Decreased glucose utilization during prolonged anaesthesia and surgery

The neuroendocrine stress response compensates for suppression of insulin secretion by volatile anesthetic agents: An observational study

Alterations in perioperative metabolic function, particularly hyperglycemia, are associated with increased post-operative complications, even in patients without preexisting metabolic abnormalities. Anesthetic medications and the neuroendocrine stress response to surgery may both contribute to altered energy metabolism through impaired glucose and insulin homeostasis but the discrete pathways involved are unclear. Prior human studies, though informative, have been limited by analytic sensitivity or technique, preventing resolution of underlying mechanisms. We hypothesized that general anesthesia with a volatile agent would suppress basal insulin secretion without altering hepatic insulin extraction, and that surgical stress would promote hyperglycemia through gluconeogenesis, lipid oxidation, and insulin resistance. In order to address these hypotheses, we conducted an observational study of subjects undergoing multi-level lumbar surgery with an inhaled anesthetic agent. We measured circulating glucose, insulin, c-peptide, and cortisol frequently throughout the perioperative period and analyzed the circulating metabolome in a subset of these samples. We found volatile anesthetic agents suppress basal insulin secretion and uncouple glucose-stimulated insulin secretion. Following surgical stimulus, this inhibition disappeared and there was gluconeogenesis with selective amino acid metabolism. No robust evidence of lipid metabolism or insulin resistance was observed. These results show that volatile anesthetic agents suppress basal insulin secretion, which results in reduced glucose metabolism. The neuroendocrine stress response to surgery ameliorates the inhibitory effect of the volatile agent on insulin secretion and glucose metabolism, promoting catabolic gluconeogenesis. A better understanding of the complex metabolic interaction between anesthetic medications and surgical stress is needed to inform design of clinical pathways aimed at improving perioperative metabolic function.

Perioperative catabolism

PURPOSE

This article reviews the pathophysiology, clinical relevance, and therapy of the catabolic response to surgical stress.

PRINCIPLE FINDINGS

The key clinical features of perioperative catabolism are hyperglycemia and loss of body protein, both metabolic consequences of impaired insulin function. Muscle weakness and (even moderate) increases in perioperative blood glucose are associated with morbidity after major surgery. Although the optimal glucose concentration for improving clinical outcomes is unknown, most medical associations recommend treatment of random blood glucose > 10 mmol·L(-1). Neuraxial anesthesia blunts the neuroendocrine stress response and enhances the anabolic effects of nutrition. There is evidence to suggest that the avoidance of preoperative fasting prevents insulin resistance and accelerates recovery after major abdominal surgery.

CONCLUSIONS

Current anticatabolic therapeutic strategies include glycemic control and perioperative nutrition in combination with optimal pain control and the avoidance of preoperative starvation. All these elements are part of Enhanced Recovery After Surgery (ERAS) programs.

A randomized trial of preoperative oral carbohydrates in abdominal surgery

Background

Carbohydrate-rich liquid drinks (CRLDs) have been recommended to attenuate insulin resistance by shortening the preoperative fasting interval. The aim of our study the effect of preoperative oral administration of CRLDs on the well-being and clinical status of patients.

Methods

A randomized, double blind, prospective study of patients undergoing open colorectal operations (CR) and open cholecyctectomy (CH) was conducted. Patients were divided into three groups: study, placebo, and control. Visual analogue scale (VAS) scores for seven parameters (thirst, hunger, anxiety, mouth dryness, nausea, weakness and sleep quality) were recorded and compared for two different time periods (up to 24 h postoperatively and from 36 to 48 h postoperatively). The Simplified Acute Physiology Score changes (SAPS)-II between the three groups were also studied.

Results

There were 142 patients American Society of Anesthesiology (ASA) I or II enrolled in the study (CR = 71 and CH = 71). There were no significant differences in postoperative SAPS-II scores or lengths of hospital stay (LOS) between the groups. However, in CR patients, the degree of thirst was partially improved by drinking CRLDs (P = 0.027). In CH patients, on the other hand, feelings of thirst, hunger, mouth dryness, nausea and weakness showed significant improvement (P < 0.05).

Conclusion

Oral administration of carbohydrate-rich liquid drinks (CRLDs) improves the well-being in patients undergoing CH, but the effect is less evident in patients undergoing CR. No significant improvements were seen in clinical status or in length of hospital stay in either group.

