Time of peritoneal cavity exposure influences postoperative glucose production

The effect of single low-dose dexamethasone on blood glucose concentrations in the perioperative period: a randomized, placebo-controlled investigation in gynecologic surgical patients

BACKGROUND

The effect of single low-dose dexamethasone therapy on perioperative blood glucose concentrations has not been well characterized. In this investigation, we examined the effect of 2 commonly used doses of dexamethasone (4 and 8 mg at induction of anesthesia) on blood glucose concentrations during the first 24 hours after administration.

METHODS

Two hundred women patients were randomized to 1 of 6 groups: Early-control (saline); Early-4 mg (4 mg dexamethasone); Early-8 mg (8 mg dexamethasone); Late-control (saline); Late-4 mg (4 mg dexamethasone); and Late-8 mg (8 mg dexamethasone). Blood glucose concentrations were measured at baseline and 1, 2, 3, and 4 hours after administration in the early groups and at baseline and 8 and 24 hours after administration in the late groups. The incidence of hyperglycemic events (the number of patients with at least 1 blood glucose concentration >180 mg/dL) was determined.

RESULTS

Blood glucose concentrations increased significantly over time in all control and dexamethasone groups (from median baselines of 94 to 102 mg/dL to maximum medians ranging from 141 to 161.5 mg/dL, all P < 0.001). Blood glucose concentrations did not differ significantly between the groups receiving dexamethasone (either 4 or 8 mg) and those receiving saline at any measurement time. The incidence of hyperglycemic events did not differ in any of the early (21%-28%, P = 0.807) or late (13%-24%, P = 0.552) groups.

CONCLUSIONS

Because blood glucose concentrations during the first 24 hours after administration of single low-dose dexamethasone did not differ from those observed after saline administrations, these results suggest clinicians need not avoid using dexamethasone for nausea and vomiting prophylaxis out of concerns related to hyperglycemia.

Epidural ropivacaine and sufentanil and the perioperative stress response after a radical retropubic prostatectomy

BACKGROUND

The effects of an epidural opioid and a local anesthetic on the perioperative stress responses have not been fully investigated in elderly patients undergoing cancer surgery. We hypothesized that the stress response after a radical retropubic prostatectomy (RRP) would be attenuated by epidural ropivacaine and sufentanil.

METHODS

In this randomized, double-blinded study, we included patients above 65 years of age who were scheduled for a RRP. In addition to general anesthesia, they received either epidural saline continuously (5 ml/h) (C group, n=20); 0.3% ropivacaine (R group, n=20); or 0.3% ropivacaine combined with 1 μg/ml sufentanil (RS group; n=20). We determined the concentrations of glucose, insulin, cortisol, epinephrine, norepinephrine, and prolactin before, during, and up to 48 h after surgery.

RESULTS

The concentrations of glucose and insulin increased in all the groups. The cortisol level increased in the C group while it decreased significantly in the RS group. Epinephrine and norepinephrine concentrations increased significantly after surgery in the C group, but not in the R and RS groups. The prolactin concentration increased in all the groups, and was higher in the RS group than in the other groups (P=0.002). Post-operative pain scores and analgesic requirement were lower in the R and RS groups.

CONCLUSION

Epidural ropivacaine blunted the perioperative stress responses in elderly patients undergoing a RRP. The combination of epidural ropivacaine and sufentanil was associated with the most pronounced attenuation of the stress response. ClinicalTrial.gov registration number: NCT01086956.

Peri-operative hyperglycemia: a consideration for general surgery?

BACKGROUND

Intraoperative hyperglycemia in cardiac and neurosurgical patients is significantly associated with morbidity. Little is known about the perioperative glycemic profile or its impact in other surgical populations or in nondiabetic patients.

