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Eckhardt S, Laus K, DeAndrade S, Lee J, Nguyen J. The impact of diabetes mellitus on pelvic organ prolapse recurrence after robotic sacrocolpopexy. Int Urogynecol J 2023; 34:1859-1866. [PMID: 36780019 DOI: 10.1007/s00192-023-05455-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 12/20/2022] [Indexed: 02/14/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Data examining the effect of diabetes mellitus (DM) on prolapse recurrence after sacrocolpopexy (SCP) is limited. The primary objective of this study was to determine if DM affects prolapse recurrence after robotic SCP. METHODS This was a retrospective cohort study of women who underwent robotic SCP between 2012 and 2019 at Kaiser Permanente Southern California. The cohort was divided into women with and without DM at the time of SCP. The primary outcome was composite failure. Secondary outcomes included recurrent compartment-specific prolapse, reoperation rates, and surgical complications. RESULTS Of 547 patients included, 100 had DM. Women with DM were older, had higher BMI, higher parity, and were more likely to be nonwhite. Women with DM had more advanced prolapse at baseline but were not more likely to undergo concomitant procedures at the time of SCP. Over a median follow-up of 2.1 years (IQR 1.3, 3.4), women with DM had significantly increased risk of anterior vaginal prolapse (AVP) recurrence (13% vs 3%, p<0.01), but not composite failure (21% vs 14%, p=0.14). On multivariate regression, women with DM were almost 4 times as likely to experience AVP recurrence over time (AVP hazard ratio (HR) 3.93, 95% CI 1.29-12.03, p=0.02). CONCLUSION In our cohort, DM was a risk factor for AVP recurrence but not composite failure after robotic SCP.
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Affiliation(s)
- Sarah Eckhardt
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Kaiser Permanente Downey Medical Center, 9449 E. Imperial Hwy., C327, Downey, CA, 90242, USA.
| | - Katharina Laus
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Kaiser Permanente Downey Medical Center, 9449 E. Imperial Hwy., C327, Downey, CA, 90242, USA
- Department of Female Pelvic Medicine and Reconstructive Surgery, Harbor UCLA Medical Center, Torrance, CA, USA
| | - Samantha DeAndrade
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Kaiser Permanente Downey Medical Center, 9449 E. Imperial Hwy., C327, Downey, CA, 90242, USA
- Department of Female Pelvic Medicine and Reconstructive Surgery, Harbor UCLA Medical Center, Torrance, CA, USA
| | - Janet Lee
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - John Nguyen
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Kaiser Permanente Downey Medical Center, 9449 E. Imperial Hwy., C327, Downey, CA, 90242, USA
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Grip J, Norberg Å, Klevebro F. Limitations of reliance on metabolic markers following surgery. Acta Anaesthesiol Scand 2023; 67:562-563. [PMID: 36653963 DOI: 10.1111/aas.14202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 01/14/2023] [Indexed: 01/20/2023]
Affiliation(s)
- Jonathan Grip
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Huddinge, Sweden
| | - Åke Norberg
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Huddinge, Sweden
| | - Fredrik Klevebro
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Cancer Theme, Karolinska University Hospital, Stockholm, Sweden
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3
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Ngo F, Urman RD, English W, Kothari S, DeMaria E, Wadhwa A. An analysis of enhanced recovery pathways for bariatric surgery-preoperative fasting, carbohydrate loading, and aspiration risk: a position statement from the International Society for the Perioperative Care of Patients with Obesity. Surg Obes Relat Dis 2023; 19:171-177. [PMID: 36732143 DOI: 10.1016/j.soard.2022.12.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 12/10/2022] [Indexed: 01/06/2023]
Abstract
Enhanced recovery pathways (ERPs) and recommendations have become widely accepted for metabolic and bariatric surgery, including recommendations for preoperative carbohydrate loading and duration of fasting status. There is still a lack of consensus regarding such protocols and the underlying issues of gastric emptying time, resting gastric volume and pH, and risk of aspiration in patients with severe obesity and in patients undergoing bariatric surgery. The goal of this position statement by the International Society for the Perioperative Care of Patients with Obesity (ISPCOP) is to provide an analysis of available data on preoperative fasting and loading with oral complex clear carbohydrate drinks as well its potential effects on perioperative risk of aspiration in the context of Enhanced Recovery Pathways for Metabolic and Bariatric Surgery (ERAMBS).
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Affiliation(s)
- Fallon Ngo
- Department of Anesthesiology and Pain Management, University of Texas, Southwestern Medical Center, Dallas, Texas
| | - Richard D Urman
- International Society of Perioperative Care of Patients with Obesity, Lynnwood, Washington; Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Wayne English
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shanu Kothari
- Department of Surgery, University of South Carolina Greenville, Prisma Health - Greenville Memorial Medical Campus, Greenville, South Carolina.
| | - Eric DeMaria
- Department of Surgery, East Carolina University, Greenville, North Carolina
| | - Anupama Wadhwa
- Department of Anesthesiology and Pain Management, University of Texas, Southwestern Medical Center, Dallas, Texas; International Society of Perioperative Care of Patients with Obesity, Lynnwood, Washington; Outcomes Research Consortium, Cleveland Clinic, Cleveland, Ohio
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4
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Liu Q, Aggarwal A, Wu M, Darwish OA, Baldino K, Haug V, Agha RA, Orgill DP, Panayi AC. Impact of diabetes on outcomes in breast reconstruction: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2022; 75:1793-1804. [PMID: 35351394 DOI: 10.1016/j.bjps.2022.02.053] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 02/14/2022] [Accepted: 02/17/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND As rates of breast cancer and type II diabetes increase, so does the number of women with diabetes undergoing breast reconstruction (BR). Patients with diabetes are at increased risk of postoperative complications. This meta-analysis seeks to evaluate the post-operative outcomes of women with diabetes who underwent BR following mastectomy. METHOD This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The EMBASE, PUBMED, and MEDLINE electronic databases were searched from inception to November 1, 2020 for studies published in English. Outcomes evaluated were overall complications, surgical complications, and longer hospital stay. Subgroup analysis investigated outcomes, such as implant/flap failure, infection, and necrosis. RESULTS Sixty-five studies met our inclusion criteria and 38 provided data to be included in the meta-analysis. A total of 151,585 patients were included, of which 9299 had diabetes. Women with diabetes were more likely to experience overall complications (11.6% vs 5.6%; p<0.0001) and surgical complications (7.7% vs 3.3%; p<0.0001), and were more likely to have a prolonged hospital stay (p = 0.04) than women without diabetes. Subgroup analysis showed that implant loss (2.5% vs 1.6%; p = 0.0003), infection (6.8% vs 2.5%; p<0.0001) and necrosis (23.8% vs 6.5; p = 0.001) were significantly higher in women with diabetes. CONCLUSIONS This study provides evidence that diabetes mellitus increases the risk of complications in patients with breast cancer undergoing BR after mastectomy. Prospective studies are required to establish whether diabetes that is well-controlled prior to reconstruction, including diabetes that is paired with adjuvant radiation therapy, reduces the perioperative risks.
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Affiliation(s)
- Qinxin Liu
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, United States of America; Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ayushi Aggarwal
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, United States of America; University of Maryland School of Medicine, Baltimore, MD 21201, United States of America
| | - Mengfan Wu
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, United States of America; Department of Plastic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong 518036, China
| | - Oliver A Darwish
- California Northstate University College of Medicine, Elk Grove, CA 95757, United States of America
| | - Kodi Baldino
- The University of Connecticut School of Medicine, Farmington, CT 06030, United States of America
| | - Valentin Haug
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Riaz A Agha
- Department of Plastic Surgery, Barts Health NHS Trust, London, United Kingdom
| | - Dennis P Orgill
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, United States of America
| | - Adriana C Panayi
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, United States of America.
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Salari N, Karami MM, Bokaee S, Chaleshgar M, Shohaimi S, Akbari H, Mohammadi M. The prevalence of urinary tract infections in type 2 diabetic patients: a systematic review and meta-analysis. Eur J Med Res 2022; 27:20. [PMID: 35123565 PMCID: PMC8817604 DOI: 10.1186/s40001-022-00644-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 01/19/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Urinary tract infection is the most common infection in type 2 diabetic patients. Various studies have reported different outbreaks of urinary tract infections in type 2 diabetic patients. Therefore, the present study aimed to determine the prevalence of urinary tract infections in type 2 diabetic patients during a systematic review and meta-analysis in order to develop interventions to reduce the incidence of urinary tract infections in type 2 diabetic patients.
Methods
In this study, systematic review and meta-analysis of study data related to the prevalence of urinary tract infection in type 2 diabetic patients were conducted using keywords including type 2 diabetes, urinary tract infection, diabetes, prevalence, meta-analysis and their English equivalents in SID, MagIran, IranMedex, IranDoc, Google Scholar, Cochrane, Embase, Science Direct, Scopus, PubMed and Web of Science (WoS) databases from 1993 to 2020. In order to perform the analysis of qualified studies, the model of random-effects was used, and the inconsistency of studies with the I2 index was investigated. Data analysis was performed with Comprehensive Meta-Analysis (Version 2).
Results
Based on a total of 15 studies with a sample size of 827,948 in meta-analysis, the overall prevalence of urinary tract infection in patients with type 2 diabetes was 11.5% (95% confidence interval: 7.8–16.7%). The prevalence of urinary tract infections in diabetic Iranian patients increased with increasing number of years of research, (p < 0.05), and with increasing age of participants (p < 0.05), but however the prevalence decreased with increasing sample size (p < 0.05).
Conclusion
This study shows that urinary tract infections are highly prevalent in patients with type 2 diabetes. Therefore, due to the growing prevalence of diabetes and its complications such as urinary tract infections, the need for appropriate screening programs and health care policies is becoming more apparent.
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Gümüs K, Pirhan Y, Aydın G, Keloglan S, Tasova V, Kahveci M. The Effect of Preoperative Oral Intake of Liquid Carbohydrate on Postoperative Stress Parameters in Patients Undergoing Laparoscopic Cholecystectomy: An Experimental Study. J Perianesth Nurs 2021; 36:526-531. [PMID: 33926804 DOI: 10.1016/j.jopan.2020.10.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 10/07/2020] [Accepted: 10/11/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE The aim of this study is to investigate the effects of preoperative oral intake of liquid carbohydrate on postoperative stress parameters (blood glucose, insulin resistance, cortisol, noradrenaline, and adrenaline levels) in patients who underwent laparoscopic cholecystectomy. DESIGN This is an experimental study with intervention and control groups. METHODS The sample consisted of 68 patients who underwent laparoscopic cholecystectomy (control group = 33; intervention group = 35). Twelve-hour preoperative fasting was applied to the patients in the control group in accordance with the clinical routine. Clear oral liquid carbohydrate (400 mL; 12.5 g/100 mL maltodextrin, 50 kcal/100 mL, pH 5.0) was administered to the patients in the intervention group at the preoperative second hour. Blood samples were taken from the patients at the preoperative 2nd and postoperative 2nd and 24th hours, and their blood glucose, insulin resistance, cortisol, noradrenaline, and adrenaline levels were measured. RESULTS Preoperative oral intake of carbohydrate had no effect on blood glucose (P > .05) but decreased insulin resistance at the postoperative 24th hour (P = .044; intervention and control group: 3.62 ± 3.44 to 8.16 ± 12.57 respectively) and cortisol level at the postoperative 2nd hour (P = .005; intervention and control group: 15.16 ± 6.53 mg/dl to 20.14 ± 7.49 mg/dl, respectively). In all of the three measurements, we found that the noradrenaline level of the patients in the intervention group was higher than the value of those in the control group (319.80 ± 301.49 pg/mL to 211.65 ± 141.11 pg/mL [P = .450]; 361.40 ± 213.50 pg/mL to 216.13 ± 114.53 [P = .001]; 268.40 ± 164.04 pg/mL to 196.00 ± 83.33 pg/mL [P = .026], respectively). Preoperative oral intake of liquid carbohydrate had no effect on postoperative adrenaline level (P > .05). CONCLUSIONS Oral intake of liquid carbohydrate given at the preoperative 2nd hour decreased postoperative stress response through insulin resistance and cortisol.
