Intranasal administration of 40 and 80 units of insulin does not cause hypoglycemia during cardiac surgery: a randomized controlled trial (original) (raw)
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International Journal of Environmental Research and Public Health
Delayed neurocognitive recovery and postoperative neurocognitive disorders are major complications of surgery, hospitalization, and anesthesia that are receiving increasing attention. Their incidence is reported to be 10–80% after cardiac surgery and 10–26% after non-cardiac surgery. Some of the risk factors include advanced age, level of education, history of diabetes mellitus, malnutrition, perioperative hyperglycemia, depth of anesthesia, blood pressure fluctuation during surgery, chronic respiratory diseases, etc. Scientific evidence suggests a causal association between anesthesia and delayed neurocognitive recovery or postoperative neurocognitive disorders, and various pathophysiological mechanisms have been proposed: mitochondrial dysfunction, neuroinflammation, increase in tau protein phosphorylation, accumulation of amyloid-β protein, etc. Insulin receptors in the central nervous system have a non-metabolic role and act through a neuromodulator-like action, while an interac...
High-dose insulin administration is associated with hypoaminoacidemia during cardiac surgery
Metabolism, 2011
Although the effects of insulin on glucose homeostasis are well recognized in surgical patients, its effect on perioperative protein metabolism has received little attention. The purpose of this study was to examine the effect of high-dose insulin therapy on the plasma concentrations of amino acids (AAs) in patients undergoing coronary artery bypass grafting surgery. We studied 20 nondiabetic patients scheduled for elective coronary artery bypass grafting surgery. Patients were randomly allocated to receive either standard metabolic care (target glycemia 6.0-10.0 mmol/L, control group, n = 10) or high-dose insulin therapy (insulin group, n = 10). Insulin was administered at 5 mU . kg −1. min −1 beginning at skin incision. Simultaneously, 20% dextrose was infused at a variable rate adjusted to maintain glycemia between 4.0 and 6.0 mmol/L. Plasma AAs, glucose, cortisol, and insulin were measured immediately before surgery and at sternal closure. Differences in mean values were assessed by Student t test. Plasma concentrations of all AAs decreased in the insulin group, with 15 of 22 AAs, including all branched-chain AAs, being significantly lower at sternal closure when compared with the control group. At the end of surgery, plasma glucose concentration was significantly lower in the insulin group (4.2 ± 0.6 vs 7.3 ± 1.0 mmol/L, P = .0001), whereas plasma cortisol levels did not show any difference between groups. High-dose insulin therapy resulted in a significant reduction in plasma AAs, particularly branched-chain AAs, during cardiac surgery. A v a i l a b l e a t w w w . s c i e n c e d i r e c t . c o m Metabolism w w w . m e t a b o l i s m j o u r n a l . c o m
Therapy with insulin in cardiac surgery: controversies and possible solutions
The Annals of Thoracic Surgery, 2003
Insulin has been used in the treatment of patients undergoing cardiac surgery or suffering from acute myocardial infarction. Most of these investigations have demonstrated that the metabolic cocktail consisting of glucoseinsulin-potassium (GIK) improves recovery of function and outcome after cardiac surgery and substantially reduces mortality of patients with acute myocardial infarction. There is also evidence suggesting that insulin is not effective under these conditions, as demonstrated in a recent large randomized trial in cardiac surgery. It is therefore not surprising that insulin or GIK is not used routinely in clinical practice. Many hypotheses have been advanced to explain the effects of insulin and GIK but none of them has enjoyed convincing support. In cardiac surgery the many different application protocols described make it difficult to compare the results. The application of GIK after cardiac surgery may be complicated by severe disturbances in glucose or potassium homeostasis. In this article we review the literature in this field, addressing the areas of controversy. We discuss the different mechanisms suggested and we propose potential solutions. We conclude that a multifactorial mechanism is likely to explain the effects of insulin or GIK after ischemia and we propose that in a practical sense the application of high-dose insulin during reperfusion, utilizing a newly described, direct nonmetabolic effect, is a convincing concept. We will further demonstrate our clinical experience in establishing a protocol for putting this concept into clinical practice.
