Magnitude and Associated Factors of intraoperative hyperglycemia among orthopedics surgical patients. A cross-sectional study

Magnitude and Associated Factors of intraoperative hyperglycemia among orthopedics surgical patients. 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A cross-sectional study Geresu Gebeyehu, Gutu Leta, selamawit shiferaw This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2756181/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Jul, 2023 Read the published version in Journal of Clinical Surgery and Research → Version 1 posted You are reading this latest preprint version Abstract Background: Intraoperative hyperglycemia is a common problem among patients undergoing orthopedic surgery. Its incidence varies from country to country and not clearly studied in developing countries. Method: Multi-center cross-sectional study was conducted on eligible adult elective patients who underwent orthopedic surgical procedures. The participants were selected using a systematic random sampling technique. Data was collected on basic characteristics, medical and surgical history. On the arrival of patients to the OR, blood glucose was measured and recorded and repeated after administering anesthesia. The data was analyzed using descriptive statistics and bivariate and multivariate logistic regression. P<0.05 was considered as statistically significant. Results : Intraoperative hyperglycemia was observed in 20.4% of patients. Hypothermia (AOR:2.45;95% CI:0.97-6.27, p=0.05), infused dextrose iv fluids (AOR:2.94;95% CI:1.64-5.16, p=0.05) , blood transfusion (AOR:6.64;95% CI:2.92-15.08, p=0.00) and history of hypertension (AOR:2.19;95% CI:1.23-3.71, p=0.01) were factors identified to be associated with intraoperative hyperglycemia. Conclusions and recommendations This study showed the magnitude of intraoperative hyperglycemia was high. Anesthetists should identify all risk factors preoperatively and make appropriate adjustments for patient care. Hypertension should be optimized, refrain from routine administering of dextrose IV fluids, and unnecessary transfusions, as well as monitor patients’ body temperature. Orthopedics magnitude intraoperative hyperglycemia orthopedic surgery associated factors Figures Figure 1 Figure 2 1. Introduction The number of orthopedic surgical approaches is growing in older individual in whom the magnitude of diabetic disease is dramatically alarming currently( 1 ). Acute hyperglycemia, which occurs after traumatic injury, has also obtained a lot of attention; because trauma induces the release of stress hormone, mostly mediated by glucagon, leading to an increase in oxidative stress and insulin resistance, finally hyperglycemia occurs( 2 ). It was well known that poor perioperative glycemic management were associated with negative outcomes encompassing impaired wound healing, hardware or implant failure, extended threat of surgical site infections, and pseudarthrosis for the duration of orthopedic surgical procedures( 3 ). The American Diabetes Association estimates that 12–25% of hospitalized personnel have diabetes mellitus (DM). With the growing occurrence of diabetic suffererspresentingfor surgical process and the elevated threat of headaches related to diabetes mellitus, suitable perioperative evaluation and control are imperative( 4 ). It wasreported that 10 to 20% of orthopedic surgery patients were diagnosed with diabetes. Corsino and colleagues in their study reported that 22 to 46% of non-critically ill patients faced hyperglycemia with or without a history of diabetes and Umpierrez et al. also estimated hyperglycemia in 32 to 38% of hospitalized individuals in community health facilities( 5 , 6 ). Kwon et al reported that non-diabetic patients who encountered perioperative hyperglycemia had nearly twice the risk of infection, reoperative intervention, and in-hospital death when compared with known diabetic patients( 7 ). Another study conducted by Meltem T. et al. reported that in-hospital hyperglycemia is an important clinical indicator, carrying a higher 1- and 5-year mortality risk than those who have previous history of diabetes( 8 ). It was reported in the past that transient hyperglycemia among patients in critical condition is without adverse outcome, even imagining that it is beneficial; but several studies showed that there is clear mortality and morbidity advantages from strict glycemic control of glucose level with insulin therapy in critically sick ICU individuals without considering diabetic or non-diabetic status of the patients ( 9 ). Reports came out by Gerard M. et al speculating that the health professionals’ attitude to screen out, monitor, and follow perioperative blood glucose, and start therapy for hyperglycemia is not much enough and neglected unless subject has history of diabetes mellitus( 10 ). Even though, the number of individuals requiring advanced technologies and procedures are increasing in orthopedics unit( 11 ) but, evidence regarding magnitude and associated factors of intraoperative hyperglycemia for adult patients who underwent orthopedic surgery does not exist in developing nations including our country Ethiopia. This study was aimed at determining the magnitude and associated factors of hyperglycemia in elective non-diabetic adult orthopedic patients in public tertiary hospitals in Ethiopia. 1.1 conceptual framework The conceptual framework prepared based on the literatures reviewed for the evidences in this study. (Fig. 1 ) 2. Methods 2.1 Study design and setting, period, and population A multicenter cross-sectional study was conducted at selected public hospitals in Addis Ababa from January 01 to April 01, 2022. The source population was all adult orthopedic surgical patients admitted to public hospitals in Addis Ababa. The study population was all eligible adult orthopedic surgical patients during the study period. All ASA I and II, and aged above 18 years old were included into this study. Patients with a history of diabetes mellitus, confirmed pregnancy and taking steroid therapy were excluded. 2.2 Sample size determination The sample size was determined using the single population proportion for the first objective, which is the magnitude of intraoperative hyperglycemia in non-diabetic adult patients who underwent elective orthopedic surgical procedures. Since there was no related study conducted in the study area, we used P = 0.5 for calculation to get the maximum sample size, 95% level of significance, 5% margin of error, and 10% for incomplete or as contingency data will be used as parameters. n = 384 By using correction the formula for finite population, since source populations were less than 10,000 nf = n/ (1 + n/N), N = 506…. Correction formula for population less than 10,000. Nf = n/1 + n/N = 384/ (1 + 384/506) = 218 . By Adding 10% contingency for non-response rate(i.e., 218 + 22 = 240). As a result, a total of 240 adult major elective orthopedic surgery patients were included in this study. Nf = Final sample size, n = sample size, N = total number of adult patients who underwent elective orthopedic surgery 2.3 Sampling techniques and procedures Systematic random sampling technique was used. The study settings have been selected randomly from Addis Ababa governmental city hospitals. We included every second adult patient underwent elective orthopedics surgery during the study period. Patients’ capillary blood glucose was measured immediately after the patient arrived the operation theater and then continued from induction of anesthesia and every hour up to the end of the surgery. 