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Affiliation(s)
- Kenan Gümüs
- Department of Surgical Nursing, Faculty of Health Sciences, Amasya University, Amasya, Turkey.
| | - Yavuz Pirhan
- Department of General Surgery, Sabuncuoğlu Şerefeddin Research and Training Hospital, Amasya University, Amasya, Turkey
| | - Gökcen Aydın
- Department of Surgical Nursing, Faculty of Health Sciences, Bozok University, Yozgat, Turkey
| | - Seval Keloglan
- Department of Physiology, Faculty of Medicine, Adıyaman University, Adıyaman, Turkey
| | - Volkan Tasova
- Department of General Surgery, Sabuncuoğlu Şerefeddin Research and Training Hospital, Amasya University, Amasya, Turkey
| | - Mürsel Kahveci
- Department of Anesthesia and Reanimation, Sabuncuoğlu Şerefeddin Research and Training Hospital, Amasya University, Amasya, Turkey
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Potentially preventable urinary tract infection in patients with type 2 diabetes - A hospital-based study. ACTA ACUST UNITED AC 2020; 17:100190. [PMID: 32289092 PMCID: PMC7103955 DOI: 10.1016/j.obmed.2020.100190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 01/25/2020] [Indexed: 11/23/2022]
Abstract
Aim To investigate the prevalence of urinary tract infections in hospitalized patients with type 2 diabetes mellitus and identify corresponding risk factors. Methods We conducted a cross-sectional study on 7.347 patients with type 2 diabetes mellitus as the principal diagnosis, using hospitalization discharge summary data from January 1 to December 31, 2015. Disease stages were classified as stages 1, 2, and 3. Results Of 7.347 patients, 16.2% had urinary tract infections. The urinary tract infection prevalence was 24.4% in 428 patients in stage 1 and 4.8% in 2.840 patients in stage 2; it was higher among patients who underwent medical procedures than among those who underwent surgery (24.4% vs 4.8%). In multivariate regression analysis, age (OR = 1.031; 95% CI = 1.02-1.04), length of hospitalization (OR = 1.018; 95% CI = 1.013-1.024), sex (woman) (OR = 2.248; 95% CI = 1.778-2.842), comorbidity of stage 3 cerebrovascular disease (OR = 1.737; 95% CI = 1.111-2.714), and comorbidity of stage 1 colorectal cancer (OR = 2.417; 95% CI = 1.152-5.074) were found to be the risk factors of urinary tract infection in the ten hospitals considered. Conclusions Our findings suggest that urinary tract infection prevalence was higher in women without evidence of organ injury and those receiving medical treatment. Comorbidities (cerebrovascular disease and colorectal cancer) were identified as risk factors.
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8
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Zaidi SO, Khan Y, Razak BS, Malik BH. Insight Into the Perioperative Management of Type 2 Diabetes. Cureus 2020; 12:e6878. [PMID: 32190441 PMCID: PMC7058399 DOI: 10.7759/cureus.6878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 02/04/2020] [Indexed: 01/14/2023] Open
Abstract
Diabetic people are at risk of developing acute complications when exposed to stress. Surgery brings a stressful period when the patient is exposed not only to surgical stress but also the effects of medications used during that particular period. The patient's comorbidities can influence the perioperative management of diabetes. Poorly controlled diabetes can complicate the hospital course. The literature was searched through PubMed and the articles of the last 5 years, from 2014 to 2019, were looked into. The studies available as a free text, in the English language and related to humans, were included. Inclusion criteria also included adults with type 2 diabetes undergoing surgery. The perioperative management of diabetes is a challenging one. Apart from the diabetes control; comorbidities, general health, intake, and interaction of medications both anti-diabetic and non-diabetic, type and duration of surgery, are some of the factors that influence the outcome of the surgery. With a variety of options available to manage diabetes currently, it is important to have a good insight into their effects to prevent complications to occur and ensure safe discharge from the hospital. The good control of diabetes is essential in bringing favorable outcomes. The perioperative management of diabetes should be individualized. Oral anti-hyperglycemic medications, other than sulfonylureas and SGLT2 inhibitors, provide a reasonable alternative to insulin and can be continued safely perioperatively depending upon the type of surgery and the patient is expected to resume oral intake soon postoperatively.
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Affiliation(s)
- Syed Owais Zaidi
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Yusra Khan
- Pharmacy, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Bibi S Razak
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Bilal Haider Malik
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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Hagve M, Gjessing PF, Hole MJ, Jansen KM, Fuskevåg OM, Mollnes TE, Larsen TS, Irtun Ø. Perioperative Infusion of Glucagon-Like Peptide-1 Prevents Insulin Resistance After Surgical Trauma in Female Pigs. Endocrinology 2019; 160:2892-2902. [PMID: 31589305 DOI: 10.1210/en.2019-00374] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 09/30/2019] [Indexed: 12/13/2022]
Abstract
Insulin resistance is an independent negative predictor of outcome after elective surgery and increases mortality among surgical patients in intensive care. The incretin hormone glucagon-like peptide-1 (GLP-1) potentiates glucose-induced insulin release from the pancreas but may also increase insulin sensitivity in skeletal muscle and directly suppress hepatic glucose release. Here, we investigated whether a perioperative infusion of GLP-1 could counteract the development of insulin resistance after surgery. Pigs were randomly assigned to three groups; surgery/control, surgery/GLP-1, and sham/GLP-1. Both surgery groups underwent major abdominal surgery. Whole-body glucose disposal (WGD) and endogenous glucose release (EGR) were assessed preoperatively and postoperatively using D-[6,6-2H2]-glucose infusion in combination with hyperinsulinemic euglycemic step-clamping. In the surgery/control group, peripheral insulin sensitivity (i.e., WGD) was reduced by 44% relative to preoperative conditions, whereas the corresponding decline was only 9% for surgery/GLP-1 (P < 0.05). Hepatic insulin sensitivity (i.e., EGR) remained unchanged in the surgery/control group but was enhanced after GLP-1 infusion in both surgery and sham animals (40% and 104%, respectively, both P < 0.05). Intraoperative plasma glucose increased in surgery/control (∼20%) but remained unchanged in both groups receiving GLP-1 (P < 0.05). GLP-1 diminished an increase in postoperative glucagon levels but did not affect skeletal muscle glycogen or insulin signaling proteins after surgery. We show that GLP-1 improves intraoperative glycemic control, diminishes peripheral insulin resistance after surgery, and suppresses EGR. This study supports the use of GLP-1 to prevent development of postoperative insulin resistance.
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Affiliation(s)
- Martin Hagve
- Gastrosurgical Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
- Cardiovascular Research Group, Department of Medical Biology, UiT The Arctic University of Norway, Tromsø, Norway
| | - Petter F Gjessing
- Gastrosurgical Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
- Department of Digestive Surgery, University Hospital of North Norway, Tromsø, Norway
| | - Mikal J Hole
- Gastrosurgical Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Kirsten M Jansen
- Cardiovascular Research Group, Department of Medical Biology, UiT The Arctic University of Norway, Tromsø, Norway
| | - Ole Martin Fuskevåg
- Department of Laboratory Medicine, Division of Diagnostic Services, University Hospital of North Norway, Tromsø, Norway
| | - Tom Eirik Mollnes
- Research Laboratory, Nordland Hospital, Bodø, Norway
- Faculty of Health Sciences, K. G. Jebsen TREC, UiT The Arctic University of Norway, Tromsø, Norway
- Center of Molecular Inflammation Research and Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Immunology, Oslo University Hospital, and K. G. Jebsen IRC, University of Oslo, Oslo, Norway
| | - Terje S Larsen
- Cardiovascular Research Group, Department of Medical Biology, UiT The Arctic University of Norway, Tromsø, Norway
| | - Øivind Irtun
- Gastrosurgical Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
- Department of Digestive Surgery, University Hospital of North Norway, Tromsø, Norway
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Anesthesia for Open Radical Retropubic Prostatectomy: A Comparison between Combined Spinal Epidural Anesthesia and Combined General Epidural Anesthesia. Prostate Cancer 2019; 2019:4921620. [PMID: 31218084 PMCID: PMC6536977 DOI: 10.1155/2019/4921620] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/29/2019] [Accepted: 04/28/2019] [Indexed: 01/18/2023] Open
Abstract
Background Several anesthesiologic regimens can be used for open radical retropubic prostatectomy. The aim of this retrospective analysis was to compare the combined general epidural anesthesia and the combined spinal epidural anesthesia with regard to availability, efficacy, side effects, and perioperative time consumption in a high-volume center. Methods A retrospective analysis was performed by querying the electronic medical records of 1207 consecutive patients from the database of our online documentation software. All patients underwent open radical retropubic prostatectomy from 01/2008 to 08/2011 and met the study criteria. Linear and multivariate regression analyses were performed to identify differences in parameters such as time consumption in the operating unit, hemodynamic parameters, volume replacement, and catecholamine therapy. Results 698 (57.8%) patients have been undergoing open radical retropubic prostatectomy under combined spinal epidural anesthesia and 509 (42.2%) patients by combined general epidural anesthesia. Operating unit (p <0.0001) and post-anesthesia care unit stay (p <0.0001) as well as total hospital stay (p <0.0001) were significantly shorter in the combined spinal epidural anesthesia group. In addition, this group had reduced intraoperative volume need (p <0.0001) as well as lower need of catecholamines (p <0.0001). Conclusions This retrospective study suggests that the combined spinal epidural anesthesia seems to be a suitable and efficient anesthesia technique for patients undergoing open radical retropubic prostatectomy. This specific approach reduces time in the operation unit and length of hospital stay.
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Allen S, Brown V, Prabhu P, Scott M, Rockall T, Preston S, Sultan J. A randomised controlled trial to assess whether prehabilitation improves fitness in patients undergoing neoadjuvant treatment prior to oesophagogastric cancer surgery: study protocol. BMJ Open 2018; 8:e023190. [PMID: 30580268 PMCID: PMC6318540 DOI: 10.1136/bmjopen-2018-023190] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION Neoadjuvant therapy prior to oesophagogastric resection is the gold standard of care for patients with T2 and/or nodal disease. Despite this, studies have taught us that chemotherapy decreases patients' functional capacity as assessed by cardiopulmonary exercise (CPX) testing. We aim to show that a multimodal prehabilitation programme, comprising supervised exercise, psychological coaching and nutritional support, will physically, psychologically and metabolically optimise these patients prior to oesophagogastric cancer surgery so they may better withstand the immense physical and metabolic stress placed on them by radical curative major surgery. METHODS AND ANALYSIS This will be a prospective, randomised, controlled, parallel, single-centre superiority trial comparing a multimodal 'prehabilitation' intervention with 'standard care' in patients with oesophagogastric malignancy who are treated with neoadjuvant therapy prior to surgical resection. The primary aim is to demonstrate an improvement in baseline cardiopulmonary function as assessed by anaerobic threshold during CPX testing in an interventional (prehab) group following a 15-week preoperative exercise programme, throughout and following neoadjuvant treatment, when compared with those that undergo standard care (control group). Secondary objectives include changes in peak oxygen uptake and work rate (total watts achieved) at CPX testing, insulin resistance, quality of life, chemotherapy-related toxicity and completion, nutritional assessment, postoperative complication rate, length of stay and overall mortality. ETHICS AND DISSEMINATION This study has been approved by the London-Bromley Research Ethics Committee and registered on ClinicalTrials.gov. The results will be disseminated in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT02950324; Pre-results.
