Micronutrients after burn injury: a review

Supplementation of micronutrients after burn injury is common practice in order to fight oxidative stress, support the immune system, and optimize wound healing. Assessing micronutrient status after burn injury is difficult because of hemodilution in the resuscitation phase, redistribution of nutrients from the serum to other organs, and decreases in carrier proteins such as albumin. Although there are many preclinical data, there are limited studies in burn patients. Promising research is being conducted on combinations of micronutrients, especially via the intravenous route.

The Effects of Propofol and Isoflurane on Blood Glucose during Abdominal Hysterectomy in Diabetic Patients

BACKGROUND

Acute hyperglycemia in the perioperative period is associated with significantly increased complications. In few human studies the effects of propofol and inhalational anesthetic on the glucose metabolism were compared. In this study we evaluated the effect of propofol and isoflurane on blood glucose during abdominal hysterectomy in diabetic patients.

METHODS

After approval by the Ethical Committee and written informed consent, thirty 35 to 65 years old diabetic women underwent for elective abdominal hysterectomy under general anesthesia were studied in this randomized single blind clinical trial study. The plasma glucose was maintained at 100 to 180 mg/dL during the operation. Anesthesia protocol was similar in two groups except maintenance of anesthesia that was with infusion of propofol in the propofol group and with isoflurane in the isoflurane group. Blood glucose level and the rate of insulin intake during surgery compared between two groups.

RESULTS

Mean blood glucose before induction of anesthesia did not have significant difference between two groups, but 60 and 90 minutes after starting the operation blood glucose in the propofol group was significantly lower than isoflurane group. Also with using Repeated Measure test, two groups was significantly different according to blood glucose (P=0.045). Mean of administration of insulin during the surgery did not have significant difference between two groups by using repeated measure test and P=0.271. Also mean of bispectral index in different times during the surgery between two groups didn't have significant difference (P=0.35 repeated measure test).

CONCLUSION

Blood glucose increased during maintenance of anesthesia with isoflurane compared to propofol during the surgery.

Consensus guidelines for enhanced recovery after gastrectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations

BACKGROUND

Application of evidence-based perioperative care protocols reduces complication rates, accelerates recovery and shortens hospital stay. Presently, there are no comprehensive guidelines for perioperative care for gastrectomy.

METHODS

An international working group within the Enhanced Recovery After Surgery (ERAS®) Society assembled an evidence-based comprehensive framework for optimal perioperative care for patients undergoing gastrectomy. Data were retrieved from standard databases and personal archives. Evidence and recommendations were classified according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system and were discussed until consensus was reached within the group. The quality of evidence was rated 'high', 'moderate', 'low' or 'very low'. Recommendations were graded as 'strong' or 'weak'.

RESULTS

The available evidence has been summarized and recommendations are given for 25 items, eight of which contain procedure-specific evidence. The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations.

CONCLUSION

The present evidence-based framework provides comprehensive advice on optimal perioperative care for the patient undergoing gastrectomy and facilitates multi-institutional prospective cohort registries and adequately powered randomized trials for further research.

Implementing a structured Enhanced Recovery After Surgery (ERAS) protocol reduces length of stay after abdominal hysterectomy

OBJECTIVE

To study the effects of introducing an Enhanced Recovery After Surgery (ERAS) protocol, modified for gynecological surgery, on length of stay and complications following abdominal hysterectomy.

DESIGN

Observational study.

SETTING

Department of Obstetrics and Gynecology, Örebro University Hospital, Sweden.

POPULATION

Eighty-five patients undergoing abdominal hysterectomy for benign or malignant indications between January and December 2012, with or without salpingo-oophorectomy. Outcomes were compared with all consecutive patients who had undergone the same surgery from January to December 2011, immediately before establishing the ERAS protocol (n = 120).

METHODS

The ERAS protocol was initiated in January 2012 as part of a targeted implementation program. Data were extracted from patient records and from a specific database.

MAIN OUTCOME MEASURES

Length of stay and the proportion of patients achieving target length of stay (2 days).

RESULTS

Length of stay was significantly reduced in the study population after introducing the ERAS protocol from a mean of 2.6 (SD 1.1) days to a mean of 2.3 (SD 1.2) days (p = 0.011). The proportion of patients discharged at 2 days was significantly increased from 56% pre-ERAS to 73% after ERAS (p = 0.012). No differences were found in complications (5% vs. 3.5% in primary stay, 12% vs. 15% within 30 days after discharge), reoperations (2% vs. 1%) or readmission (4% vs. 4%).

CONCLUSIONS

Introducing the ERAS protocol for abdominal hysterectomy reduced length of stay without increasing complications or readmissions.

Intravenous ghrelin accelerates postoperative gastric emptying and time to first bowel movement in humans

BACKGROUND

Ghrelin has been shown to stimulate gastric emptying in healthy humans and patients with delayed gastric emptying. The aim of this study is to assess the effect of ghrelin on gastric emptying on day 2 after open colorectal surgery.

