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Tigchelaar C, van Zuylen ML, Hulst AH, Preckel B, van Beek AP, Kema IP, Hermanides J, Absalom AR. Elevated cerebrospinal fluid glucose levels and diabetes mellitus are associated with activation of the neurotoxic polyol pathway. Diabetologia 2022; 65:1098-1107. [PMID: 35380232 PMCID: PMC9174140 DOI: 10.1007/s00125-022-05693-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 01/17/2022] [Indexed: 01/01/2023]
Abstract
AIMS/HYPOTHESIS During hyperglycaemia, some glucose bypasses glycolysis and is metabolised via the potentially neurotoxic polyol pathway, in which glucose is metabolised to sorbitol and fructose. Increased polyol concentrations have been demonstrated in the cerebrospinal fluid (CSF) of neurological patients with and without diabetes mellitus. However, polyol levels in patients without evident neurological abnormalities have not been investigated so far. The aim of this study was to determine CSF polyol concentrations in patients without major neurological disease with normal or elevated CSF glucose concentrations. METHODS This observational cohort study used CSF and plasma analyses, as well as clinical data, from 30 participants of the Anaesthetic Biobank of Cerebrospinal Fluid study. Biomaterial was collected from adult patients scheduled for elective surgery under spinal anaesthesia. CSF polyol concentrations were measured by GC/flame ionisation detector in ten patients with normal CSF glucose levels (group 1), ten patients with elevated CSF glucose levels (group 2) and ten patients with elevated CSF glucose levels and type 2 diabetes (group 3). We compared the concentrations of plasma glucose, CSF glucose, sorbitol and fructose, and CSF polyol/glucose ratios between the three groups, and determined the correlation between plasma glucose levels and CSF glucose, sorbitol and fructose levels. RESULTS Groups 2 and 3 had significantly higher CSF fructose levels compared with group 1 (p=0.036 and p<0.001, respectively). Group 3 showed significant differences compared with groups 1 and 2 for CSF sorbitol (p<0.001 and 0.036, respectively). Moreover, patients with diabetes had a significantly higher CSF sorbitol/glucose ratio compared with patients without diabetes. There was a strong positive correlation between plasma glucose and CSF glucose, sorbitol and fructose. Finally, age, sex, CSF/plasma albumin ratio and preoperative cognitive function scores were significantly correlated with plasma glucose and CSF glucose, sorbitol and fructose levels. CONCLUSIONS/INTERPRETATION Hyperglycaemia causes a proportional increase in polyol concentrations in CSF of patients without major neurological disease. Furthermore, this study provides the first indication of upregulation of the cerebral polyol pathway in patients with diabetes without evident neurological abnormalities.
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Affiliation(s)
- Celien Tigchelaar
- Department of Anaesthesiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
| | - Mark L van Zuylen
- Department of Anaesthesiology, Amsterdam UMC - Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Abraham H Hulst
- Department of Anaesthesiology, Amsterdam UMC - Location AMC, University of Amsterdam, Amsterdam, the Netherlands
- Department of Intensive Care, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Benedikt Preckel
- Department of Anaesthesiology, Amsterdam UMC - Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - André P van Beek
- Department of Endocrinology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Ido P Kema
- Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Jeroen Hermanides
- Department of Anaesthesiology, Amsterdam UMC - Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Anthony R Absalom
- Department of Anaesthesiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Ruzycki SM, Harrison TG, Enns E, McKeen J, Helmle K, Cameron A. Quality gaps in screening and monitoring for postoperative hyperglycemia in a Canadian hospital: a retrospective cohort study. BMJ Open Diabetes Res Care 2021; 9:e002445. [PMID: 34711544 PMCID: PMC8557293 DOI: 10.1136/bmjdrc-2021-002445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/18/2021] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Evidence-based preoperative, intraoperative and postoperative glycemic management may reduce poor surgical outcomes. Previous studies suggest that quality gaps in perioperative glycemic management may be common. RESEARCH DESIGN AND METHODS This retrospective cohort study used administrative health and laboratory data from a single center to estimate quality gaps in perioperative glycemic management in patients with and without diabetes between April 2019 and March 2020. We examined the proportion of patients with preoperative hemoglobin A1c (HbA1c) measurement, postoperative point-of-care testing (POCT) for glucose, hyperglycemia, and basal bolus insulin regimens. We compared the median length of stay (LOS) in patients with and without postoperative hyperglycemia, adjusted for age and sex. RESULTS There were 6576 patients in our cohort; 1165 (17.8%) had diabetes. Most patients with diabetes had an HbA1c measured prior to surgery (n=697, 59.8%). Postoperatively, 16.9% of patients with diabetes had no POCT monitoring (n=197) and 65.7% had hyperglycemia (n=636). Only 35.9% of patients who received insulin had a basal bolus insulin regimen (n=229). Patients with diabetes who had postoperative hyperglycemia had a longer median LOS compared with those who did not have postoperative hyperglycemia (8.4 days (95% CI 7.5 to 9.4) and 6.7 days (95% CI 6.3 to 7.1), respectively). In patients without diabetes, median LOS was 7.4 days (95% CI 4.4 to 10.4) for those with hyperglycemia and 5.2 days (95% CI 5.1 to 5.4) for those with in-target glucose. CONCLUSIONS Quality gaps in perioperative glycemic management include measurement of blood glucose after surgery and treatment of postoperative hyperglycemia. These gaps may contribute to longer LOS.