2.4 Operational Definitions Preoperative The time that extends from the decision to have surgery to induction of anesthesia( 12 ). Intraoperative The period that extends from induction of anesthesia until the patient is transported to PACU( 13 ). Perioperative the period comprises all three periods (preoperative, intraoperative and postoperative)( 6 ). Hypothermia Core body temperature below 36 degree Celsius( 14 ). MINS (Myocardial injury in non-diabetic surgery) : Factors unique to hyperglycemia conditions that increase atherosclerotic plaque formation and thrombosis, thereby contributing to myocardial infarction( 15 ). SIH (Stress induced hyperglycemia): Stress hyperglycemia or hospital-related hyperglycemia as any blood glucose concentration > 7.8 mmol/l (140 mg/dl) without evidence of previous diabetes( 16 ). 2.5 Data collection tool and procedures Data was gatheredusingpretested questionnaires. Training was provided for all data collectors on data collection procedures in each of the study settings. The data collection tool included socio-demographic, medical history and intraoperative clinicalconditions and anesthetic agents. Sociodemographic and medical history were obtained from the patients charts on the immediate arrival of patients into the OR, and regarding intraoperative blood glucose, and anesthetic and surgical dataduring the intraoperative period were recorded from anesthesia charts during anesthetic induction and every one-hour interval until surgery ends. 2.6 Data quality control To assure the quality of data, training on the objectives and relevance of the study and brief orientations on the assessment tools were provided for data collectors. The questionnaires were pretested on 5% of the study population at ALERT hospital. 2.7 Data processing and analysis The collected data was coded, cleaned, retrieved, and entered in to SPSS for analysis. Descriptive statistics were used to analyze sociodemographic characteristics. Bivariate and multivariable regression analysis were performed to assess the association between dependent and independent variables.Odds ratios with 95% CI were used to determine the degree of association between dependent and independent variables. In multivariable regression analysis, variables with a p-valueof < 0.05 were considered as statistically significant. The results were presented using words, tables, and figures. 3. Result 3.1 Socio-demographic characteristics of study participants 240 elective major orthopedic adult patients were included in the study with a 100% response rate. (Table 1 ) Table 1 Socio-demographic and preoperative clinical characteristics of elective orthopedics surgery patients at tertiary public hospitals, Addis Ababa, Ethiopia 2022 Variables Category Frequency Percentage (%) Gender Male 196 81.7 Female 44 18.3 Age 18–40 178 74.2 41–60 51 21.3 > 60 11 4.6 ASA status ASA I 190 79.2 ASA II 39 16.3 ASA III 11 4.6 BMI 30 5 2.1 Co-existing diseases History of Hypertension Yes 21 8.8 No 219 92.2 History of Anemia Yes 56 23.3 No 184 76.7 History of sepsis Yes 36 15.0 No 204 85.0 3.2 Anesthetic and surgical characteristics of patients Intraoperative anesthetic and surgical characteristics were analyzed and the findings were presented below. (Table 2 ) Table 2 Anesthetic and surgical characteristics of elective orthopedics surgery patients at tertiary public hospitals, Addis Ababa, Ethiopia2022 Variables Category Frequency Percentage (%) Anesthesia type General 32 13.3 Spinal 183 76.3 Combined 15 10.4 Surgery time ≤ 60min 38 15.9 > 60 min 202 84.1 Tourniquet used Yes 24 10.0 No 216 90.0 Steroids used Yes 41 17.1 No 11 4.6 Vasopressors used Yes 29 12.1 No 13 5.4 Dextrose IV fluids Yes 29 12.1 No 211 87.9 Blood transfusion Yes 31 12.9 No 209 87.1 Blood loss ≤ 300ml 138 57.5 > 300ml 102 42.5 Hypothermia Yes 22 9.2 No 218 90.8 3.3 Magnitude of Intraoperative hyperglycemia in patients undergoing orthopedics surgery Intra-operative hyperglycemia report was displayed below. (Fig. 2 ) 3.4 Factors associated with Intraoperative hyperglycemia Both bivariate and multivariate analysis were conducted to determine the association between the outcome variable and the independent variables and the strength of associations and the findings displayed in Table 3 . Table 3 Associated factors of intraoperative hyperglycemia of elective orthopedics surgerypatients at tertiary public hospitals, Addis Ababa, Ethiopia2022 Variables categories Intraoperative Hyperglycemia COR,95%CI AOR,95%CI P-value Yes No Gender Male 34 162 0.40;0.23–0.89 0.42;0.20-.84 0.54 Female 15 29 I Age 18–40 32 146 I 41–60 16 35 4.57;0.54–38.18 0.48;0.0.24–0.97 0.16 > 60 1 10 0.21;0.03–1.86 0.16;0.15-0,17 0.17 ASA status ASAI 34 163 0.10;0.06–0.19 0.58;0.15–2.30 0.32 ASAII 12 20 0.34;0.15–0.78 0.49;0.23–1.08 0.1 ASAIII 3 8 I No 34 164 I Anesthesia type General 7 25 3.25;0.25–18.77 0.97;0.35–2.69 0.188 Spinal 34 149 3.68;0.75–18.07 1.32;0.67–4.5 0.19 combined 8 17 I History of hypertension Yes 12 19 2.94;1.3–6.60 2.19;1.23–3.71 0.01** No 37 172 I Preoperative sepsis Yes 14 22 0.19;0.16–0.64 2.27;1.36–3.77 0.18 No 35 169 I Duration of surgery ≤ 60 min 13 29 I > 60 min 36 162 1.5;0.73–3.09 1.70;099-2.92 0.28 Tourniquet used Yes 5 19 2.12;1.23–4.12 1.02;.45-2.33 0.12 No 44 172 I Dextrose infusion Yes 7 6 5.14;1.64–18.08 2.94;1.64–5.16 0.05 ** No 42 185 I Intraoperative hypothermia Yes 8 14 2.47;0.01–0.25 2.45;0.97–6.27 0.05** No 41 177 I Blood transfusion Yes 16 13 0.32;0.20–0.42 6.64;2.92–15.08 0.00** No 33 178 I ** = statistically significant, COR = crude odds ratio, CI = confidence interval, AOR = adjusted odds ratio, I = reference 4. Discussion Hyperglycemia is a common response to intraoperative stress of surgery and critical illnesses, and associated with poor outcomes in critically ill patients regardless of their diabetic status. It has been studied that the degree of rise of blood sugar levels due to surgical stress in controlled diabetics is less significant as compared to non-diabetics( 17 ). In our study, 20.4% of the study participants that underwent elective orthopedic surgery became hyperglycemic intraoperatively. This result is higher than that of a retrospective cohort study done by Mark P. et al.to evaluate the association between SIH and incident diabetes in survivors of critical illness( 18 ). Another cross‑sectional observational study done on 536 non-diabetic patients presented to the Intensive Care Unit (ICU) at Gandhi Medical College and allied Hamidia Hospital, Bhopal, between March, 2015, and May, 2015 identified 20.33%of participants developed stress hyperglycemia( 19 ). The result of our study was supported by the findings of the above study. However, the finding of our study was smaller than the result of the observational study reported by Cornelia K. et al. where they reported 52.9% of intraoperative hyperglycemia out of 87 participants aged 65 years old and above( 20 ). This may be due to their inclusion of only geriatric patients in their study subjects. An observational prospective study conducted at New Jersey Medical School, University of Medicine and Dentistry of New Jersey, USA, on 295 patients aged 18–80 years undergoing elective non-cardiac surgery reported the findings higher (49%) than the finding of this study( 21 ). The reason for this difference might be their inclusion of all non -cardiac surgery and hyperglycemia definitions they used (> 126 mg/dl). Furthermore, the magnitude in this study was lower than the findings of a prospective observational study conducted on 191 patients who underwent primary hip and knee replacement, in which 40% of subjects developed hyperglycemia and 48 of them 25% of developed severe hyperglycemia( 22 ). The possible cause of these variations might be due to the exclusion of known diabetic patients from our study participants. Patients with a history of hypertension were 2.19 times more likely to develop intraoperative hyperglycemia than normotensive individuals. This finding was in line with the Canadian Journal of Cardiology 2018 which stated that patients with hypertension often exhibit insulin