METHODS

Twenty-four patients (mean age 69.2 ± 1.4, BMI 25.8 ± 0.8 kg m(-2) ) were randomized to saline or ghrelin infusion (15 pmol kg(-1)  min(-1) ) during 3 h before and on day 2 after open colorectal surgery. Of these, 20 were assessed both before and after surgery. At start of infusion, a liquid meal (480 kcal, 200 mL) was administered together with 1.5 g acetaminophen. Plasma was obtained at regular intervals together with visual analogue scales for hunger, satiety and nausea. Acetaminophen was analyzed as a marker of gastric emptying. Plasma glucose, insulin, acyl-ghrelin, glucagon-like peptide-1 (GLP-1), glucose-dependent insulinoptrophic peptide (GIP), pancreatic polypeptide and peptide YY (PYY) were analyzed.

KEY RESULTS

Gastric emptying was faster during ghrelin infusion compared to saline before and after surgery (P < 0.02). In addition, plasma glucose was increased (P < 0.05). With ghrelin infusion, plasma insulin was unchanged except for lower values postoperatively (P < 0.05). Ghrelin did not alter plasma concentrations of gut peptides. After surgery, ghrelin shortened the time to first bowel movement compared to saline (2.1 ± 0.3 vs 3.5 ± 0.4 days, P = 0.02).

CONCLUSIONS & INFERENCES

A 3-h ghrelin infusion increased the gastric emptying rate and hastened the time to first bowel movement after surgery. Ghrelin/ghrelin receptor agonists have a therapeutic potential in postoperative ileus; Karolinska Clinical Trial Registry nr CT20110084.

Management of hyperglycemia during enteral and parenteral nutrition therapy

Hyperglycemia is a frequent complication of enteral and parenteral nutrition in hospitalized patients. Extensive evidence from observational studies indicates that the development of hyperglycemia during parenteral and enteral nutrition is associated with an increased risk of death and infectious complications. There are no specific guidelines recommending glycemic targets and effective strategies for the management of hyperglycemia during specialized nutritional support. Managing hyperglycemia in these patients should include optimization of carbohydrate content and administration of intravenous or subcutaneous insulin therapy. The administration of continuous insulin infusion and insulin addition to nutrition bag are efficient approaches to control hyperglycemia during parenteral nutrition. Subcutaneous administration of long-acting insulin with scheduled or corrective doses of short-acting insulin is superior to the sliding scale insulin strategy in patients receiving enteral feedings. Randomized controlled studies are needed to evaluate safe and effective therapeutic strategies for the management of hyperglycemia in patients receiving nutritional support.

Does glutamine promote benefits for patients with diabetes mellitus scheduled for cardiac surgery?

BACKGROUND

We hypothesised, that perioperative use of N(2)-L-alanyl-L-glutamine confers cardioprotection and improves insulin resistance in diabetic patients with coronary artery disease operated under cardiopulmonary bypass.

METHODS

This double-blind, placebo-controlled, randomised study included 64 patients with diabetes mellitus type 2 who were scheduled for on-pump coronary artery bypass graft surgery. The protocol group (32 patients) and the control group (32 patients) glutamine (0.4 g/kg/day of 20% solution of N(2)-L-alanyl-L-glutamine ("Dipeptiven(®)" Fresenius Kabi, Germany)) and placebo (0.9% NaCl), respectively. Perioperative concentration of troponin I in plasma was considered as the primary end-point. Whereas the secondary end-points were insulin resistance, insulin sensitivity, β-cell function, blood glucose, plasma triglycerides and free fatty acids concentrations. Insulin resistance, insulin sensitivity and β-cell function were measured using HOMA equation. Thermodilution method was used to measure haemodynamics in all the patients.

RESULTS

No differences have been found in perioperative dynamics of troponin I, insulin resistance, insulin sensitivity, β-cell function, blood glucose, plasma triglycerides free fatty acids concentrations and haemodynamics.

CONCLUSION

Our results have failed to confirm the cardioprotective properties and modulatory effect on perioperative insulin resistance that are thought to be attributable to parenteral glutamine administration in dose 0.4 g/kg/day among cardiac patients with DM operated on under CPB.

Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations

BACKGROUND

This review aims to present a consensus for optimal perioperative care in colonic surgery and to provide graded recommendations for items for an evidenced-based enhanced perioperative protocol.

METHODS

Studies were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts. For each item of the perioperative treatment pathway, available English-language literature was examined, reviewed and graded. A consensus recommendation was reached after critical appraisal of the literature by the group.

RESULTS

For most of the protocol items, recommendations are based on good-quality trials or meta-analyses of good-quality trials (quality of evidence and recommendations according to the GRADE system).

CONCLUSIONS

Based on the evidence available for each item of the multimodal perioperative-care pathway, the Enhanced Recovery After Surgery (ERAS) Society, International Association for Surgical Metabolism and Nutrition (IASMEN) and European Society for Clinical Nutrition and Metabolism (ESPEN) present a comprehensive evidence-based consensus review of perioperative care for colonic surgery.