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Affiliation(s)
- Shannon M Ruzycki
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Tyrone G Harrison
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Edwin Enns
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Julie McKeen
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Karmon Helmle
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Anna Cameron
- Department of Obstetrics and Gynecology, Cumming School of Medicine, Calgary, Alberta, Canada
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Influence of preoperative hemoglobin A1c on early outcomes in patients with diabetes mellitus undergoing off-pump coronary artery bypass surgery. J Thorac Cardiovasc Surg 2020; 159:568-576. [DOI: 10.1016/j.jtcvs.2019.01.086] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 01/23/2019] [Accepted: 01/23/2019] [Indexed: 02/07/2023]
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Hulst AH, Plummer MP, Hollmann MW, DeVries JH, Preckel B, Deane AM, Hermanides J. Systematic review of incretin therapy during peri-operative and intensive care. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:299. [PMID: 30428906 PMCID: PMC6236901 DOI: 10.1186/s13054-018-2197-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 09/24/2018] [Indexed: 01/10/2023]
Abstract
Background Glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic peptide (GIP) are incretin hormones. By lowering blood glucose in a glucose-dependent manner, incretin-based therapies represent a novel and promising intervention to treat hyperglycaemia in hospital settings. We performed a systematic review of the literature for all current applications of incretin-based therapies in the peri-operative and critical care settings. Methods We searched MEDLINE, the Cochrane Library, and Embase databases for all randomised controlled trials using exogenous GLP-1, GLP-1 receptor agonists, exogenous GIP and dipeptidyl peptidase IV inhibitors in the setting of adult peri-operative care or intensive care. We defined no comparator treatment. Outcomes of interest included blood glucose, frequency of hypoglycaemia and insulin administration. Results Of the 1190 articles identified during the initial literature search, 38 fulfilled criteria for full-text review, and 19 single-centre studies were subsequently included in the qualitative review. Of the 18 studies reporting glycaemic control, improvement was reported in 15, defined as lower glucose concentrations in 12 and as reduced insulin administration (with similar glucose concentrations) in 3. Owing to heterogeneity, meta-analysis was possible only for the outcome of hypoglycaemia. This revealed an incidence of 7.4% in those receiving incretin-based therapies and 6.8% in comparator groups (P = 0.94). Conclusions In small, single-centre studies, incretin-based therapies lowered blood glucose and reduced insulin administration without increasing the incidence of hypoglycaemia. Trial registration PROSPERO, CRD42017071926. Electronic supplementary material The online version of this article (10.1186/s13054-018-2197-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Abraham H Hulst
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ, Amsterdam, the Netherlands
| | - Mark P Plummer
- Intensive Care Unit, Royal Melbourne Hospital, 300 Grattan Street, Parkville, VIC, 3050, Australia
| | - Markus W Hollmann
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ, Amsterdam, the Netherlands
| | - J Hans DeVries
- Department of Endocrinology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ, Amsterdam, the Netherlands
| | - Benedikt Preckel
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ, Amsterdam, the Netherlands.
