Thoracic Epidural Anesthesia and Blood Glucose Levels in Diabetic Patients Undergoing Cardiopulmonary Bypass Under Insulin Infusion According to the Portland Protocol

Abstract

Background: We investigated the effect of thoracic epidural anesthesia on perioperative blood glucose levels in diabetic patients undergoing cardiopulmonary bypass by continuous insulin infusion according to the Portland Protocol.

Material and Methods: Diabetic patients undergoing surgery with cardiopulmonary bypass were assigned to receive either general anesthesia alone (n=40) or general anesthesia with thoracic epidural anesthesia (n=18). Patient data were retrospectively reviewed from prospective chart records used in our anesthesia clinic. In all study patients, insulin infusion with the Portland Protocol was used to maintain stable blood glucose levels. We evaluated blood glucose levels in both groups at 6 time points including before surgery, before cardiopulmonary bypass, during cardiopulmonary bypass, immediately following cardiopulmonary bypass, and on the first and second postoperative days. The amounts of insulin required at the intraoperative period and during two postoperative days were compared between two groups.

Results: Groups were similar with respect to the duration of cardiopulmonary bypass, aortic cross-clamping, surgery, and blood glucose levels at any of the 6 time points, mean insulin requirements during intraoperative period and mean insulin requirements and blood glucose levels during the first 2 postoperative days (General anesthesia alone, 189±29 mg/dl vs. General anesthesia with thoracic epidural anesthesia, 191±19 mg/dl; p=0.782).

Conclusions: In diabetic patients undergoing cardiopulmonary bypass receiving insulin infusion by the Portland Protocol for glycemic control, thoracic epidural anesthesia provides no additional benefit for maintaining blood glucose levels during surgery.

Key words

thoracic epidural anesthesia - diabetes mellitus - cardiovascular surgery - blood glucose - portland protocol

References

• 1 Anderson RE, Ehrenberg J, Barr G. et al . Effects of thoracic epidural analgesia on glucose homeostasis after cardiac surgery in patients with and without diabetes mellitus.  Eur J Anaesthesiol. 2005;  22 524-529
• 2 Anderson RE, Brismar K, Barr G. et al . Effects of cardiopulmonary bypass on glucose homeostasis after coronary artery bypass surgery.  Eur J Cardiothorac Surg. 2005;  28 425-430
• 3 Bessey PQ, Watters JM, Aoki TT. et al . Combined hormonal infusion simulates the metabolic response to injury.  Ann Surg. 1984;  200 264-281
• 4 Furnary AP, Zerr KJ, Grunkemeier GL. et al . Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures.  Ann Thorac Surg. 1999;  67 352-360 discussion 360–362 
• 5 Furnary AP, Gao G, Grunkemeier GL. et al . Continuous insulin infusion reduced mortality in patients with diabetes undergoing coronary artery bypass grafting.  J Thorac Cardiovasc Surgery. 2003;  125 1007-1021
• 6 Furnary AP, Wu Y, Bookin SO. Effect of hyperglycemia and continuous intravenous insulin infusions on outcomes of cardiac surgical procedures: the Portland Diabetic Project.  Endocr Pract. 2004;  10 ((Suppl 2)) 21-33
• 7 Furnary AP, Wu Y. Clinical effects of hyperglycemia in the cardiac surgery population: the Portland Diabetic Project.  Endocr Pract. 2006;  12 ((Suppl 3)) 22-26
• 8 Gulcan O, Turkoz A, Caliskan E. et al . Comparison of continuous insulin infusion with IV bolus insulin application in diabetic patients undergoing coronary artery bypass surgery.  iü Kardiyol Enst Derg. 2004;  3 14-18
• 9 Kayhan Z. Metabolik/Endokrin Sistem ve Anestezi. In: Kayhan Z ed. Klinik Anestezi. 3rd ed. Istanbul, Logos Yayıncılık 2004: 406-436
• 10 Kehlet H, Brandt MR, Hansen AP. et al . Effect of epidural analgesia on metabolic profiles during and after surgery.  Br J Surg. 1979;  66 543-546
• 11 Kehlet H. Modification of responses to surgery by neural blockade. In: Cousins MJ, Bridenbaugh PO, eds. Neural Blockade in Clinical Anesthesia and Management of Pain. Philadelphia, Lippincott-Raven Publishers 1988: 129-175
• 12 Kilickan L, Yumuk Z, Bayindir O. The effect of combined preinduction thoracic epidural anaesthesia and glucocorticoid administration on perioperative interleukin –10 levels and hyperglycemia. A randomized controlled trial.  J Cardiovasc Surg. 2008;  49 87-93
• 13 Kuntschen FR, Galletti PM, Hahn C. Glucose-insulin interactions during cardiopulmonary bypass. Hypothermia versus normothermia.  J Thorac Cardiovasc Surg. 1986;  91 451-459
• 14 Lattermann R, Carli F, Wykes L. et al . Epidural blockade modifies perioperative glucose production without affecting protein catabolism.  Anesthesiology. 2002;  97 374-381
• 15 Lee KU, Lee HK, Koh CS. et al . Artificial induction of intravascular lipolysis by lipid-heparin infusion leads to insulin resistance in man.  Diabetologia. 1988;  31 285-290
• 16 Lehot JJ, Piriz H, Villard J. et al . Glucose homeostasis. Comparison between hypothermic and normothermic cardiopulmonary bypass.  Chest. 1992;  102 106-111
• 17 Lund J, Stjernstrom H, Jorfeldt L. et al . Effect of extradural analgesia on glucose metabolism and gluconeogenesis. Studies in association with upper abdominal surgery.  Br J Anaesth. 1986;  58 851-857
• 18 Mehta Y, Arora D, Sharma KK. et al . Comparison of continuous thoracic epidural and paravertebral block for postoperative analgesia after robotic-assisted coronary artery bypass surgery.  Ann Card Anaesth. 2008;  11 91-96
• 19 Moore CM, Cross MH, Desborough JP. et al . Hormonal effects of thoracic extradural analgesia for cardiac surgery.  Br J Anaesth. 1995;  75 387-393
• 20 Scott NB, Turfrey DJ, Ray DA. et al . A prospective randomized study of the potential benefits of thoracic epidural anesthesia and analgesia in patients undergoing coronary artery bypass grafting.  Anesth Analg. 2001;  93 528-535
• 21 Thourani VH, Weintraub WS, Stein B. et al . Influence of diabetes mellitus on early and late outcome after coronary arte ry bypass grafting.  Ann Thorac Surg. 1999;  67 1045-1052
• 22 Turfrey DJ, Ray DA, Sutcliffe NP. et al . Thoracic epidural anaesthesia for coronary artery bypass graft surgery. Effects on postoperative complications.  Anaesthesia. 1997;  52 1090-1095

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