Intraoperative Dysglycemia Detected in 25.5% of Young Infants

Key Takeaways

• At one third-level center, infants aged 0–90 days undergoing major surgery had hypoglycemia detected more often than hyperglycemia.
• Longer surgery and preoperative PN were independently associated with overall dysglycemia, while prematurity was not.
• Longer surgery was associated with hypoglycemia; the authors also reported an adjusted association involving the absence of preoperative enteral nutrition (aOR, 0.45).
• Intraoperative inotrope or vasopressor use was the only factor independently associated with hyperglycemia.
• In an exploratory comparison among infants receiving preoperative PN, hypoglycemia was detected less often when PN continued intraoperatively than when it was discontinued.

Neonates and young infants undergoing major surgery have limited metabolic reserves and high metabolic demands, making perioperative glucose disturbances a concern. Nutrition before and during an operation can vary, while standardized guidance for managing glucose in this setting is lacking. For these infants, it remains unclear how perioperative nutrition relates to detected glucose abnormalities.

Investigators retrospectively analyzed 318 infants aged 0–90 days undergoing major surgery at a single third-level center in the Nutrients study. Under routine clinical practice, detected intraoperative hypoglycemia was defined as glucose <46 mg/dL and hyperglycemia as >180 mg/dL. Investigators assessed clinical, surgical, and nutritional factors using univariate and multivariable logistic regression. They also identified 127 infants receiving preoperative parenteral nutrition (PN) for an exploratory comparison of intraoperative PN continuation versus discontinuation.

Under routine intraoperative care, dysglycemia was detected in 25.5% (81/318) of infants. Hypoglycemia was detected in 18.9%, compared with 7.2% for hyperglycemia.

Each additional hour of surgery was associated with greater adjusted odds of overall dysglycemia (adjusted odds ratio [aOR], 1.33). Preoperative PN was also independently associated with overall dysglycemia, whereas prematurity was not. In the separate hypoglycemia model, longer surgery was associated with higher odds; the authors also reported an adjusted association between hypoglycemia and preoperative enteral-nutrition status (aOR, 0.45; p = 0.038). They abstract reported an aOR of 0.45 (p = 0.038) for the absence of preoperative enteral nutrition, which reads as having preoperative enteral nutrition being associated with lower odds of hypoglycemia. Intraoperative inotrope or vasopressor use was the only factor independently associated with hyperglycemia. Among infants receiving preoperative PN, the exploratory comparison found hypoglycemia in 0/21 whose PN continued intraoperatively versus 31.1% of 106 whose PN was discontinued.

These single-center retrospective associations do not establish that surgical duration, nutrition, or vasoactive medication caused the observed glucose abnormalities. The exploratory PN comparison likewise cannot show that continuing PN prevents hypoglycemia: the groups were observed under routine care rather than assigned to nutrition strategies. Because detection occurred during routine practice, the observed frequencies cannot establish how often glucose disturbances went undetected. The findings describe associations within the center’s perioperative setting, not the effect of a defined glucose-management protocol.

The authors called for standardized, protocol-driven perioperative glucose stewardship and prospective, protocolized research, without establishing a specific intervention through these observations. They concluded that intraoperative glucose abnormalities, particularly hypoglycemia, were frequent among young infants undergoing major surgery.

Clinician Questions

Was preoperative parenteral nutrition independently associated with hypoglycemia in infants undergoing major surgery after adjustment?

In this surgical cohort, preoperative PN’s apparent association with intraoperative hypoglycemia weakened and was not statistically significant after adjustment for procedure duration and preoperative enteral nutrition. This differs from its independent adjusted association with overall dysglycemia and does not establish a causal effect of PN.

Why was intraoperative inotrope or vasopressor use associated with hyperglycemia in young surgical infants?

The authors interpreted the association between intraoperative inotrope or vasopressor use and hyperglycemia among infants aged 0–90 days undergoing major surgery as potentially reflecting illness severity, rather than a demonstrated drug effect or mechanism.