| | - Adam M Deane
- Intensive Care Unit, Royal Melbourne Hospital, 300 Grattan Street, Parkville, VIC, 3050, Australia
| | - Jeroen Hermanides
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ, Amsterdam, the Netherlands
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Teixeira LG, Martins LR, Schimites PI, de Oliveira RB, Bonella J, Campos RV, Mangini LT, Gasparotto JC, Soares AV. Peripheral perfusion index does not accurately reflect hypoperfusion in healthy dogs undergoing elective ovariohysterectomy. Vet J 2018; 240:27-30. [PMID: 30268329 DOI: 10.1016/j.tvjl.2018.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 08/28/2018] [Accepted: 09/02/2018] [Indexed: 11/18/2022]
Abstract
This study evaluated the variability of the peripheral perfusion index (PI) in 22 anaesthetised female dogs undergoing elective ovariohysterectomy and examined the relationship between peripheral PI and heart rate, blood pressure, blood pH, end tidal CO2 (EtCO2), O2 saturation (SpO2), core-peripheral temperature gradient (ΔTc-p), partial pressure of CO2 (PCO2), and concentrations of glucose, cortisol, lactate and bicarbonate (HCO3-). Blood pH, lactate and glucose concentrations were determined 15, 30, 45min into the ovariohysterectomy procedure and after extubation. Cortisol concentrations were assessed before anaesthesia and after extubation. Other variables were recorded at every 5min throughout the ovariohysterectomy procedure. Hyperglycaemia was observed in 59% of bitches during surgery, but serum cortisol concentrations remained unchanged. Most measures of perfusion (ΔTc-p, pH, PCO2, EtCO2, SpO2) and heart rate remained unchanged throughout anaesthesia and did not correlate with peripheral PI. Mean arterial pressure increased during the ovariohysterectomy procedure, while peripheral PI decreased, resulting in negative correlations between these variables at 30 and 45min. Lactate concentrations decreased from baseline to the time of measurement post-extubation. Peripheral PI gradually decreased during the ovariohysterectomy procedure, probably reflecting vasoconstriction induced by nociceptive stimuli. Using lactate concentrations as the reference standard for peripheral perfusion, low peripheral PI in healthy bitches undergoing ovariohysterectomy might not represent peripheral hypoperfusion.
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Affiliation(s)
- L G Teixeira
- Graduate Programme of Veterinary Medicine, Centre of Rural Science, Federal University of Santa Maria (UFSM), Avenida Roraima n° 1000/97, 97195-000 Santa Maria, Rio Grande do Sul State, Brazil.
| | - L R Martins
- Graduate Programme of Veterinary Medicine, Centre of Rural Science, Federal University of Santa Maria (UFSM), Avenida Roraima n° 1000/97, 97195-000 Santa Maria, Rio Grande do Sul State, Brazil
| | - P I Schimites
- Graduate Programme of Veterinary Medicine, Centre of Rural Science, Federal University of Santa Maria (UFSM), Avenida Roraima n° 1000/97, 97195-000 Santa Maria, Rio Grande do Sul State, Brazil
| | - R B de Oliveira
- Graduate Programme of Veterinary Medicine, Centre of Rural Science, Federal University of Santa Maria (UFSM), Avenida Roraima n° 1000/97, 97195-000 Santa Maria, Rio Grande do Sul State, Brazil
| | - J Bonella
- Department of Small Animal Clinics, Centre of Rural Science, Federal University of Santa Maria (UFSM), Avenida Roraima n° 1000/97, 97195-000 Santa Maria, Rio Grande do Sul State, Brazil
| | - R V Campos
- Department of Small Animal Clinics, Centre of Rural Science, Federal University of Santa Maria (UFSM), Avenida Roraima n° 1000/97, 97195-000 Santa Maria, Rio Grande do Sul State, Brazil
| | - L T Mangini
- Department of Small Animal Clinics, Centre of Rural Science, Federal University of Santa Maria (UFSM), Avenida Roraima n° 1000/97, 97195-000 Santa Maria, Rio Grande do Sul State, Brazil
| | - J C Gasparotto
- Department of Small Animal Clinics, Centre of Rural Science, Federal University of Santa Maria (UFSM), Avenida Roraima n° 1000/97, 97195-000 Santa Maria, Rio Grande do Sul State, Brazil
| | - A V Soares
- Graduate Programme of Veterinary Medicine, Centre of Rural Science, Federal University of Santa Maria (UFSM), Avenida Roraima n° 1000/97, 97195-000 Santa Maria, Rio Grande do Sul State, Brazil; Department of Small Animal Clinics, Centre of Rural Science, Federal University of Santa Maria (UFSM), Avenida Roraima n° 1000/97, 97195-000 Santa Maria, Rio Grande do Sul State, Brazil
