The effects of hyperglycemia on outcomes in surgical high-grade glioma patients

https://doi.org/10.1016/j.clineuro.2019.02.011 Get rights and content

Highlights

  • Hyperglycemia is prevalent and multi-factorial in post-operative glioma patients.

  • Post-operative hyperglycemia increases risk of serious post-operative complication.

  • Mean post-op glucose values >167 mg/dL increases risk of serious complication.

  • Mean post-op glucose values >163 mg/dL increases risk for 30-day readmissions.

Abstract

Objective

To define the glucose values associated with an increase in complication rates in post-operative brain tumor patients.

Patients and Methods

Patients who underwent craniotomy for resection of WHO Grade III or IV glioma from 2011 to 2014 were retrospectively reviewed. Post-operative blood glucose values were recorded for post-operative day #0, #1, and #2. Medians were obtained and assessed for significance. Multivariate analysis was performed to assess patient demographics, pre-operative findings, steroid use, and blood glucose values with respect to post-operative complications and to 30-day readmission.

Results

108 patients underwent craniotomy for resection of high-grade glioma and had postoperative blood glucose values documented. Median blood glucose values greater than 167 mg/dL were associated with increased serious post-operative complications, and values greater than 163 mg/dL were associated with increased 30-day readmissions.

Conclusion

Post-operative hyperglycemia in patients with high-grade gliomas places this vulnerable patient population to undue post-operative complications and readmissions, potentially delaying further treatment of their disease.

Introduction

Due to the limited survival of patients with high grade glioma (HGG), reducing post-operative complications and need for re-hospitalization is critical to ensure optimal quality of life [1,2]. Elevated blood glucose and diabetes is a known risk factor for surgical complications and morality [3,4]. Patients presenting with acute ischemic stroke, subarachnoid hemorrhage, and traumatic brain injury all have worse outcomes such as worsening neurological function, increased nosocomial infections, and longer hospitalizations with inpatient hyperglycemia or diabetes [[5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15]]. Therefore, glucose control is now a reported quality metric for both the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare and Medicaid Services (CMS) [16].

Expert recommendation for the upper limit of serum glucose varies based on acuity of care (140–180 mg/dL for critically ill patients and <140 mg/dL for non-critically ill patients) [17]. In patients with glioblastoma (GBM) elevated blood glucose is associated with poorer neurologic outcomes and reduced survival [14,18]. However, the glucose value that predicts worsened outcomes and the association between hyperglycemia and reported quality metrics has not been described. Due to the importance of complication avoidance in the post-operative period, which can delay needed medical treatment for HGG patients, we aimed to assess the role of hyperglycemia in HGG patients undergoing surgical resection. The purpose of this study was to define the glucose values associated with an increase in complication rates in post-operative HGG patients so that treatment for hyperglycemia could be targeted to a goal glucose value.

Section snippets

Patient population

The institution’s Institutional Review Board (IRB) approved this study. Electronic medical records of patients who underwent a craniotomy for resection of HHG at the institution from May 2011 to December 2014 were retrospectively reviewed. Information collected included patient sex, age at diagnosis, pre-operative presenting symptoms, pre-operative medical comorbidities, pre-operative anti-hyperglycemic agents, pre-operative calculated KPS, pre-operative MRI lesion enhancing volume, cerebral

Results

During the study period, 164 patients underwent craniotomy for surgical resection of a HGG with 108 patients having sufficient post-operative blood glucose monitoring. Out of these 108 patients, 47 were female and 61 were male with a median age of 60 years old (Table 1). Blood glucose values were obtained over the first 2 post-operative days and the average length of stay for the entire group was seven days (includes any pre-operative days). Over half were current or former smokers, and 85 were

Discussion

In this study, we investigated the association between severe post-operative complications, mortalities, and 30-day readmissions with post-operative hyperglycemia. We found that a median post-operative blood glucose value above 167.0 mg/dL (9.27 mmol/L) or higher was associated with an increase in rates of severe post-operative complication risk and a median post-operative blood glucose value above 163.0 mg/dL (9.05 mmol/L) was associated with an increase of 30-day readmission. Of the

Conclusions

This study demonstrates that persistent hyperglycemia with median blood glucose values greater than 167 mg/dL (9.27 mmol/L) within the post-operative period is associated with increased post-operative complications and a median blood glucose greater than 163 mg/dL (9.05 mmol/L) is associated with increased 30-day hospital readmission. Recognition of hyperglycemia is important to patient outcomes as indicated in this study and is substantiated by the findings of several other studies. Therefore,

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

References (21)

  • T.W. Link et al.

    Hyperglycemia is independently associated with post-operative function loss in patients with primary eloquent glioblastoma

    J. Clin. Neurosci.

    (2012)
  • R. Stupp et al.

    Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma

    N. Engl. J. Med.

    (2005)
  • R. Stupp et al.

    Maintenance therapy with tumor-treating fields plus temozolomide vs temozolomide alone for glioblastoma: a randomized clinical trial

    JAMA

    (2015)
  • D.J. Wexler et al.

    Prevalence of hyper- and hypoglycemia among inpatients with diabetes: a national survey of 44 U.S. Hospitals

    Diabetes Care

    (2007)
  • G.E. Umpierrez et al.

    Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes

    J. Clin. Endocrinol. Metab.

    (2002)
  • C.J. Weir et al.

    Is hyperglycaemia an independent predictor of poor outcome after acute stroke? Results of a long-term follow up study

    BMJ

    (1997)
  • P.J. Lindsberg et al.

    Hyperglycemia in acute stroke

    Stroke

    (2004)
  • T.A. Baird et al.

    Persistent poststroke hyperglycemia is independently associated with infarct expansion and worse clinical outcome

    Stroke

    (2003)
  • N. Badjatia et al.

    Relationship between hyperglycemia and symptomatic vasospasm after subarachnoid hemorrhage

    Crit. Care Med.

    (2005)
  • J.A. Frontera et al.

    Hyperglycemia after SAH: predictors, associated complications, and impact on outcome

    Stroke

    (2006)
There are more references available in the full text version of this article.

Cited by (7)

View all citing articles on Scopus
View full text