Journal of Diabetes and its Complications, 2008
Objective: To assess insulin resistance postoperatively in patients with (DM) and without (nonDM) a prior diagnosis of diabetes. Research Design and Methods: Following cardiac surgery, 122 nonDM and 33 DM were treated with insulin infusions to obtain glucose levels b110 mg dl À1. Glucose levels, insulin infusion rates, and insulin infusion rate/glucose ratios were calculated to assess insulin resistance. Results: The average blood glucose at insulin drip initiation (209 vs. 173 mg dl À1 ; Pb.001) and during the first 12 h (146 vs. 135 mg dl À1 ; Pb.05) was higher in DM, but during Hours 12-24 glucose levels were not different. The peak (5.7 vs. 4.1 U h À1 ; Pb.001) and average insulin drip rates (3.7 vs. 2.9 U h À1 ; Pb.01) were higher in DM. Insulin resistance (insulin drip rate/glucose ratio) was higher in DM during Hours 1-12 (0.029 vs. 0.022 U h À1 mg À1 dl À1 ; Pb.001), but not during Hours 12-24 (P=.57). To eliminate glucotoxicity as a cause of the insulin resistance, 23 DM patients were pair matched with 23 nonDM patients based first on glucose levels at drip initiation then by body mass index (BMI) and then catecholamine use to maintain blood pressure. The average blood glucose levels, insulin drip rates, and insulin resistance ratios were not significantly different between the pair-matched groups at all time points. Conclusions: When matched for initial glucose levels, insulin resistance is not different between DM and nonDM following cardiac surgery, likely due to the overwhelming stress response. Insulin drip protocols used postoperatively do not have to be modified for those with a prior diagnosis of diabetes.
Glucose Control by Insulin for Critically Ill Surgical Patients
The Journal of Trauma: Injury, Infection, and Critical Care, 2004
H yperglycemia associated with insulin resistance is common among critically ill patients, even those who do not have diabetes. 1-3 It is a known factor for poor prognosis in hospitalized patients, 4-7 especially after myocardial infarction, 8-10 congestive heart failure, 9 cerebral vascular accident, 11 cardiopulmonary bypass, 12,13 burns, and major surgery. 14,15 Several conditions are related to acute hyperglycemia including diuresis, dehydration, ketonemia, electrolyte imbalance, and change in mental status. Several other pathologies have been documented in critically ill patients, such as an impaired immune response to injury or infection, 16 a higher rate of serious infection, 17 impaired gastrointestinal motility, 18,19 high cardiovascular tonus, 20 impaired wound healing, 21,22 and a higher mortality rate. 23 Acute or new hyperglycemia could be undiagnosed diabetes or stress-induced hyperglycemia. 24 Stress-induced hyperglycemia, described in 5% to 30% of critically ill patients, is believed to be secondary to increased levels of stress hormones. It also can be reproduced after the administration of endotoxin or injection of several stress hormones to healthy volunteers. 25 Umpierrez et al. 6 showed that hyperglycemia in hospitalized patients is a factor for poor outcome and an independent marker of in-hospital mortality, mainly among patients with undiagnosed diabetes (65% of their study patients). Moreover, patients with new hyperglycemia had a higher rate of admission to the intensive care unit (ICU), longer hospitalization, and a higher rate of in-hospital mortality. 6 The clinical significance of new hyperglycemia is unclear. This article presents a review of the literature describing the effect of hyperglycemia on several major systems and recommends treatment management based on a consensus of the data. The major effects of insulin on major body systems are summarized in Table 1.
Safety and Efficacy of Intensive Insulin Therapy in Critical Neurosurgical Patients
Anesthesiology, 2009
Background: Intensive insulin therapy to maintain blood glucose at or below 6.11 mM reduces morbidity and mortality after cardiac surgery and morbidity in medical intensive care unit (ICU) patients. The authors investigated the clinical safety and outcome effects of intensive insulin therapy compared to conventional insulin therapy in patients receiving postoperative intensive care after neurosurgical procedures.
Medanta insulin protocols in patients undergoing cardiac surgery
Indian journal of endocrinology and metabolism, 2014
Hyperglycemia is common in patients undergoing cardiac surgery and is associated with poor outcomes. This is a review of the perioperative insulin protocol being used at Medanta, the Medicity, which has a large volume cardiac surgery setup. Preoperatively, patients are usually continued on their preoperative outpatient medications. Intravenous insulin infusion is intiated postoperatively and titrated using a column method with a choice of 7 scales. Insulin dose is calculated as a factor of blood glucose and patient's estimated insulin sensitivity. A comparison of this protocol is presented with other commonly used protocols. Since arterial blood gas analysis is done every 4 hours for first two days after cardiac surgery, automatic data collection from blood gas analyzer to a central database enables collection of glucose data and generating glucometrics. Data auditing has helped in improving performance through protocol modification.