Morbidity and Mortality during Anaesthesia in Patients with versus without Diabetes: Single-Centre Cohort Study

Noelly Mukuna¹, Wilfrid Mbombo^1,2*, Joseph Nsiala¹, Aliocha Nkodila³, Alphonse Mosolo^1,2, Freddy Mbuyi^1,2,3, Jonathan Kukila^4,5, Paul Kambala⁶, Rémy Kashala⁷, Chris Nsitwavibidila¹, Patrick Kobo¹, Dan Kankonde¹, Gracias Likinda³, Jean Claude Mubenga¹, Khazi Anga¹, Lionel Diyamona¹, Berthe Barhayiga¹

¹Department of Anaesthesia and Intensive Care, Kinshasa University Clinics, University of Kinshasa, Kinshasa, DRC.
²Department of Anaesthesia and Intensive Care, Monkole Hospital, Kinshasa, DRC.
³Protestant University of Congo, Kinshasa, DRC.
⁴Laboratory Department, Monkole Hospital, Kinshasa, DRC.
⁵Department of Clinical Biology, Kinshasa University Clinics, University of Kinshasa, Kinshasa, DRC.
⁶Surgical Department, Monkole Hospital, Kinshasa, DRC.
⁷Department of Internal Medicine, Monkole Hospital, Kinshasa, DRC.

DOI: 10.4236/ojanes.2024.143007                

Abstract

Background and objective: Classically, diabetic subjects are at high risk of anaesthesia compared with general population. However, some recent publications have shown contrasting and sometimes contrary results. The aim of our study was to evaluate morbidity and mortality during and after anaesthesia in patients with versus without diabetes operated on at Monkole Hospital over the last ten years. Methods: Retrospective cohort study including all patients who underwent all-comers surgery excluding cardiac surgery between 2011 and 2021. Each diabetic patient was matched to 2 non-diabetic controls on age and sex. The evaluation criterion was the frequency of occurrence of at least one perioperative complication and/or death up to day 30. A multivariate analysis using a Cox model was used to determine the factors associated with the occurrence of this morbidity and mortality. The model was adjusted for comorbidities, preoperative hyperglycaemia, ASA score, type of anaesthesia and severity of surgery. Results: A total of 351 diabetic patients (mean age 53.3 ± 14.18 years) and 701 non-diabetic patients (mean age 53.52 ± 14.7 years) were included and analysed. Preoperatively, hyperglycaemia (blood glucose > 180 mg/dl) was observed in 24.3% of diabetic patients compared with 1.6% of non-diabetic patients. The incidence of overall perioperative complications was 25.6% in diabetic patients compared with 28.6% in non-diabetic patients (p = 0.27). The risk factors associated with this morbidity were general anaesthesia with oro-tracheal intubation vs loco-regional anaesthesia (OR = 3.06 [95%CI: 1.91 - 4.94]; p < 0.001) and major vs minor surgery (OR =2.09 [95%CI: 1.19 - 3.69]; p = 0.01). Diabetic status was not identified as an independent risk factor (OR = 1.2 [95%CI: 0.73 - 1.99]; p = 0.148). Mortality was 2.3% in diabetic patients versus 3% in non-diabetic patients (p = 0.226). Conclusion: This study shows that there is not significant increase in perioperative morbidity and mortality in diabetic patients compared with non-diabetic ones of similar severity. These results suggest that diabetes itself (excluding associated comorbidities) has only a minor impact on perioperative morbidity and mortality.

Keywords

Anaesthesia, Diabetes, Morbidity, Mortality, Perioperative

Table 1. Preoperative characteristics of patients.

Table 2. Anaesthetic techniques.

Table 3. Anaesthetic products.

Table 4. Intraoperative complications.

Table 5. Postoperative complications.

Table 6. Factors associated with morbidity during and after anaesthesia.

1. 1. Rathmann, W. and Giani, G. (2004) Prevalence mondiale du diabete: Estimations pour l’annee 2000 et projections pour 2030. Traitements Diabetiques, 27, 2568-2569.


