Perioperative catabolism.

Purpose: This article reviews the pathophysiology, clinical relevance, and therapy of the catabolic response to surgical stress.

Principle Findings: The key clinical features of perioperative catabolism are hyperglycemia and loss of body protein, both metabolic consequences of impaired insulin function. Muscle weakness and (even moderate) increases in perioperative blood glucose are associated with morbidity after major surgery.

Glucose and insulin administration while maintaining normoglycemia inhibits whole body protein breakdown and synthesis after cardiac surgery.

We investigated the effect of insulin administered as part of a hyperinsulinemic-normoglycemic clamp on protein metabolism after coronary artery bypass grafting (CABG) surgery. Eighteen patients were studied, with nine patients in the control group receiving standard metabolic care and nine patients receiving insulin (5 mU·kg(-1)·min(-1)). Whole body glucose production, protein breakdown, synthesis, and oxidation were determined using stable isotope tracer kinetics (l-[1-(13)C]leucine, [6,6-(2)H2]glucose) before and 6 h after the procedure.

Insulin preconditioning elevates p-Akt and cardiac contractility after reperfusion in the isolated ischemic rat heart.

Insulin induces cardioprotection partly via an antiapoptotic effect. However, the optimal timing of insulin administration for the best quality cardioprotection remains unclear. We tested the hypothesis that insulin administered prior to ischemia provides better cardioprotection than insulin administration after ischemia.

Feasibility and precision of subcutaneous continuous glucose monitoring in patients undergoing CABG surgery.

Objectives: To evaluate if subcutaneous continuous glucose monitoring (sCGM) is feasible in cardiac surgery and if reliable glucose values are reported under hypothermic extracorporeal circulation.

Design: Feasibility trial.

Setting: University hospital.

Albumin synthesis in surgical patients.

Albumin plasma concentrations are being used as indicators of nutritional status and hepatic function based on the assumption that plasma levels reflect the rate of albumin synthesis. However, it has been shown that albumin levels are not reliable markers of albumin synthesis under a variety of clinical conditions including inflammation, malnutrition, diabetes mellitus, liver disease, and surgical tissue trauma. To date, only a few studies have measured albumin synthesis in surgical and critically ill patients.

The anabolic effect of perioperative nutrition depends on the patient's catabolic state before surgery.

Objective: We tested the hypothesis that the anabolic effect of hypocaloric, isonitrogenous nutrition in patients undergoing colorectal surgery depends on the patient's preoperative catabolic state.

Background: Although there is evidence to suggest that total parenteral nutrition more effectively spares protein in depleted than in nondepleted cancer patients, the influence of preoperative catabolism on the anabolic effects of hypocaloric nutrition in patients undergoing elective surgery is unknown.

Methods: Seventeen patients undergoing colorectal surgery received intravenous infusion of glucose with amino acids.

Statin intake is associated with decreased insulin sensitivity during cardiac surgery.

Objective: Surgical trauma impairs intraoperative insulin sensitivity and is associated with postoperative adverse events. Recently, preprocedural statin therapy is recommended for patients with coronary artery disease. However, statin therapy is reported to increase insulin resistance and the risk of new-onset diabetes.

High-dose insulin therapy reduces postoperative liver dysfunction and complications in liver resection patients through reduced apoptosis and altered inflammation.

Context: An exaggerated inflammatory response in patients undergoing major liver resection coupled with poor nutrition diminishes liver regenerative capacity and increases the risk of postoperative complications.

Objectives: Our objective was to evaluate the biological context leading to better clinical outcomes in patients undergoing liver resection coupled with hyperinsulinemic-normoglycemic clamp vs. standard care (insulin sliding care).

High-dose insulin administration improves left ventricular function after coronary artery bypass graft surgery.

Objective: To test the hypothesis that the intravenous administration of high doses of insulin while maintaining normoglycemia (GIN therapy) improves myocardial function after coronary artery bypass graft (CABG) surgery.

