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Effects of thoracic epidural analgesia on glucose homeostasis after cardiac surgery in patients with and without diabetes mellitus

Published online by Cambridge University Press:  29 June 2005

R. E. Anderson ,
J. Ehrenberg ,
G. Barr ,
K. Brismar ,
A. Öwall ,
T. Alserius  and
T. Ivert
R. E. Anderson
Affiliation:
Karolinska Hospital, Department of Thoracic Surgery and Anaesthesiology, Stockholm, Sweden
J. Ehrenberg
Affiliation:
Karolinska Hospital, Department of Thoracic Surgery and Anaesthesiology, Stockholm, Sweden
G. Barr
Affiliation:
Karolinska Hospital, Department of Thoracic Surgery and Anaesthesiology, Stockholm, Sweden
K. Brismar
Affiliation:
Karolinska Hospital, Department of Endocrinology and Diabetology, Stockholm, Sweden
A. Öwall
Affiliation:
Karolinska Hospital, Department of Thoracic Surgery and Anaesthesiology, Stockholm, Sweden
T. Alserius
Affiliation:
Karolinska Hospital, Department of Thoracic Surgery and Anaesthesiology, Stockholm, Sweden
T. Ivert
Affiliation:
Karolinska Hospital, Department of Thoracic Surgery and Anaesthesiology, Stockholm, Sweden
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Extract

Summary

Background and objective: Even moderate hyperglycaemia increases mortality/morbidity after coronary artery bypass grafting, stroke and myocardial infarction. The goal of this prospective study was to determine if using thoracic epidural analgesia from start of surgery until the end of the third postoperative day would blunt postoperative hyperglycaemia. Methods: Forty-four patients had diabetes mellitus, 60 did not; half of each group had an epidural with continuous local anaesthetics. All patients received continuous insulin infusions during the initial 24 h period beginning with surgery. Blood glucose was measured four times daily (fasting or 2–3 h post-prandial) until end of the third postoperative day. Results: For patients without diabetes, the epidural group had lower mean blood glucose and insulin requirements (P < 0.02) than controls during the initial 24 h period beginning with surgery. For patients with diabetes mellitus, thoracic epidural analgesia reduced mean blood glucose (P = 0.017) with unchanged insulin requirements. Epidural did not diminish the increase (vs. preoperative) in fasting blood glucose on the third postoperative day (32% vs. 22%, P < 0.001) for non-diabetics. Epidural analgesia was not able to attenuate hyperglycaemia during the first 3 postoperative days. Conclusions: Epidural analgesia improved glucose homeostasis minimally during the initial 24 postoperative hours but did not attenuate hyperglycaemia during the subsequent 3 postoperative days.

Keywords

ANAESTHESIA EPIDURAL, thoracicDIABETES MELLITUSTHORACIC SURGERY, cardiovascularBLOOD GLUCOSEANAESTHESIA GENERAL
Type
Original Article
Information
European Journal of Anaesthesiology , Volume 22 , Issue 7 , July 2005 , pp. 524 - 529
Copyright
© 2005 European Society of Anaesthesiology

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References

van den Berghe G, Wouters P, Weekers F et al. Intensive insulin therapy in the critically ill patients. New Engl J Med 2001; 345: 1359–1367.Google Scholar
Muhlestein JB, Anderson JI, Horne BD et al. Effect of fasting glucose levels on mortality rate in patients with and without diabetes mellitus and coronary artery disease undergoing percutaneous coronary intervention. Am Heart J 2003; 146: 351–358.Google Scholar
Norhammar AM, Rydén L, Malmberg K. Admission plasma glucose: independent risk factor for long-term prognosis after myocardial infarction even in non-diabetic patients. Diab Care 1999; 22: 1827–1831.Google Scholar
Alvarez-Sabin J, Molina CA, Montaner J et al. Effects of admission hyperglycaemia on stroke outcome in reperfused tissue plasminogen activator-treated patients. Stroke 2003; 34: 1235–1241.Google Scholar
Krinsley JS. Effect of an intensive glucose management protocol on the mortality of critically ill adult patients. Mayo Clin Proc 2004; 79: 992–1000.Google Scholar
Mesotten D, Delhanty JD, Vanderhoydonc F et al. Intensive insulin therapy in the critically ill patients. J Clin Endocrin Metab 2003; 87: 5516–5523.Google Scholar
Furnary AP, Gao G, Grunkemeier GL et al. Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thor Cardiovasc Surg 2003; 125: 1007–1021.Google Scholar
Thorell A, Efendic S, Gutniak M, Haggmark T, Ljungqvist O. Insulin resistance after abdominal surgery. Br J Surg 1994; 81: 59–63.Google Scholar
Thorell A, Nygren J, Ljungqvist O. Insulin resistance: a marker of surgical stress. Curr Opin Clin Nutr Metab Care 1999; 2: 69–78.Google Scholar
Carvalho G, Moore A, Qizilbash B, Lachapelle K, Schricker T. Maintenance of normoglycemia during cardiac surgery. Anesth Analg 2004; 99: 319–324.Google Scholar
Moore CM, Cross MH, Descorough JP et al. Hormonal effects of thoracic extradural analgesia for cardiac surgery. Br J Anaesth 1995; 75: 387–393.Google Scholar
Stenseth R, Bjella L, Berg EM, Christensen O, Levang OW, Gisvold SE. Thoracic epidural analgesia in aortocoronary bypass surgery. II: Efects on the endocrine metabolic response. Acta Anaesth Scand 1994; 38: 834–839.Google Scholar
Richardson J, Sabanathan S, Jones J, Shah RD, Cheema S, Mearns AJ. A preospective, randomized comparison of preoperative and continuous balanced epidural or paravertabral bupivacaine on post-thoractomy pain, pulmonary function and stress responses. Br J Anaesth 1999; 83: 387–392.Google Scholar
Latterman R, Carli F, Wykes L et al. Epidural blockade modifies perioperative glucose production without affecting protein catabolism. Anesthesiology 2002; 97: 374–381.Google Scholar
Uchida I, Asoh T, Shirasaka C, Tsuji H. Effect of epidural analgesia on postoperative insulin resistance as evaluated by insulin clamp technique. Br J Surg 1988; 75: 557–562.Google Scholar
Roth-Isigkeit A, Dibbelt L, Eichler W, Schumacher J, Schmucker P. Blood levels of atrial natriuretic peptide, endothelin, cortisol and ACTH in patients undergoing coronary artery bypass grafting surgery with cardiopulmonary bypass. J Endocrin Invest 2001; 24: 777–785.Google Scholar
Werb MR, Zinman B, Teasdale SJ, Goldman BS, Scully HE, Marliss EB. Hormonal and metabolic responses during coronary artery bypass surgery: role of infused glucose. J Clin Endocrin Metab 1989; 69: 1010–1018.Google Scholar
Bromage PR, Shibata HR, Willoughby HW. Influence of prolonged epidural blockade on blood sugar and cortisol responses to operations on the upper part of the abdomen and thorax Surgery. Gynecol Obstet 1971; 132: 1051–1056.Google Scholar
Loick HM, Schmidt C, Van Aken H et al. Thigh thoracic epidural anesthesia, but not clonidine attenuates the perioperative stress response via sympatholysis and reduces the release of tropinin T in patients undergoing coronary artery bypass grafting. Anesth Analg 1999; 88: 701–709.Google Scholar
Liem TH, Booij LH, Gielen MJ, Hasenbos MA, van Egmond J. Coronary artery bypass grafting using two different anesthetic techniques. Part 3: Adrenergic responses. J Thor Cardiovasc Anesth 1992; 6: 162–167.Google Scholar