METHODS

A systematic review of blood glucose values during major general surgical procedures reported since 1980 was conducted. Data extracted included blood glucose measures, study sample size, gender distribution, age grouping, study purpose, surgical procedure, anesthetic details, and infusion regime. Excluded studies were those with subjects with diabetes insipidus, insulin-treated diabetes, renal or hepatic failure, adrenal gland tumors or dysfunction, pregnancy, and emergency or trauma surgery.

RESULTS

Blood glucose levels rose significantly with the induction of anesthesia (P < .001) in nondiabetic patients. At incision, 2 hours, 4 hours, and 6 hours, 30%, 40%, 38%, and 40% of studies, respectively, reported hyperglycemia.

CONCLUSIONS

Factors that confound or protect against significant rises in perioperative glycemic levels in nondiabetic patients were identified. The findings facilitate investigating the impact of hyperglycemia on general surgical outcomes.

Comparison of Stress Hormone Response, Interleukin-6 and Anaesthetic Characteristics of Two Anaesthetic Techniques: Volatile Induction and Maintenance of Anaesthesia using Sevoflurane versus Total Intravenous Anaesthesia using Propofol and Remifentanil

This prospective randomized study compared the effects of two types of anaesthesia on peri-operative anaesthetic profiles from induction to recovery and on immunological and neurohormonal responses to anaesthesia and surgical stress. Forty patients were assigned to undergo either volatile induction and maintenance of anaesthesia (VIMA) with sevoflurane or total intravenous anaesthesia (TIVA) with propofol and remifentanil. Plasma adrenaline, noradrenaline, cortisol, glucose and interleukin-6 (IL-6) levels were measured at baseline, induction, incision and extubation. TIVA produced a significantly lower intubation score, shorter time to intubation and faster waking time than VIMA, but recovery profiles did not differ. Adrenaline, noradrenaline, cortisol and glucose levels were significantly lower with TIVA than VIMA, but there was no difference in IL-6 levels between the two groups. TIVA with propofol and remifentanil may be preferable to VIMA with sevoflurane alone because it leads to smoother, more rapid induction, more rapid awakening and lower stress responses to surgical stimuli.

Anaesthetic requirement and stress hormone responses in patients undergoing lumbar spine surgery: anterior vs. posterior approach

BACKGROUND

The intensity of nociceptive stimuli reflects the severity of tissue injury. The anaesthetic requirement and stress hormonal responses were determined to learn whether they differ according to different surgical approaches (anterior vs. posterior) during the spinal surgery.

METHODS

Patients undergoing lumbar spine surgery without neurological deficits were divided into two groups: one having posterior (n=13) and the other having anterior fusion (n=13). The end-tidal sevoflurane concentrations (ET(SEVO)) required to maintain the bispectral index score at 40-50 were determined. Mean arterial pressure (MAP), heart rate (HR), central venous pressure (CVP), serum osmolality and plasma concentrations of catecholamines, cortisol and vasopressin (AVP) were measured.

RESULTS

There were no differences in MAP, HR, CVP and serum osmolality between the groups. ET(SEVO) was higher in the anterior than in the posterior group (P<0.05). The plasma concentrations of norepinephrine and cortisol increased in both groups during the surgery, whereas those of epinephrine remained unchanged. AVP concentrations increased during the surgery in the anterior group, and remained unaltered in the posterior group. The anterior group needed more analgesics (P<0.01) during the first 1 h after the operation.

CONCLUSIONS

The anterior approach required a deeper level of anaesthesia while undergoing spinal surgery and more use of post-operative analgesics than the posterior approach. It was also associated with a more pronounced AVP release during the surgery.

Leptin and perioperative neuroendocrine stress response with two different anaesthetic techniques

BACKGROUND

Stress response to surgery is modulated by several factors, including magnitude of the injury, pain, type of procedure and choice of anaesthesia. Our purpose was to compare intra- and post-operative hormonal changes during total intravenous anaesthesia (TIVA) using propofol and remifentanil vs. sevoflurane anaesthesia in a low stress level surgical model (laparoscopy).