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Affiliation(s)
- Sophie Allen
- The Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Vanessa Brown
- The Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Pradeep Prabhu
- The Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Michael Scott
- The Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Timothy Rockall
- The Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Shaun Preston
- The Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Javed Sultan
- The Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
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Micić D, Lalić N, Djukić V, Stanković S, Trajković G, Oluić B, Polovina S. Influence of IL-6, TNF-α and Hs-CRP on Insulin Sensitivity in Patients after Laparoscopic Cholecystectomy or Open Hernia Repair. J Med Biochem 2018; 37:328-335. [PMID: 30598630 PMCID: PMC6298464 DOI: 10.1515/jomb-2017-0043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 08/12/2017] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The aim of this study was to investigate the influence of IL-6, TNF-α and hs-CRP on insulin sensitivity during postoperative follow-up in patients with laparoscopic cholecystectomy (LC) or open hernia repair (OHR). METHODS 65 patients were studied: after laparoscopic cholecystectomy (LC; n=40) or open hernia repair (OHR; n=25). Glucose, insulin, hs-CRP, IL-6 and TNF-a were determined at day 0 (before the operation) and at days 1, 3 and 7 (after the operation). RESULTS There were no difference between LC and OHR groups concerning age, BMI, glucose, insulin, hs-CRP, IL-6 and TNF-α at day 0. hs-CRP increased at day 1, 3 and 7 vs. day 0 (p<0.0005), without difference between groups (p=0.561). IL-6 increased at day 1 and day 3 vs. day 0 (p<0.005). IL-6 was higher at day 1 in OHR group in comparison with LC group (p=0.044). There were no differences in TNF-a levels between LC and OHR groups (p=0.056). There was increase of HOMA-IR at day 1, 3 and 7 vs. day 0 (p<0.0005) in both groups. Significantly higher increase of HOMA-IR was in OHR group compared with LC group at day 1 (p=0.045). There was a positive correlation between hs-CRP and HOMA-IR (r=0.46; p=0.025) and between IL-6 and HOMA-IR at day 1 in OHR group (r=0.44; p=0.030). CONCLUSIONS Significantly higher HOMA-IR was found in OHR group compared with LC. Positive correlation between hs-CRP and IL-6 with HOMA-IR in OHR group at day 1, indicate possible influence of this mediators on impairment of insulin sensitivity.
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Affiliation(s)
- Dušan Micić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic for Emergency Surgery, Emergency Center, Clinical Center of Serbia, Belgrade, Serbia
| | - Nebojša Lalić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic for Endocrinology, Diabetes and Diseases of Metabolism, Clinical Center of Serbia, Belgrade, Serbia
| | - Vladimir Djukić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic for Emergency Surgery, Emergency Center, Clinical Center of Serbia, Belgrade, Serbia
| | - Sanja Stanković
- Center for Medical Biochemistry, Clinical Center of Serbia, Belgrade, Serbia
| | - Goran Trajković
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Department for Medical Statistics and Informatics, Faculty of Medicine, University ofBelgrade, Serbia
| | - Branislav Oluić
- Clinic for Emergency Surgery, Emergency Center, Clinical Center of Serbia, Belgrade, Serbia
| | - Snežana Polovina
- Clinic for Endocrinology, Diabetes and Diseases of Metabolism, Clinical Center of Serbia, Belgrade, Serbia
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13
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Effects of peri-operative administration of steroids on the blood glucose levels of patients with and without diabetes undergoing laparoscopic cholecystectomy. JOURNAL OF SURGERY AND MEDICINE 2018. [DOI: 10.28982/josam.424450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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14
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Liu Z, Dumville JC, Norman G, Westby MJ, Blazeby J, McFarlane E, Welton NJ, O'Connor L, Cawthorne J, George RP, Crosbie EJ, Rithalia AD, Cheng H. Intraoperative interventions for preventing surgical site infection: an overview of Cochrane Reviews. Cochrane Database Syst Rev 2018; 2:CD012653. [PMID: 29406579 PMCID: PMC6491077 DOI: 10.1002/14651858.cd012653.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Surgical site infection (SSI) rates vary from 1% to 5% in the month following surgery. Due to the large number of surgical procedures conducted annually, the costs of these SSIs can be considerable in financial and social terms. Many interventions are used with the aim of reducing the risk of SSI in people undergoing surgery. These interventions can be broadly delivered at three stages: preoperatively, intraoperatively and postoperatively. The intraoperative interventions are largely focused on decontamination of skin using soap and antiseptics; the use of barriers to prevent movement of micro-organisms into incisions; and optimising the patient's own bodily functions to promote best recovery. Both decontamination and barrier methods can be aimed at people undergoing surgery and operating staff. Other interventions focused on SSI prevention may be aimed at the surgical environment and include methods of theatre cleansing and approaches to managing theatre traffic. OBJECTIVES To present an overview of Cochrane Reviews of the effectiveness and safety of interventions, delivered during the intraoperative period, aimed at preventing SSIs in all populations undergoing surgery in an operating theatre. METHODS Published Cochrane systematic reviews reporting the effectiveness of interventions delivered during the intraoperative period in terms of SSI prevention were eligible for inclusion in this overview. We also identified Cochrane protocols and title registrations for future inclusion into the overview. We searched the Cochrane Library on 01 July 2017. Two review authors independently screened search results and undertook data extraction and 'Risk of bias' and certainty assessment. We used the ROBIS (risk of bias in systematic reviews) tool to assess the quality of included reviews, and we used GRADE methods to assess the certainty of the evidence for each outcome. We summarised the characteristics of included reviews in the text and in additional tables. MAIN RESULTS We included 32 Cochrane Reviews in this overview: we judged 30 reviews as being at low risk of bias and two at unclear risk of bias. Thirteen reviews had not been updated in the past three years. Two reviews had no relevant data to extract. We extracted data from 30 reviews with 349 included trials, totaling 73,053 participants. Interventions assessed included gloving, use of disposable face masks, patient oxygenation protocols, use of skin antiseptics for hand washing and patient skin preparation, vaginal preparation, microbial sealants, methods of surgical incision, antibiotic prophylaxis and methods of skin closure. Overall, the GRADE certainty of evidence for outcomes was low or very low. Of the 77 comparisons providing evidence for the outcome of SSI, seven provided high- or moderate-certainty evidence, 39 provided low-certainty evidence and 31 very low-certainty evidence. Of the nine comparisons that provided evidence for the outcome of mortality, five provided low-certainty evidence and four very low-certainty evidence.There is high- or moderate-certainty evidence for the following outcomes for these intraoperative interventions. (1) Prophylactic intravenous antibiotics administered before caesarean incision reduce SSI risk compared with administration after cord clamping (10 trials, 5041 participants; risk ratio (RR) 0.59, 95% confidence interval (CI) 0.44 to 0.81; high-certainty evidence - assessed by review authors). (2) Preoperative antibiotics reduce SSI risk compared with placebo after breast cancer surgery (6 trials, 1708 participants; RR 0.74, 95% CI 0.56 to 0.98; high-certainty evidence - assessed by overview authors). (3) Antibiotic prophylaxis probably reduce SSI risk in caesarean sections compared with no antibiotics (82 relevant trials, 14,407 participants; RR 0.40, 95% CI 0.35 to 0.46; moderate-certainty evidence; downgraded once for risk of bias - assessed by review authors). (4) Antibiotic prophylaxis probably reduces SSI risk for hernia repair compared with placebo or no treatment (17 trials, 7843 participants; RR 0.67, 95% CI 0.54 to 0.84; moderate-certainty evidence; downgraded once for risk of bias - assessed by overview authors); (5) There is currently no clear difference in the risk of SSI between iodine-impregnated adhesive drapes compared with no adhesive drapes (2 trials, 1113 participants; RR 1.03, 95% CI 0.66 to 1.60; moderate-certainty evidence; downgraded once for imprecision - assessed by review authors); (6) There is currently no clear difference in SSI risk between short-term compared with long-term duration antibiotics in colorectal surgery (7 trials; 1484 participants; RR 1.05 95% CI 0.78 to 1.40; moderate-certainty evidence; downgraded once for imprecision - assessed by overview authors). There was only one comparison showing negative effects associated with the intervention: adhesive drapes increase the risk of SSI compared with no drapes (5 trials; 3082 participants; RR 1.23, 95% CI 1.02 to 1.48; high-certainty evidence - rated by review authors). AUTHORS' CONCLUSIONS This overview provides the most up-to-date evidence on use of intraoperative treatments for the prevention of SSIs from all currently published Cochrane Reviews. There is evidence that some interventions are useful in reducing SSI risk for people undergoing surgery, such as antibiotic prophylaxis for caesarean section and hernia repair, and also the timing of prophylactic intravenous antibiotics administered before caesarean incision. Also, there is evidence that adhesive drapes increase SSI risk. Evidence for the many other treatment choices is largely of low or very low certainty and no quality-of-life or cost-effectiveness data were reported. Future trials should elucidate the relative effects of some treatments. These studies should focus on increasing participant numbers, using robust methodology and being of sufficient duration to adequately assess SSI. Assessment of other outcomes such as mortality might also be investigated as part of non-experimental prospective follow-up of people with SSI of different severity, so the risk of death for different subgroups can be better understood.
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Affiliation(s)
- Zhenmi Liu
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Jo C Dumville
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Gill Norman
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Maggie J Westby
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Jane Blazeby
- University of BristolNIHR Bristol Biomedical Research Centre, School of Social and Community Medicine, Bristol Medical SchoolBristolUK
| | - Emma McFarlane
- National Institute for Health and Care ExcellenceCentre for GuidelinesLevel 1A, City TowerPiccadilly PlazaManchesterUKM1 4BD
| | - Nicky J Welton
- University of BristolNIHR Bristol Biomedical Research Centre, School of Social and Community Medicine, Bristol Medical SchoolBristolUK
| | - Louise O'Connor
- Central Manchester University Hospitals NHS Foundation TrustInfection Prevention and Control / Tissue Viability TeamCobbett HouseOxford RoadManchesterUKM13 9WL
| | - Julie Cawthorne
- Central Manchester University Hospitals NHS Foundation TrustInfection Prevention and Control / Tissue Viability TeamCobbett HouseOxford RoadManchesterUKM13 9WL
| | - Ryan P George
- Central Manchester University Hospitals NHS Foundation TrustInfection Prevention and Control / Tissue Viability TeamCobbett HouseOxford RoadManchesterUKM13 9WL
| | - Emma J Crosbie
- Faculty of Biology, Medicine and Health, University of ManchesterDivision of Cancer Sciences5th Floor ‐ ResearchSt Mary's HospitalManchesterUKM13 9WL
| | - Amber D Rithalia
- Independent Researcher7 Victoria Terrace, KirkstallLeedsUKLS5 3HX
| | - Hung‐Yuan Cheng
- University of BristolBristol Centre for Surgical Research, Bristol Medical SchoolOffice 2.01Canynge Hall, 39 Whatley RoadBristolUKBS8 2PS
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15
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Sasso FC, Rinaldi L, Lascar N, Marrone A, Pafundi PC, Adinolfi LE, Marfella R. Role of Tight Glycemic Control during Acute Coronary Syndrome on CV Outcome in Type 2 Diabetes. J Diabetes Res 2018; 2018:3106056. [PMID: 30402502 PMCID: PMC6193345 DOI: 10.1155/2018/3106056] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 08/22/2018] [Accepted: 09/13/2018] [Indexed: 12/18/2022] Open
Abstract
Both incidence and mortality of acute coronary syndrome (ACS) among diabetic patients are much higher than those among nondiabetics. Actually, there are many studies that addressed glycemic control and CV risk, whilst the literature on the role of tight glycemic control during ACS is currently poor. Therefore, in this review, we critically discussed the studies that investigated this specific topic. Hyperglycemia is implicated in vascular damage and cardiac myocyte death through different molecular mechanisms as advanced glycation end products, protein kinase C, polyol pathway flux, and the hexosamine pathway. Moreover, high FFA concentrations may be toxic in acute ischemic myocardium due to several mechanisms, thus leading to endothelial dysfunction. A reduction in free fatty acid plasma levels and an increased availability of glucose can be achieved by using a glucose-insulin-potassium infusion (GIKi) during AMI. The GIKi is associated with an improvement of either long-term prognosis or left ventricular mechanical performance. DIGAMI studies suggested blood glucose level as a significant and independent mortality predictor among diabetic patients with recent ACS, enhancing the important role of glucose control in their management. Several mechanisms supporting the protective role of tight glycemic control during ACS, as well as position statements of Scientific Societies, were highlighted.