Trial registration

ANZCTR.org.au: ACTRN12614000995673 (registered on 16/09/2014).

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2253-14-93) contains supplementary material, which is available to authorized users.

Effect of intraoperative acetated Ringer's solution with 1% glucose on glucose and protein metabolism

PURPOSE

To investigate the effects of the intraoperative administration of Ringer's solution with 1% glucose on the metabolism of glucose, lipid and muscle protein during surgery.

METHODS

Thirty-one adult patients, American Society of Anesthesiologists physical status I or II, undergoing elective otorhinolaryngeal, head and neck surgeries were randomly assigned to one of two patient groups: those receiving acetated Ringer's solution with 1% glucose (Group G) or those receiving acetated Ringer's solution without glucose (Group R) throughout the surgical procedure. Plasma glucose was measured at anesthetic induction (T0), artery 1 h (T1), 2 h (T2), 3 h after anesthetic induction (T3) and at the end of surgery (T4). Plasma ketone bodies, insulin and 3-methylhistidine were measured at T0 and T4.

RESULTS

The intravenous infusion for patients in Group G and R was 6.1 + or - 0.8 and 6.3 + or - 1.7 ml/kg/h, respectively, with Group G patients receiving a dose of 4.1 g/h glucose. Plasma glucose levels were significantly higher in Group G than in Group R patients at T1, T2, T3 and T4; however, plasma glucose remained <150 mg/dl in both groups. The plasma concentration of ketone bodies was significantly higher (P < 0.05) in Group R than in Group G patients at T4. Changes in plasma 3-methylhistidine concentration was significantly lower in Group G than in Group R patients. These results indicate that acetated Ringer's solution with 1% glucose decreased protein catabolism without hyperglycemia among the Group G patients.

CONCLUSION

The infusion of a small dose of glucose (1%) during minor otorhinolaryngeal, head and neck surgeries may suppress protein catabolism without hyperglycemia and hypoglycemia.

Maintenance of Normoglycemia During Cardiac Surgery

We used the hyperinsulinemic normoglycemic clamp technique, i.e., infusion of insulin at a constant rate combined with dextrose titrated to clamp blood glucose at a specific level, to preserve normoglycemia during elective cardiac surgery. Ten nondiabetic and seven diabetic patients entered the clamp protocols. Perioperative glucose control was also assessed in 19 nondiabetic and 11 diabetic patients (control group) receiving a conventional insulin infusion sliding scale. In patients of the clamp group, a priming bolus of insulin (2 U) was started before the induction of anesthesia followed by infusions of insulin at 5 mU. kg(-1). min(-1) and of variable amounts of dextrose. Arterial blood glucose was measured every 5 min in the clamp group and every 20 min in the control group. Control of normoglycemia was defined as > or =95% of the glucose levels within 4.0-6.0 mmol/L. Glucose concentration was recorded before surgery, 15 min before cardiopulmonary bypass (CPB), during early and late CPB, and at sternal closure. Patients of the control group became progressively hyperglycemic during surgery (late CPB; nondiabetics, 9.0 +/- 3.2 mmol/L; diabetics, 10.1 +/- 3.6 mmol/L), whereas normoglycemia was achieved in the study group (late CPB; nondiabetics, 5.5 +/- 0.7 mmol/L; diabetics, 4.9 +/- 0.6 mmol/L; P < 0.05 versus control group). In conclusion, it seems that normal blood glucose concentration during open heart surgery can be reliably maintained in nondiabetic and diabetic patients by using the hyperinsulinemic normoglycemic clamp technique.

Laparoscopic-assisted vaginal hysterectomy and the hyperglycemic response to surgery: an observational study

PURPOSE

To test the hypothesis that laparoscopic-assisted vaginal hysterectomy (LAVH) attenuates the hyperglycemic response to surgery when compared to vaginal hysterectomy (VH).

METHODS

Fourteen patients received either LAVH (n=7) or VH (n=7). Whole body glucose production was measured before and three hours after surgery using [6.6-2H2] glucose. Before, during and after the operation, plasma concentrations of glucose, insulin, glucagon, cortisol, epinephrine and norepinephrine were determined.