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Hulst AH, Polderman JAW, Ouweneel E, Pijl AJ, Hollmann MW, DeVries JH, Preckel B, Hermanides J. Peri-operative continuation of metformin does not improve glycaemic control in patients with type 2 diabetes: A randomized controlled trial. Diabetes Obes Metab 2018; 20:749-752. [PMID: 28940961 DOI: 10.1111/dom.13118] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 09/01/2017] [Accepted: 09/09/2017] [Indexed: 11/26/2022]
Abstract
Historically, metformin was withheld before surgery for fear of metformin-associated lactic acidosis. Currently, however, this risk is deemed to be low and guidelines have moved towards the continuation of metformin. We hypothesized that continuing metformin peri-operatively would lower postoperative serum glucose level without an effect on plasma lactate levels. We performed a single-blind multicentre randomized controlled trial in people with type 2 diabetes mellitus scheduled for non-cardiac surgery and continued (MF+ group) or withheld (MF- group) metformin before surgery. The main outcome measures were the differences in peri-operative plasma glucose and lactate levels. We randomized 70 patients (37 MF+ group and 33 MF- group) with type 2 diabetes mellitus. Postoperative glucose levels were similar in the MF+ and the MF- groups (8.2 ± 1.8 vs 8.3 ± 2.3 mmol/L P = .95) Although preoperative lactate levels were slightly higher in the MF+ group compared with the MF- group (1.5 vs 1.2 mmol/L; P = .02), the postoperative lactate levels were not significantly different (1.2 vs 1.0 mmol/L; P = .18). In conclusion, continuation of metformin during elective non-cardiac surgery does not improve glucose control or raise lactate levels to a clinically relevant degree.
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Affiliation(s)
- A H Hulst
- Department of Anaesthesiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - J A W Polderman
- Department of Anaesthesiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - E Ouweneel
- Department of Anaesthesiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - A J Pijl
- Department of Anaesthesiology, Medical Centre Slotervaart, Amsterdam, The Netherlands
| | - M W Hollmann
- Department of Anaesthesiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - J H DeVries
- Department of Internal Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - B Preckel
- Department of Anaesthesiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - J Hermanides
- Department of Anaesthesiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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Polderman JAW, van Steen SCJ, Thiel B, Godfried MB, Houweling PL, Hollmann MW, DeVries JH, Preckel B, Hermanides J. Peri-operative management of patients with type-2 diabetes mellitus undergoing non-cardiac surgery using liraglutide, glucose-insulin-potassium infusion or intravenous insulin bolus regimens: a randomised controlled trial. Anaesthesia 2017; 73:332-339. [DOI: 10.1111/anae.14180] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2017] [Indexed: 12/12/2022]
Affiliation(s)
- J. A. W. Polderman
- Department of Anaesthesiology; Academic Medical Centre Amsterdam; Amsterdam the Netherlands
| | - S. C. J. van Steen
- Department of Endocrinology; Academic Medical Centre Amsterdam; Amsterdam the Netherlands
| | - B. Thiel
- Department of Anaesthesiology; Onze Lieve Vrouwe Gasthuis; Amsterdam the Netherlands
| | - M. B. Godfried
- Department of Anaesthesiology; Onze Lieve Vrouwe Gasthuis; Amsterdam the Netherlands
| | - P. L. Houweling
- Department of Anaesthesiology; Diakonessenhuis; Utrecht the Netherlands
| | - M. W. Hollmann
- Department of Anaesthesiology; Academic Medical Centre Amsterdam; Amsterdam the Netherlands
| | - J. H. DeVries
- Department of Endocrinology; Academic Medical Centre Amsterdam; Amsterdam the Netherlands
| | - B. Preckel
- Department of Anaesthesiology; Academic Medical Centre Amsterdam; Amsterdam the Netherlands
| | - J. Hermanides
- Department of Anaesthesiology; Academic Medical Centre Amsterdam; Amsterdam the Netherlands
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