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Affiliation(s)
- Ferdinando Carlo Sasso
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, University of Campania, Naples, Italy
| | - Luca Rinaldi
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, University of Campania, Naples, Italy
| | - Nadia Lascar
- School of Life and Health Sciences, Aston University, Birmingham, UK
| | - Aldo Marrone
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, University of Campania, Naples, Italy
| | - Pia Clara Pafundi
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, University of Campania, Naples, Italy
| | - Luigi Elio Adinolfi
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, University of Campania, Naples, Italy
| | - Raffaele Marfella
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, University of Campania, Naples, Italy
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16
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Polderman JAW, van Steen SCJ, Thiel B, Godfried MB, Houweling PL, Hollmann MW, DeVries JH, Preckel B, Hermanides J. Peri-operative management of patients with type-2 diabetes mellitus undergoing non-cardiac surgery using liraglutide, glucose-insulin-potassium infusion or intravenous insulin bolus regimens: a randomised controlled trial. Anaesthesia 2017; 73:332-339. [DOI: 10.1111/anae.14180] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2017] [Indexed: 12/12/2022]
Affiliation(s)
- J. A. W. Polderman
- Department of Anaesthesiology; Academic Medical Centre Amsterdam; Amsterdam the Netherlands
| | - S. C. J. van Steen
- Department of Endocrinology; Academic Medical Centre Amsterdam; Amsterdam the Netherlands
| | - B. Thiel
- Department of Anaesthesiology; Onze Lieve Vrouwe Gasthuis; Amsterdam the Netherlands
| | - M. B. Godfried
- Department of Anaesthesiology; Onze Lieve Vrouwe Gasthuis; Amsterdam the Netherlands
| | - P. L. Houweling
- Department of Anaesthesiology; Diakonessenhuis; Utrecht the Netherlands
| | - M. W. Hollmann
- Department of Anaesthesiology; Academic Medical Centre Amsterdam; Amsterdam the Netherlands
| | - J. H. DeVries
- Department of Endocrinology; Academic Medical Centre Amsterdam; Amsterdam the Netherlands
| | - B. Preckel
- Department of Anaesthesiology; Academic Medical Centre Amsterdam; Amsterdam the Netherlands
| | - J. Hermanides
- Department of Anaesthesiology; Academic Medical Centre Amsterdam; Amsterdam the Netherlands
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17
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Varadhan KK, Constantin-Teodosiu D, Constantin D, Greenhaff PL, Lobo DN. Inflammation-mediated muscle metabolic dysregulation local and remote to the site of major abdominal surgery. Clin Nutr 2017; 37:2178-2185. [PMID: 29129636 PMCID: PMC6295976 DOI: 10.1016/j.clnu.2017.10.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 10/24/2017] [Accepted: 10/26/2017] [Indexed: 11/06/2022]
Abstract
Background & aims Postoperative hyperglycaemia is common in patients having major surgery and is associated with adverse outcomes. This study aimed to determine whether bacteraemia contributed to postoperative systemic inflammation, and whether increases in the expression of muscle mRNAs and proteins reflecting increased muscle inflammation, atrophy and impaired carbohydrate oxidation were evident at the time of surgery, and both local and distant to the site of trauma, and could be associated with impaired glucoregulation. Methods Fifteen adult patients without diabetes undergoing major abdominal surgery participated in this observational study set in a university teaching hospital. Arterialised-venous blood samples and muscle biopsies were obtained before and after major elective abdominal surgery, from sites local (rectus abdominis – RA) and remote to the site of surgery (vastus lateralis – VL). The main outcome measures included blood glucose concentrations, gut permeability and changes in expression of muscle mRNAs and proteins linked to inflammation and glucose regulation. Results Immediately postoperatively, RA demonstrated markedly increased mRNA expression levels of cathepsin-L (7.5-fold, P < 0.05), FOXO1 (10.5-fold, P < 0.05), MAFbx (11.5-fold, P < 0.01), PDK4 (7.8-fold, P < 0.05), TNF-α (16.5-fold, P < 0.05) and IL-6 (1058-fold, P < 0.001). A similar, albeit blunted, response was observed in VL. Surgery also increased expression of proteins linked to inflammation (IL-6; 6-fold, P < 0.01), protein degradation (MAFbx; 4.5-fold, P < 0.5), and blunted carbohydrate oxidation (PDK4; 4-fold, P < 0.05) in RA but not VL. Increased systemic inflammation (TNF-α, P < 0.05; IL-6, P < 0.001), and impaired postoperative glucose tolerance (P < 0.001), but not bacteraemia (although gut permeability was increased significantly, P < 0.05) or increased plasma cortisol, were noted 48 h postoperatively. Conclusions A systemic postoperative proinflammatory response was accompanied by muscle inflammation and metabolic dysregulation both local and remote to the site of surgery, and was not accompanied by bacteraemia. Clinical trial registration Registered at http://clinicaltrials.gov (NCT01134809).
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Affiliation(s)
- Krishna K Varadhan
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute of Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, UK
| | - Dumitru Constantin-Teodosiu
- MRC/ARUK Centre for Musculoskeletal Ageing Research, National Institute of Health Research (NIHR) Nottingham Biomedical Research Centre, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, UK
| | - Despina Constantin
- MRC/ARUK Centre for Musculoskeletal Ageing Research, National Institute of Health Research (NIHR) Nottingham Biomedical Research Centre, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, UK
| | - Paul L Greenhaff
- MRC/ARUK Centre for Musculoskeletal Ageing Research, National Institute of Health Research (NIHR) Nottingham Biomedical Research Centre, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, UK
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute of Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, UK.
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18
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Dumville JC, Norman G, Westby MJ, Blazeby J, McFarlane E, Welton NJ, O'Connor L, Cawthorne J, George RP, Liu Z, Crosbie EJ. Intra-operative interventions for preventing surgical site infection: an overview of Cochrane reviews. Hippokratia 2017. [DOI: 10.1002/14651858.cd012653] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Jo C Dumville
- University of Manchester, Manchester Academic Health Science Centre; Division of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & Health; Manchester UK M13 9PL
| | - Gill Norman
- University of Manchester, Manchester Academic Health Science Centre; Division of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & Health; Manchester UK M13 9PL
| | - Maggie J Westby
- University of Manchester, Manchester Academic Health Science Centre; Division of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & Health; Manchester UK M13 9PL
| | - Jane Blazeby
- University of Bristol; NIHR Bristol Biomedical Research Centre, School of Social & Community Medicine; Canynge Hall 39 Whatley Road Bristol UK BS8 2PS
| | - Emma McFarlane
- National Institute for Health and Care Excellence; Centre for Guidelines; Level 1A, City Tower Piccadilly Plaza Manchester UK M1 4BD
| | - Nicky J Welton
- University of Bristol; School of Social and Community Medicine; Bristol UK
| | - Louise O'Connor
- Central Manchester University Hospitals NHS Foundation Trust; Infection Prevention & Control / Tissue Viability Team; Cobbett House Oxford Road Manchester UK M13 9WL
| | - Julie Cawthorne
- Central Manchester University Hospitals NHS Foundation Trust; Infection Prevention & Control / Tissue Viability Team; Cobbett House Oxford Road Manchester UK M13 9WL
| | - Ryan P George
- Central Manchester University Hospitals NHS Foundation Trust; Infection Prevention & Control / Tissue Viability Team; Cobbett House Oxford Road Manchester UK M13 9WL
| | - Zhenmi Liu
- University of Manchester, Manchester Academic Health Science Centre; Division of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & Health; Manchester UK M13 9PL
| | - Emma J Crosbie
- Faculty of Biology, Medicine & Health, University of Manchester; Division of Molecular and Clinical Cancer Sciences; 5th Floor - Research St Mary's Hospital Manchester UK M13 9WL
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19
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Labgaa I, Joliat GR, Kefleyesus A, Mantziari S, Schäfer M, Demartines N, Hübner M. Is postoperative decrease of serum albumin an early predictor of complications after major abdominal surgery? A prospective cohort study in a European centre. BMJ Open 2017; 7:e013966. [PMID: 28391235 PMCID: PMC5775466 DOI: 10.1136/bmjopen-2016-013966] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To test postoperative serum albumin drop (ΔAlb) as a marker of surgical stress response and early predictor of clinical outcomes. DESIGN Prospective cohort study (NCT02356484). Albumin was prospectively measured in 138 patients undergoing major abdominal surgery. Blood samples were collected before surgery and on postoperative days 0, 1 2 and 3. ΔAlb was compared to the modified estimation of physiologic ability and surgical stress (mE-PASS) score and correlated to the performances of C reactive protein (CRP), procalcitonin (PCT) and lactate (LCT). Postoperative outcomes were postoperative complications according to Clavien classification and Comprehensive Complication Index (CCI), and length of hospital stay (LoS). SETTING Department of abdominal surgery in a European tertiary centre. PARTICIPANTS Adult patients undergoing elective major abdominal surgery, with anticipated duration ≥2 hours. Patients on immunosuppressive or antibiotic treatments before surgery were excluded. RESULTS The level of serum albumin rapidly dropped after surgery. ΔAlb correlated to the mE-PASS score (r=0.275, p=0.01) and to CRP increase (r=0.536, p<0.001). ΔAlb also correlated to overall complications (r=0.485, p<0.001), CCI (r=0.383, p<0.001) and LoS (r=0.468, p<0.001). A ΔAlb ≥10 g/L yielded a sensitivity of 77.1% and a specificity of 67.2% (AUC: 78.3%) to predict complications. Patients with ΔAlb ≥10 g/L on POD 1 showed a threefold increased risk of overall postoperative complications. CONCLUSIONS Early postoperative decrease of serum albumin correlated with the extent of surgery, its metabolic response and with adverse outcomes such as complications and length of stay. A decreased concentration of serum albumin ≥10 g/L on POD 1 was associated with a threefold increased risk of overall postoperative complications and may thus be used to identify patients at risk.
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Affiliation(s)
- Ismail Labgaa
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Gaëtan-Romain Joliat
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Amaniel Kefleyesus
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Styliani Mantziari
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Markus Schäfer
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
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20
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Filho NO, Alves RL, Fernandes AT, Castro FSP, Melo JRT, Módolo NSP. Association of increased morbidity with the occurrence of hyperglycemia in the immediate postoperative period after elective pediatric neurosurgery. J Neurosurg Pediatr 2016; 17:625-9. [PMID: 26722865 DOI: 10.3171/2015.9.peds1559] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The acute elevation of blood glucose in perioperative pediatric patients subjected to cardiac surgery and in victims of head trauma is associated with higher rates of postoperative complications. Data on the occurrence of hyperglycemia and its association with unfavorable outcomes among patients who have undergone elective neurosurgery are scarce in the literature. This study aimed to determine whether the occurrence of hyperglycemia during the perioperative period of elective neurosurgery for the resection of tumors of the CNS in children is associated with increased morbidity. METHODS This retrospective cohort analysis included 105 children up to 12 years of age who underwent elective neurosurgery for resection of supratentorial and infratentorial CNS tumors between January 2005 and December 2010 at the São Rafael Hospital, a tertiary care medical center in Salvador, Brazil. Demographic data and intraoperative and postoperative information were collected from the medical records. Differences in blood glucose levels during the perioperative period were evaluated with nonparametric tests. RESULTS The patients who developed postoperative complications exhibited higher blood glucose levels on admission to the intensive care unit (ICU) (162.0 ± 35.8 mg/dl vs 146.3 ± 43.3 mg/dl; p = 0.016) and peak blood glucose levels on postoperative Day 1 (171.9 ± 30.2 mg/dl vs 156.1 ± 43.2 mg/dl; p = 0.008). Multivariate analysis showed that peak blood glucose levels on postoperative Day 1 were independently associated with a higher odds ratio for postoperative complication (OR 1.05). The occurrence of hyperglycemia (>150 mg/dl) upon admission to the ICU was associated with longer ICU (p = 0.003) and hospital (p = 0.001) stays. CONCLUSIONS The occurrence of hyperglycemia during the postoperative period after elective pediatric neurosurgery for the resection of CNS tumors was associated with longer hospital and ICU stays. Postoperative complications were associated with higher blood glucose levels upon admission to the ICU and higher peak blood glucose on the first postoperative day.