RESULTS

Plasma glucose concentration increased in both groups during and after surgery showing a significantly higher value after VH than after LAVH (VH: 8.3 +/- 1.4 mmol x L(-1); LAVH: 6.6 +/- 0.9 mmol x L(-1), P <0.05). The postoperative increase in glucose production was comparable in both groups. While plasma concentrations of insulin and glucagon remained unchanged, intra- and postoperative plasma cortisol concentrations were significantly higher in the VH group than in the LAVH group. Plasma catecholamine concentrations significantly increased after both types of surgery to the same extent.

CONCLUSION

In this observational study, LAVH appears to blunt the hyperglycemic and cortisol response to surgery when compared to VH.

Effects of intraoperative glucose administration on circulating metabolites and nitrogen balance during prolonged surgery

STUDY OBJECTIVES

To compare the effects of intraoperative administration of 2.5% glucose or Ringer's solution on metabolism during prolonged surgery.

DESIGN

Prospective, randomized study.

SETTING

Teaching hospital.

PATIENTS

20 ASA physical status I and II adults patients scheduled for thoracic or abdominal surgery lasting at least 3 hours.

INTERVENTIONS

Patients received Ringer's solution (Group R) or 2.5% glucose solution (Group G) 10 ml.kg-1.h-1 during surgery and 2 ml.kg-1.h-1 during the first two postoperative hours (Ringer's or glucose), then 40 ml.kg-1.day-1 of 5% intravenous (i.v.) glucose postoperatively.

MEASUREMENTS AND MAIN RESULTS

Plasma glucose, free fatty acids, ketone bodies, lactate, insulin, glucagon, cortisol, and growth hormone concentrations were determined after an overnight fast (T0), on induction of anesthesia (T1), at the end of surgery (T2), 2 hours thereafter (T3), and on the following morning (T4). Capillary blood glucose was determined every 30 minutes from T1 to T2. Urinary nitrogen and 3-methylhistidine were measured every day for 5 days. There were no differences between groups in demographic data, anesthesia, or surgical procedures. All data were comparable at baseline and on the following morning. In Group R, no patient experienced hypoglycemia, but plasma fatty acids and ketone bodies increased during surgery. In Group G, glycemia rose to very high levels, with a significant increase in insulin during surgery. Other hormones were the same within the two groups. Urinary nitrogen and 3-methylhistidine were similar in both groups.

CONCLUSION

The absence of glucose infusion in prolonged surgery did not cause hypoglycemia, and no increase in protein catabolism was observed.

Surgery-induced insulin resistance in human patients: relation to glucose transport and utilization

To investigate the underlying molecular mechanisms for surgery-induced insulin resistance in skeletal muscle, six otherwise healthy patients undergoing total hip replacement were studied before, during, and after surgery. Patients were studied under basal conditions and during physiological hyperinsulinemia (60 microU/ml). Biopsies of vastus lateralis muscle were used to measure GLUT-4 translocation, glucose transport, and glycogen synthase activities. Surgery reduced insulin-stimulated glucose disposal (P < 0.05) without altering the insulin-stimulated increase in glucose oxidation or suppression of endogenous glucose production. Preoperatively, insulin infusion increased plasma membrane GLUT-4 in all six subjects (P < 0.05), whereas insulin-stimulated GLUT-4 translocation only occurred in three patients postoperatively (not significant). Moreover, nonoxidative glucose disposal rates and basal levels of glycogen synthase activities in muscle were reduced postoperatively (P < 0.05). These findings demonstrate that peripheral insulin resistance develops immediately postoperatively and that this condition might be associated with perturbations in insulin-stimulated GLUT-4 translocation as well as nonoxidative glucose disposal, presumably at the level of glycogen synthesis.

Time of peritoneal cavity exposure influences postoperative glucose production

PURPOSE

To examine the effect of the duration of peritoneal cavity exposure on glucose metabolism after abdominal surgery.

METHODS

In eight otherwise healthy patients (ASA 1) with uterine myoma, endogenous glucose production (Ra glucose) was measured immediately before and two hours after abdominal hysterectomy by a stable isotope dilution technique using primed continuous infusions of [6,6-2H2]-glucose. Plasma concentrations of glucose, lactate, insulin, glucagon, cortisol, epinephrine and norepinephrine were determined before, during (5 and 60 min after peritoneal incision, skin closure) and two hours after surgery. Pre- and postoperative glucose clearance was calculated as Ra glucose divided by plasma glucose concentration.

