Background: The use of intraoperative dexamethasone has been on the rise because of its ability to reduce postoperative nausea, vomiting, pain and accelerate post-operative recovery. Use of intraoperative dexamethasone can result in uncontrolled hyperglycemia in the postoperative period especially in patients with a diagnosis of diabetes. The extent and duration of post-operative steroid-induced hyperglycemia is unclear, especially since most studies only monitored glucose from a few hours to 12 hours postoperatively, occasionally extending to 24 hours. Many of these studies come from the anesthesia literature, which rarely monitors outcomes beyond 24 hours. Since we have anecdotally needed to address severe steroid-exacerbated hyperglycemia occurring when post-operative patients return to the floor, at times with intravenous insulin drips and at others delaying hospital discharge, we wanted to more systematically evaluate the issue from a quality improvement perspective. We therefore retrospectively assessed the longer-term impact of intra-operative steroids administered to patients with type 2 diabetes undergoing orthopedic procedures in our institution.
Methods: This was a retrospective analysis from a single large safety-net hospital. Data for the analysis were collected from our electronic medical record on patients with type 2 diabetes admitted between 1/2016- 12/2017 for an orthopedic procedure. We present demographic and admission-related data, including pre- and post-operative glycemic control for up to 2 days following the procedure in patients who received or did not receive intra-operative dexamethasone.
Results: We evaluated 102 encounters in 96 unique patients (69% female, Hispanic 51%, AA 20%, 13% White non-Hispanic, 8% Asian, 10% unknown/other, mean age 64±8 years) with mean A1C of 6.7±1.2% on admission. Patients that received intraoperative steroids (N=84 events), compared to those that did not receive them (N=18 events), had numerically lower mean pre-op capillary blood glucose (CBG) (121±35 vs. 142±46 mg/dl, respectively p=0.088), and similar post-op day 0 CBG (191±64 vs 191±58 mg/dl, respectively p=0.99). Overall mean CBG for the entire 2-day post-operative period was lower for patients receiving intraoperative dexamethasone than for those that did not (172±57 vs. 187±55 mg/dl p=0.002). There were 2 episodes of hypoglycemia (CBG<70 mg/dl) in the group that received dexamethasone and none in the other group. Median and mean length of hospital stay was 3.4 and 5.0±6.1 days, respectively, for patients receiving intraoperative steroids and 4.3 and 5.9±5.4 days, respectively for patients that did not receive intraoperative steroids.
Conclusions: In a group of very well controlled patients with type 2 diabetes undergoing orthopedic procedures, the use of intra-operative dexamethasone did not appear to increase the risk of hyperglycemia, either immediately post-operatively or up to POD #2. In such patients, the continued practice of administering intra-operative steroids appears warranted. We plan to expand our analysis to patients undergoing non-orthopedic surgeries, in whom pre-operative glycemic control might not be as tight, to understand the extent of post-operative hyperglycemia following intra-operative steroids.