2. 2. Bieleli, E., Moswa, J., Ditu, I., Kandjingu, K. and Mulumba, P. (2000) Prevalence du diabete sucre au sein de la population de kinshasa. Congo Medical, 15, 1058-1061.


3. 3. Burgos, L.G., Ebert, T.J., Asiddao, C., Turner, L.A., Pattison, C.Z., Wang-Cheng, R. and Kampine, J.P. (1989) Augmentation de la morbidite cardiovasculaire peroperatoire chez les diabetiques atteints de neuropathie autonome. Anesthesiologie, 70, 591-597. https://doi.org/10.1097/00000542-198904000-00006


4. 4. Frisch, A., Chandra, P., Smiley, D., Peng, L., Rizzo, M., Gatcliffe, C., Hudson, M., Mendoza, J., Johnson, R., Lin, E. and Umpierrez, G.E. (2010) Prevalence and Clinical Outcome of Hyperglycemia in the Perioperative Period in Noncardiac Surgery. Diabetes Care, 33, 1783-1788. https://doi.org/10.2337/dc10-0304


5. 5. Palermo, N.E. and Garg, R. (2019) Perioperative Management of Diabetes Mellitus: Novel Approaches. Current Diabetes Reports, 19, Article No. 14. https://doi.org/10.1007/s11892-019-1132-7


6. 6. Cosson, E., Catargi, B., Cheisson, G., Jacqueminet, S., Ichai, C., Leguerrier, A.M., Ouattara, A., Tauveron, I., Bismuth, E., Benhamou, D. and Valensi, P. (2018) Practical Management of Diabetes Patients before, during and after Surgery: A Joint French Diabetology and Anaesthesiology Position Statement. Diabetes & Metabolism, 44, 200-216. https://doi.org/10.1016/j.diabet.2018.01.014


7. 7. Ouattara, A., Lecomte, P., Le Manach, Y., Landi, M., Jacqueminet, S., Platonov, I., et al. (2005) Poor Intraoperative Blood Glucose Control Is Associated with a Worsened Hospital Outcome after Cardiac Surgery in Diabetic Patients. Anesthesiology, 103, 687-694. https://doi.org/10.1097/00000542-200510000-00006


8. 8. Kwon, S., Thompson, R., Dellinger, P., Yanez, D., Farrohki, E. and Flum, D. (2013) Importance of Perioperative Glycemic Control in General Surgery: A Report from the Surgical Care and Outcomes Assessment Program. Annals of Surgery, 257, 8-14. https://doi.org/10.1097/SLA.0b013e31827b6bbc


9. 9. Chen, J.Y., Nassereldine, H., Cook, S.B., Thornblade, L.W., Dellinger, E.P. and Flum, D.R. (2022) Paradoxical Association of Hyperglycemia and Surgical Complications among Patients with and without Diabetes. JAMA Surgery, 157, 765-770. https://doi.org/10.1001/jamasurg.2021.5561


10. 10. Myles, P.S., Grocott, M.P.W., Boney, O. and Moonesinghe, S.R. (2016) Standardizing End Points in Perioperative Trials: Towards a Core and Extended Outcome Set. British Journal of Anaesthesia, 116, 586-589. https://doi.org/10.1093/bja/aew066


11. 11. Kotagal, M., Symons, R.G., Hirsch, I.B., Umpierrez, G.E., Dellinger, E.P., et al. (2015) Perioperative Hyperglycemia and Risk of Adverse Events among Patients with and without Diabetes. Annals of Surgery, 261, 97-103. https://doi.org/10.1097/SLA.0000000000000688


12. 12. Hjortrup, A., Sørensen, C., Dyremose, E., Hjortsø, N.C. and Kehlet, H. (1985) Influence of Diabetes Mellitus on Operative Risk. British Journal of Surgery, 72, 783-785. https://doi.org/10.1002/bjs.1800721005


