Abstract
Introduction
Patients with diabetes have a worse postoperative course and longer length of hospital stay after surgery. A good indicator of proper long-term (3 months) glycemic control is glycated hemoglobin (HbA1c), and fructosamine in the short term (2–3 weeks).
Aim
To determine the degree of glycemic control evaluated preoperatively by HbA1c and/or fructosamine influence on the postoperative course of patients with diabetes undergoing coronary artery bypass grafting (CABG) in 2014–2015.
Material and methods
Before the operation HbA1c (N < 7.0) and fructosamine (N < 280 µmol/l) were measured and depending on the results the respondents were divided into 4 groups: group I (n = 46) – normal both parameters; group II (n = 22) – high both values; group III (n = 4) – normal fructosamine/HbA1c high; group IV (n = 33) – high HbA1c/fructosamine normal. Statistical analysis was performed using the t-test assuming p < 0.05 to be statistically significant.
Results
One hundred and five patients were treated by CABG/OPCAB (39 female, 66 males). The mean age was 65.7 ±7.3, HbA1c: 7.23 ±1.2%, fructosamine: 261.8 ±43.8. There was no difference in the incidence of other postoperative complications between the two groups.
Conclusions
Glycated hemoglobin and fructosamine levels to a similar extent define the risk of perioperative complications in patients undergoing cardiac surgery. In patients in whom there is a need to quickly compensate for elevated blood glucose consider enabling determination of fructosamine.
Keywords: glycated hemoglobin, fructosamine, diabetes mellitus
Abstract
Wstęp
Chorzy na cukrzycę mają gorszy przebieg pooperacyjny i dłuższy czas hospitalizacji po operacjach. Dobrym wskaźnikiem prawidłowego, długoterminowego (3 miesiące) wyrównania glikemii są wartości hemoglobiny glikowanej (HbA1c), a krótkoterminowego (2–3 tygodnie) – fruktozaminy.
Cel
Ocena, jak stopień wyrównania glikemii przedoperacyjnej oceniany wartością HbA1c i/lub fruktozaminy wpływa na przebieg pooperacyjny u chorych na cukrzycę poddanych pomostowaniu tętnic wieńcowych (CABG).
Materiał imetody
Przeanalizowano łącznie 105 pacjentów chorych na cukrzycę poddanych CABG w latach 2014–2015. Przed operacją oznaczono wartości HbA1c (N < 7,0) i fruktozaminy (N < 280 µmol/l) i w zależności od wyników chorych podzielono na 4 grupy: grupa I (n = 46) – prawidłowe wartości obu parametrów, grupa II (n = 22) – duże wartości obu parametrów, grupa III (n = 4) – prawidłowa wartość HbA1c i wysoka fruktozaminy, grupa IV (n = 33) – wysoka wartość HbA1c, a fruktozaminy w normie. Dane opracowano statystycznie przy użyciu t-testu, przyjmując p < 0,05 za istotne statystycznie.
Wyniki
Analizie poddano 105 chorych, w tym 39 kobiet, 66 mężczyzn, operowanych metodą CABG/OPCAB. Średnia wieku wynosiła 65,7 ±7,3 roku, HbA1c 7,23 ±1,2%, a fruktozaminy 261,8 ±43,8. Najczęstszym powikłaniem było pooperacyjne napadowe migotanie przedsionków (n = 13) obserwowane w grupie I. Nie stwierdzono różnic w zakresie częstości występowania innych powikłań pooperacyjnych pomiędzy obiema grupami.
Wnioski
Stwierdzono, że odsetek HbA1c i stężenie fruktozaminy w podobnym stopniu definiują ryzyko powikłań okołooperacyjnych u chorych poddawanych zabiegom kardiochirurgicznym. Ze względu na dynamikę czasową zmian stężeń tych substancji w przypadku szybkiej normalizacji glikemii należy rozważyć włączenie oznaczenia fruktozaminy do panelu badań wykonywanych przed zabiegiem, zwłaszcza u chorych, u których zachodzi konieczność szybkiego wyrównania podwyższonego stężenia glukozy.
Introduction
Diabetes, in particular type 2, is a condition which significantly increases the risk of development and progression of atherosclerosis [1, 2]. It is estimated that 60% of patients hospitalized with coronary artery disease have varying degrees of impaired glucose tolerance [3, 4]. Metabolic disorders in diabetes can cause coagulation disorders, hypertension, dyslipidemia, and synthesis of free radicals [5]. They can worsen the perioperative course and prognosis in patients undergoing cardiac surgery [6]. According to the recommendations of the Polish Association of Diabetes, metabolic preparation of the patient for surgery includes normalization of blood glucose [7]. The measure of glycemic control is the determination of the concentration of glycated hemoglobin (HbA1c). It is assumed that the patient eligible for surgery should have a balanced glucose level of HbA1c < 7%. Remember, however, it should be that the concentration of glycated hemoglobin reflects the alignment within 3 months preceding the mark [8]. In a situation where the patient is eligible for the procedure, and does not meet the metabolic control (HbA1c < 7%), it is necessary to intensify hypoglycemic therapy that will lead to the normalization of the blood glucose profile. There remains the situation where the patient has a normal blood glucose daily profile and still maintains elevated glycosylated hemoglobin, which according to the recommendations disqualifies a patient from the planned surgery.