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Affiliation(s)
- Nazel Oliveira Filho
- Departments of 1 Anesthesiology and.,Department of Anesthesiology, Hospital Universitário Professor Edgar Santos, Salvador, Bahia
| | - Rodrigo L Alves
- Departments of 1 Anesthesiology and.,Department of Anesthesiology, Hospital Universitário Professor Edgar Santos, Salvador, Bahia
| | | | | | - José Roberto Tude Melo
- Pediatric Neurosurgery, Hospital São Rafael;,Hospital Universitário Professor Edgar Santos, Salvador, Bahia; and
| | - Norma S P Módolo
- Department of Anesthesiology, Faculdade Medicina de Botucatu, Universidade Estadual Paulista, Botucatu, São Paulo, Brazil
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21
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Pereira VR, Azuma RA, Gatto BEO, Silva Junior JM, Carmona MJC, Malbouisson LMS. [Hyperglycemia assessment in the post-anesthesia care unit]. Rev Bras Anestesiol 2016; 67:565-570. [PMID: 27005828 DOI: 10.1016/j.bjan.2015.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Accepted: 08/17/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Hyperglycemia in surgical patients may cause serious problems. Analyzing this complication in this scenario contributes to improve the management of these patients. The aim of this study was to evaluate the prevalence of hyperglycemia in the post-anesthetic care unit (PACU) in non-diabetic patients undergoing elective surgery and analyze the possible risk factors associated with this complication. METHODS We evaluated non-diabetic patients undergoing elective surgeries and admitted in the PACU. Data were collected from medical records through precoded questionnaire. Hyperglycemia was considered when blood glucose was>120mg.dL-1. Patients with hyperglycemia were compared to normoglycemic ones to assess factors associated with the problem. We excluded patients with endocrine-metabolic disorders, diabetes, children under 18 years, body mass index (BMI) below 18 or above 35, pregnancy, postpartum or breastfeeding, history of drug use, and emergency surgeries. RESULTS We evaluated 837 patients. The mean age was 47.8±16.1 years. The prevalence of hyperglycemia in the postoperative period was 26.4%. In multivariate analysis, age (OR=1.031, 95% CI 1.017-1.045); BMI (OR=1.052, 95% CI 1.005-1.101); duration of surgery (OR=1.011, 95% CI 1.008-1.014), history of hypertension (OR=1.620, 95% CI 1.053-2.493), and intraoperative use of corticosteroids (OR=5.465, 95% CI 3.421-8.731) were independent risk factors for postoperative hyperglycemia. CONCLUSION The prevalence of hyperglycemia was high in the PACU, and factors such as age, BMI, corticosteroids, blood pressure, and duration of surgery are strongly related to this complication.
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Affiliation(s)
- Vinicius Rodovalho Pereira
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas de São Paulo, São Paulo, SP, Brasil
| | - Rodrigo Akio Azuma
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas de São Paulo, São Paulo, SP, Brasil
| | - Bruno Emanuel Oliva Gatto
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas de São Paulo, São Paulo, SP, Brasil
| | - João Manoel Silva Junior
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas de São Paulo, São Paulo, SP, Brasil.
| | - Maria Jose Carvalho Carmona
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas de São Paulo, São Paulo, SP, Brasil
| | - Luiz Marcelo Sá Malbouisson
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas de São Paulo, São Paulo, SP, Brasil
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Azagury D, Ris F, Pichard C, Volonté F, Karsegard L, Huber O. Does perioperative nutrition and oral carbohydrate load sustainably preserve muscle mass after bariatric surgery? A randomized control trial. Surg Obes Relat Dis 2015; 11:920-6. [DOI: 10.1016/j.soard.2014.10.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 10/07/2014] [Accepted: 10/09/2014] [Indexed: 01/05/2023]
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Effect of Cyclooxygenase-2-Specific Inhibitors on Postoperative Analgesia after Major Open Abdominal Surgery. Pain Manag Nurs 2015; 16:242-8. [DOI: 10.1016/j.pmn.2014.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 06/24/2014] [Accepted: 07/02/2014] [Indexed: 11/22/2022]
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Polderman JAW, Houweling PL, Hollmann MW, DeVries JH, Preckel B, Hermanides J. Study protocol of a randomised controlled trial comparing perioperative intravenous insulin, GIK or GLP-1 treatment in diabetes-PILGRIM trial. BMC Anesthesiol 2014; 14:91. [PMID: 25419179 PMCID: PMC4240889 DOI: 10.1186/1471-2253-14-91] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 10/07/2014] [Indexed: 01/04/2023] Open
Abstract
Background Diabetes mellitus (DM) is associated with poor outcome after surgery. The prevalence of DM in hospitalised patients is up to 40%, meaning that the anaesthesiologist will encounter a patient with DM in the operating room on a daily basis. Despite an abundance of published glucose lowering protocols and the known negative outcomes associated with perioperative hyperglycaemia in DM, there is no evidence regarding the optimal intraoperative glucose lowering treatment. In addition, protocol adherence is usually low and protocol targets are not simply met. Recently, incretins have been introduced to lower blood glucose. The main hormone of the incretin system is glucagon-like peptide–1 (GLP-1). GLP-1 increases insulin and decreases glucagon secretion in a glucose-dependent manner, resulting in glucose lowering action with a low incidence of hypoglycaemia. We set out to determine the optimal intraoperative treatment algorithm to lower glucose in patients with DM type 2 undergoing non-cardiac surgery, comparing intraoperative glucose-insulin-potassium infusion (GIK), insulin bolus regimen (BR) and GPL-1 (liragludite, LG) treatment. Methods/Design This is a multicentre randomised open label trial in patients with DM type 2 undergoing non-cardiac surgery. Patients are randomly assigned to one of three study arms; intraoperative glucose-insulin-potassium infusion (GIK), intraoperative sliding-scale insulin boluses (BR) or GPL-1 pre-treatment with liraglutide (LG). Capillary glucose will be measured every hour. If necessary, in all study arms glucose will be adjusted with an intravenous bolus of insulin. Researchers, care givers and patients will not be blinded for the assigned treatment. The main outcome measure is the difference in median glucose between the three study arms at 1 hour postoperatively. We will include 315 patients, which gives us a 90% power to detect a 1 mmol l−1 difference in glucose between the study arms. Discussion The PILGRIM trial started in January 2014 and will provide relevant information on the perioperative use of GLP-1 agonists and the optimal intraoperative treatment algorithm in patients with diabetes mellitus type 2. Trial registration ClinicalTrials.gov, NCT02036372
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Affiliation(s)
- Jorinde A W Polderman
- Department of Anaesthesiology, Academic Medical Centre, Amsterdam, the Netherlands, Postbus 22660, 1100 DD Amsterdam, the Netherlands
| | - Peter L Houweling
- Department of Anaesthesiology, Diakonessenhuis, Utrecht, the Netherlands, Bosboomstraat 1, 3582 KE Utrecht, the Netherlands
| | - Markus W Hollmann
- Department of Anaesthesiology, Academic Medical Centre, Amsterdam, the Netherlands, Postbus 22660, 1100 DD Amsterdam, the Netherlands
| | - J Hans DeVries
- Department of Internal Medicine, Academic Medical Centre, Amsterdam, the Netherlands, Postbus 22660, 1100 DD Amsterdam, the Netherlands
| | - Benedikt Preckel
- Department of Anaesthesiology, Academic Medical Centre, Amsterdam, the Netherlands, Postbus 22660, 1100 DD Amsterdam, the Netherlands
| | - Jeroen Hermanides
- Department of Anaesthesiology, Academic Medical Centre, Amsterdam, the Netherlands, Postbus 22660, 1100 DD Amsterdam, the Netherlands
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Şimşek T, Şimşek HU, Cantürk NZ. Response to trauma and metabolic changes: posttraumatic metabolism. ULUSAL CERRAHI DERGISI 2014; 30:153-9. [PMID: 25931917 DOI: 10.5152/ucd.2014.2653] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 03/03/2014] [Indexed: 11/22/2022]
Abstract
Stress response caused by events such as surgical trauma includes endocrine, metabolic and immunological changes. Stress hormones and cytokines play a role in these reactions. More reactions are induced by greater stress, ultimately leading to greater catabolic effects. Cuthbertson reported the characteristic response that occurs in trauma patients: protein and fat consumption and protection of body fluids and electrolytes because of hypermetabolism in the early period. The oxygen and energy requirement increases in proportion to the severity of trauma. The awareness of alterations in amino acid, lipid, and carbohydrate metabolism changes in surgical patients is important in determining metabolic and nutritional support. The main metabolic change in response to injury that leads to a series of reactions is the reduction of the normal anabolic effect of insulin, i.e. the development of insulin resistance. Free fatty acids are primary sources of energy after trauma. Triglycerides meet 50 to 80 % of the consumed energy after trauma and in critical illness. Surgical stress and trauma result in a reduction in protein synthesis and moderate protein degradation. Severe trauma, burns and sepsis result in increased protein degradation. The aim of glucose administration to surgical patients during fasting is to reduce proteolysis and to prevent loss of muscle mass. In major stress such as sepsis and trauma, it is important both to reduce the catabolic response that is the key to faster healing after surgery and to obtain a balanced metabolism in the shortest possible time with minimum loss. For these reasons, the details of metabolic response to trauma should be known in managing these situations and patients should be treated accordingly.
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Affiliation(s)
- Turgay Şimşek
- Clinic of General Surgery, Sakarya Toyotasa Emergency Service Hospital, Sakarya, Turkey
| | - Hayal Uzelli Şimşek
- Department of Obstetrics and Gynaecology Sakarya University Training and Research Hospital, Sakarya, Turkey
| | - Nuh Zafer Cantürk
- Department of General Surgery, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
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Koumpan Y, VanDenKerkhof E, van Vlymen J. An observational cohort study to assess glycosylated hemoglobin screening for elective surgical patients. Can J Anaesth 2014; 61:407-16. [PMID: 24585230 DOI: 10.1007/s12630-014-0124-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 02/11/2014] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION Uncontrolled blood glucose is associated with a higher incidence of surgical site infections, greater utilization of resources, and increased mortality. Preoperative screening for diabetes in elective surgical patients is not routinely performed. The purpose of this study was to examine blood glucose control in a preoperative surgical population. METHODS Following ethics approval, adults presenting to the pre-surgical screening clinic in preparation for elective surgery were recruited. Data collection included a self-administered questionnaire on diabetic risk factors and blood glucose testing, including glycosylated hemoglobin (HbA1c). Descriptive analyses were conducted. RESULTS Seventy of the 402 participants (17.4%) had a previous diagnosis of diabetes (diabetics). Among those without a history of diabetes (n = 332 non-diabetics), 23.2% (n = 77) were considered very high risk for diabetes (HbA1c = 6.0-6.4%), and 3.9% (n = 13) had a provisional diagnosis of diabetes (HbA1c ≥ 6.5%). Fifty-six percent (n = 39/70) of diabetics had suboptimal glycemic control (HbA1c > 7.0%), and 51.3% (n = 20/39) of this subgroup presumed their blood sugars were reasonably or very well controlled. Fifteen percent (n = 2/13) of patients with a provisional diagnosis of diabetes (HbA1c ≥ 6.5%) had an elevated random blood sugar (RBS) (≥ 11.1 mmol·L(-1)), while 67% (n = 8/12) had an elevated fasting blood sugar (FBS) (≥ 7.0 mmol·L(-1)). Forty-two percent (n = 16/38) of suboptimally controlled diabetics (HbA1c > 7.0%) had an elevated RBS (≥ 11.1 mmol·L(-1)), and 86% (n = 31/36) had an elevated FBS (≥ 7.0 mmol·L(-1)). DISCUSSION Many elective surgical patients are at risk for unrecognized postoperative hyperglycemia and associated adverse outcomes. Random blood sugar testing has limited value and HbA1c may be a more appropriate test for the preoperative assessment of diabetic patients.