13. 13. Desai, S.P., Henry, L.L., Holmes, S.D., Hunt, S.L., Martin, C.T. and Hebsur, S.N. (2012) Strict versus Liberal Target Range for Perioperative Glucose in Patients Undergoing Coronary Artery Bypass Grafting: A Prospective Randomized Controlled Trial. The Journal of Thoracic and Cardiovascular Surgery, 143, 318-325. https://doi.org/10.1016/j.jtcvs.2011.10.070


14. 14. Bhamidipati, C.M., La Par, D.J., Stukenborg, G.J., Morrison, C.C., Kern, J.A., Kron, I.L. and Ailawadi, G. (2011) Superiority of Moderate Control of Hyperglycemia to Tight Control in Patients Undergoing Coronary Artery Bypass Grafting. The Journal of Thoracic and Cardiovascular Surgery, 141, 543-551. https://doi.org/10.1016/j.jtcvs.2010.10.005


15. 15. Fish, L.H., Weaver, T.W., Moore, A.L. and Steel, L.G. (2003) Value of Postoperative Blood Glucose in Predicting Complications and Length of Stay after Coronary Artery Bypass Grafting. American Journal of Cardiology, 92, 74-76. https://doi.org/10.1016/S0002-9149(03)00472-7


16. 16. American Diabetes Association (2017) Classification and Diagnosis of Diabetes. Diabetes Care, 40, S11-S24. https://doi.org/10.2337/dc17-S005


17. 17. Tsubo, T., Kudo, T., Matsuki, A. and Oyama, T. (1990) Decreased Glucose Utilization during Prolonged Anaesthesia and Surgery. Canadian Journal of Anesthesia, 37, 645-649. https://doi.org/10.1007/BF03006483


18. 18. Gandhi, G.Y., Nuttall, G.A., Abel, M.D., Mullany, C.J., Schaff, H.V., O’Brien, P.C., et al. (2007) Intensive Intraoperative Insulin Therapy versus Conventional Glucose Management during Cardiac Surgery: A Randomized Trial. Annals of Internal Medicine, 146, 233-243. https://doi.org/10.7326/0003-4819-146-4-200702200-00002


19. 19. Schricker, T., Berroth, A., Pfeiffer, U., Schreiber, M., Geisser, W., Goertz, A., et al. (1997) Assessment of Perioperative Glycerol Metabolism by Stable Isotope Tracer Technique. Nutrition, 13, 191-195. https://doi.org/10.1016/S0899-9007(96)00400-5


20. 20. Braden, H., Cheema-Dhadli, S., Mazer, C.D., McKnight, D.J., Singer, W. and Halperin, M.L. (1998) Hyperglycemia during Normothermic Cardiopulmonary Bypass: The Ôle of the Kidney. The Annals of Thoracic Surgery, 65, 1588-1593. https://doi.org/10.1016/S0003-4975(98)00238-0


21. 21. Sicardi Salomón, Z., Rodhe, P. and Hahn, R.G. (2006) Progressive Decrease in Glucose Clearance during Surgery. Acta Anaesthesiologica Scandinavica, 50, 848-854. https://doi.org/10.1111/j.1399-6576.2006.01066.x


22. 22. Lejeune, D., Hardy, P.-Y., Kaba, A. and Joris, J. (2023) Postoperative Morbidity and Mortality in Patients with Diabetes after Colorectal Surgery with an Enhanced Recovery Program: A Monocentric Retrospective Study. Journal of Visceral Surgery, 160, 180-187. https://doi.org/10.1016/j.jviscsurg.2022.11.001


23. 23. Krolikowska, M., Kataja, M., Pöyhiä, R., Drzewoski, J. and Hynynen, M. (2009) Mortality in Diabetic Patients Undergoing Non-Cardiac Surgery: A 7-Year Follow-Up Study. Acta Anaesthesiologica Scandinavica, 53, 749-758. https://doi.org/10.1111/j.1399-6576.2009.01963.x