resistance and are at greater risk of diabetes developing than are normotensive individuals( 23 ). Exaggerated catecholamine responseand consequent insulin resistance could be the probable reason for this. In this study, patients who took intraoperative IV infusion of dextrose fluids were 2.94 times more likely to be hyperglycemic. This was supported by the findings of the study conducted by SaringCarinkul and Kotrawera in 2009, which found a progressive increase in blood glucose levels in patients receiving 5% dextrose during surgery( 24 ). The reason is obviously that any bicarbonate containing fluids can be metabolized into glucose. In this study, intraoperative hypothermia showed a strong relationship with intraoperative hyperglycemia (AOR = 2.45; 95% CI: 0.97–6.27) than normothermic ones. The finding of a prospective cohort study conducted by Nadine et al. supported our findings ( 14 ). The possible explanation can be an increased metabolic activity and insulin resistance induced by hypothermia. According to this study, intraoperative blood transfusion showed a strong relation with intraoperative hyperglycemia (AOR: 6.64, 95% CI: 2.92–15.08) (p = 0.00). Hassani V et al evaluated the Changes in Blood Glucose after Blood Transfusion in non-diabetic Patients who Underwent Lumbar Posterior Spinal Fusion and determined the existing strong association between intraoperative hyperglycemia and intraoperative blood transfusion( 25 ). 5. Conclusions And Recommendations This study found the magnitude of intraoperative hyperglycemia was high. History of hypertension(AOR: 2.19, 95% CI: 1.23–3.71),Intraoperative hypothermia (AOR: 2.45; 95% CI: 0.97–6.27), intraoperative dextrose fluid infusion (AOR = 2.94; 95% CI; 1.64–5.16), Intraoperative blood transfusion (AOR: 6.64, 95% CI: 2.92–15.08) (p = 0.00) were factors identified factors with significant association. The anesthetists and perioperative team should give attention to the identified factors and take necessary remedies to respective factors. This manuscript was prepared from the academic research conducted at Addis Ababa University and deposited in the repository by Gutu Leta and Geresu Gebeyehu in 2022 ( 26 ). Abbreviations AaBET Addis Ababa Burn, Emergency and Trauma ASA A merican Society of Anesthesiologists AMI Acute Myocardial Infarction CBG Capillary Blood Glucose FMOH Federal Ministry of Healthy SIH stress-induced hyperglycemia Declarations Ethics approval and consent Ethical clearance was received from Addis Ababa University IRB and Addis Ababa City Administration Health Bureau as well as informed verbal consent was secured from the study participants. Confidentiality was assured throughout the study. Funding information: Financial support for this study was obtained from Addis Ababa University Authors' contributions All authors took part in an inception, design, analysis, interpretation, and drafting of the thesis manuscript. Moreover, all authors read and approved the revised manuscript for publication. Availability of data and materials The data will be available from the corresponding author up on reasonable request. Competing interest: The authors state that there is no competing interest in this work. Acknowledgments The authors would like to thank Addis Ababa University for giving an ethical clearance and the study participants for participation. We also thank the study hospitals for accepting to conduct the study. Our special gratitude also goes tothe study subjects for accepting and taking consent to conduct this study. References Akiboye F, Rayman G. Management of Hyperglycemia and Diabetes in Orthopedic Surgery. Curr Diab Rep. 2017;17(2). Di Luzio R, Dusi R, Mazzotti A, Petroni ML, Marchesini G, Bianchi G. Stress hyperglycemia and complications following traumatic injuries in individuals with/without diabetes: The case of orthopedic surgery. Diabetes, Metab Syndr Obes Targets Ther. 2020;13:9–17. Rose A, Madden AR. Perioperative Glucose Management in Orthopedic Surgery. Frisch A, Chandra P, Smiley D, Peng L, Rizzo M, Gatcliffe C, et al. Prevalence and clinical outcome of hyperglycemia in the perioperative period in noncardiac surgery. Vol. 33, Diabetes Care. 2010. p. 1783–8. CDC. National Diabetes Statistics Report | Diabetes | CDC [Internet]. National Diabetes Statistics Report Estimates of Diabetes and Its Burden in the United States. 2022. Available from: https://www.cdc.gov/diabetes/data/statistics-report/index.html Sebranek JJ, Lugli AK, Coursin DB. Glycaemic control in the perioperative period. Br J Anaesth. 2013;111(SUPPL.1). Duggan E, Carlson K, Umpierresz G. Metabolic Consequences of Surgical Stress. Anesthesiology. 2017;(March):1–14. Tuna M, Manuel DG, Bennett C, Lawrence N, van Walraven C, Keely E, et al. One- and five-year risk of death and cardiovascular complications for hospitalized patients with hyperglycemia without diagnosed diabetes: An observational study. Vol. 9, Journal of Hospital Medicine. 2014. p. 365–71. Hsu C-W. 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Clinical and epidemiological study of stress hyperglycemia among medical intensive care unit patients in Central India. Indian J Endocrinol Metab. 2017;21(1):137–41. Knaak C, Wollersheim T, Mörgeli R, Spies C, Vorderwülbecke G, Windmann V, et al. Risk factors of intraoperative dysglycemia in elderly surgical patients. Int J Med Sci. 2019;16(5). Tilak V, Schoenberg C, Castro III AF, Sant M. Factors Associated with Increases in Glucose Levels in the Perioperative Period in Non-Diabetic Patients. Open J Anesthesiol. 2013;03(03):176–85. Jämsen E, Nevalainen PI, Eskelinen A, Kalliovalkama J, Moilanen T. Risk factors for perioperative hyperglycemia in primary hip and knee replacements A prospective observational study of 191 patients with osteoarthritis. 2015;86(2):175–82. Petrie JR, Guzik TJ, Touyz RM. Diabetes, Hypertension, and Cardiovascular Disease: Clinical Insights and Vascular Mechanisms. Can J Cardiol [Internet]. 2018;34(5):575–84. Available from: https://doi.org/10.1016/j.cjca.2017.12.005 Khetarpal R, Chatrath V, Kaur J, Bala A, Singh H. Impact of different intravenous fluids on blood glucose levels in nondiabetic patients undergoing elective major noncardiac surgeries. Vol. 10, Anesthesia: Essays and Researches. 2016. p. 425. Hassani V, Alimian M, Rahimizadeh A, Safaeian R, Nikoobakht N, Sefati S. Abstract PR374. Anesth Analg. 2016;123(3):479–80. Gebeyehu G., Leta G. MAGNITUDE AND ASSOCIATED FACTORS OF INTRAOPERATIVE HYPERGLYCEMIA AMONG NON-DIABETIC PATIENTS UNDERWENT ELECTIVE ORTHOPEDICS SURGERIES AT PUBLIC HOSPITALS. ADDIS ABABA, ETHIOPIA, 2022. MULTICENTER CROSS-SECTIONAL STUDY. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2756181","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":187789091,"identity":"f9066f6c-918e-4e48-a0e3-982aeca98456","order_by":0,"name":"Geresu Gebeyehu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIiWNgGAWjYJCCA0Bczy9/GERLyBCtJUFyBlsCSAsP0TYlGNzgMQAxCGuRd+99eOhGzZ08hts9n1/dqLHgYWA/fHQDPi2GZ44bHM459qyYcc7ZbdY5x4AO40lLu4FXy4w0hsM5bIcZmxlytxnnsAG1SPCY4dcy/xlQy7/DjG0MOc+Mc/4RoUVego3hcG7b4cQeiRzmx7ltRGgx4AE6LLfvsLEEzzEz5tw+CR42Qn6Rbz/G/Dnn22E5++PNj4GMOjl+9sPH8NtyAMFmkwCT+JSDbWlAsJk/EFI9CkbBKBgFIxMAAMMPTCCZorhPAAAAAElFTkSuQmCC","orcid":"","institution":"Addis Ababa University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Geresu","middleName":"","lastName":"Gebeyehu","suffix":""},{"id":187789092,"identity":"88c2685a-f9e1-474f-9e1d-ac49b94f77c4","order_by":1,"name":"Gutu Leta","email":"","orcid":"","institution":"Wollega Universiry","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Gutu","middleName":"","lastName":"Leta","suffix":""},{"id":187789491,"identity":"21ecd19e-914a-4bde-8cd1-6d2503fb6c27","order_by":2,"name":"selamawit shiferaw","email":"","orcid":"","institution":"Addis Ababa University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"selamawit","middleName":"","lastName":"shiferaw","suffix":""}],"badges":[],"createdAt":"2023-03-30 11:08:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2756181/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2756181/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.31579/2768-2757/085","type":"published","date":"2023-07-04T00:42:42+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":35126342,"identity":"45ef57d3-6dca-486b-8aff-7d4d7cdef8cd","added_by":"auto","created_at":"2023-03-31 21:51:35","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":146994,"visible":true,"origin":"","legend":"\u003cp\u003eConceptual framework indicating factors affecting intraoperative hyperglycemia for adult patients undergoing elective orthopedic surgical procedures at tertiary hospitals, Addis Ababa, Ethiopia2022.