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Glycemic control during pancreas transplantation: continous infusion versus bolus
Glycemic Control During Pancreas Transplantation: Continous Infusion Versus Bolus H. Halpern, E. Miyoshi, L.M. Kataoka, R.A. Khouri Fo, S.B.P. Miranda, C.K. Marumo, P.P.P. Caravatto, T. Genzini, and M.P. Miranda ABSTRACT Pancreas transplantation is a method to restore endogenous insulin secretion in insulindependent diabetic patients. Because glycemia ⬎150 mg/dL may harm pancreatic graft beta cells, early glucose control using insulin administration is recommended during transplantation. The aim of this study was to evaluate the benefits of strict glycemic control during pancreas transplantation by comparing two types of insulin and glucose administration: continuous infusion and bolus. Capillary glucose was measured every 30 minutes after anesthetic induction for pancreas transplantation alone or simultaneously with kidney transplantation. Intravenous regular insulin was administered for values ⬎150 mg/dL or glucose for values ⬍100 mg/dL. The following timepoints were evaluated: anesthetic induction, before pancreatic graft reperfusion, and the first 4 minutes after reperfusion. Pancreatic graft ischemia time was significantly lower in the bolus group (P ⬍ .02). Immediately after reperfusion, there was a small increase in glycemia with a decrease in subsequent measurements in both groups. No significant difference in glycemia was observed between the groups at any time. Induction values were greater than all other timepoints in both groups. Glycemic control is important; it was successfully obtained with both methods. The trend to decrease glucose after reperfusion suggest early graft function.
P
ANCREAS transplantation is a method to restore endogenous insulin secretion in insulin-dependent diabetic patients. Because glycemia ⬎150 mg/dL may harm pancreatic graft beta cells, early glucose control and insulin administration are advised during pancreas transplantation. The aim of this study was to evaluate strict glycemic control during pancreas transplantation, comparing two types of insulin and glucose administration: continuous infusion versus bolus. METHODS Capillary glucose was measured every 30 minutes from anesthetic induction during pancreas transplantation alone or simultaneously with kidney transplantation using a blood glucose monitor. Intravenous regular insulin was administered for values ⬎150 mg/dL and glucose 5% (continuous infusion group) or glucose 50% (bolus group) for values ⬍100 mg/dL. The following timepoints were evaluated: anesthetic induction, before pancreatic graft reperfusion (before), and the first 4 moments after reperfusion (after-1, after-2, after-3, and after-4).
RESULTS
Data are shown in Table 1. Both groups contained more male patients but were similar in age, weight, length of 0041-1345/04/$–see front matter doi:10.1016/j.transproceed.2004.03.086 984
diabetic disease daily amount of neutral protamine hagerdon insulin, and minutes between pancreatic graft reperfusion and first measurement (after-1). Pancreatic graft ischemia time was significantly shorter in the bolus group (P ⬍ 0.02). Immediately after reperfusion, there was a small increase in glycemia with a decrease in subsequent measures in both groups. No significant differences were observed in glycemia between the groups at any time. When comparing the times, induction values were greater than all other times in both groups. DISCUSSION
It has already been proven that pancreatic beta cells start releasing insulin 5 minutes after graft reperfusion, normalizing the physiologic axis (correlation between glycemic levels and C peptide secretion) starts 25 minutes after From the Albert Einstein Jewish Hospital, and Sa˜o Camilo Hospital and Maternity, Sa˜o Paulo, SP Brazil. Address reprint requests to H. Halpern, Rua Dr. Homem de Melo, 379/152-Sao Paulo-SP-Brazil-05007-001. E-mail: [email protected] © 2004 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 36, 984 –985 (2004)
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Table 1. Glycemia: Mean ⴞ Standard Deviation (Minimum ⴚ Maximum) at Anesthetic Induction, Before Pancreatic Graft Reperfusion (Before), and the First 4 Timepoints After Reperfusion (After-1, After-2, After-3, and After-4) Bolus Infusion (n ⫽ 45)
Age (y) Sex (male/female) Weight (kg) Diabetes time (y) NPH insulin (IU/d) Ischemic time (min) Reperfusion-after-1 (min) Glycemia (moments) Induction Before After-1 After-2 After-3 After-4
Continuous Infusion (n ⫽ 35)
34.49 ⫾ 8.26 36/9 63.86 ⫾ 16.73 21.27 ⫾ 7.78 31.59 ⫾ 11.60 627.09 ⫾ 160.61 13.80 ⫾ 8.47
34.11 ⫾ 6.35 21/14 61.78 ⫾ 8.55 20.78 ⫾ 7.01 38.22 ⫾ 20.29 747.08 ⫾ 188.87 16.31 ⫾ 8.78
218.58 ⫾ 137.47 (33–572) 136.00 ⫾ 39.88 (73–232) 137.49 ⫾ 40.40 (47–249) 138.96 ⫾ 49.58 (33–222) 123.31 ⫾ 39.80 (49 –205) 120.31 ⫾ 33.31 (53–199)
197.31 ⫾ 103.46 (52– 468) 123.80 ⫾ 51.39 (47–316) 130.11 ⫾ 47.25 (47–267) 124.60 ⫾ 43.08 (60 –271) 118.63 ⫾ 41.73 (56 –240) 118.11 ⫾ 39.11 (53–221)
reperfusion.1 Glycemic control is important and was successfully obtained with both methods, but with apparently better results with continuous infusion. In favor of continuous infusion is that it is closer to the endogenous insulin secretion without great fluctuations.2 However, bolus doses seem to obtain the same effect. It is simpler and less costly. In our study, immediately after reperfusion, there was a small increase in glycemia with a trend to a decrease in the other measurements. This indicated early graft function and that glycemic control should be obtained in short intervals
(30 to 60 minutes) to avoid hypoglycemia during the early postoperative period.1–3 REFERENCES 1. Troppmann C, Gruessner AC, Papalois BE, et al: Transplantation 61:1323, 1996 2. Raucoules-Aime M, Lugrin D, Boussofar M, et al: Br J Anaesth 73:443, 1994 3. Beebe DS, Liao JC, Belani KG: In Klinch JR, Lindop MJ (eds): Anesthesia and Perioperative Care for Organ Transplantation. London: Chapman and Hall Medical; 1998, p 281
P
ANCREAS transplantation is a method to restore endogenous insulin secretion in insulin-dependent diabetic patients. Because glycemia ⬎150 mg/dL may harm pancreatic graft beta cells, early glucose control and insulin administration are advised during pancreas transplantation. The aim of this study was to evaluate strict glycemic control during pancreas transplantation, comparing two types of insulin and glucose administration: continuous infusion versus bolus. METHODS Capillary glucose was measured every 30 minutes from anesthetic induction during pancreas transplantation alone or simultaneously with kidney transplantation using a blood glucose monitor. Intravenous regular insulin was administered for values ⬎150 mg/dL and glucose 5% (continuous infusion group) or glucose 50% (bolus group) for values ⬍100 mg/dL. The following timepoints were evaluated: anesthetic induction, before pancreatic graft reperfusion (before), and the first 4 moments after reperfusion (after-1, after-2, after-3, and after-4).