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Affiliation(s)
- Yuri Koumpan
- Department of Anesthesiology and Perioperative Medicine, Kingston General Hospital, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada,
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Lidder P, Thomas S, Fleming S, Hosie K, Shaw S, Lewis S. A randomized placebo controlled trial of preoperative carbohydrate drinks and early postoperative nutritional supplement drinks in colorectal surgery. Colorectal Dis 2013; 15:737-45. [PMID: 23406311 DOI: 10.1111/codi.12130] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Accepted: 11/01/2012] [Indexed: 12/12/2022]
Abstract
AIM There is evidence that preoperative carbohydrate drinks and postoperative nutritional supplements improve the outcome of colorectal surgery. There is little information on their individual contribution. METHOD A prospective four-arm double-blind controlled trial was carried out in which patients were randomized to carbohydrate or placebo drinks preoperatively and a polymeric supplement or placebo drink postoperatively. The primary outcome was insulin resistance (using the short insulin tolerance test and HOMA-IR). Secondary outcomes included handgrip strength, pulmonary function, intestinal permeability and postoperative complications. RESULTS A total of 120 patients were randomized to four demographically well matched groups. Patients who received preoperative and postoperative supplements had better glucose homeostasis (P = 0.004), peak expiratory flow rate (P = 0.035), handgrip strength (P = 0.002) and less insulin resistance (P = 0.001) compared with those who only received placebo drinks. CONCLUSION Oral nutritional supplements given preoperatively and postoperatively improve postoperative handgrip strength, pulmonary function and insulin resistance. A weaker effect was seen in patients who received supplements either preoperatively or postoperatively. Oral nutritional supplements should be given both preoperatively and postoperatively.
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Affiliation(s)
- P Lidder
- Department of Surgery, Derriford Hospital, Plymouth, UK
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Hassanain M, Metrakos P, Fisette A, Doi SAR, Schricker T, Lattermann R, Carvalho G, Wykes L, Molla H, Cianflone K. Randomized clinical trial of the impact of insulin therapy on liver function in patients undergoing major liver resection. Br J Surg 2013; 100:610-8. [PMID: 23339047 DOI: 10.1002/bjs.9034] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Postoperative liver dysfunction is the major source of morbidity and mortality in patients undergoing partial hepatectomy. This study tested the benefits of a metabolic support protocol based on insulin infusion, for reducing liver dysfunction following hepatic resection. METHODS Consecutive consenting patients scheduled for liver resection were randomized to receive preoperative dextrose infusion followed by insulin therapy using the hyperinsulinaemic normoglycaemic clamp protocol (n = 29) or standard therapy (control group, n = 27). Patients in the insulin therapy group followed a strict dietary regimen for 24 h before surgery. Intravenous dextrose was started at 2 mg per kg per min the night before and continued until surgery. Hyperinsulinaemic therapy for a total of 24 h was initiated at 2 munits per kg per min at induction of anaesthesia, and continued at 1 munit per kg per min after surgery. Normoglycaemia was maintained (3.5-6.0 mmol/l). Control subjects received no additional dietary supplement and a conventional insulin sliding scale during fasting. All patients were tested serially to evaluate liver function using the Schindl score. Liver tissue samples were collected at two time points during surgery to measure glycogen levels. RESULTS Demographics were similar in the two groups. More liver dysfunction occurred in the control cohort (liver dysfunction score range 0-8 versus 0-4 with insulin therapy; P = 0.031). Median (interquartile range) liver glycogen content was 278 (153-312) and 431 (334-459) µmol/g respectively (P = 0.011). The number of complications rose with increasing severity of postoperative liver dysfunction (P = 0.032) CONCLUSION: The glucose-insulin protocol reduced postoperative liver dysfunction and improved liver glycogen content. REGISTRATION NUMBER NCT00774098 (http://www.clinicaltrials.gov).
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Affiliation(s)
- M Hassanain
- Department of Surgery, Royal Victoria Hospital, McGill University Health Centre, Canada
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Hui ML, Kumar A, Adams GG. Protocol-directed insulin infusion sliding scales improve perioperative hyperglycaemia in critical care. Perioper Med (Lond) 2012; 1:7. [PMID: 24764523 PMCID: PMC3964337 DOI: 10.1186/2047-0525-1-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 09/21/2012] [Indexed: 12/25/2022] Open
Abstract
Perioperative hyperglycaemia is associated with poor outcomes in patients undergoing cardiac surgery. Frequent postoperative hyperglycaemia in cardiac surgery patients has led to the initiation of an insulin infusion sliding scale for quality improvement. A systematic review was conducted to determine whether a protocol-directed insulin infusion sliding scale is as safe and effective as a conventional practitioner-directed insulin infusion sliding scale, within target blood glucose ranges. A literature survey was conducted to identify reports on the effectiveness and safety of an insulin infusion protocol, using seven electronic databases from 2000 to 2012: MEDLINE, CINAHL, EMBASE, the Cochrane Library, the Joanna Briggs Institute Library and SIGLE. Data were extracted using pre-determined systematic review and meta-analysis criteria. Seven research studies met the inclusion criteria. There was an improvement in overall glycaemic control in five of these studies. The implementation of protocols led to the achievement of blood glucose concentration targets more rapidly and the maintenance of a specified target blood glucose range for a longer time, without any increased frequency of hyperglycaemia. Of the seven studies, four used controls and three had no controls. In terms of the meta-analysis carried out, four studies revealed a failure of patients reaching target blood glucose levels (P < 0.0005) in the control group compared with patients in the protocol group. The risk of hypoglycaemia was significantly reduced (P <0.00001) between studies. It can be concluded that the protocol-directed insulin infusion sliding scale is safe and improves blood glucose control when compared with the conventional practitioner-directed insulin infusion sliding scale. This study supports the adoption of a protocol-directed insulin infusion sliding scale as a standard of care for post-cardiac surgery patients.
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Affiliation(s)
- Man Lin Hui
- The Queen Elizabeth Hospital, 30 Gascoigne Road, Kowloon, Hong Kong
| | - Arun Kumar
- Faculty of Medicine and Health Science, University of Nottingham, Clifton Boulevard, Nottingham, NG7 2RD, UK
| | - Gary G Adams
- Insulin and Diabetes Experimental Research (IDER) Group, Faculty of Medicine and Health Science, University of Nottingham, Clifton Boulevard, Nottingham, NG7 2RD, UK
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Hyperglycemia as a Risk Factor in the Perioperative Patient. AORN J 2012; 95:352-61; quiz 362-4. [DOI: 10.1016/j.aorn.2011.06.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2011] [Accepted: 06/01/2011] [Indexed: 01/08/2023]
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Survey of assessment and management of pain for critically ill adults. Intensive Crit Care Nurs 2011; 27:121-8. [PMID: 21398127 DOI: 10.1016/j.iccn.2011.02.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Revised: 02/01/2011] [Accepted: 02/05/2011] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To investigate critical care nurses' current practice and knowledge related to pain assessment and management for critically ill adults able and unable to self-report pain. DESIGN Cross sectional self-report survey. RESULTS Survey response rate was 57%. Though more respondents used formal pain assessment tools often or routinely for patients able to self-report compared to patients unable to communicate (P<0.0001), there was no difference in perceived importance of pain assessment tools. Nurses were less confident in their ability to accurately assess pain for patients unable to self-report (P<0.0001). Behaviours most frequently considered routinely indicative of pain were grimacing (88/140, 62.9%), vocalisation (78/140, 55.7%) and wincing (73/140, 52.1%). Haemodynamic instability, nursing workload and patient inability to communicate were the barriers considered to interfere with pain assessment and management most frequently. Enablers to effective management included pain prioritisation, and adequate prescription of analgesia. Most respondents (118/140 84.3%) had received continuing education on topics related to pain. CONCLUSIONS Though nurses considered pain assessment equally important for patients unable and able to selfreport, formal assessment tools were used less frequently and nurses were less confident in their ability to assess pain for patients unable to self-report.
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Protein balance in nondiabetic versus diabetic patients undergoing colon surgery: effect of epidural analgesia and amino acids. Reg Anesth Pain Med 2010; 35:355-60. [PMID: 20607877 DOI: 10.1097/aap.0b013e3181e66e4f] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Surgical injury provokes a stress response that is thought to be pronounced in patients with diabetes mellitus type 2 (DM2) leading to intensified catabolism. The aim of this study was to compare the effects of perioperative epidural analgesia (EDA) versus patient controlled analgesia (PCA) and amino acid infusion on postoperative metabolism in patients with and without DM2. METHODS For this study, 12 nondiabetic patients and 12 diabetic patients undergoing colorectal surgery were randomly assigned to 4 groups (n = 6 per group) receiving either EDA (nondiabetic EDA and diabetic EDA [DEDA group]) or PCA with morphine (nondiabetic PCA and diabetic PCA) for perioperative pain control. Protein and glucose kinetics were measured on the second postoperative day using L-[1-13C]leucine and [6,6-2H2]glucose infusion during a fasted state and a 3-hr fed state with amino acid infusion. RESULTS The transition from the fasted to fed state suppressed endogenous rate of appearance (Ra) of glucose (P G 0.001) with a distinct effect for the DEDA group (P G 0.001). The Ra of leucine and the endogenous rate of appearance of leucine tended to be lower in the DEDA group(P = 0.056 and P = 0.07). Leucine oxidation was more suppressed in the DEDA group (P = 0.02) and when receiving amino acids(P = 0.001). Diabetic patients achieved a higher protein balance than nondiabetic patients (P = 0.032) and when receiving EDA instead of PCA (P = 0.012) or infusion of amino acids (P = 0.014). CONCLUSIONS A short-term infusion of amino acids reduced protein breakdown, increased protein synthesis, and rendered protein balance positive. This anabolic effect was pronounced in diabetic patients with EDA compared with nondiabetic patients or PCA, respectively, and prevented an undesirable hyperglycemia.
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Ekström M, Halle M, Bjessmo S, Liska J, Kolak M, Fisher R, Eriksson P, Tornvall P. Systemic inflammation activates the nuclear factor-kappaB regulatory pathway in adipose tissue. Am J Physiol Endocrinol Metab 2010; 299:E234-40. [PMID: 20484010 DOI: 10.1152/ajpendo.00115.2010] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Adipose tissue (AT) is a store of energy but also an endocrine organ with the capacity to produce and release proinflammatory mediators into the circulation. The mechanism that may trigger human AT inflammation on a cellular level still remains largely unknown. The aim of this study was to investigate whether an acute systemic inflammation increases AT inflammatory activity, focused on innate immunity. Open heart surgery results in an extensive acute systemic inflammation. Therefore, we investigated the in vivo gene expression and production of inflammatory mediators in omental and subcutaneous AT stimulated by surgery. Biopsies from omental and subcutaneous AT were collected before and after cardiopulmonary bypass. Blood samples were collected at the same time as the AT biopsies and plasma IL-6 levels were measured with ELISA. RT-PCR was used for quantification of relative AT gene expression. To verify the gene expression results on a protein level, we used immunohistochemistry and microdialysis. After surgery, in both omental and subcutaneous AT, there was a strong upregulation of nuclear factor-kappaB-regulated genes, e.g., chemokine ligand-2, E-selectin, IL-1beta, IL-6, IL-8, and Toll-like receptor-2. Immunohistochemistry showed staining for E-selectin associated with a high number of macrophages in close contact with and in the vascular wall. Increased levels of IL-6 were detected in microdialysate from subcutaneous AT. In conclusion, we present the novel finding that this model of inflammation induced a strong inflammatory response in both omental and subcutaneous AT including adhesion of macrophages to an activated endothelium and release of IL-6 from AT interstitium. It can be hypothesized that AT exerts a modulatory effect on innate immunity in humans.
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Affiliation(s)
- Mattias Ekström
- Cardiology Unit and Atherosclerosis Research Unit, Department of Medicine, Karolinska University Hospital, Solna, Stockholm, Sweden.