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-2756181/v1/7393bdff940065279b324382.png"},{"id":35126341,"identity":"50087ed6-37ed-46bd-a019-63c8b71d841c","added_by":"auto","created_at":"2023-03-31 21:51:35","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":16236,"visible":true,"origin":"","legend":"\u003cp\u003ethe magnitude of intraoperative hyperglycemia in orthopedic surgical patients at public hospitals, Addis Ababa, Ethiopia, 2022.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-2756181/v1/c98b1018c2795367c6857ee5.png"},{"id":56897885,"identity":"cdb0650e-640c-47ba-9918-97e8245d96f4","added_by":"auto","created_at":"2024-05-22 00:42:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":854861,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2756181/v1/5e102dbb-049a-4f64-8e5b-e4e4727b0b8a.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eMagnitude and Associated Factors of intraoperative hyperglycemia among orthopedics surgical patients. A cross-sectional study\u003c/p\u003e","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eThe number of orthopedic surgical approaches is growing in older individual in whom the magnitude of diabetic disease is dramatically alarming currently(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Acute hyperglycemia, which occurs after traumatic injury, has also obtained a lot of attention; because trauma induces the release of stress hormone, mostly mediated by glucagon, leading to an increase in oxidative stress and insulin resistance, finally hyperglycemia occurs(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIt was well known that poor perioperative glycemic management were associated with negative outcomes encompassing impaired wound healing, hardware or implant failure, extended threat of surgical site infections, and pseudarthrosis for the duration of orthopedic surgical procedures(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe American Diabetes Association estimates that 12\u0026ndash;25% of hospitalized personnel have diabetes mellitus (DM). With the growing occurrence of diabetic suffererspresentingfor surgical process and the elevated threat of headaches related to diabetes mellitus, suitable perioperative evaluation and control are imperative(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIt wasreported that 10 to 20% of orthopedic surgery patients were diagnosed with diabetes. Corsino and colleagues in their study reported that 22 to 46% of non-critically ill patients faced hyperglycemia with or without a history of diabetes and Umpierrez et al. also estimated hyperglycemia in 32 to 38% of hospitalized individuals in community health facilities(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eKwon et al reported that non-diabetic patients who encountered perioperative hyperglycemia had nearly twice the risk of infection, reoperative intervention, and in-hospital death when compared with known diabetic patients(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Another study conducted by Meltem T. et al. reported that in-hospital hyperglycemia is an important clinical indicator, carrying a higher 1- and 5-year mortality risk than those who have previous history of diabetes(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIt was reported in the past that transient hyperglycemia among patients in critical condition is without adverse outcome, even imagining that it is beneficial; but several studies showed that there is clear mortality and morbidity advantages from strict glycemic control of glucose level with insulin therapy in critically sick ICU individuals without considering diabetic or non-diabetic status of the patients (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eReports came out by Gerard M. et al speculating that the health professionals\u0026rsquo; attitude to screen out, monitor, and follow perioperative blood glucose, and start therapy for hyperglycemia is not much enough and neglected unless subject has history of diabetes mellitus(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEven though, the number of individuals requiring advanced technologies and procedures are increasing in orthopedics unit(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) but, evidence regarding magnitude and associated factors of intraoperative hyperglycemia for adult patients who underwent orthopedic surgery does not exist in developing nations including our country Ethiopia. This study was aimed at determining the magnitude and associated factors of hyperglycemia in elective non-diabetic adult orthopedic patients in public tertiary hospitals in Ethiopia.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003e1.1 conceptual framework\u003c/h2\u003e \u003cp\u003eThe conceptual framework prepared based on the literatures reviewed for the evidences in this study. (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"2. Methods","content":"\u003cdiv class=\"Section2\" id=\"Sec4\"\u003e\n \u003ch2\u003e2.1 Study design and setting, period, and population\u003c/h2\u003e\n \u003cp\u003eA multicenter cross-sectional study was conducted at selected public hospitals in Addis Ababa from January 01 to April 01, 2022. The source population was all adult orthopedic surgical patients admitted to public hospitals in Addis Ababa. The study population was all eligible adult orthopedic surgical patients during the study period. All ASA I and II, and aged above 18 years old were included into this study. Patients with a history of diabetes mellitus, confirmed pregnancy and taking steroid therapy were excluded.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec5\"\u003e\n \u003ch2\u003e2.2 Sample size determination\u003c/h2\u003e\n \u003cp\u003eThe sample size was determined using the single population proportion for the first objective, which is the magnitude of intraoperative hyperglycemia in non-diabetic adult patients who underwent elective orthopedic surgical procedures. Since there was no related study conducted in the study area, we used P\u0026thinsp;=\u0026thinsp;0.5 for calculation to get the maximum sample size, 95% level of significance, 5% margin of error, and 10% for incomplete or as contingency data will be used as parameters.\u003c/p\u003e\n \u003cp\u003e\u003cimg 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\" width=\"223\" height=\"125\"\u003e\u003c/p\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;384\u003c/p\u003e\n \u003cp\u003eBy using correction the formula for finite population, since source populations were less than 10,000\u003c/p\u003e\n \u003cp\u003enf\u0026thinsp;=\u0026thinsp;n/ (1\u0026thinsp;+\u0026thinsp;n/N), N\u0026thinsp;=\u0026thinsp;506\u0026hellip;. Correction formula for population less than 10,000.\u003c/p\u003e\n \u003cp\u003eNf\u0026thinsp;=\u0026thinsp;n/1\u0026thinsp;+\u0026thinsp;n/N\u0026thinsp;=\u0026thinsp;384/ (1\u0026thinsp;+\u0026thinsp;384/506)\u0026thinsp;=\u0026thinsp;\u003cstrong\u003e218\u003c/strong\u003e. By Adding 10% contingency for non-response rate(i.e., 218\u0026thinsp;+\u0026thinsp;22\u0026thinsp;=\u0026thinsp;240). As a result, a total of 240 adult major elective orthopedic surgery patients were included in this study.