Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Dec 2009
ReviewModulating postoperative insulin resistance by preoperative carbohydrate loading.
The concept of preoperative overnight fasting was challenged and proved to have no benefits over allowing patients to drink clear fluids up until 2 h before surgery. This led to changes in the guidelines for preoperative fasting in many countries around the world. This concept has more recently been developed further. ⋯ This article summarises the present understanding of the mechanisms behind the positive clinical effects and gives an overview of the information available regarding the clinical effects of this treatment. Finally, the article summarises the most recently published national guidelines on preoperative fasting routines where preoperative carbohydrates are recommended for use before a major surgery. These are to be considered for all patients allowed to drink clear fluids and undergoing elective surgery.
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Best Pract Res Clin Anaesthesiol · Dec 2009
ReviewClinical benefits of tight glycaemic control: focus on the paediatric patient.
Hyperglycaemia and glucose variability occur frequently during critical illness or after major surgery in children and are associated with worse outcome. Association does not necessarily imply causality however, and the question whether tight glycaemic control (TGC) with insulin infusion improves morbidity and mortality can only be answered by randomised controlled trials (RCTs). ⋯ Before universal implementation in paediatric intensive care both long-term effects on outcome and development and issues regarding optimal levels of blood glucose control need to be cleared in multicentre prospective RCTs. Technological improvement might be helpful in optimising blood glucose control.
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Best Pract Res Clin Anaesthesiol · Dec 2009
ReviewClinical benefits of tight glycaemic control: effect on the kidney.
Acute kidney injury is a frequent and life-threatening complication of critical illness. Prevention of this condition is crucial. Two randomized single center trials in critically ill patients have shown a decrease in acute kidney injury by tight glycaemic control, an effect that appears most pronounced in surgical patients. ⋯ This apparent contradiction is likely explained by methodological differences between studies, including different patient populations, insufficient patient numbers, comparison with a different control group, use of inaccurate blood glucose analyzers, and differences in the degree of reaching the target blood glucose level. The optimal glycaemic target for renoprotection in critical illness remains to be defined. Possible mechanisms underlying the renoprotective effect of tight glycaemic control are prevention of glucose overload and toxicity and the associated mitochondrial damage, an anti-inflammatory or anti-apoptotic effect, prevention of endothelial dysfunction, and an improvement of the lipid profile.
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Best Pract Res Clin Anaesthesiol · Dec 2009
ReviewClinical benefits of tight glycaemic control: focus on the perioperative setting.
The benefits of tight glycaemic control (TGC) were first shown in cardiac surgical patients with diabetes. These concepts migrated to other surgical and medical specialties through intensive care units caring for a variety of patients with a variety of disease states Although some disagreement and controversy surrounds the use of TGC in the medical population, the benefits of this therapy ir the diabetes cardiac surgery population is unblemished. Perioperative hyperglycaemia has been shown to be associated with adverse surgical outcomes in several different patient populations TGC for 3 full postoperative days or more mitigates these risks Although this has been definitively proven in the diabetes coronary artery bypass graft (CABG) population, evidence for beneficia effects of TGC in other surgical populations remains elusive at this point in time. In this article, we explore the risks of hyper- and hypoglycaemia in the surgical patient; safety and efficacy of insulin protocols in the surgical population, target range goals and dura tion of therapy; the beneficial effects of TGC on decreasing mortality, reducing infectious complications, length of stay and other complications; define target surgical populations tha benefit from TGC; analyse current controversies as they relate to surgical populations; and describe questions that remain for the future of TGC.
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Best Pract Res Clin Anaesthesiol · Dec 2009
ReviewHow accurately do we measure blood glucose levels in intensive care unit (ICU) patients?
Hyperglycaemia is commonly found in critically ill patients as a result of numerous processes such as increased gluconeogenesis and glycogenolysis caused by elevated levels of corresponding hormones and insulin resistance. As the clinical consequence of hyperglycaemia has been shown to increase morbidity and mortality in various clinical settings, many hospitals by now use tight glycaemic control protocols for their patients in intensive care units to maintain normoglycaemia. ⋯ Therefore, in almost all cases, this will be done by point-of-care testing methods, raising the question of how accurately blood glucose levels are actually measured and what devices should be used. This review focusses on glucose assay principles, specimen matrices, influences and interferences of glucose measurements and finally looks at the numerous evaluation reports on point-of-care glucose testing devices.