March 7, 2010

Journal Review: "Peri-operative hyperglycemia: a consideration for general surgery?"

Extract from: The American Journal of Surgery (2010) 199, 240–248

Writer: Wendy F. Bower, Ping Yin Lee, Alice P.S. Kong, et al.

In healthy, mobile individuals, irrespective of fasting or feeding status or external environment, blood glucose is maintained within a narrow range of 4 to 7 mmol/L (72–126 mg/dL)

Currently, dextrose infusion is an important perioperative source of calories for a fasting patient. However, it is noted that it may also give rise to hyperglycemia

Hyperglycaemia is secondary response to the stress associated with surgical insult

During surgery, there is an increased rate of hepatic glucogenesis and a reduction of glucose disposal.Despite a rise in absolute levels of insulin, glucose uptake is limited during surgical procedures, suggesting impaired insulin action

This may be associated with the stress-induced endogenous release of catecholamines and cortisone, increased free fatty acid production, vasoconstriction, or endothelial dysfunction.

Poor glycemic control at the point of surgery and during the postoperative period can cause the following

1) Can impair leukocyte function

2) Predictor of early wound infection

3) Association with postoperative surgical complications

4) Increase resource utilization

Meta analysis shows that tight control of glucose level post-operatively in patient manages in intensive care environment have reduced risk for septicemia.

Blood glucose levels rose significantly with the induction of anesthesia (P less than 0.001) in non diabetic patients. At incision, 2 hours, 4 hours, and 6 hours, 30%, 40%, 38%, and 40% of studies, respectively, reported hyperglycemia.

Surgical approach using open or video-assisted means did not influence the mean or spread of glycemic values

Patients undergoing abdominal surgery appeared to maintain stable blood glucose after a post induction rise

Neurosurgical patients showed a significantly sharper and sustained rise in maximum mean values of peripheral blood glucose after post induction rise

Cardiac surgical procedures performed with cardiopulmonary bypass were associated with a marked rise in blood glucose that was sustained for the first 12 hours postoperatively

Administration of adjunctive epidural anesthesia perioperatively was associated with attenuated glycemic dysregulation

Infusion of glucose perioperatively resulted in significantly higher glycemic levels than those seen in patients without glucose infusion

Hyperglycemia was evident in the glucose infusion group from the onset of surgery and peaked (mean maximum) between 2 and 4 hours.

Postoperative values within the first 12 hours were markedly higher in the glucose infusion Group compared with the control group.

There was no overall difference in blood glucose levels between patients who received lactate infusions and those whose infusions were lactate free

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