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Hörer T, Norgren L, Jansson K. Complications but not obesity or diabetes mellitus have impact on the intraperitoneal lactate/pyruvate ratio measured by microdialysis. Scand J Gastroenterol 2010; 45:115-21. [PMID: 19961346 DOI: 10.3109/00365520903386713] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Studies have shown a higher risk of postoperative complications in diabetic and obese patients. An increased intraperitoneal lactate/pyruvate ratio as measured by microdialysis has been reported before postoperative complications have been discovered. It is not known whether diabetes or obesity have any influence on the intraperitoneal metabolism (lactate/pyruvate ratio, glucose, glycerol) in relation to major abdominal surgery. The aim of this study was to investigate the postoperative intraperitoneal and subcutaneous carbohydrate and fat metabolism as measured by microdialysis in obese and diabetic patients after major abdominal surgery without postoperative complications. MATERIAL AND METHODS Seven obese patients (body mass index > 30 kg/m(2)) and six diabetic but non-obese patients were studied up to 48 h after major abdominal surgery and were compared with 31 non-diabetic, non-obese patients, all without complications. Microdialysis was performed to measure glucose, lactate, pyruvate and glycerol intraperitoneally and subcutaneously. The lactate/pyruvate ratio was calculated. RESULTS The lactate/pyruvate ratio did not differ between the groups. In the diabetic patients, glucose levels were higher intraperitoneally at both Days 1 and 2 compared to controls. Higher glycerol levels were found subcutaneously in obese patients at Day 2. CONCLUSIONS The lactate/pyruvate ratio does not increase intraperitoneally after non-complicated major abdominal surgery in diabetic and obese patients. Obese patients have increased release of free fatty acids and glycerol subcutaneously, while diabetic patients show higher glucose levels intraperitoneally than controls.
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Affiliation(s)
- Tal Hörer
- Department of Surgery, University Hospital, Orebro, Sweden.
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Ead H. Glycemic control and surgery-optimizing outcomes for the patient with diabetes. J Perianesth Nurs 2010; 24:384-95. [PMID: 19962105 DOI: 10.1016/j.jopan.2009.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2009] [Revised: 08/07/2009] [Accepted: 10/14/2009] [Indexed: 11/19/2022]
Abstract
Diabetes mellitus (DM) has reached epidemic proportions globally, and its incidence continues to rise. Considering the increasing number of patients diagnosed with diabetes and the associated complications, such as cardiovascular and renal disease, the complexity of care for this population can be very challenging. In addition, specific postoperative complications, such as delayed wound healing, infections, and cardiac dysrhythmias, are more likely to occur in the presence of perioperative hyperglycemia. Recognition of the presence of diabetes and implementation of a diabetic management protocol will optimize patient outcomes by providing guidelines for avoiding such complications. Although comparative studies of the current published protocols are limited, there is agreement that health care facilities must have a protocol in place that considers the individual's health history, planned surgery, and glycemic control to guide management of diabetes.
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Affiliation(s)
- Heather Ead
- PACU, Day Surgery, Trillium Health Centre, Mississauga, Ontario L5B 2B6, Canada.
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The relationship between glycosylated hemoglobin and perioperative glucose control in patients with diabetes. Can J Anaesth 2010; 57:322-9. [PMID: 20127531 DOI: 10.1007/s12630-010-9266-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2009] [Accepted: 01/07/2010] [Indexed: 01/04/2023] Open
Abstract
PURPOSE Hyperglycemia and elevated glycosylated hemoglobin (HbA(1c)) are associated with perioperative morbidity in patients with diabetes, but the relationship between long-term glycemic control and perioperative glucose control is unknown. The purpose of this study was to determine the relationship between glycosylated hemoglobin (HbA(1c)) and perioperative glucose in fasting patients with type 2 diabetes undergoing elective non-cardiac surgery. METHODS This was a prospective observational study of 244 adult patients with type 2 diabetes who were evaluated before elective non-cardiac surgery at a preoperative medicine clinic in a tertiary care medical centre during the period September 2004 to May 2005. Preoperative HbA(1c) levels were determined, and preoperative and postoperative glucose values were measured on the day of surgery. The primary outcome variables were preoperative and postoperative blood glucose values. RESULTS Half of all study patients had an HbA(1c) > or = 7%, including 23% of patients with HbA(1c) >/= 8%. HbA(1c) levels predict preoperative glucose levels, and preoperative glucose levels and duration of surgery predict postoperative glucose levels. Glucose levels in one-third of the patients with type 2 diabetes decreased during surgery without administration of insulin or glucose-regulating medications. CONCLUSION HbA(1c) values may serve as biomarkers for glucose control during the immediate perioperative period in patients with type 2 diabetes undergoing elective surgery.
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Wang ZG, Wang Q, Wang WJ, Qin HL. Randomized clinical trial to compare the effects of preoperative oral carbohydrate versus placebo on insulin resistance after colorectal surgery. Br J Surg 2010; 97:317-27. [PMID: 20101593 DOI: 10.1002/bjs.6963] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Abstract
Background
Preoperative oral carbohydrate (OCH) reduces postoperative insulin resistance (PIR). This randomized trial investigated whether this effect is related to insulin-induced activation of the phosphatidylinositol 3-kinase (PI3K)/protein kinase B (PKB) signalling pathway.
Methods
Patients with colorectal cancer scheduled for elective open resection were randomly assigned to preoperative OCH, fasting or placebo. Preoperative general well-being, insulin resistance before and immediately after surgery, and postoperative expression of PI3K, PKB, protein tyrosine kinase (PTK) and glucose transporter 4 (GLUT4) in rectus abdominis muscle were evaluated.
Results
Patient and operative characteristics did not differ between groups. Subjective well-being was significantly better in OCH and placebo groups than in the fasting group, primarily because of reduced thirst (P = 0·005) and hunger (P = 0·041). PIR was significantly greater in fasting and placebo groups (P < 0·010). By the end of surgery, muscle PTK activity as well as PI3K and PKB levels were significantly increased in the OCH group compared with values in fasting and placebo groups (P < 0·050), but GLUT4 expression was unaffected.
Conclusion
PIR involves the PI3K/PKB signalling pathway. Preoperative OCH intake improves preoperative subjective feelings of hunger and thirst compared with fasting, while attenuating PIR by stimulation of the PI3K/PKB pathway. Registration number: NCT00755729 (http://www.clinicaltrials.gov).
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Affiliation(s)
- Z G Wang
- Department of General Surgery, Shanghai Chang Zheng Hospital, Second Military Medical University, Shanghai, China
| | - Q Wang
- Department of General Surgery, Shanghai Chang Zheng Hospital, Second Military Medical University, Shanghai, China
| | - W J Wang
- Department of General Surgery, Shanghai Chang Zheng Hospital, Second Military Medical University, Shanghai, China
| | - H L Qin
- Department of General Surgery, Shanghai Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
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Abstract
Several studies have shown a relationship between poor outcome and uncontrolled blood glucose (BG) in cardiac, neurosurgical, critical care, and general surgical patients. A major study showed that tight glycemic control (80-110mg/dl) was related to increased mortality. Based on evidence from controlled studies, the American Diabetes Association, and the Society of Thoracic Surgeons, maintaining intraoperative BG levels in the 140-180 mg/dl range seems appropriate. Optimization of the patient's preoperative medications and the use of insulin infusions, as well as surgical and anesthetic technique, are important factors for achieving desirable perioperative BG control. Minimizing BG variability during surgery should be part of the glycemic control strategy. Advances in real-time glucose monitoring may soon benefit hospitalized diabetes and nondiabetes patients.
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Affiliation(s)
- Tejal A Raju
- Department of Anesthesiology, Cooper University Hospital, The Robert Wood Johnson Medical School, UMDNJ, Camden, New Jersey 08103, USA
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Kao LS, Meeks D, Moyer VA, Lally KP. Peri-operative glycaemic control regimens for preventing surgical site infections in adults. Cochrane Database Syst Rev 2009:CD006806. [PMID: 19588404 PMCID: PMC2893384 DOI: 10.1002/14651858.cd006806.pub2] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Surgical site infections (SSIs) are associated with significant morbidity, mortality, and resource utilization and are potentially preventable. Peri-operative hyperglycaemia has been associated with increased SSIs and previous recommendations have been to treat glucose levels above 200 mg/dL. However, recent studies have questioned the optimal glycaemic control regimen to prevent SSIs. Whether the benefits of strict or intensive glycaemic control with insulin infusion as compared to conventional management outweigh the risks remains controversial. OBJECTIVES To summarise the evidence for the impact of glycaemic control in the peri-operative period on the incidence of surgical site infections, hypoglycaemia, level of glycaemic control, all-cause and infection-related mortality, and hospital length of stay and to investigate for differences of effect between different levels of glycaemic control. SEARCH STRATEGY A search strategy was developed to search the following databases: Cochrane Wounds Group Specialised Register (searched 25 March 2009), The Cochrane Central Register of Controlled Trials, The Cochrane Library 2009, Issue 1; Ovid MEDLINE (1950 to March Week 2 2009); Ovid EMBASE (1980 to 2009 Week 12) and EBSCO CINAHL (1982 to March Week 3 2009). The search was not limited by language or publication status. SELECTION CRITERIA Randomised controlled trials (RCTs) were eligible for inclusion if they evaluated two (or more) glycaemic control regimens in the peri-operative period (within one week pre-, intra-, and/or post-operative) and reported surgical site infections as an outcome. DATA COLLECTION AND ANALYSIS The standard method for conducting a systematic review in accordance with the Cochrane Wounds Group was used. Two review authors independently reviewed the results from the database searches and identified relevant studies. Two review authors extracted study data and outcomes from each study and reviewed each study for methodological quality. Any disagreement was resolved by discussion or by referral to a third review author. MAIN RESULTS Five RCTs met the pre-specified inclusion criteria for this review. No trials evaluated strict glycaemic control in the immediate pre-operative period or outside the intensive care unit. Due to heterogeneity in patient populations, peri-operative period, glycaemic target, route of insulin administration, and definitions of outcome measures, combination of the results of the five included trials into a meta-analysis was not appropriate. The methodological quality of the trials was variable. In terms of outcomes, only one trial demonstrated a significant reduction in SSIs with strict glycaemic control, but the quality of this trial was difficult to assess as a result of poor reporting; furthermore the baseline rate of SSIs was high (30%). The other trials were either underpowered to detect a difference in SSIs, due to a low baseline rate (less than or equal to 5%), or did not report SSIs as a single outcome but as part of a composite. Of the three trials reporting hypoglycaemia (which was not consistently defined) all had a higher rate in the strict glycaemic control group but none attributed significant morbidity to the hypoglycaemia. Adequacy of glucose control between groups was measured differently among studies. Studies could not be compared due to differences in target ranges, and were susceptible to measurement bias due to differences in frequency of measurement and lack of blinding by the providers following the glycaemic protocols. Infection-related mortality was not reported in any of the trials, and no trials demonstrated a significant difference in all-cause mortality. Length of hospital stay was significantly reduced in the strict glycaemic control groups in only one trial. AUTHORS' CONCLUSIONS There is insufficient evidence to support strict glycaemic control versus conventional management (maintenance of glucose < 200 mg/dL) for the prevention of SSIs. No trials were found that evaluated strict glycaemic control in the immediate pre-operative period or outside the setting of an intensive care unit. The trials were limited by small sample size, inconsistencies in the definitions of the outcome measures and methodological quality. Further large randomised trials are required to address this question and may be most appropriately performed in patients at high risk for SSIs.