The process of non-enzymatic glycation, which is the product of glycated hemoglobin, is a reaction that includes all proteins. It consists of a combination of a glucose molecule with the free amino group of the polypeptide chain [9]. The protein albumin is subject to glycation and as a result of this process produces fructosamine, a somewhat forgotten parameter that determines the glycemic control. Given the life of albumin, the concentration of fructosamine determines glycemic control during the 3–4 weeks prior to the measurement [10]. It seems, therefore, that determination of fructosamine can be a useful study determining the metabolic alignment, especially the situation of hypoglycemic treatment and the need to verify the information factors.
Aim
Glycemic control is necessary in patients with diabetes subjected to cardiac surgery. Evaluation of alignment is based on the determination of the percentage of glycated hemoglobin A1c, which reflects the alignment of the preceding 3 months. The open issue is whether the determination of the concentration of fructosamine reflecting alignment in the previous 3 weeks will be a comparable parameter. The aim of the study is to evaluate metabolic control by the concentration of fructosamine and the percentage of HbA1c with respect to the occurrence of postoperative complications in diabetic patients undergoing coronary artery bypass grafting.
Material and methods
We analyzed the results of off-pump coronary artery bypass (OPCAB) and coronary artery bypass graft (CABG) procedures performed in 105 patients with type 2 diabetes in 2014–2015. The mean age was 65.7 ±7.3.
Diabetes duration was 9.2 ±2.3 years. In all subjects, the concentration of fructosamine and HbA1c was designated. The analysis included postoperative complications. We analyzed the following complications: delirium, stroke, prolonged respiratory therapy > 24 h, slow wound healing, visceral ischaemia, death.
Statistical analysis
The results were statistically analyzed. Average value ± SD and events of interest were calculated. Comparisons between selected groups were made using the χ2 test with Yates correction for continuity.
Results
Mean HbA1c level in the study group was 7.23 ±1.2% and fructosamine concentration was 261 ±43.8 mmol/l. Figure 1 shows the correlation between the percentage of glycated hemoglobin A1c and fructosamine. There was a significant correlation between these parameters (r = 0.597, p < 0.001).
Fig. 1.
Correlation between HbA1c vs. fructosamine
In the total study group of 105 patients perioperative complications occurred in 9 (8.5%) patients. There was a higher, though not significantly, value of the tested parameters of glycemic control in diabetic patients with perioperative complications compared to patients with an uncomplicated course (Tab. I).
Tab. I.
Percentages of glycated hemoglobin (HbA1c), and fructosamine, in patients with perioperative complications compared to patients with uncomplicated course (data are presented as mean ± SD)
| Parameter | Patients with perioperative complications | Patients without perioperative complications |
|---|---|---|
| HbA1c (%) | 7.2 ±1.19 | 7.5 ±1.4 |
| Fructosamine [µmol/l] | 260 ±40 | 286 ±69 |
Next we calculated percentages of patients who experienced perioperative complications depending on the HbA1c and the corresponding concentration of fructosamine. As the cut-off point for HbA1c we adopted HbA1c 7% – a reference value for optimal glycemic control during the perioperative period [7]. Complications occurred in 4 (3.8%) patients with HbA1c < 7%, and 5 (4.8%) patients with HbA1c ≥ 7% (n.s.). For fructosamine the figures were 6 (5.7%) patients with a concentration of < 285 µmol/l and 3 (2.9%) at a concentration ≥ 285 µmol/l (n.s.).
Discussion
In the present study, we found that the percentage of HbA1c as much as the concentration of fructosamine defines the risk of perioperative complications in patients undergoing cardiac surgery. The analysis includes only those complications that are potentially associated with the environment hyperglycemia [11].
First, an analysis of the correlation between HbA1c and fructosamine was performed. There was a high, statistically significant correlation, indicating that both of these parameters to a comparable extent describe the metabolic control of patients.
Subsequently we rated interdependent incidence of perioperative complications and concentrations of the test parameters. Noteworthy is the fact that the incidence of complications in the study group is small, not different from their appearance in our center [12]. This is due to the fact that one of the elements taken into account to qualify for the surgery is the degree of metabolic control.
Glycemic control plays an important role in the prognosis after cardiac surgery [13, 14]. Zerr et al. analyzing a database including 8910 patients, including 1585 patients with diabetes, found that the implementation of procedures of treatment, enabling one to obtain blood glucose during the perioperative period of less than 200 mg%, reduces the incidence of deep wound infection from 2.4% to 1.5% (p < 0.02). We noted a similar percentage of deep wound infection in our study, where one of the elements of the qualification is to assess glycemic control. In the present analysis, the percentage of patients with delayed wound healing was 2.17% in the group with HbA1c < 7%, and 1.69.% for HbA1c ≥ 7% and the corresponding concentration of fructosamine.
Conclusions
The HbA1c and fructosamine levels to a similar extent define the risk of perioperative complications in patients undergoing cardiac surgery. Given the dynamics of temporal changes in the concentrations of these substances in the event of a rapid normalization of blood glucose, one should consider including designation of fructosamine panel tests performed before surgery, especially in patients in whom there is a need to quickly compensate for elevated blood glucose.
Biography
Disclosure
Authors report no conflict of interest.
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