24. 24. Krinsley, J.S. (2006) Glycemic Control, Diabetic Status, and Mortality in a Heterogeneous Population of Critically Ill Patients before and during the Era of Intensive Glycemic Management: Six and One-Half Years Experience at a University Affiliated Community Hospital. Seminars in Thoracic and Cardiovascular Surgery, 18, 317-325. https://doi.org/10.1053/j.semtcvs.2006.12.003


25. 25. Kabey, A., Lubanga, M., Tshamba, M., Kaut, M., Kakambal, K., Muteya, M., et al. (2015) Anesthesia Practice in Lubumbashi: Indications, Types of Surgery and Patient Types. The Pan African Medical Journal, 21, Article No. 240. https://doi.org/10.11604/pamj.2015.21.240.6091


26. 26. Mazurek, J.A., Hailpern, S.M., Goring, T. and Nordin, C. (2010) Prevalence of Hemoglobin A1c Greater than 6.5% and 7.0% among Hospitalized Patients without Known Diagnosis of Diabetes at an Urban Inner City Hospital. The Journal of Clinical Endocrinology & Metabolism, 95, 1344-1348. https://doi.org/10.1210/jc.2009-1151

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

References

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[19]	Schricker, T., Berroth, A., Pfeiffer, U., Schreiber, M., Geisser, W., Goertz, A., et al. (1997) Assessment of Perioperative Glycerol Metabolism by Stable Isotope Tracer Technique. Nutrition, 13, 191-195. https://doi.org/10.1016/S0899-9007(96)00400-5
[20]	Braden, H., Cheema-Dhadli, S., Mazer, C.D., McKnight, D.J., Singer, W. and Halperin, M.L. (1998) Hyperglycemia during Normothermic Cardiopulmonary Bypass: The Ôle of the Kidney. The Annals of Thoracic Surgery, 65, 1588-1593. https://doi.org/10.1016/S0003-4975(98)00238-0
[21]	Sicardi Salomón, Z., Rodhe, P. and Hahn, R.G. (2006) Progressive Decrease in Glucose Clearance during Surgery. Acta Anaesthesiologica Scandinavica, 50, 848-854. https://doi.org/10.1111/j.1399-6576.2006.01066.x
[22]	Lejeune, D., Hardy, P.-Y., Kaba, A. and Joris, J. (2023) Postoperative Morbidity and Mortality in Patients with Diabetes after Colorectal Surgery with an Enhanced Recovery Program: A Monocentric Retrospective Study. Journal of Visceral Surgery, 160, 180-187. https://doi.org/10.1016/j.jviscsurg.2022.11.001
[23]	Krolikowska, M., Kataja, M., Pöyhiä, R., Drzewoski, J. and Hynynen, M. (2009) Mortality in Diabetic Patients Undergoing Non-Cardiac Surgery: A 7-Year Follow-Up Study. Acta Anaesthesiologica Scandinavica, 53, 749-758. https://doi.org/10.1111/j.1399-6576.2009.01963.x
[24]	Krinsley, J.S. (2006) Glycemic Control, Diabetic Status, and Mortality in a Heterogeneous Population of Critically Ill Patients before and during the Era of Intensive Glycemic Management: Six and One-Half Years Experience at a University Affiliated Community Hospital. Seminars in Thoracic and Cardiovascular Surgery, 18, 317-325. https://doi.org/10.1053/j.semtcvs.2006.12.003
[25]	Kabey, A., Lubanga, M., Tshamba, M., Kaut, M., Kakambal, K., Muteya, M., et al. (2015) Anesthesia Practice in Lubumbashi: Indications, Types of Surgery and Patient Types. The Pan African Medical Journal, 21, Article No. 240. https://doi.org/10.11604/pamj.2015.21.240.6091
[26]	Mazurek, J.A., Hailpern, S.M., Goring, T. and Nordin, C. (2010) Prevalence of Hemoglobin A1c Greater than 6.5% and 7.0% among Hospitalized Patients without Known Diagnosis of Diabetes at an Urban Inner City Hospital. The Journal of Clinical Endocrinology & Metabolism, 95, 1344-1348. https://doi.org/10.1210/jc.2009-1151