glucosePeriop - Perioperative Glucose Management An...

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Perioperative Glucose Management Charles E. Smith, MD, FRCPC Professor, Case Western Reserve University Director, Cardiothoracic and Trauma Anesthesia MetroHealth Medical Center Cleveland, OH An Evolving Standard of Care
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Objectives Harmful effects of hyperglycemia Beneficial effects of insulin + glycemic control Observational studies Interventional studies Protocol implementation
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Surgery Stress + fasting associated with surgery leads to relative insulin deficiency ↑ insulin resistance ↓ insulin secretion Insulin deficiency leads to hyperglycemia + excess circulating free fatty acids Gandhi GY et al. Mayo Clin Proc 2008;83:418-30
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Surgical stress Degree of hyperglycemia depends on severity + extent of tissue trauma; anesthesia factors Elective intraperitoneal surgery +nondiabetics: ↑ 126-180 mg/dL (7-10 mmol/L) Cardiac surgery: impressive disturbance of glucose homeostasis. > 270 mg/dL (15 mmol/L) in nondiabetics > 360 mg/dL (20 mmol/L) in diabetics Schricker + Carvalho. J CTVA 2005;19:684-8
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Surgical stress + hyperglycemia Typical metabolic + endocrine alterations ↑ glucose production ↓ glucose utilization ↑ renal absorption of filtered glucose ↓ insulin activity Cardiac surgery: pancreatic hypoperfusion, excess glucose in prime + cardioplegia, hypothermia Schricker + Carvalho J CTVA 2005. Smith et al: JCTVA 2005;19:201-8
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Immune system + hyperglycemia Impaired microvascular response Adhesion + transmigration of leucocytes Complement cascade Cytokine network Chemokine formation Chemotaxis, phagocytosis • Generation of reactive O 2 species Neutrophil apoptosis Turina M. CCM 2005;33:1624
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Beneficial effects of glycemic control Protects hepatocytic mitochondria Improved PMN neutrophil function Better bactericidal + opsonic activity Partial correction of abnormal serum lipids Counteracts catabolism of critical illness ↑ endothelial function + myocardial protection ↓ inflammation + apoptosis Brindley et al. CJA 2006;53:947-9
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Beneficial effects of insulin Stimulates glucose uptake + lipogenesis Inhibits lipolysis, proteolysis +glycogenolysis Multiple nonmetablic effects: ↓ levels circulating adhesion molecule + E-selectin ↓ circulating NO levels by suppressing inducible nitric oxide synthetase gene expression Protects vascular endothelium from injury Prevents organ system dysfunction Schricker J CTVA 2005. Langouche et al. J Clin Invest 2005.
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This note was uploaded on 12/16/2011 for the course BIOLOGY 101 taught by Professor Mr.wallace during the Fall '11 term at Montgomery College.

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glucosePeriop - Perioperative Glucose Management An...

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