followed for a maximum of 18 months.

Results: The median postoperative observation period was 10 months (range 0–18 months). Overall postoperative mortality was 24% (95% confidence interval (CI) 17–31%). One third of the fatalities occurred during the first 30 days. Ischaemic heart disease diagnosed before the operation was associated with an overall postoperative mortality of 44% (95% CI 29–58%), which was significantly (P < 0.03) higher than in diabetic patients without known cardiovascular disease. The major causes of death in 18 out of 39 (46%) patients were diseases of the cardiovascular system.

Conclusions: Diabetic patients undergoing major non-cardiac surgery seem to have a high mortality, often because of cardiovascular death. Future strategies should focus on implementing cardio-protective treatment during the perioperative period.

Keywords

CARDIOVASCULAR DISEASESGLUCOSE METABOLISM DISORDERS, DIABETES MELLITUSMORTALITYSURGERY
Type
Original Article
Information
European Journal of Anaesthesiology , Volume 21 , Issue 7 , July 2004 , pp. 523 - 529
Copyright
2004 European Society of Anaesthesiology

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Hamdan AD, Saltzberg SS, Sheahan M, et al. Lack of association of diabetes with increased postoperative mortality and cardiac morbidity: results of 6565 major vascular operations. Arch Surg 2002; 137: 417–421.Google Scholar
Hjortrup A, Sorensen C, Dyremose E, Hjortso NC, Kehlet H. Influence of diabetes mellitus on operative risk. Br J Surg 1985; 72: 783–785.Google Scholar
Morricone L, Ranucci M, Denti S, et al. Diabetes and complications after cardiac surgery: comparison with a non-diabetic population. Acta Diabetol 1999; 36: 77–84.Google Scholar
Zarich SW, Cohen MC, Lane SE, et al. Routine perioperative dipyridamole 201tl imaging in diabetic patients undergoing vascular surgery. Diabetes Care 1996; 19: 355–360.Google Scholar
Fietsam JrR, Bassett J, Glover JL. Complications of coronary artery surgery in diabetic patients. Am Surg 1991; 57: 551–557.Google Scholar
Walsh DB, Eckhauser FE, Ramsburgh SR, Burney RB. Risk associated with diabetes mellitus in patients undergoing gallbladder surgery. Surgery 1982; 91: 254–257.Google Scholar
Herlitz J, Wognsen GB, Emanuelsson H, et al. Mortality and morbidity in diabetic and nondiabetic patients during a 2-year period after coronary artery bypass grafting. Diabetes Care 1996; 19: 698–703.Google Scholar
Risum O, Abdelnoor M, Svennevig JL, et al. Diabetes mellitus and morbidity and mortality risks after coronary artery bypass surgery. Scand J Thorac Cardiovasc Surg 1996; 30: 71–75.Google Scholar
Stewart RD, Lahey SJ, Levitsky S, Sanchez C, Campos CT. Clinical and economic impact of diabetes following coronary artery bypass. J Surg Res 1998; 76: 124–130.Google Scholar
Thourani VH, Weintraub WS, Stein B, et al. Influence of diabetes mellitus on early and late outcome after coronary artery bypass grafting. Ann Thorac Surg 1999; 67: 1045–1052.Google Scholar
Dawson I, van Bockel JH. Reintervention and mortality after infrainguinal reconstructive surgery for leg ischaemia. Br J Surg 1999; 86: 38–44.Google Scholar
Zerr KJ, Furnary AP, Grunkemeier GL, Bookin S, Kanhere V, Starr A. Glucose control lowers the risk of wound infection in diabetics after open heart operations. Ann Thorac Surg 1997; 63: 356–361.Google Scholar
Mangano DT, Layug EL, Wallace A, Tateo I. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Multicenter study of perioperative ischemia research group. New Engl J Med 1996; 335: 1713–1720.Google Scholar
Meyer S. Grading of patients for surgical procedures. Anesthesiology 1941; 2: 228–285.Google Scholar
Nickelsen TN. Data validity and coverage in the Danish National Health Registry. A literature review. Ugeskr Laeger 2001; 164: 33–37.Google Scholar
Raby KE, Goldman L, Creager MA, et al. Correlation between preoperative ischemia and major cardiac events after peripheral vascular surgery. New Engl J Med 1989; 321: 1296–1300.Google Scholar
Mangano DT, Browner WS, Hollenberg M, London MJ, Tubau JF, Tateo IM. Association of perioperative myocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery. The study of perioperative ischemia research group. New Engl J Med 1990; 323: 1781–1788.Google Scholar
Mangano DT, Browner WS, Hollenberg M, Li J, Tateo IM. Long-term cardiac prognosis following noncardiac surgery. The study of perioperative ischemia research group. JAMA 1992; 268: 233–239.Google Scholar
Mangano DT, Hollenberg M, Fegert G, et al. Perioperative myocardial ischemia in patients undergoing noncardiac surgery – I: incidence and severity during the 4 day perioperative period. The Study of Perioperative Ischemia (SPI) Research Group. J Am Coll Cardiol 1991; 17: 843–850.Google Scholar
Waller BF, Palumbo PJ, Lie JT, Roberts WC. Status of the coronary arteries at necropsy in diabetes mellitus with onset after age 30 years: analysis of 229 diabetic patients with and without clinical evidence of coronary heart disease and comparison to 183 control subjects. Am J Med 1980; 69: 498–506.Google Scholar