RESULTS

Ra glucose increased from 11.8 +/- 1.2 to 16.8 +/- 3.2 micromol x kg(-1) x min(-1) two hours after hysterectomy (P < 0.05) with a correlation between the degree of increase and the time of peritoneal cavity exposure (r = 0.859, P = 0.006). Plasma glucose concentration increased after surgery from 4.7 +/- 0.8 to 8.3 +/- 1.9 mmol x l(-1) (P < 0.05), while glucose clearance decreased from 2.6 +/- 0.4 to 2.1 +/- 0.4 ml x kg(-1) x min(-1) (P < 0.05). Plasma concentrations of cortisol and catecholamines increased after hysterectomy (cortisol from 6 +/- 2 to 31 +/- 7 microg x dl(-1), epinephrine from 25 +/- 14 to 205 +/- 132 pg x ml(-1), norepinephrine from 182 +/- 82 to 377 +/- 132 pg x ml(-1), P < 0.05), whereas plasma lactate, insulin and glucagon concentrations remained unchanged.

CONCLUSION

The magnitude of increase of glucose production after abdominal hysterectomy is associated with the duration of peritoneal cavity exposure.

Intracerebroventricular administration of leptin markedly enhances insulin sensitivity and systemic glucose utilization in conscious rats

This study examines the acute, subacute (overnight), and chronic (7-day) effects of intracerebroventricular (i.c.v.) administration of r-metMuLeptin on insulin sensitivity and systemic glucose turnover in conscious unrestrained rats (body weight, 250 to 300 g). Under postabsorptive conditions, acute i.c.v. leptin ([AL] 10 microg bolus) did not affect tracer (3-(3)H-glucose)-determined glucose production (GP) and utilization (GU) rates during the 2-hour hyperinsulinemic (2 mU x kg(-1) x min(-1)) euglycemic clamp. Chronic i.c.v. leptin ([CL] 10 microg/d for 7 days) administered by osmotic pumps markedly reduced the daily food consumption (P < .05), body weight (P < .05), and postabsorptive basal plasma glucose level (P < .01). During the glucose clamp, GP was markedly suppressed (55%) with CL (P < .001 v vehicle and pair-fed control groups). The insulin-induced increment in GU was significantly greater with CL (23.3 +/- 1.8 mg(-1) x kg(-1) x min(-1)) than with vehicle (16.9 +/- 0.2) and pair-feeding (17.1 +/- 0.6, both P < .001). Subacute i.c.v. leptin ([SL] 10 microg bolus) moderately but insignificantly decreased overnight food consumption (-18%) and body weight (-2.5 +/- 1.5 g). The glucose infusion rate during the final 60 minutes of the glucose clamp was 43% greater than for the vehicle group (P < .0001). SL also significantly increased GU (P < .005) and suppressed GP (P < .05) during the glucose clamp. Thus, we conclude that i.c.v. administered leptin has strong actions on the central nervous system that result in significant increases in insulin sensitivity and systemic GU, and these effects are achieved as early as overnight after leptin administration.

[Epidural anesthesia and metabolic response to surgical stress]

Surgical stress leads to reproducible physiological metabolic and hormonal responses, characterized by on altered carbohydrate metabolism, a net loss of protein and an increased lipolysis. They are due to an increased secretion of catecholamines, ACTH, cortisol and cytokines. Epidural analgesia prevents the hyperglycaemic, cortisol and adrenocortical responses to surgery. The lipolysis and the loss of protein are also attenuated. This effect only occurs in lower abdominal surgery, with an epidural blockade extending from T4 to S5, carried out with local anesthetic agents and started before the skin incision. However, such a blockade abates, but does not suppress, the metabolic response to upper abdominal or thoracic surgery, probably because of persistent vagal afferences, the incomplete blockade of somatic afferents, and a stimulation of the diaphragm and peritoneal free nerve endings. Likewise, epidural morphine does not modify the intraoperative metabolic and hormonal responses. The main reason is most probably the failure of opioids to block the sympathetic system, as well as their insignificant effects on fast conducting fibers.