\u003c/p\u003e\n \u003cp\u003eNf\u0026thinsp;=\u0026thinsp;Final sample size,\u003c/p\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;sample size,\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;total number of adult patients who underwent elective orthopedic surgery\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec6\"\u003e\n \u003ch2\u003e2.3 Sampling techniques and procedures\u003c/h2\u003e\n \u003cp\u003eSystematic random sampling technique was used. The study settings have been selected randomly from Addis Ababa governmental city hospitals. We included every second adult patient underwent elective orthopedics surgery during the study period. Patients\u0026rsquo; capillary blood glucose was measured immediately after the patient arrived the operation theater and then continued from induction of anesthesia and every hour up to the end of the surgery.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec7\"\u003e\n \u003ch2\u003e2.4 Operational Definitions\u003c/h2\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThe time that extends from the decision to have surgery to induction of anesthesia(\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eIntraoperative\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThe period that extends from induction of anesthesia until the patient is transported to PACU(\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePerioperative\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003ethe period comprises all three periods (preoperative, intraoperative and postoperative)(\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eHypothermia\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eCore body temperature below 36 degree Celsius(\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMINS\u003c/strong\u003e(Myocardial injury in non-diabetic surgery) : Factors unique to hyperglycemia conditions that increase atherosclerotic plaque formation and thrombosis, thereby contributing to myocardial infarction(\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSIH\u003c/strong\u003e(Stress induced hyperglycemia): Stress hyperglycemia or hospital-related hyperglycemia as any blood glucose concentration\u0026thinsp;\u0026gt;\u0026thinsp;7.8 mmol/l (140 mg/dl) without evidence of previous diabetes(\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec8\"\u003e\n \u003ch2\u003e2.5 Data collection tool and procedures\u003c/h2\u003e\n \u003cp\u003eData was gatheredusingpretested questionnaires. Training was provided for all data collectors on data collection procedures in each of the study settings. The data collection tool included socio-demographic, medical history and intraoperative clinicalconditions and anesthetic agents. Sociodemographic and medical history were obtained from the patients charts on the immediate arrival of patients into the OR, and regarding intraoperative blood glucose, and anesthetic and surgical dataduring the intraoperative period were recorded from anesthesia charts during anesthetic induction and every one-hour interval until surgery ends.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec9\"\u003e\n \u003ch2\u003e2.6 Data quality control\u003c/h2\u003e\n \u003cp\u003eTo assure the quality of data, training on the objectives and relevance of the study and brief orientations on the assessment tools were provided for data collectors. The questionnaires were pretested on 5% of the study population at ALERT hospital.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec10\"\u003e\n \u003ch2\u003e2.7 Data processing and analysis\u003c/h2\u003e\n \u003cp\u003eThe collected data was coded, cleaned, retrieved, and entered in to SPSS for analysis. Descriptive statistics were used to analyze sociodemographic characteristics. Bivariate and multivariable regression analysis were performed to assess the association between dependent and independent variables.Odds ratios with 95% CI were used to determine the degree of association between dependent and independent variables. In multivariable regression analysis, variables with a p-valueof\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered as statistically significant. The results were presented using words, tables, and figures.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"3. Result","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Socio-demographic characteristics of study participants\u003c/h2\u003e \u003cp\u003e240 elective major orthopedic adult patients were included in the study with a 100% response rate. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographic and preoperative clinical characteristics of elective orthopedics surgery patients at tertiary public hospitals, Addis Ababa, Ethiopia 2022\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e196\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e81.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e18.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e18\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e178\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e74.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e41\u0026ndash;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e21.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eASA status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eASA I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e190\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e79.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eASA II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eASA III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;18.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e18.5\u0026ndash;24.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e193\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e80.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e25-29.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eCo-existing diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHistory of\u003c/p\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e219\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e92.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHistory of Anemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e23.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e184\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e76.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHistory of sepsis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e204\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e85.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Anesthetic and surgical characteristics of patients\u003c/h2\u003e \u003cp\u003eIntraoperative anesthetic and surgical characteristics were analyzed and the findings were presented below. (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAnesthetic and surgical characteristics of elective orthopedics surgery patients at tertiary public hospitals, Addis Ababa, Ethiopia2022\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnesthesia type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeneral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpinal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e183\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e76.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCombined\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSurgery time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026le;\u003c/span\u003e\u0026thinsp;60min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;60 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e202\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e84.