Вариjации на инсулинемија и гликемија кај хируршки болни кои предоперативно примаат инфузија со амино киселини

Abstract

Background and objectives: Surgical stress response incorporates wide rage of hormonal and metabolic disturbances. Glycoregulatory physiology is changed and mainly variations of glycemia, insulinemia, utilization and glucose uptake in the tissues are disturbed. During this glicometabolic disturbances, body goes to emphysized inflammatory response with disturbation of acute protein levels. In no stress condition, when the body has high protein concentrations avable glicemia and insulin levels are positively correlated to normal glucose uptake and utilization even in diabetic patients. This fact, opens the question wheather preoperative amino acid infusions could influence the levels of glycemia and insulinemia, and as result of this does it influence inflammatory acute protein response. The aim of this study was to analyze the levels of postoperative glycemia, inulinemia, insulin reasistance(glicose uptake) in patients who preoperatively received diferent type of fluid therapy and to analyze this chanches in correlation to acute phase proteins (albumin and CRP). Material and method: The study included 72 female patients scheduled for mastectomy, aged 30– 60 years, without known diabetes, BMI < 30 m2, ASA I,II, divided into three groups. Group A(n=30) included patients (with levels of HbA1c<5.7 %), who preoperatively recived amino acid infusions with regime od 1.2ml/kg/120min, group B(n=30) included patients (with HbA1c < 5.7%) who preoperatevely with the same regime received Ringer Lactat (control group). Group C (n=12) where patients in whom, HbA1c was>5.7%- 6.5% and received preoperatevily Ringer lactat(second control group). All patients underwent standardized anesthesia and surgery protocol. In all groups, glucose, C-peptide, insulin,cortisol, CRP and albumin levels were determinate preoperatively (T1), after the infusion ended (T2) and 24 hour postoperativel (T3). From the obtained C-peptide, insulin and glucose values, with the help of computer and matematical models ( HOMA 1 and HOMA2), the insulin resistance (IR) and Insulin sensitivity were calculated. Occurrence of insulin resistance was registrated for any value above 2.5U. Results: After the ending of the infusion (T2) and postoperatively (T3) rise of the values of glycemia was registrated,when compared to values in T1. In the first group glycemia rised 4,9mmol/l →5.6 mmol/l→5.3 mmol/l, in the second group 4.9 mmol/l→ 5.3 mmol/l → 6.2 mmol/l and in the third group 5.5mmol/l →6.3 mmol/l→7.7mmol/l. Statisticaly significant difference in glicemia values was found in T2(p=0.00)) and T3(p=0.000). Average insulin levels in the first group were 5.3 uIU/ml → 14.7 uIU/ml → 12.3 uIU/ml, in the second group 5.4 uIU/ml →9.2 uIU/ml →20.9 uIU/ml and in the third group 6.9 uIU/ml →20.7 uIU/ml →34.1 uIU/ml. Statisticaly larger number of patients had postoperative hyperglycemia and hyperinsulinemia in the group B and group C compared to group A. Average values of IR were significantly higer in the second(3.9U) and third group (6.9U) compared to the first group (2.2).Postoperative cortisol levels were higer then the preoperative for all group but no statistivcal difference was found between the groups. Postoperative values of inflammatory marker CRP were higer and albumin levels were lower in the groups with higer insulin resistace. Conclusion: Surgical patients who preoperatively receive amino acid infusions postoperatively have better regulated glycemia, lower insulin and C-peptide levels, lower IR in the presence of high cortisol levels. Acute phase proteins (CRP and albumin) in this patients show lower inflammatory response to trauma.