RESULTS
Data are shown in Table 1. Both groups contained more male patients but were similar in age, weight, length of 0041-1345/04/$–see front matter doi:10.1016/j.transproceed.2004.03.086 984
diabetic disease daily amount of neutral protamine hagerdon insulin, and minutes between pancreatic graft reperfusion and first measurement (after-1). Pancreatic graft ischemia time was significantly shorter in the bolus group (P ⬍ 0.02). Immediately after reperfusion, there was a small increase in glycemia with a decrease in subsequent measures in both groups. No significant differences were observed in glycemia between the groups at any time. When comparing the times, induction values were greater than all other times in both groups. DISCUSSION
It has already been proven that pancreatic beta cells start releasing insulin 5 minutes after graft reperfusion, normalizing the physiologic axis (correlation between glycemic levels and C peptide secretion) starts 25 minutes after From the Albert Einstein Jewish Hospital, and Sa˜o Camilo Hospital and Maternity, Sa˜o Paulo, SP Brazil. Address reprint requests to H. Halpern, Rua Dr. Homem de Melo, 379/152-Sao Paulo-SP-Brazil-05007-001. E-mail: [email protected] © 2004 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 36, 984 –985 (2004)
GLYCEMIC CONTROL
985
Table 1. Glycemia: Mean ⴞ Standard Deviation (Minimum ⴚ Maximum) at Anesthetic Induction, Before Pancreatic Graft Reperfusion (Before), and the First 4 Timepoints After Reperfusion (After-1, After-2, After-3, and After-4) Bolus Infusion (n ⫽ 45)
Age (y) Sex (male/female) Weight (kg) Diabetes time (y) NPH insulin (IU/d) Ischemic time (min) Reperfusion-after-1 (min) Glycemia (moments) Induction Before After-1 After-2 After-3 After-4
Continuous Infusion (n ⫽ 35)
34.49 ⫾ 8.26 36/9 63.86 ⫾ 16.73 21.27 ⫾ 7.78 31.59 ⫾ 11.60 627.09 ⫾ 160.61 13.80 ⫾ 8.47
34.11 ⫾ 6.35 21/14 61.78 ⫾ 8.55 20.78 ⫾ 7.01 38.22 ⫾ 20.29 747.08 ⫾ 188.87 16.31 ⫾ 8.78
218.58 ⫾ 137.47 (33–572) 136.00 ⫾ 39.88 (73–232) 137.49 ⫾ 40.40 (47–249) 138.96 ⫾ 49.58 (33–222) 123.31 ⫾ 39.80 (49 –205) 120.31 ⫾ 33.31 (53–199)
197.31 ⫾ 103.46 (52– 468) 123.80 ⫾ 51.39 (47–316) 130.11 ⫾ 47.25 (47–267) 124.60 ⫾ 43.08 (60 –271) 118.63 ⫾ 41.73 (56 –240) 118.11 ⫾ 39.11 (53–221)
reperfusion.1 Glycemic control is important and was successfully obtained with both methods, but with apparently better results with continuous infusion. In favor of continuous infusion is that it is closer to the endogenous insulin secretion without great fluctuations.2 However, bolus doses seem to obtain the same effect. It is simpler and less costly. In our study, immediately after reperfusion, there was a small increase in glycemia with a trend to a decrease in the other measurements. This indicated early graft function and that glycemic control should be obtained in short intervals
(30 to 60 minutes) to avoid hypoglycemia during the early postoperative period.1–3 REFERENCES 1. Troppmann C, Gruessner AC, Papalois BE, et al: Transplantation 61:1323, 1996 2. Raucoules-Aime M, Lugrin D, Boussofar M, et al: Br J Anaesth 73:443, 1994 3. Beebe DS, Liao JC, Belani KG: In Klinch JR, Lindop MJ (eds): Anesthesia and Perioperative Care for Organ Transplantation. London: Chapman and Hall Medical; 1998, p 281