Insulin resistance as a perioperative consideration and basis for enhanced recovery after cardiovascular surgery
DOI:
https://doi.org/10.6016/ZdravVestn.3164Keywords:
diabetes mellitus, perioperative hyperglycaemia, insulin therapy, cardiovascular and major vascular surgery, enhanced recovery after surgeryAbstract
Insulin resistance, the state of reduced biological response to physiological levels of insulin, is a key risk factor for cardiovascular disease. Consequently, it frequently occurs in patients undergoing cardiovascular surgery. Inflammatory processes, tissue damage, and hormonal response in the perioperative period further contribute to insulin resistance, leading to various biochemical changes. These negatively affect organ functioning, postoperative complications and recovery after surgery. Insulin resistance manifests itself as a wide range of clinical conditions that gradually progress from hyperinsulinaemia to impaired glucose tolerance and finally overt hyperglycaemia; when normoglycaemia is no longer maintained despite increasing insulin secretion. The recommendations of various professional associations regarding target values of blood glucose in the perioperative period are not unequivocal. Breakthrough research has initially shown that strict glycaemic control leads to better outcomes, but the incidence of hypoglycaemia is an important safety consideration. Current protocols for perioperative insulin administration target glycaemic values between 7.8 and 10 mmol/L (140 to 180 mg/dL). Whether morbidity and mortality are affected by the degree of hyperglycaemia or the mere presence of diabetes or insulin resistance itself, remains to be elucidated. Insulin resistance in the perioperative period can be avoided with a minimally invasive surgical approach, optimal choice of anaesthesia and analgesia and with shortened periods of starvation. The present manuscript discusses the pathophysiology and clinical consequences of insulin resistance or hyperglycaemia, and describes perioperative strategies to reduce insulin resistance, selecting the best treatment options for enhanced recovery after cardiac and complex aortic surgery.
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