Carbohydrate balance in the perioperative period

Abstract

Background. Deep and multifaceted disorders during the perioperative period can lead to severe metabolic disorders that are life-threatening and require immediate care. Such conditions include the disorders of carbohydrate metabolism (CHM).
 Objective. To describe CHM disorders in the perioperative period and the possibility of their correction.
 Materials and methods. Analysis of literature sources on this topic.
 Results and discussion. The pathogenesis of CHM disorders in the perioperative period includes such links as the impact of surgical stress and/or infections, relative insulin deficiency, increased production of ketone bodies etc. Grades of CHM disorders include compensation (normoglycemia, aglucosuria), subcompensation (moderate glycemia (up to 13.9 mmol/L), slight glucosuria), and decompensation (high glycemia, significant glucosuria, ketone bodies). The main tasks of preoperative preparation in patients with CHM disorders include CHM normalization, correction of volemic disorders, maximum compensation of renal function, prevention and treatment of infectious complications. Glycemic levels in perioperative CHM disorders are highly variable and are not always associated with the severity of the condition, although glycemia >30 mmol/L is usually associated with severe diabetic ketoacidosis. Surgery is one of the triggers of stress hyperglycemia (for patients without diabetes, the glucose level in these cases is 7.7-11.0 mmol/L). In the treatment of persistent hyperglycemia in hospitalized patients, insulin therapy should be initiated, starting from a blood glucose threshold of 10.0 mmol/L. The target is 7.8-10.0 mmol/L. Ketoacidotic coma is an absolute contraindication to surgery due to concomitant severe water-electrolyte disorders. Surgery for vital indications can be performed only after restorative measures in 3-4 hours after recovery of consciousness and reduction of glycemia to <15 mmol/L. Only profuse, life-threatening bleeding can be the basis for reducing the time and volume of preoperative preparation of a patient with diabetes decompensation. Criteria of readiness for surgery include normal or close to normal blood glucose levels, adequate hydration and elimination of ketoacidosis. In patients with severe diabetes, relative compensation (8.8-10.0 mmol/L) can be used as a criterion. Most researchers recommend transitioning patients with impaired CHM to simple insulin injections before surgery. Insulin concentration is important for wound healing and prevention of purulent complications. Sodium bicarbonate or Soda-Bufer (“Yuria-Pharm”) can be used to correct metabolic acidosis. Ketogenesis should be eliminated with xylitol (Xylate, “Yuria-Pharm”). Routine glucose use in critically ill patients has been abandoned.
 Conclusions. 1. Many patients in the perioperative period develop CHM disorders, which worsen the course of the underlying disease. 2. The main tasks of preoperative preparation in patients with CHM disorders are CHM normalization, correction of volemic disorders, maximum compensation of renal function, prevention and treatment of infectious complications. 3. In the treatment of persistent hyperglycemia in hospitalized patients, insulin therapy should be started, starting from the glycemic threshold of 10.0 mmol/L. 4. Ketoacidotic coma is an absolute contraindication to surgery due to concomitant severe water-electrolyte disorders. 5. Criteria of readiness for surgery include normal or close to normal blood glucose levels, adequate hydration and elimination of ketoacidosis. 6. Sodium bicarbonate or Soda-Bufer can be used to correct metabolic acidosis. 7. Ketogenesis should be eliminated with Xylate.