Differential Effects of a Perioperative Hyperinsulinemic Normoglycemic Clamp on the Neurohumoral Stress Response during Coronary Artery Surgery

Abstract

A hyperinsulinemic normoglycemic clamp during CABG delays and attenuates the HPA axis response during the first 18 h of the myocardial reperfusion period, whereas after the clamp, plasma epinephrine is higher. The impact of delaying cortisol responses on clinical outcome of CABG remains to be elucidated.

Catecholamine-resistant shock and hypoglycemic coma after cardiotomy in a patient with unexpected isolated ACTH deficiency

“…In heart surgery carried out under cardiopulmonary bypass, cortisol has been reported to increase after detachment from the heart-lung apparatus and remain high until postoperative day 2, whereas ACTH peaks at 6 h after detachment and returns to normal within a day after surgery [4]. However, in our case, both cortisol and ACTH levels were below normal prior to anesthesia induction and remained low until 12 h after surgery, showing no increase after surgical invasion.…”

Perioperative hyperinsulinaemic normoglycaemic clamp causes hypolipidaemia after coronary artery surgery

“…Thirty-six patients also participated in our previously reported neurohumoural stress study. 18 Excluded were patients with the following characteristics: LV ejection fraction ,45%, unstable angina pectoris, atrioventricular conduction defects, and diabetes mellitus. The last were excluded on the basis of a known diagnosis of diabetes mellitus or fasting plasma glucose levels of at least 7.0 mmol litre 21 .…”

The effect of perioperative glucose control on postoperative insulin resistance

“…Moreover, insulin exhibits a positive effect on the inflammatory response to trauma, in addition to suppressing platelet activation 15,36 . As demonstrated, patients subjected to an hyperinsulinemic normoglycemic clamp during cardiac surgery displayed an attenuated inflammatory response 117 and a decreased and delayed stress response, indicated by a reduced ACTH and cortisol release 118 . Nygren et al could present similar reduction in cortisol response during insulin infusion 113 .…”

“…However, Mita et al presented positive results on postoperative kidney function using a similar period of treatment 168 , while other findings of attenuated liver dysfunction and cytokine expression have been based on a prolonged treatment up to 24 hours 169,170 . In other trials, in which HNC was performed during and after cardiac surgery, an attenuated and delayed inflammatory and neuroendocrine stress response was demonstrated, until the clamp was terminated, where after the stress levels were restored 117,118 . Thus, glucose control has been associated with positive effects on postoperative myocardial and kidney function and on stress levels in general, despite insulin administration only in the intra-or in the early postoperative phase.…”

“…The insulin dosage during the HNC in paper III and IV, 80 mU/m 2 /min or 2.0 mU/kg/min, differed in amount from that used in studies by Thorell, Nygren and Soop et al, 0.8 mU/kg/min 39,113,126 . In contrast, other investigators have used even higher amounts during HNC 118,129,136,287 . It is assumed that EGP is suppressed at a plasma insulin level of 60 µU/ml, whereas higher levels only increases glucose disposal 270 .…”