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Affiliation(s)
- Lillian S Kao
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Derek Meeks
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Virginia A Moyer
- Academic General Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
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Braga M, Ljungqvist O, Soeters P, Fearon K, Weimann A, Bozzetti F. ESPEN Guidelines on Parenteral Nutrition: surgery. Clin Nutr 2009; 28:378-86. [PMID: 19464088 DOI: 10.1016/j.clnu.2009.04.002] [Citation(s) in RCA: 384] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Accepted: 04/01/2009] [Indexed: 12/15/2022]
Abstract
In modern surgical practice it is advisable to manage patients within an enhanced recovery protocol and thereby have them eating normal food within 1-3 days. Consequently, there is little room for routine perioperative artificial nutrition. Only a minority of patients may benefit from such therapy. These are predominantly patients who are at risk of developing complications after surgery. The main goals of perioperative nutritional support are to minimize negative protein balance by avoiding starvation, with the purpose of maintaining muscle, immune, and cognitive function and to enhance postoperative recovery. Several studies have demonstrated that 7-10 days of preoperative parenteral nutrition improves postoperative outcome in patients with severe undernutrition who cannot be adequately orally or enterally fed. Conversely, its use in well-nourished or mildly undernourished patients is associated with either no benefit or with increased morbidity. Postoperative parenteral nutrition is recommended in patients who cannot meet their caloric requirements within 7-10 days orally or enterally. In patients who require postoperative artificial nutrition, enteral feeding or a combination of enteral and supplementary parenteral feeding is the first choice. The main consideration when administering fat and carbohydrates in parenteral nutrition is not to overfeed the patient. The commonly used formula of 25 kcal/kg ideal body weight furnishes an approximate estimate of daily energy expenditure and requirements. Under conditions of severe stress requirements may approach 30 kcal/kg ideal body weights. In those patients who are unable to be fed via the enteral route after surgery, and in whom total or near total parenteral nutrition is required, a full range of vitamins and trace elements should be supplemented on a daily basis.
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Affiliation(s)
- M Braga
- Department of Surgery, San Raffaele University, Milan, Italy
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Preoperative Fasting of 2 Hours Minimizes Insulin Resistance and Organic Response to Trauma After Video-Cholecystectomy: A Randomized, Controlled, Clinical Trial. World J Surg 2009; 33:1158-64. [DOI: 10.1007/s00268-009-0010-x] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Witasp A, Nordfors L, Schalling M, Nygren J, Ljungqvist O, Thorell A. Increased expression of inflammatory pathway genes in skeletal muscle during surgery. Clin Nutr 2009; 28:291-8. [PMID: 19346035 DOI: 10.1016/j.clnu.2009.03.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2008] [Revised: 02/18/2009] [Accepted: 03/01/2009] [Indexed: 01/24/2023]
Abstract
BACKGROUND & AIMS Postoperative insulin resistance, resulting in hyperglycemia, is strongly associated to morbidity and mortality in surgical patients but the underlying mechanisms are unclear. As increasing data suggests a link between inflammation and insulin resistance, we aimed to evaluate if the expression of inflammatory and insulin signaling genes is regulated in skeletal muscle during surgery. METHODS Eight patients (4 females, 63 [46-69] years, body mass index 25.5 [16.5-29.8]kg/m(2)) undergoing major abdominal surgery were included. Biopsies from m. rectus abdominis were obtained at the beginning and at the end of the operation. mRNA levels of 45 genes were analyzed. RESULTS The time elapsed between the two biopsies was 224 (198-310) min. An increased (p<0.05) expression was noted for genes encoding both inflammatory mediators, such as interleukin 6, tumor necrosis factor, and nuclear factor of kappa light polypeptide gene enhancer in B cells, and metabolic regulators, such as peroxisome proliferator-activated receptor delta, while the analysis did not detect significant expression changes of the insulin signaling pathway genes. CONCLUSIONS The observed gene expression changes in skeletal muscle during surgery occurred mainly in inflammatory pathways, suggesting a possible role for inflammation in the development of postoperative insulin resistance.
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Affiliation(s)
- Anna Witasp
- Karolinska Institutet, Department of Molecular Medicine and Surgery, Centre for Molecular Medicine, Karolinska University Hospital, Stockholm, Sweden.
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Insulin and antidiabetic drugs--implications for the perioperative setting. J Perianesth Nurs 2008; 23:426-9. [PMID: 19038750 DOI: 10.1016/j.jopan.2008.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2008] [Accepted: 09/09/2008] [Indexed: 11/22/2022]
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Dunwoody CJ, Krenzischek DA, Pasero C, Rathmell JP, Polomano RC. Assessment, physiological monitoring, and consequences of inadequately treated acute pain. Pain Manag Nurs 2008; 9:S11-21. [PMID: 18294590 DOI: 10.1016/j.pmn.2007.11.006] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Postoperative pain is a major health care issue. Several factors have contributed to inadequate postoperative pain control, including a lack of understanding of preemptive pain management strategies, mistaken beliefs and expectations of patients, inconsistencies in pain assessment practices, use of as-needed analgesics that patients must request, and lack of analgesic regimens that account for interindividual differences and requirements. Untreated acute pain has the potential to produce acute neurohumoral changes, neuronal remodeling, and long-lasting psychologic and emotional distress and may lead to prolonged chronic pain states. To effectively manage postoperative pain, nurses must be able to adequately assess pain severity in diverse patient populations, understand how to monitor physiologic changes associated with pain and its treatment, be prepared to address the psychosocial experiences accompanying pain, and know the consequences of inadequate analgesia. It is important for nurses to be aware of relevant research and evidence-based guidelines that are available to guide pain assessments and patient monitoring practices.
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Dunwoody CJ, Krenzischek DA, Pasero C, Rathmell JP, Polomano RC. Assessment, physiological monitoring, and consequences of inadequately treated acute pain. J Perianesth Nurs 2008; 23:S15-27. [PMID: 18226790 DOI: 10.1016/j.jopan.2007.11.007] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Postoperative pain is a major health care issue. Several factors have contributed to inadequate postoperative pain control, including a lack of understanding of preemptive pain management strategies, mistaken beliefs and expectations of patients, inconsistencies in pain assessment practices, use of as-needed analgesics that patients must request, and lack of analgesic regimens that account for inter-individual differences and requirements. Untreated acute pain has the potential to produce acute neurohumoral changes, neuronal remodeling, and long-lasting psychological and emotional distress, and may lead to prolonged chronic pain states. To effectively manage postoperative pain, nurses must be able to adequately assess pain severity in diverse patient populations, understand how to monitor physiological changes associated with pain and its treatment, be prepared to address the psychosocial experiences accompanying pain, and know the consequences of inadequate analgesia. It is important for nurses to be aware of relevant research and evidence-based guidelines that are available to guide pain assessments and patient-monitoring practices.
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Zargar-Shoshtari K, Hill AG. OPTIMIZATION OF PERIOPERATIVE CARE FOR COLONIC SURGERY: A REVIEW OF THE EVIDENCE. ANZ J Surg 2008; 78:13-23. [DOI: 10.1111/j.1445-2197.2007.04350.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Vick MM, Murphy BA, Sessions DR, Reedy SE, Kennedy EL, Horohov DW, Cook RF, Fitzgerald BP. Effects of systemic inflammation on insulin sensitivity in horses and inflammatory cytokine expression in adipose tissue. Am J Vet Res 2008; 69:130-9. [DOI: 10.2460/ajvr.69.1.130] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Abstract
Objective—To determine whether an inflammatory challenge induces insulin resistance in horses and examine possible contributions of adipose tissue to inflammatory cytokine production.
Animals—15 adult mares.
Procedures—Lipopolysaccharide (0.045 μg/kg, IV) or saline solution was administered, and insulin sensitivity was determined by means of the hyperinsulinemic, euglycemic clamp procedure or an adipose tissue biopsy was performed. Adipose tissue samples were collected, and mature adipocytes were obtained. Mature adipocytes were stimulated with lipopolysaccharide or dedifferentiated into preadipocytes and then stimulated with lipopolysaccharide. Interleukin-1, interleukin-6, and tumor necrosis factor A expression in blood, adipose tissue, and adipocytes was quantified with a real-time, reverse transcriptase– PCR assay.
Results—Lipopolysaccharide induced a transient increase in insulin sensitivity followed by a reduction in insulin sensitivity at 24 hours. Increased cytokine expression was observed in blood and adipose tissue following administration of lipopolysaccharide, and adipocytes and preadipocytes stimulated with lipopolysaccharide stained positive for tumor necrosis factor A. Expression of interleukin-1, interleukin-6, and tumor necrosis factor A was detected in preadipocytes stimulated with lipopolysaccharide, and interleukin-6 and tumor necrosis factor A were detected in mature adipocytes stimulated with lipopolysaccharide.
Conclusions and Clinical Relevance—Results indicated that insulin resistance develops following systemic inflammation in horses and suggested that adipose tissue may contribute to this inflammatory response. Methods to regulate insulin sensitivity may improve clinical outcome in critically ill patients.
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Lundholm K, Körner U, Gunnebo L, Sixt-Ammilon P, Fouladiun M, Daneryd P, Bosaeus I. Insulin treatment in cancer cachexia: effects on survival, metabolism, and physical functioning. Clin Cancer Res 2007; 13:2699-706. [PMID: 17473202 DOI: 10.1158/1078-0432.ccr-06-2720] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE The present study was designed to evaluate whether daily insulin treatment for weight-losing cancer patients attenuates the progression of cancer cachexia and improves metabolism and physical functioning in palliative care. EXPERIMENTAL DESIGN One hundred and thirty-eight unselected patients with mainly advanced gastrointestinal malignancy were randomized to receive insulin (0.11 +/- 0.05 units/kg/d) plus best available palliative support [anti-inflammatory treatment (indomethacin), prevention of anemia (recombinant erythropoietin), and specialized nutritional care (oral supplements + home parenteral nutrition)] according to individual needs. Control patients received the best available palliative support according to the same principles. Health-related quality of life, food intake, resting energy expenditure, body composition, exercise capacity, metabolic efficiency during exercise, and spontaneous daily physical activity as well as blood tests were evaluated during follow-up (30-824 days) according to intention to treat. RESULTS Patient characteristics at randomizations were almost identical in study and control groups. Insulin treatment for 193 +/- 139 days (mean +/- SD) significantly stimulated carbohydrate intake, decreased serum-free fatty acids, increased whole body fat, particularly in trunk and leg compartments, whereas fat-free lean tissue mass was unaffected. Insulin treatment improved metabolic efficiency during exercise, but did not increase maximum exercise capacity and spontaneous physical activity. Tumor markers in blood (CEA, CA-125, CA 19-9) did not indicate the stimulation of tumor growth by insulin; a conclusion also supported by improved survival of insulin-treated patients (P<0.03). CONCLUSION Insulin is a significant metabolic treatment in multimodal palliation of weight-losing cancer patients.
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Affiliation(s)
- Kent Lundholm
- Department of Surgery, Sahlgrenska University Hospital, Göteborg University, Göteborg, Sweden.
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LJUNGQVIST OLLE, HAUSEL JONATAN, NYGREN JONAS, THORELL ANDERS, SOOP MATTIAS. Preoperative patient preparation for enhanced recovery after surgery. ACTA ACUST UNITED AC 2007. [DOI: 10.1111/j.1778-428x.2007.00045.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Søreide E, Ljungqvist O. Modern preoperative fasting guidelines: a summary of the present recommendations and remaining questions. Best Pract Res Clin Anaesthesiol 2007; 20:483-91. [PMID: 17080698 DOI: 10.1016/j.bpa.2006.03.002] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
This chapter is complementary to the others in this volume focusing on preoperative fasting routines. In it we discuss some of the issues in need of more research to define best practice. One of these is the role of fasting in emergency patients. Modern preoperative fasting recommendations almost exclusively deal with elective patients. In emergency patients preoperative fasting cannot secure gastric emptying to reduce the risk of pulmonary aspiration. Hence, surgery should be timed according to the urgency of the situation, and the patient should always be treated as if the stomach was full. More data are needed to better define what is going on in the gastrointestinal tract during the perioperative period in these patients. In certain patient groups--such as patients with diabetes, gastro-oesophageal reflux disease and/or obesity--the data are insufficient to give complete guidance to best practice. Preoperative fasting guidelines also affect fluid balance and perioperative fluid management, a topic of debate in recent years. In addition, carbohydrate-enriched fluids for oral use in the preoperative phase have been shown to have a positive effect on postoperative metabolism. Recent studies also suggest that the immune system would be less affected by surgery with such preparations. Last but not least, new scientific evidence alone is not enough to change daily practice. Active implementation of new evidence is also needed. To improve perioperative care, anaesthesiologists, surgeons and the nursing staff must work together.
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Affiliation(s)
- Eldar Søreide
- Department of Anaesthesia, Division of Acute Care Medicine, Stavanger University Hospital, Stavanger, Norway.
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