Malmberg K, Ryden L, Hamsten A, Herlitz J, Waldenstrom A, Wedel H. Mortality prediction in diabetic patients with myocardial infarction: experiences from the DIGAMI study. Cardiovasc Res 1997; 34: 248–253.Google Scholar
Renner IG, Savage III WT, Pantoja JL, Renner VJ. Death due to acute pancreatitis. A retrospective analysis of 405 autopsy cases. Dig Dis Sci 1985; 30: 1005–1018.Google Scholar
Abbud ZA, Shindler DM, Wilson AC, Kostis JB. Effect of diabetes mellitus on short- and long-term mortality rates of patients with acute myocardial infarction: a statewide study. Myocardial infarction data acquisition system study group. Am Heart J 1995; 130: 51–58.Google Scholar
Rytter L, Troelsen S, Beck-Nielsen H. Prevalence and mortality of acute myocardial infarction in patients with diabetes. Diabetes Care 1985; 8: 230–234.Google Scholar
Burgos LG, Ebert TJ, Asiddao C, et al. Increased intraoperative cardiovascular morbidity in diabetics with autonomic neuropathy. Anesthesiology 1989; 70: 591–597.Google Scholar
Charlson ME, MacKenzie CR, Gold JP. Preoperative autonomic function abnormalities in patients with diabetes mellitus and patients with hypertension. J Am Coll Surg 1994; 179: 1–10.Google Scholar
Sundkvist G, Almer L, Lilja B. Respiratory influence on heart rate in diabetes mellitus. BMJ 1979; 1: 924–925.Google Scholar
Morrish NJ, Stevens LK, Head J, Fuller JH, Jarrett RJ, Keen H. A prospective study of mortality among middle-aged diabetic patients (the London cohort of the WHO multinational study of vascular disease in diabetics) II: associated risk factors. Diabetologia 1990; 33: 542–548.Google Scholar
Hirsch IB, McGill JB. Role of insulin in management of surgical patients with diabetes mellitus. Diabetes Care 1990; 13: 980–991.Google Scholar
Oliver MF, Opie LH. Effects of glucose and fatty acids on myocardial ischaemia and arrhythmias. Lancet 1994; 343: 155–158.Google Scholar
Vik-Mo H, Mjos OD. Influence of free fatty acids on myocardial oxygen consumption and ischemic injury. Am J Cardiol 1981; 48: 361–365.Google Scholar
Lawrie GM, Morris GC, Glaeser DH. Influence of diabetes mellitus on the results of coronary bypass surgery. Follow-up of 212 diabetic patients ten to 15 years after surgery. JAMA 1986; 256: 2967–2971.Google Scholar
Furnary AP, Zerr KJ, Grunkemeier GL, Starr A. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures [see comments]. Ann Thorac Surg 1999; 67: 352–360.Google Scholar
Golden SH, Peart-Vigilance C, Kao WH, Brancati FL. Perioperative glycemic control and the risk of infectious complications in a cohort of adults with diabetes. Diabetes Care 1999; 22: 1408–1414.Google Scholar
Lazar HL, Chipkin S, Philippides G, Bao Y, Apstein C. Glucose–insulin–potassium solutions improve outcomes in diabetics who have coronary artery operations. Ann Thorac Surg 2000; 70: 145–150.Google Scholar
van den BG, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. New Engl J Med 2001; 345: 1359–1367.Google Scholar
Pedersen T, Eliasen K, Ravnborg M, et al. Risk factors, complications and outcome in anaesthesia. A pilot study. Eur J Anaesthesiol 1986; 3: 225–239.Google Scholar
Fowkes FG, Lunn JN, Farrow SC, Robertson IB, Samuel P. Epidemiology in anaesthesia. III: mortality risk in patients with coexisting physical disease. Br J Anaesth 1982; 54: 819–825.Google Scholar
Lauven PM, Stoeckel H, Ebeling BJ. Perioperative morbidity and mortality of geriatric patients. A retrospective study of 3905 cases. Anasth Intensivther Notfallmed 1990; 25 : 3–9.Google Scholar
Prause G, Offner A, Ratzenhofer-Komenda B, Vicenzi M, Smolle J, Smolle-Juttner F. Comparison of two preoperative indices to predict perioperative mortality in non-cardiac thoracic surgery. Eur J Cardiothorac Surg 1997; 11: 670–675.Google Scholar
Bottiger BW, Martin E. Prevention of perioperative myocardial ischemia – an update. Anaesthesist 2000; 49: 174–186.Google Scholar
Brandrup-Wognsen G, Haglid M, Karlsson T, Berggren H, Herlitz J. Mortality during the two years after coronary artery bypass grafting in relation to perioperative factors and urgency of operation. Eur J Cardiothorac Surg 1995; 9: 685–691.Google Scholar
Wallace A, Layug B, Tateo I, et al. Prophylactic atenolol reduces postoperative myocardial ischemia. MCSPI Research Group. Anesthesiology 1998; 88: 7–17.Google Scholar
Poldermans D, Boersma E, Bax JJ, et al. The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. Dutch echocardiographic cardiac risk evaluation applying stress echocardiography study group. New Engl J Med 1999; 341: 1789–1794.Google Scholar
Juul AB, Wetterslev J, Kofoed-Enevoldsen A, Callesen T, Jensen G, Gluud C. The DIPOM Group. The DIPOM trial: rationale and design of a multicenter randomized placebo-controlled clinical trial of metoprolol for diabetic patients undergoing major noncardic surgery. Am Heart J [In press].