Glycemic Control of Surgical Patients. What is Correct, What is Not
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Glycemic Control of Surgical Patients. What is Correct, What is Not Kouroumalis A, Spantideas N, Kioleoglou Z, Kokkali K, Vamvakopoulou D, Nomikos IN
Abstract Perioperative hyperglycemia is very common among critically ill patients with or without diabetes mellitus (DM). Perioperative elevated levels of blood glucose (BG) have been linked with increases in morbidity, infections, anastomotic failure, autoimmune dysfunction, and raised mortality and prolongation of hospitalization. A variety of different approaches have been taken for the control of BG in the perioperative period, and different methods of measurement have been proposed, among which, point of care (POC) meters, arterial blood gas analysis and venous plasma analysis prevail. The aim of this literature review was to provide evidence-based answers as to how BG levels should be monitored. We conclude that more conservative glycemic control is preferable to “tight glycemic control” (TGC), in order to avoid complications associated with episodes of hypoglycemia. Key words: Glycemic control; surgical patients; perioperative hyperglycemia
Introduction
The background
Perioperative hyperglycemia is very common among critically ill patients with or without diabetes mellitus (DM) [1]. Stress hyperglycemia is often present only during the hospital stay and resolves afterwards [2]. Studies have demonstrated that a significant number of non-diabetic surgical patients, ranging from 21% to 66%, have raised perioperative blood glucose (BG) levels [3-5]. Stress hyperglycemia is defined as persistent hyperglycemia (BG≥180mg/dL) on repeated checks [3]. Several studies have shown this to be associated with increases in morbidity, particularly infections, anastomotic failure, autoimmune dysfunction, and raised mortality and prolongation of hospitalization [1,2,4,6-9]. In spite of an abundance of studies related to protocols of perioperative BG level control, there is still much controversy concerning the optimal approach [10]. There is a necessity, therefore, for a widely approved protocol to minimize the adverse effects of hyperglycemia.
The mechanism of hyperglycemia
Kouroumalis A, Spantideas N, Kioleoglou Z, Kokkali K, Nomikos I Department of Surgery (B' Unit), “Metaxa” Cancer Memorial Hospital, Pireaus Vamvakopoulou D Department of Pediatrics, School of Medicine, University of Thessaly Corresponding author: Kouroumalis Andreas 51 Botasi Street, 18537, Pireaus, Greece Tel.: +30 6949118749, e-mail: [email protected] Received Jan 11, 2018; Accepted Feb 22, 2018
Hellenic Journal of Surgery 90
Acute hyperglycemia increases inflammatory markers such as interleukin 6 (IL6) and tumor necrosis factor (TNF), which stimulates the synthesis of acute phase proteins such as C reactive protein (CRP) [11]. Hyperglycemia also promotes oxidative stress, the generation of reactive oxygen species, and thereby endothelial cellular dysfunction and consequently thrombosis, which leads to local ischemia and impedes wound healing [12]. Further, hyperglycem
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