Jonathan E. Rhoads Lecture 2011

Abstract

This lecture reviews the current understanding of how insulin resistance, as a marker of the metabolic stress, is involved in recovery after major surgery. Insulin resistance develops as a graded response related to the magnitude of the operation. It lasts for weeks after medium-size surgery and affects all parts of body metabolism. Although hyperglycemia develops, muscle and fat uptake is reduced and other non-insulin-sensitive cells have an increase in glucose uptake as a result of the elevated glucose levels. Reduced glucose uptake and storage in muscle along with loss of lean body mass help explain reduced muscle function that will impair mobilization. The increased uptake of glucose in non-insulin-sensitive cells is involved in the development of several of the most common postoperative complications, including infections and cardiovascular problems. Many of the perioperative treatments in use are outdated, and modern care involves a multimodal approach with several treatments, such as preoperative carbohydrate treatment instead of overnight fasting, continuous epidural anesthesia for postoperative pain care, early feeding, and mobilization, all of which affect insulin by reducing the stress and enhancing recovery. Most of the previous mandatory catabolic responses to surgery can be avoided, resulting in substantially faster recovery and fewer complications. Methods to implement these modern treatments have been developed and used in Europe, resulting in improved care and shorter length of stay.

Enhanced Recovery after Surgery Protocol in Abdominal Hysterectomies for Malignant versus Benign Disease

“…The physiology behind the improvements gained by the ERAS protocol is believed to be stress reduction [13]. The current data suggest that the same benefit from the ERAS program should be expected in patients with malignant disease.…”

Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 1: pathophysiological considerations

“…This concept not only applies to physiological/metabolic changes but also to changes in the innate immune system. This combination of catecholamine release and hyper‐inflammation followed by immunosuppression can contribute, among other things, to a state of insulin resistance 19, 20…”

“…Any major injury including surgery disrupts metabolic homoeostasis and cause insulin resistance. Insulin resistance can be defined as a condition, whereby a normal concentration of insulin produces a subnormal biological response 19. Studies have demonstrated a significant correlation between the degree of the patient's insulin sensitivity on the first post‐operative day and length of hospital stay ( r  = 0.53, P  = 0.0001) 20.…”

The Effects of Propofol and Isoflurane on Blood Glucose during Abdominal Hysterectomy in Diabetic Patients

“…One of the most important metabolic reactions during surgery is resistance to insulin and hyperglycemia [1]. Hyperglycemia in the perioperative period is due to stress hormones such as epinephrine, cortisol, and inflammatory mediators.…”