Anesthetic considerations in diabetic patients. Part II: intraoperative and postoperative management of patients with diabetes mellitus

[Complications and emergencies in the recovery room]

The recovery room as a central monitoring unit plays a crucial role in the perioperative care of patients. Here, the patient is monitored until the subsequent transfer to a further care ward; however, due to the previous anesthesia and surgery the recovery room also provides a high risk for (the development of) complications. The present article provides an overview of the most frequent complications to be expected in the recovery room (in adults), the diagnostics and the acute treatment.

Effects of intraoperative administration of carbohydrates during long-duration oral and maxillofacial surgery on the metabolism of carbohydrates, proteins, and lipids

PURPOSE

Insulin resistance in patients undergoing invasive surgery impairs glucose and lipid metabolism and increases muscle protein catabolism, which may result in delayed recovery and prolonged hospital stay. We examined whether intraoperative administration of carbohydrates during long-duration oral and maxillofacial surgery under general anesthesia affects carbohydrate, proteins, and lipid metabolism and the length of hospital stay.

METHODS

We studied 16 patients with normal liver, kidney, and endocrine functions, and ASA physical status I or II, but without diabetes. Patients were randomly assigned to receive 0.1 g/kg/h of (n = 8) or lactated Ringer's solution (n = 8). Blood was collected before (T0) and 4 h after (T1) the start of surgery. We analyzed the plasma levels of glucose, ketone bodies, 3-methylhistidine (3-MH), and the length of hospital stay.

RESULTS

At T0, no statistically significant differences were observed in the levels of glucose, ketone bodies, and 3-MH between the groups. At T1, no statistically significant difference in glucose levels was found between the groups. However, ketone bodies were significantly lower, and the changes in 3-MH levels were significantly less pronounced in the glucose-treated group compared with controls. No significant differences were observed between the groups in terms of length of hospital stay.

CONCLUSIONS

The administration of low doses of glucose during surgery was safe, did not cause hyperglycemia or hypoglycemia, and inhibited lipid metabolism and protein catabolism. Additional experiments with larger cohorts will be necessary to investigate whether intraoperative management with glucose facilitates postoperative recovery of patients with oral cancer.

[Aspects of perioperative care in patients with diabetes]

Diabetes is a common disease in Germany. Due to diabetes-associated end-organ disease, such as large and small vessel disease and neuropathy, diabetic patients require more intense anesthesia care during the perioperative phase. An in-depth and comprehensive medical history focusing on hemodynamic alterations, gastroparesis, neuropathy and stiff joint syndrome is a cornerstone of perioperative care and may affect outcome of diabetes patients more than specific anesthetic medications or the anesthetic procedure. Intraoperative anesthetic care needs to focus on preservation of hemodynamic stability, perioperative infection control and maintenance of glucose homeostasis. Whereas some years ago strict glucose control by aggressive insulin therapy was adamantly advocated, the results of recent studies have put the risk of such therapeutic algorithms into perspective. Therefore, optimized perioperative care of diabetic patients consists of setting a predefined targeted blood glucose level, evidence-based therapeutic approaches to reach that goal and finally adequate and continuous monitoring and amendment of the therapeutic approach if required.

Time course of changes in cerebral blood flow velocity after tourniquet deflation in patients with diabetes mellitus or previous stroke under sevoflurane anesthesia

We observed an increase in mean middle cerebral artery blood flow velocity (V(mca)) after tourniquet deflation during orthopedic surgery under sevoflurane anesthesia in patients with diabetes mellitus or previous stroke. Eight controls, seven insulin-treated diabetic patients, and eight previous stroke patients were studied. Arterial blood pressure, heart rate, V(mca), arterial blood gases, and plasma lactate levels were measured every minute for 10 min after tourniquet release in all patients. V(mca) was measured using a transcranial Doppler probe. V(mca) in all three groups increased after tourniquet deflation, the increase lasting for 4 or 5 min. However, the degree of increase in V(mca) in the diabetic patients was smaller than that in the other two groups after tourniquet deflation (at 2 min after tourniquet deflation: control 58.5 ± 3.3, previous stroke 58.4 ± 4.6, diabetes 51.7 ± 2.3; P < 0.05 compared with the other two groups). In conclusion, the degree of increase in V (mca) in diabetic patients is smaller than that in controls and patients with previous stroke.