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Canadian Journal of Anesthesia 54:44577 (2007)
© Canadian Anesthesiologists' Society, 2007

Sunday June 24; 1030 - 1230

44577 - CARDIOPULMONARY-BYPASS INDUCES HYPERGLYCEMIA ONLY IN PREOPERATIVE INSULIN RESISTANT PATIENTS

Donatelli Francesco1, Patrizia Cavagna2, Piervirgilio Parrella3, A Catenacci4, G Di Dedda5, L Lorini6, R Fumagalli7 and F Carli8

1 Ospedali Riuniti di Bergamo, Lallio (BG), IT, Italy
2 Ospedali Riuniti di Bergamo
3 Ospedali Riuniti di Bergamo
4 Ospedali Riuniti di Bergamo
5 Ospedali Riuniti di Bergamo
6 Ospedali Riuniti di Bergamo
7 Università Degli Studi Milano Bicocca
8 McGill University

Abstract

Background: Cardiopulmonary-bypass (CPB) induces insulin resistance (IR) and severe hyperglycemia. There is growing evidence that aggressive maintenance of blood glucose within the physiological range is an essential component of perioperative care. Notwithstanding the adverse clinical effects of hyperglycemia on outcome, perioperative normoglycemia cannot be reliably achieved, despite the use of large doses of insulin. The aim of this study was to determine to what extent preoperative insulin resistance affects the development of hyperglycemia and the amount of insulin infused during CPB.

Methods: Local IRB approval was obtained for this study. Fifty patients undergoing cardiac surgery were screened by using the Homeostatic Model Assessment (HOMA) in two populations: insulin-resistant patients (RP) and non-insulin resistant patients (NP). Patients with a preoperative HOMA less than 2.1 were defined NP, and patients with a preoperative HOMA more than 2.1 were defined RP. Al patients received a total intravenous anesthesia with remifentanil 0.4 mcg/kg/min and propofol 70 mcg/kg/min. During surgery blood glucose levels were measured in all patients and hyperglycemia was treated with a standard protocol of continuous insulin infusion. HOMA was repeated 48 h after surgery to determine the postoperative state of insulin resistance.

Results: The proportion of NP who had at least once blood glucose level over 120 mg/dl during CPB was 22% while in RP this proportion was 100% (p < 0.001). The proportion of NP who received at least one unit of insulin during CPB was 11% while in RP this proportion was 100% (p < 0.001). Blood glucose levels during surgery are reported in figure 1. Mean cumulative amount of insulin infused during surgery are reported in figure 2. Risk factors for postoperative insulin resistance were preoperative insulin resistance (p = 6.9 x 10 –8), aortic cross-clamping time (p=0.004) and mixed oxygen venous saturation arriving in ICU (p = 0.04).


Figure 1
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  		Figure 1: Blood glucose during cardiac surgery

 
Conclusions: Only patients who are IR before cardiac surgery develop hyperglycemia and need insulin infusion during CPB.

References

Anesth Analg 1999;89:1091–5.[Abstract/Free Full Text]

Anesth Analg 2002;94:1113–9, table of contents.[Abstract/Free Full Text]

J Cardiothorac Vasc Anesth 2005;19:201–8.[Medline]






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