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTourniquet used\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e216\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e90.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSteroids used\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVasopressors used\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDextrose IV fluids\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e211\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e87.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBlood transfusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e209\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e87.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBlood loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026le;\u003c/span\u003e\u0026thinsp;300ml\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e138\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e57.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;300ml\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e42.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHypothermia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e90.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Magnitude of Intraoperative hyperglycemia in patients undergoing orthopedics surgery\u003c/h2\u003e \u003cp\u003eIntra-operative hyperglycemia report was displayed below. (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Factors associated with Intraoperative hyperglycemia\u003c/h2\u003e \u003cp\u003eBoth bivariate and multivariate analysis were conducted to determine the association between the outcome variable and the independent variables and the strength of associations and the findings displayed in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociated factors of intraoperative hyperglycemia of elective orthopedics surgerypatients at tertiary public hospitals, Addis Ababa, Ethiopia2022\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ecategories\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eIntraoperative Hyperglycemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCOR,95%CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAOR,95%CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e162\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.40;0.23\u0026ndash;0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.42;0.20-.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e146\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41\u0026ndash;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.57;0.54\u0026ndash;38.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.48;0.0.24\u0026ndash;0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.21;0.03\u0026ndash;1.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.16;0.15-0,17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eASA status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eASAI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e163\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.10;0.06\u0026ndash;0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.58;0.15\u0026ndash;2.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eASAII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.34;0.15\u0026ndash;0.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.49;0.23\u0026ndash;1.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eASAIII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAnesthesia type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeneral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.25;0.25\u0026ndash;18.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.97;0.35\u0026ndash;2.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.188\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpinal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.68;0.75\u0026ndash;18.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.32;0.67\u0026ndash;4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ecombined\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHistory of hypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.94;1.3\u0026ndash;6.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.19;1.23\u0026ndash;3.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.01**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e172\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePreoperative sepsis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.19;0.16\u0026ndash;0.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.27;1.36\u0026ndash;3.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e169\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDuration of surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026le;\u003c/span\u003e\u0026thinsp;60 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;60 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e162\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.5;0.73\u0026ndash;3.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.70;099-2.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTourniquet used\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.12;1.23\u0026ndash;4.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.02;.45-2.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e172\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDextrose infusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.14;1.64\u0026ndash;18.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.94;1.64\u0026ndash;5.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.05\u003c/b\u003e**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e185\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eIntraoperative hypothermia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.47;0.01\u0026ndash;0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.45;0.97\u0026ndash;6.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.05**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e177\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBlood transfusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.32;0.20\u0026ndash;0.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.64;2.92\u0026ndash;15.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.00**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e178\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e** = statistically significant, COR\u0026thinsp;=\u0026thinsp;crude odds ratio, CI\u0026thinsp;=\u0026thinsp;confidence interval, AOR\u0026thinsp;=\u0026thinsp;adjusted odds ratio, I\u0026thinsp;=\u0026thinsp;reference\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e "},{"header":"4. Discussion","content":"\u003cp\u003eHyperglycemia is a common response to intraoperative stress of surgery and critical illnesses, and associated with poor outcomes in critically ill patients regardless of their diabetic status. It has been studied that the degree of rise of blood sugar levels due to surgical stress in controlled diabetics is less significant as compared to non-diabetics(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn our study, 20.4% of the study participants that underwent elective orthopedic surgery became hyperglycemic intraoperatively. This result is higher than that of a retrospective cohort study done by Mark P. et al.to evaluate the association between SIH and incident diabetes in survivors of critical illness(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Another cross‑sectional observational study done on 536 non-diabetic patients presented to the Intensive Care Unit (ICU) at Gandhi Medical College and allied Hamidia Hospital, Bhopal, between March, 2015, and May, 2015 identified 20.33%of participants developed stress hyperglycemia(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The result of our study was supported by the findings of the above study.