Postoperative insulin secretion is decreased in patients with preoperative insulin resistance

Glycemic profile and quality of recovery after emergency abdominal surgery-A prospective explorative cohort study

Associations between degrees of postoperative hyperglycemia and morbidity has previously been established. There may be an association between the glycemic profile and patient-reported recovery, and this may be a target for perioperative quality improvements. We aimed to investigate the association between metrics of the 30-day glycemic profile and patient-reported recovery in nondiabetic patients after major abdominal surgery. In a prospective, explorative cohort study, nondiabetic adult patients undergoing acute, major abdominal surgery were included within 24 h after surgery. Interstitial fluid glucose concentration was measured for 30 consecutive days with a continuous glucose measurement device. The validated questionnaire 'Quality of Recovery-15' was used to assess patient-reported quality of recovery on postoperative days 10, 20, and 30. Follow-up time was divided into five-day postoperative intervals using days 26-30 as a reference. Linear mixed models were applied to investigate temporal changes in mean p-glucose, coefficient of variation, time within 70-140 mg/dl, and time above 200 mg/dl in relation to patient-reported recovery. Twenty-seven patients completed the study per protocol. A hyperglycemic event (>200 mg/dl) occurred in 18 of 27 patients (67%) within the first three postoperative days. Compared to the reference period, the coefficient of variation was significantly increased during all time intervals, indicating prolonged postoperative insulin resistance. During 30 days of follow-up, patient-reported recovery was associated with the coefficient of variation measured for 3 and 5 days before the corresponding recovery score assessment (recovery score estimate -1.52 [p < .001] and -0.92 [p = .006], respectively). We did not find an association between the remaining metrics and patient-reported recovery. Alterations in the glycemic profile are frequent and prolonged during the first postoperative month after major surgery probably due to peripheral insulin resistance. Our findings indicate that high-glycemic variation is associated with poorer patient-reported recovery and might represent a proxy for care improvements in the postoperative period.

Pain Management of Hallux Valgus Surgery Is Achieved by Cocktail Therapy

Background. Hallux valgus is a relatively common forefoot disease in clinical practice. The aim of our study was to assess the role of local cocktail drugs and postoperative pain after hallux valgus surgery. Methods. A retrospective case-control study was conducted to analyze 75 moderate to severe hallux valgus patients from June 1, 2018 to December 1, 2019. All patients were divided into cocktail and control groups according to whether the cocktail therapy was used or not after the operation. The anesthesiologist did not provide analgesic treatment other than nerve block anesthesia and intravenous anesthesia, such as analgesic pumps. The operative region of the cocktail group received a mixture of 10 ml of 0.75% ropivacaine, 10 ml of flurbiprofen axetil injection, and 1 ml of compound betamethasone injection, whereas the control group received nothing in the surgical spot. We recorded patients’ VAS scores preoperatively and at 6, 24 hours postoperatively; the length of hospital stay and the number of hospitalization expenses; the scores of Kolcaba comfort level; and the scores of Pittsburgh sleep quality. Result. There was no significant difference in age or sex between the two groups. The VAS scores at 6 and 24 hours postoperatively were significantly lower in the cocktail group. The average length of hospital stay was 8.24 days in the control group and 3.73 days in the cocktail group. The average total hospitalization cost of the control group was ¥28285.16, and that of the cocktail group was ¥22366.31. In expenses of total hospitalization costs, the cocktail group was lower than the control group. Kolcaba’s comfort various scores and the total score of the cocktail group were higher than the control group. The total score of PSQI and all dimensions in the experimental group were lower than those in the control group. Conclusion. We found a significant difference in the results of postoperative pain management except for age, sex, and hospitalization expenses. After hallux valgus surgery, inject cocktail drugs around the first metatarsophalangeal joint did reduce postoperative pain level. Level of Evidence. Level III, case-control study.

Prehabilitation: metabolic considerations

PURPOSE OF REVIEW

The major components of ERAS attenuate the inflammatory response and modulate metabolism in direction of sparing body protein and preserving function. However, these perioperative interventions might have limited effectiveness on postoperative outcomes if preoperative risk factors are not addressed and optimized.

RECENT FINDINGS

The preoperative metabolic perturbations characterized by insulin resistance and sarcopenia might predispose patients to a higher degree of postoperative catabolism. High-risk populations for such metabolic disturbances include elderly and frail patients, and patients with metabolic syndrome. Research on the effect of prehabilitation on perioperative metabolism is limited, but recent findings suggest that interventions designed to improve insulin sensitivity prior to surgery might represent a promising therapeutic target to minimize surgical complications.

SUMMARY

The present paper will discuss the metabolic implications of modulating preoperative risk factors with elements of multimodal prehabilitation, such as exercise training and nutrition.

Isoflurane aggravates peripheral and central insulin resistance in high-fat diet/streptozocin-induced type 2 diabetic mice

Isoflurane anesthesia is reported to induce insulin resistance (IR) in the peripheral tissues. However, researches on the impact of isoflurane on insulin-related metabolism in the central nervous system, especially in type 2 diabetes mellitus (T2DM), are scarce. This study sought to explore whether isoflurane anesthesia had a negative effect on insulin sensitivity both in peripheral and central tissues. Moreover, the possible role of isoflurane anesthesia in T2DM mice with pre-existing IR was analyzed. T2DM model in C57BL/6J mice was established by high fat diet (HFD) and single intraperitoneal injection of streptozotocin (STZ, 60 mg/kg). Both HFD/STZ-induced T2DM mice and normal mice received 6 h isoflurane exposure. Blood glucose level and serum insulin concentration were detected and the homeostasis model assessment of IR (HOMA-IR) index was calculated to estimate peripheral IR. Relative levels of genes and proteins in the insulin-dependent signaling pathway in mouse prefrontal cortex and hippocampus were determined to measure central IR. Results indicated that 6 h isoflurane exposure induced hyperglycemia, hyperinsulinemia and raised HOMA-IR index. Meanwhile, phosphorylated insulin receptor substrate-1 (pIRS1) (Ser639) and phosphorylated insulin receptor substrate-2 (pIRS2) (Ser731) were upregulated, while phosphorylated protein kinase B (pAKT) (Ser473) and phosphorylated glycogen synthase kinase-3 beta (pGSK3β) (Ser9) were downregulated in the prefrontal cortex and hippocampus of anesthetized mice. Notably, isoflurane anesthesia significantly aggravated the degree of central IR in the aspects of gene transcriptions and protein expressions in HFD/STZ-induced T2DM mice with pre-existing IR. This study suggested that isoflurane anesthesia induced peripheral and central IR and aggravated pre-existing insulin resistance in T2DM mice.