Transplantation/immunologyEffect of Intraoperative Hyperglycemia During Liver Transplantation
Introduction
The first prospective, randomized, controlled study on the importance of strict glycemic control demonstrating improved morbidity and mortality in the critically ill postoperative patient was reported in 2001 [1]. Studies have also suggested that the blood glucose level, rather than the total insulin dose administered, confers the benefit [2]. After implementation of intensive insulin therapy to maintain strict glycemic control, the benefits of normoglycemia on morbidity and mortality were largely reproduced [3]. The advantage of strict glycemic control in the critically ill patient is now well accepted, and the Institute for Healthcare Improvement and Surviving Sepsis Campaign have set adequate glycemic control as part of the sepsis management bundle [4, 5].
The role of strict intraoperative glycemic control, however, is less well established. A prospective observational study showed that diabetic patients undergoing on-pump heart surgery had a decreased rate of severe postoperative morbidity if strict intraoperative glycemic control was maintained with aggressive insulin therapy [6]. A retrospective study of patients undergoing carotid endarterectomy demonstrated that an increased glucose concentration on the operative day blood draw was independently associated with perioperative stroke or transient ischemic attack, myocardial infarction, and death [7].
The current study examines the effect of intraoperative glycemic control in liver transplant recipients. Intraoperatively, liver transplantation incurs an acute stress state in the recipient for several hours, often with major blood loss, fluid shifts, an anhepatic phase, and a reperfusion phase. Recipients are also given large doses of glucocorticoids during induction of anesthesia or early in the procedure. Given these major metabolic derangements and stressors associated with an operation with a considerable morbidity and mortality, liver transplantation was used as a model to evaluate the effect of strict intraoperative glycemic control on postoperative outcomes.
Section snippets
Methods
A retrospective review of all adult liver recipients transplanted at the University of Michigan Health System between January 1, 2004 and July 6, 2006 was performed. Donor and recipient demographics, intraoperative variables (collected in real time by an automated intraoperative data manager), and postoperative outcomes were collected by chart review.
Intraoperative glucose measurements were performed by the anesthesiology team and treated by intravenous insulin bolus or continuous infusion.
Results
During the period from January 1, 2004 and July 6, 2006, a total of 184 patients underwent liver transplantation and were analyzed. Sixty recipients (32.6%) had strict intraoperative glycemic control while 124 (67.4%) were poorly controlled. Although recipients with poorly controlled intraoperative glycemia were significantly older, both groups were well matched with respect to gender, race, body mass index, incidence of coronary artery disease, need for preoperative hemodialysis, severity of
Discussion
In the present study, the effect of intraoperative glycemic control on postoperative outcomes in 184 liver transplant recipients was analyzed. Overall, both infectious complications and short-term mortality were improved in patients with a mean intraoperative blood glucose concentration of less than 150 mg/dL. As demonstrated in previous reports, benefit seemed to be conferred by the blood glucose concentration rather than by the amount of insulin administered [2, 8]. Maintaining blood glucose
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Effects of Intensive Blood Glucose Control on Surgical Site Infection for Liver Transplant Recipients: A Randomized Controlled Trial
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2022, Journal of Cardiothoracic and Vascular AnesthesiaCitation Excerpt :An electrocardiogram should be routinely evaluated in the postoperative period and medications adjusted in case of QTc prolongation. Studies have demonstrated that perioperative hyperglycemia in LT recipients is associated with an increased risk of postoperative infection, graft rejection, and mortality.21,22 With the rising number of NASH-related LTs, the need for close glucose monitoring in the perioperative period has become even more important.23
2020 Clinical Update in Liver Transplantation
2022, Journal of Cardiothoracic and Vascular AnesthesiaSafety of artificial pancreas in hepato-biliary-pancreatic surgery: A prospective study
2020, Asian Journal of SurgeryCitation Excerpt :However, the enrolled patients’ diseases and planned surgical procedures were intrinsically different, compared with previous study. Our study group was divided into PD, MH, and LT patients, and their pathophysiological status was suggested to fall into severe disturbance of glucose tolerance, insulin production, and sensitivity.17–19 Our results show that the insulin dose during the study period was high, compared with previous reports.11
Management of metabolic syndrome and cardiovascular risk after liver transplantation
2019, The Lancet Gastroenterology and HepatologyCitation Excerpt :Moreover, new-onset diabetes following liver transplantation has been associated with late-onset hepatic artery thrombosis and acute and chronic rejection.43,50 Several studies51–53 have shown that in the intraoperative period, strict glycaemic control results in significantly fewer infections, shorter intensive care unit stays, and increased 1-year survival. In the period immediately following liver transplantation, glycaemic control can be difficult because of pain, surgical stress, introduction of immunosuppression, and administration of steroids.
Management of diabetes mellitus in patients undergoing liver transplantation
2019, Pharmacological ResearchCitation Excerpt :As intra-operative hyperglycaemia during liver transplantation was associated with an increased risk of post-operative infection and mortality, a strict intra-operative glycaemic control is recommended to reduce the rates of mortality and infections [75]. Total insulin requirement is usually increased after transplantation, due to immunosuppression with corticosteroids, acute pain, and surgical stress and, hence, intravenous or subcutaneous intensive insulin therapy using validated algorithms is the standard of care during the immediate post-transplant phase [240–243]. Once patients have returned to a regular eating pattern, they can be transitioned into a subcutaneous basal-bolus insulin regimen, starting from a total daily dose of 0.2-0.4 U/Kg, of which half as basal insulin and half as prandial insulin [244,245].