\u003c/p\u003e \u003cp\u003eHowever, the finding of our study was smaller than the result of the observational study reported by Cornelia K. et al. where they reported 52.9% of intraoperative hyperglycemia out of 87 participants aged 65 years old and above(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). This may be due to their inclusion of only geriatric patients in their study subjects.\u003c/p\u003e \u003cp\u003eAn observational prospective study conducted at New Jersey Medical School, University of Medicine and Dentistry of New Jersey, USA, on 295 patients aged 18\u0026ndash;80 years undergoing elective non-cardiac surgery reported the findings higher (49%) than the finding of this study(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The reason for this difference might be their inclusion of all non -cardiac surgery and hyperglycemia definitions they used (\u0026gt;\u0026thinsp;126 mg/dl).\u003c/p\u003e \u003cp\u003eFurthermore, the magnitude in this study was lower than the findings of a prospective observational study conducted on 191 patients who underwent primary hip and knee replacement, in which 40% of subjects developed hyperglycemia and 48 of them 25% of developed severe hyperglycemia(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The possible cause of these variations might be due to the exclusion of known diabetic patients from our study participants.\u003c/p\u003e \u003cp\u003ePatients with a history of hypertension were 2.19 times more likely to develop intraoperative hyperglycemia than normotensive individuals. This finding was in line with the Canadian Journal of Cardiology 2018 which stated that patients with hypertension often exhibit insulin resistance and are at greater risk of diabetes developing than are normotensive individuals(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Exaggerated catecholamine responseand consequent insulin resistance could be the probable reason for this.\u003c/p\u003e \u003cp\u003eIn this study, patients who took intraoperative IV infusion of dextrose fluids were 2.94 times more likely to be hyperglycemic. This was supported by the findings of the study conducted by SaringCarinkul and Kotrawera in 2009, which found a progressive increase in blood glucose levels in patients receiving 5% dextrose during surgery(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The reason is obviously that any bicarbonate containing fluids can be metabolized into glucose.\u003c/p\u003e \u003cp\u003eIn this study, intraoperative hypothermia showed a strong relationship with intraoperative hyperglycemia (AOR\u0026thinsp;=\u0026thinsp;2.45; 95% CI: 0.97\u0026ndash;6.27) than normothermic ones. The finding of a prospective cohort study conducted by Nadine et al. supported our findings (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The possible explanation can be an increased metabolic activity and insulin resistance induced by hypothermia.\u003c/p\u003e \u003cp\u003eAccording to this study, intraoperative blood transfusion showed a strong relation with intraoperative hyperglycemia (AOR: 6.64, 95% CI: 2.92\u0026ndash;15.08) (p\u0026thinsp;=\u0026thinsp;0.00). Hassani V et al evaluated the Changes in Blood Glucose after Blood Transfusion in non-diabetic Patients who Underwent Lumbar Posterior Spinal Fusion and determined the existing strong association between intraoperative hyperglycemia and intraoperative blood transfusion(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusions And Recommendations","content":"\u003cp\u003eThis study found the magnitude of intraoperative hyperglycemia was high. History of hypertension(AOR: 2.19, 95% CI: 1.23\u0026ndash;3.71),Intraoperative hypothermia (AOR: 2.45; 95% CI: 0.97\u0026ndash;6.27), intraoperative dextrose fluid infusion (AOR\u0026thinsp;=\u0026thinsp;2.94; 95% CI; 1.64\u0026ndash;5.16), Intraoperative blood transfusion (AOR: 6.64, 95% CI: 2.92\u0026ndash;15.08) (p\u0026thinsp;=\u0026thinsp;0.00) were factors identified factors with significant association. The anesthetists and perioperative team should give attention to the identified factors and take necessary remedies to respective factors.\u003c/p\u003e \u003cp\u003eThis manuscript was prepared from the academic research conducted at Addis Ababa University and deposited in the repository by Gutu Leta and Geresu Gebeyehu in 2022 (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003e\u003cb\u003eAaBET\u003c/b\u003e Addis Ababa Burn, Emergency and Trauma\u003c/p\u003e\u003cp\u003e\u003cb\u003eASA A\u003c/b\u003emerican Society of Anesthesiologists\u003c/p\u003e\u003cp\u003e\u003cb\u003eAMI\u003c/b\u003e Acute Myocardial Infarction\u003c/p\u003e\u003cp\u003e\u003cb\u003eCBG\u003c/b\u003e Capillary Blood Glucose\u003c/p\u003e\u003cp\u003e\u003cb\u003eFMOH\u003c/b\u003e Federal Ministry of Healthy\u003c/p\u003e\u003cp\u003e\u003cb\u003eSIH\u003c/b\u003e stress-induced hyperglycemia\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical clearance was received from Addis Ababa University IRB and Addis Ababa City Administration Health Bureau as well as informed verbal consent was secured from the study participants. Confidentiality was assured throughout the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding information:\u0026nbsp;\u003c/strong\u003eFinancial support for this study was obtained from Addis Ababa University\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors took part in an inception, design, analysis, interpretation, and drafting of the thesis manuscript. Moreover, all authors read and approved the revised manuscript for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data will be available from the corresponding author up on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest:\u0026nbsp;\u003c/strong\u003eThe authors state that there is no competing interest in this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank Addis Ababa University for giving an ethical clearance and the study participants for participation. We also thank the study hospitals for accepting to conduct the study. Our special gratitude also goes tothe study subjects for accepting and taking consent to conduct this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAkiboye F, Rayman G. Management of Hyperglycemia and Diabetes in Orthopedic Surgery. Curr Diab Rep. 2017;17(2). \u003c/li\u003e\n\u003cli\u003eDi Luzio R, Dusi R, Mazzotti A, Petroni ML, Marchesini G, Bianchi G. Stress hyperglycemia and complications following traumatic injuries in individuals with/without diabetes: The case of orthopedic surgery. Diabetes, Metab Syndr Obes Targets Ther. 2020;13:9\u0026ndash;17. \u003c/li\u003e\n\u003cli\u003eRose A, Madden AR. Perioperative Glucose Management in Orthopedic Surgery. \u003c/li\u003e\n\u003cli\u003eFrisch A, Chandra P, Smiley D, Peng L, Rizzo M, Gatcliffe C, et al. Prevalence and clinical outcome of hyperglycemia in the perioperative period in noncardiac surgery. Vol. 33, Diabetes Care. 2010. p. 1783\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eCDC. National Diabetes Statistics Report | Diabetes | CDC [Internet]. National Diabetes Statistics Report Estimates of Diabetes and Its Burden in the United States. 2022. Available from: https://www.cdc.gov/diabetes/data/statistics-report/index.html\u003c/li\u003e\n\u003cli\u003eSebranek JJ, Lugli AK, Coursin DB. Glycaemic control in the perioperative period. Br J Anaesth. 2013;111(SUPPL.1). \u003c/li\u003e\n\u003cli\u003eDuggan E, Carlson K, Umpierresz G. Metabolic Consequences of Surgical Stress. Anesthesiology. 2017;(March):1\u0026ndash;14. \u003c/li\u003e\n\u003cli\u003eTuna M, Manuel DG, Bennett C, Lawrence N, van Walraven C, Keely E, et al. One- and five-year risk of death and cardiovascular complications for hospitalized patients with hyperglycemia without diagnosed diabetes: An observational study. Vol. 9, Journal of Hospital Medicine. 