Design: A prospective, randomized clinical trial.

Setting: A university hospital.

Cardioprotective effects of glucose and insulin administration while maintaining normoglycemia (GIN therapy) in patients undergoing coronary artery bypass grafting.

Context: Coronary artery bypass grafting (CABG) is complicated by ischemia-reperfusion injury jeopardizing myocyte survival.

Objective: The aim of the study was to investigate whether glucose and insulin administration, while maintaining normoglycemia (GIN therapy) using a hyperinsulinemic-normoglycemic clamp technique, is cardioprotective in patients undergoing CABG.

Design And Setting: We conducted a randomized controlled trial at a tertiary care university teaching hospital.

Randomised controlled trial of the effect of oral premedication with dexamethasone on hyperglycaemic response to abdominal hysterectomy.

Background: This study was performed to evaluate the metabolic effects of a single oral dose of 8 mg dexamethasone in women undergoing hysterectomy.

Methods: Ninety non-diabetic women undergoing abdominal hysterectomy were randomised to receive 8 mg dexamethasone or placebo 2 h before surgery. Patients' perioperative care was standardised (fasting from midnight before surgery, balanced anaesthesia using propofol, fentanyl, remifentanil, cisatracurium, desflurane in oxygen/air).

Glucose and insulin administration while maintaining normoglycemia during cardiac surgery using a computer-assisted algorithm.

Background: applying the principles of the hyperinsulinemic-normoglycemic clamp technique we have introduced glucose and insulin administration while maintaining normoglycemia (GIN therapy) to surgical patients. The objective of this study was to evaluate a novel computer software (GIN Computer Software [GINCS]) program using an algorithm based on the original clamp equation and modified for its use during cardiac surgery.

Methods: thirty-six patients without diabetes undergoing elective cardiac surgery were randomly assigned to manually controlled or computer-guided GIN therapy.

The association of preoperative glycemic control, intraoperative insulin sensitivity, and outcomes after cardiac surgery.

Context: The impairment of insulin sensitivity, a marker of surgical stress, is important for outcomes.

Objective: The aim was to assess the association between the quality of preoperative glycemic control, intraoperative insulin sensitivity, and adverse events after cardiac surgery.

Design And Setting: We conducted a prospective cohort study at a tertiary care hospital.

Glucose and protein kinetics in patients undergoing colorectal surgery: perioperative amino acid versus hypocaloric dextrose infusion.

Surgical injury provokes a stress response that leads to a catabolic state and, when prolonged, interferes with the postoperative recovery process. This study tests the impact of 2 nutrition support regimens on protein and glucose metabolism as part of an integrated approach in the perioperative period incorporating epidural analgesia in 18 nondiabetic patients undergoing colorectal surgery. To test the hypothesis that parenteral amino acid infusion (amino acid group, n = 9) maintains glucose homeostasis while maintaining normoglycemia and reduces proteolysis compared with infusion of dextrose alone (DEX group, n = 9), glucose and protein kinetics were measured before and on the second day after surgery using a stable isotope tracer technique.

Perioperative glucose and insulin administration while maintaining normoglycemia (GIN therapy) in patients undergoing major liver resection.

Background: Although hyperglycemia is a well-recognized risk factor in the context of cardiac surgery, the relevance of perioperative glycemic control for patients undergoing major noncardiac operations has received little attention. We designed this study to assess the hyperglycemic response to liver resection, and to test the hypothesis that perioperative glucose and insulin administration while maintaining normoglycemia (GIN therapy) provides glycemic control superior to that achieved by the conventional use of insulin.

Methods: Patients were randomly assigned to GIN therapy or standard therapy (control group).

Perioperative tight glucose control with hyperinsulinemic-normoglycemic clamp technique in cardiac surgery.

Objective: Previous attempts to achieve tight glucose control in surgical patients were associated with a significant incidence of hypoglycemia. The purpose of this study was to evaluate the efficacy of perioperative glucose and insulin administration while maintaining normoglycemia using a hyperinsulinemic-normoglycemic clamp technique.

