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). In the GIN therapy group, insulin was administered at 2 mU . kg(-1) . min(-1) during surgery. At the end of surgery, the insulin infusion was decreased to 1 mU . kg(-1) . min(-1) and continued for 24 hours. Dextrose 20% was infused at a rate adjusted to maintain blood glucose within the target range of 3.5 to 6.1 mmol . L(-1) (63-110 mg . dL(-1)). Patients in the standard therapy group received a conventional insulin sliding scale during and after surgery. The mean and SD of blood glucose as well as the percentage of blood glucose values within the target range were calculated. To evaluate intrasubject variability, the coefficient of variability (CV) of blood glucose was calculated for each patient. Episodes of severe hypoglycemia, i.e., blood glucose <2.2 mmol . L(-1) (40 mg . dL(-1)), were recorded. The primary outcome was the proportion of normoglycemic measurements.


RESULTS
We studied 52 patients. The mean blood glucose value in patients receiving GIN therapy always remained within the target range. The blood glucose levels were lower in the GIN therapy group than in the standard therapy group (during surgery, P < 0.01; after surgery, P < 0.001). In nondiabetic patients receiving GIN therapy (n = 19), target glycemia was achieved in 90.1% of the blood glucose measurements during surgery and in 77.8% of the measurements after surgery. In diabetic patients receiving GIN therapy (n = 7), target glycemia was achieved in 81.2% of the blood glucose measurements during surgery and in 70.5% of the measurements after surgery. In nondiabetic patients receiving standard therapy (n = 19), target glycemia was achieved in 37.4% of the blood glucose measurements during surgery and in 18.3% of the measurements after surgery. In diabetic patients receiving standard therapy (n = 7), target glycemia was achieved in 4.3% of the blood glucose measurements during surgery and in 2.9% of the measurements after surgery. The SD and CV of blood glucose were smaller in the GIN therapy group than in the standard therapy group, especially in nondiabetic patients after surgery (SD, P < 0.001; CV, P = 0.027). No patients receiving GIN therapy experienced severe hypoglycemia during surgery. One patient receiving GIN therapy experienced hypoglycemia in the intensive care unit after surgery without neurological sequelae.


CONCLUSIONS
GIN therapy effectively provides normoglycemia in patients undergoing liver resection (clinicaltrials.gov, NCT00774098).
Sato
Hiroaki
H
Department of Anaesthesia, Royal Victoria Hospital, 687 Pine Ave. West, Rm. C5.20, Montreal, QC, Canada H3A 1A1.
Lattermann
Ralph
R
Carvalho
George
G
Sato
Tamaki
T
Metrakos
Peter
P
Hassanain
Mazen
M
Matsukawa
Takashi
T
Schricker
Thomas
T
D000368:Aged; D000758:Anesthesia; D001786:Blood Glucose / Q000378:metabolism*; D003422:Critical Care; D003920:Diabetes Mellitus / Q000097:blood / Q000188:drug therapy; D003924:Diabetes Mellitus, Type 2 / Q000097:blood / Q000150:complications; D005260:Female; D005947:Glucose / Q000008:administration & dosage / Q000627:therapeutic use*; D006801:Humans; D006943:Hyperglycemia / Q000150:complications / Q000517:prevention & control; D007004:Hypoglycemic Agents / Q000627:therapeutic use*; D007328:Insulin / Q000627:therapeutic use*; D008099:Liver / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019990:Perioperative Care; D011184:Postoperative Period; D011188:Potassium / Q000097:blood; D016896:Treatment Outcome
D001786:Blood Glucose; D007004:Hypoglycemic Agents; D007328:Insulin; D005947:Glucose; D011188:Potassium