胃肠手术后患者再入院与术前糖化血红蛋白水平，术后高血糖的相关性
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Association Between Preoperative Hemoglobin A1c Levels,PostoperativeHyperglycemia,and Readmissions Following Gastrointestinal Surgery
背景与目的:术前高血糖与术后患者预后不良事件相关。在目前的文献中，术前糖化血红蛋白（HbA1c）或术后血糖水平是否有助于预测术后不良事件还不得而知。检查术前糖化血红蛋白和术后早期血糖水平用于预测术后并发症和再入院率。
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方法：在这项观察性队列研究中，确定了2007年至2014年117家退伍军人医院进行的住院胃肠外科手术，并排除了手术前3天内已感染病例。术前HbA1c水平作为连续和分类变量（<5.7％，5.7％-6.5％和> 6.5％）进行检查。逻辑回归模拟术后并发症和90天内最接近术前HbA1c的再住院率和术后48小时内最高血糖。
结果：在21 541人中，1193人（5.5％）是女性，平均年龄是63.7（10.6）岁。该队列包括23 094例手术和术前HbA 1c水平和术后血糖水平。并发症和30天再入院率分别为27.2％和14.7％。在调整了HbA1c，术后血糖，术后胰岛素使用，糖尿病和体重指数（以千克体重除以身高的平方米）和其他患者及程序因素，术后血糖峰值高于250 mg / dL与30天再住院率相关（比值比1.18,95％CI 0.99-1.41; P = 0.07）。相反，术前HbA1c超过6.5％与30天再次住院率降低相关（比值比为0.85,95％CI为0.74-0.96，P = 0.01）。由于术前HbA1c升高，术后48小时血糖检查频率增加（HbA1c <5.7％，5.7％〜6.4％和> 6.5％，分别为4.92,6.89和9.71，P <0.001）。术前HbA 1c超过6.5％的患者术后胰岛素使用门槛较低。
结论：术后早期高血糖与再次住院率增加相关，但术前HbA1c升高不是。术前HbA1c较高与术后血糖水平检查和胰岛素使用增加相关，提示术后警惕性增高和治疗高血糖的低门槛可解释这一发现。
Jones C E, Graham L A, Morris M S, et al. Association Between Preoperative Hemoglobin A1c Levels, Postoperative Hyperglycemia, and Readmissions Following Gastrointestinal Surgery.[J]. 2017
IMPORTANCE Preoperative hyperglycemia is associated with adverse postoperative outcomes among patients who undergo surgery. Whether preoperative hemoglobin A1c (HbA1c) or postoperative glucose levels are more useful in predicting adverse events following surgery is uncertain in the current literature.
OBJECTIVE To examine the use of preoperative HbA1c and early postoperative glucose levels for predicting postoperative complications and readmission.
DESIGN, SETTING, AND PARTICIPANTS In this observational cohort study, inpatient gastrointestinal surgical procedures performed at 117 Veterans Affairs hospitals from 2007 to 2014 were identified, and cases of known infection within 3 days before surgery were excluded. Preoperative HbA1c levels were examined as a continuous and categorical variable (<5.7%, 5.7%-6.5%, and >6.5%). A logistic regression modeled postoperative complications and readmissions with the closest preoperative HbA1c within 90 days and the highest postoperative glucose levels within 48 hours of undergoing surgery.
MAIN OUTCOMES AND MEASURES Postoperative complications and 30-day unplanned readmission following discharge.
RESULTS Of 21 541 participants, 1193 (5.5%) were women, and the mean (SD) age was 63.7 (10.6) years. The cohort included 23 094 operations with measurements of preoperative HbA 1c levels and postoperative glucose levels. The complication and 30-day readmission rates were 27.2% and 14.7%, respectively. In logistic regression models adjusting for HbA1c, postoperative glucose levels, postoperative insulin use, diabetes, body mass index (calculated as weight in kilograms divided by height in meters squared), and other patient and procedural factors, peak postoperative glucose levels of more than 250 mg/dL were associated with increased 30-day readmissions (odds ratio, 1.18; 95% CI, 0.99-1.41; P = .07). By contrast, a preoperative HbA1c of more than 6.5% was associated with decreased 30-day readmissions (odds ratio, 0.85; 95% CI, 0.74-0.96; P = .01). As preoperative HbA1c increased, the frequency of 48-hour postoperative glucose checks increased (4.92, 6.89, and 9.71 for an HbA 1c <5.7%, 5.7%-6.4%, and >6.5%, respectively; P < .001). Patients with a preoperative HbA 1c of more than 6.5% had lower thresholds for postoperative insulin use.
CONCLUSIONS AND RELEVANCE Early postoperative hyperglycemia was associated with increased readmission, but elevated preoperative HbA1c was not. A higher preoperative HbA1c was associated with increased postoperative glucose level checks and insulin use, suggesting that heightened postoperative vigilance and a lower threshold to treat hyperglycemia may explain this finding.
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