Methods: We studied 70 non-diabetic and 40 diabetic patients undergoing cardiac procedures.

Anticatabolic effects of avoiding preoperative fasting by intravenous hypocaloric nutrition: a randomized clinical trial.

Objective: We tested the hypothesis that the avoidance of preoperative fasting by hypocaloric nutrition attenuates protein catabolism after surgery.

Summary Background Data: Prolonged fasting before major abdominal procedures has been demonstrated to accentuate the catabolic response to surgery.

Methods: Twenty-two patients undergoing colorectal cancer surgery were randomly assigned to receive glucose and amino acids intravenously starting either 20 hours before the operation or with surgical skin incision.

Hepatic protection by perioperative metabolic support?

Objective: We report the case of a 63-y-old woman undergoing left hepatectomy for hilar cholangiocarcinoma who was at high risk of postoperative liver failure due to an atrophic right liver lobe. She participated in a randomized clinical trial investigating the effect of perioperative glucose infusion on hepatic function after major liver resection.

Methods: Intravenous glucose was initiated the night before the operation at 2 mg x kg(-1) x min(-1).

A randomized controlled trial of the anticatabolic effect of epidural analgesia and hypocaloric glucose.

Background And Objectives: The goal of the present study was to investigate whether epidural analgesia exerts a protein-sparing effect after colorectal surgery in the presence of hypocaloric glucose supply initiated with surgical skin incision.

Methods: We randomly allocated 10 patients to receive general anesthesia combined with epidural anesthesia with bupivacaine, followed by epidural analgesia using bupivacaine/fentanyl, and 10 patients to receive general anesthesia, followed by patient-controlled analgesia with intravenous morphine. All patients received a 48-hour infusion of glucose 10% from surgical skin incision until the second day after surgery.

The anticatabolic effect of neuraxial blockade after hip surgery.

Unlabelled: Although the protein-sparing effect of neuraxial blockade after abdominal surgery is well established, its metabolic effect after operations on the lower extremities remains unclear. In this study, we tested the hypothesis that combined spinal and epidural blockade (CSE) inhibits amino acid oxidation after hip surgery. Sixteen patients undergoing hip replacement surgery received either general anesthesia followed by IV patient-controlled analgesia with piritramide (control; n = 8) or CSE using bupivacaine 0.

Intraoperative protein sparing with glucose.

We examined the hypothesis that glucose infusion inhibits amino acid oxidation during colorectal surgery. We randomly allocated 14 patients to receive intravenous glucose at 2 mg x kg(-1) x min(-1) (glucose group) starting with the surgical incision or an equivalent amount of normal saline 0.9% (control group).

Postoperative protein sparing with epidural analgesia and hypocaloric dextrose.

Objective: We examined the hypothesis that epidural analgesia prevents the increase in amino acid oxidation after elective colorectal surgery in patients receiving hypocaloric infusion of dextrose.

Summary Background Data: Increased oxidative protein loss after surgery may adversely affect postoperative outcome. We have previously shown that effective segmental pain relief by epidural analgesia improves postoperative substrate utilization, resulting in less protein catabolism.

Effect of i.v. dextrose administration on glucose metabolism during surgery.

Background: The inhibitory influence of exogenous dextrose on glucose production has been shown to be less pronounced during injury and sepsis. This protocol was designed to investigate the effect of i.v.

Epidural ropivacaine versus epidural morphine and the catabolic response to colonic surgery: stable isotope kinetic studies in the fasted state and during infusion of glucose.

Background: The authors examined the hypothesis that epidural administration of local anesthetic, in contrast to epidural analgesia with morphine, inhibits postoperative protein oxidation during administration of glucose.

Methods: Fourteen patients were randomly assigned to undergo a 6-h stable isotope infusion study (3 h fasted, 3 h feeding with 4 mg.kg(-1).