2014. p. 365\u0026ndash;71. \u003c/li\u003e\n\u003cli\u003eHsu C-W. Glycemic control in critically ill patients. World J Crit Care Med. 2012;1(1):31. \u003c/li\u003e\n\u003cli\u003eGerards MC, Tervaert ECC, Hoekstra JBL, Vriesendorp TM, Gerdes VEA. Physician\u0026rsquo;s attitudes towards diagnosing and treating glucocorticoid induced hyperglycaemia: Sliding scale regimen is still widely used despite guidelines. Diabetes Res Clin Pract [Internet]. 2015;109(2):246\u0026ndash;52. Available from: http://dx.doi.org/10.1016/j.diabres.2015.05.040\u003c/li\u003e\n\u003cli\u003eEDITORIAL. 2020;58:2020. \u003c/li\u003e\n\u003cli\u003eLeung V, Ragbir-Toolsie K. Perioperative Management of Patients with Diabetes. Heal Serv Insights. 2017;10:1\u0026ndash;5. \u003c/li\u003e\n\u003cli\u003eShah NJ, Leis A, Kheterpal S, Englesbe MJ, Kumar SS. Association of intraoperative hyperglycemia and postoperative outcomes in patients undergoing non-cardiac surgery: a multicenter retrospective study. 2020;1\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eCueni-Villoz N, Devigili A, Delodder F, Cianferoni S, Feihl F, Rossetti AO, et al. Increased blood glucose variability during therapeutic hypothermia and outcome after cardiac arrest. Vol. 39, Critical Care Medicine. 2011. p. 2225\u0026ndash;31. \u003c/li\u003e\n\u003cli\u003ePark J, Oh AR, Lee SH, Lee JH, Min JJ, Kwon JH, et al. Associations between preoperative glucose and hemoglobin a1c level and myocardial injury after noncardiac surgery. Vol. 10, Journal of the American Heart Association. 2021. \u003c/li\u003e\n\u003cli\u003eReyes M, Jensen L, Stewart J, Kidd WT. Glycemic control in diabetic and non-diabetic cardiac surgical patients and length of hospital stay. Vol. 19, Dynamics (Pembroke, Ont.). 2008. p. 18\u0026ndash;24. \u003c/li\u003e\n\u003cli\u003eFrisch A, Chandra P, Smiley D, Peng L, Rizzo M, Gatcliffe C, et al. Prevalence and clinical outcome of hyperglycemia in the perioperative period in noncardiac surgery. Diabetes Care. 2010 Aug;33(8):1783\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003ePlummer MP, Finnis ME, Phillips LK, Kar P, Bihari S, Biradar V, et al. Stress induced hyperglycemia and the subsequent risk of type 2 diabetes in survivors of critical illness. PLoS One. 2016;11(11):1\u0026ndash;12. \u003c/li\u003e\n\u003cli\u003eSharma J, Chittawar S, Maniram R, Dubey T, Singh A. Clinical and epidemiological study of stress hyperglycemia among medical intensive care unit patients in Central India. Indian J Endocrinol Metab. 2017;21(1):137\u0026ndash;41. \u003c/li\u003e\n\u003cli\u003eKnaak C, Wollersheim T, M\u0026ouml;rgeli R, Spies C, Vorderw\u0026uuml;lbecke G, Windmann V, et al. Risk factors of intraoperative dysglycemia in elderly surgical patients. Int J Med Sci. 2019;16(5). \u003c/li\u003e\n\u003cli\u003eTilak V, Schoenberg C, Castro III AF, Sant M. Factors Associated with Increases in Glucose Levels in the Perioperative Period in Non-Diabetic Patients. Open J Anesthesiol. 2013;03(03):176\u0026ndash;85. \u003c/li\u003e\n\u003cli\u003eJ\u0026auml;msen E, Nevalainen PI, Eskelinen A, Kalliovalkama J, Moilanen T. Risk factors for perioperative hyperglycemia in primary hip and knee replacements A prospective observational study of 191 patients with osteoarthritis. 2015;86(2):175\u0026ndash;82. \u003c/li\u003e\n\u003cli\u003ePetrie JR, Guzik TJ, Touyz RM. Diabetes, Hypertension, and Cardiovascular Disease: Clinical Insights and Vascular Mechanisms. Can J Cardiol [Internet]. 2018;34(5):575\u0026ndash;84. Available from: https://doi.org/10.1016/j.cjca.2017.12.005\u003c/li\u003e\n\u003cli\u003eKhetarpal R, Chatrath V, Kaur J, Bala A, Singh H. Impact of different intravenous fluids on blood glucose levels in nondiabetic patients undergoing elective major noncardiac surgeries. Vol. 10, Anesthesia: Essays and Researches. 2016. p. 425. \u003c/li\u003e\n\u003cli\u003eHassani V, Alimian M, Rahimizadeh A, Safaeian R, Nikoobakht N, Sefati S. Abstract PR374. Anesth Analg. 2016;123(3):479\u0026ndash;80. \u003c/li\u003e\n\u003cli\u003eGebeyehu G., Leta G. MAGNITUDE AND ASSOCIATED FACTORS OF INTRAOPERATIVE HYPERGLYCEMIA AMONG NON-DIABETIC PATIENTS UNDERWENT ELECTIVE ORTHOPEDICS SURGERIES AT PUBLIC HOSPITALS. ADDIS ABABA, ETHIOPIA, 2022. MULTICENTER CROSS-SECTIONAL STUDY.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[{"identity":"1529a628-77a8-4c4e-a831-548cc921bfaa","identifier":"10.13039/501100007941","name":"Addis Ababa University","awardNumber":"NA","order_by":0}],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"Addis Ababa University","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"magnitude, intraoperative hyperglycemia, orthopedic surgery, associated factors","lastPublishedDoi":"10.21203/rs.3.rs-2756181/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2756181/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eIntraoperative hyperglycemia is a common problem among patients undergoing orthopedic surgery. Its incidence varies from country to country and not clearly studied in developing countries.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod:\u003c/strong\u003eMulti-center cross-sectional study was conducted on eligible adult elective patients who underwent orthopedic surgical procedures. The participants were selected using a systematic random sampling technique. Data was collected on basic characteristics, medical and surgical history. On the arrival of patients to the OR, blood glucose was measured and recorded and repeated after administering anesthesia. The data was analyzed using descriptive statistics and bivariate and multivariate logistic regression. P\u0026lt;0.05 was considered as statistically significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Intraoperative hyperglycemia was observed in 20.4% of patients. Hypothermia (AOR:2.45;95% CI:0.97-6.27, p=0.05), infused dextrose iv fluids (AOR:2.94;95% CI:1.64-5.16, p=0.05) , blood transfusion (AOR:6.64;95% CI:2.92-15.08, p=0.00) and history of hypertension (AOR:2.19;95% CI:1.23-3.71, p=0.01) were factors identified to be associated with intraoperative hyperglycemia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions and recommendations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study showed the magnitude of intraoperative hyperglycemia was high. Anesthetists should identify all risk factors preoperatively and make appropriate adjustments for patient care. Hypertension should be optimized, refrain from routine administering of dextrose IV fluids, and unnecessary transfusions, as well as monitor patients’ body temperature.\u003c/p\u003e","manuscriptTitle":"Magnitude and Associated Factors of intraoperative hyperglycemia among orthopedics surgical patients. A cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-03-31 21:51:30","doi":"10.21203/rs.3.rs-2756181/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"da841b40-d1dc-470b-b49f-004841bbc373","owner":[],"postedDate":"March 31st, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":20328404,"name":"Orthopedics"}],"tags":[],"updatedAt":"2024-05-22T00:42:42+00:00","versionOfRecord":{"articleIdentity":"rs-2756181","link":"https://doi.org/10.31579/2768-2757/085","journal":{"identity":"journal-of-clinical-surgery-and-research","isVorOnly":true,"title":"Journal of Clinical Surgery and Research"},"publishedOn":"2023-07-04 00:42:42","publishedOnDateReadable":"July 4th, 2023"},"versionCreatedAt":"2023-03-31 21:51:30","video":"","vorDoi":"10.31579/2768-2757/085","vorDoiUrl":"https://doi.org/10.31579/2768-2757/085","workflowStages":[]},"version":"v1","identity":"rs-2756181","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2756181","identity":"rs-2756181","version":["v1"]},"buildId":"cBFmMYwuxLRRLfASyISRj","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}