Abstract
Many neurosurgery patients may have unrecognized diabetes or may develop stress-related hyperglycemia in the perioperative period. Diabetes patients have a higher perioperative risk of complications and have longer hospital stays than individuals without diabetes. Maintenance of euglycemia using intensive insulin therapy (IIT) continues to be investigated as a therapeutic tool to decrease morbidity and mortality associated with derangements in glucose metabolism due to surgery. Suboptimal perioperative glucose control may contribute to increased morbidity, mortality, and aggravate concomitant illnesses. The challenge is to minimize the effects of metabolic derangements on surgical outcomes, reduce blood glucose excursions, and prevent hypoglycemia. Differences in cerebral versus systemic glucose metabolism, time course of cerebral response to injury, and heterogeneity of pathophysiology in the neurosurgical patient populations are important to consider in evaluating the risks and benefits of IIT. While extremes of glucose levels are to be avoided, there are little data to support an optimal blood glucose level or recommend a specific use of IIT for euglycemia maintenance in the perioperative management of neurosurgical patients. Individualized treatment should be based on the local level of blood glucose control, outpatient treatment regimen, presence of complications, nature of the surgical procedure, and type of anesthesia administered.
Highlights
Several observational and interventional studies have indicated that hyperglycemia in diabetic and nondiabetic neurosurgical patients is associated with adverse outcomes, such as an increased prevalence of complications, prolonged hospital stay, and higher mortality rates [1,2,3,4,5]
This paper focuses on perioperative glucose control in neurosurgical patients and glucose management during the perioperative period
No consensus exists on blood glucose level goals for the perioperative period; several organizations have established general targets for neurocritically ill and neurosurgery patients [12, 16]
Summary
Several observational and interventional studies have indicated that hyperglycemia (hyperG) in diabetic and nondiabetic neurosurgical patients is associated with adverse outcomes, such as an increased prevalence of complications, prolonged hospital stay, and higher mortality rates [1,2,3,4,5]. No consensus exists as to whether hyperG is directly responsible for poor outcomes or if it is just an epiphenomenon of brain damage [10,11,12, 16] It has been hypothesized, that strict blood glucose control could have a favorable impact on patient outcome [11]. Increasing interest has evolved for tight blood glucose control using intensive insulin therapy (IIT) in neurocritically ill patients. The American Diabetes Association consensus recently established the presence of hyperG and patient treatment threshold when blood glucose values exceed 140 mg/dL (7.8 mmol/L) in two or more plasma samples [8]. Stress-induced hyperG may cause endothelial cell dysfunction, defects in immune function, increased oxidative stress, prothrombotic changes, cardiovascular effects, and specific brain area (insular cortex) injury or a direct hypothalamic damage/irritation of glucose regulatory centers [23,24,25]. hyperG has been shown to aggravate these deleterious effects, whereas optimization of glucose control has been shown to reverse them
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