METHODS

We randomly allocated 18 patients undergoing laparoscopic surgery for benign ovarian cysts in two groups to receive either TIVA (group A=9) or sevoflurane anaesthesia (group B=9). Perioperative plasma levels of norepinephrine (NE), epinephrine (E), adrenocorticotropic hormone (ACTH), cortisol and leptin were measured. Blood samples were collected pre-operatively (time 0), 30 min after the beginning of surgery (time 1), after extubation (time 2), and 2 h (time 3) and 4 h after surgery (time 4).

RESULTS

The comparative analysis between the groups shows significantly higher values of NE (P<0.001 at time 1 and P<0.01 at time 3), E (P<0.001 at times 1 and 2; P<0.01 at time 3 and P<0.05 at time 4), ACTH (P<0.001 at times 1 and 2; P<0.05 at time 3) and cortisol (P<0.001 at times 1 and 2; P<0.01 at time 3; P<0.05 at time 4) in group B. The serum values of leptin were not significantly different between the two groups.

CONCLUSION

The choice of anaesthesia does not seem to affect the leptin serum levels but influences the release of stress response markers: ACTH, cortisol, NE and E.

Integrated analysis of protein and glucose metabolism during surgery: effects of anesthesia

The aim of this study was to assess dynamic changes in protein and glucose metabolism during surgery. Twelve patients undergoing colorectal surgery received either intravenous propofol anesthesia (n = 6) or inhalational anesthesia with desflurane (n = 6). Pre- and intraoperative protein and glucose kinetics were analyzed by an isotope dilution technique using L-[1-(13)C]leucine and [6,6-(2)H(2)]glucose. Plasma concentrations of glucose, lactate, free fatty acids, insulin, glucagon, and cortisol were measured before and after 2 h of surgery. The rates of appearance of leucine and glucose, leucine oxidation, protein synthesis, and glucose clearance decreased during surgery, independent of the type of anesthesia (P < 0.05). A correlation between the rate of appearance of leucine and glucose was observed (r = 0.755, P < 0.001). Intraoperative plasma cortisol and glucose concentrations increased (P < 0.05), whereas plasma concentrations of lactate, free fatty acids, insulin, and glucagon did not change. Surgery causes a depression of whole body protein and glucose metabolism, independent of the anesthetic technique. There is a correlation between perioperative glucose production and protein breakdown.

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.

Propofol/sufentanil anesthesia suppresses the metabolic and endocrine response during, not after, lower abdominal surgery

We investigated the influence of propofol/sufentanil anesthesia on metabolic and endocrine responses during, and immediately after, lower abdominal surgery. Twenty otherwise healthy patients undergoing abdominal hysterectomy for benign myoma received either continuous infusions of propofol supplemented with sufentanil (0.01 microg. kg(-1). min(-1), n = 10) or enflurane anesthesia (enflurane, n = 10). Plasma concentrations of glucose, lactate, free fatty acids, triglycerides, insulin, glucagon, cortisol, epinephrine, and norepinephrine were measured before, during, and 2 h after surgery. Pre- and postoperative endogenous glucose production (R(a) glucose) was analyzed by an isotope dilution technique by using [6,6-(2)H(2)] glucose. Propofol/sufentanil anesthesia prevented the increase in plasma cortisol and catecholamine concentrations and attenuated the hyperglycemic response during surgery without showing any difference after the operation. Mediated through a higher glucagon/insulin quotient (propofol/sufentanil 15 +/- 7 versus enflurane 8 +/- 4 pg/microU, P < 0.05), the R(a) glucose postoperatively increased more in the propofol/sufentanil than in the enflurane group (propofol/sufentanil 15.6 +/- 2.0 versus enflurane 13.4 +/- 2.2 micromol. kg(-1). min(-1), P < 0.05).

IMPLICATIONS

The concept of stress-free anesthesia using propofol combined with sufentanil is valid only during surgery. The metabolic endocrine stress response 2 h after the operation is more pronounced than after inhaled anesthesia.