Effects of preoperative oral carbohydrate therapy on perioperative glucose metabolism during oral- maxillofacial surgery: randomised clinical trial.

BACKGROUND AND OBJECTIVES: Preoperative oral carbohydrate therapy has been suggested to attenuate postoperative insulin resistance. The purpose of this study was to investigate the effect of a carbohydrate-rich beverage given preoperatively on intraoperative glucose metabolism. METHODS AND STUDY DESIGN: This study was a randomised, open-label, placebo-controlled trial. Patients undergoing oral-maxillofacial surgery were divided into two groups. In the glucose group, patients took glucose (50 g/278 mL, p.o.) 2 h before anaesthesia induction after overnight fasting; control-group patients took mineral water. Primary outcome was blood concentrations of ketone bodies (KBs); secondary outcomes were blood concentrations of free fatty acids, insulin and glucose. Concentrations were measured 2 h before anaesthesia (T0), induction of anaesthesia (T1), and 1 h (T2), 3 h (T3), and 5h after anaesthesia start (T4). RESULTS: In the control group (n=11), KBs increased continuously from anaesthesia induction. In the glucose group (n=12), KBs were maintained at low concentrations for 3h after beverage consumption but increased remarkably at T3. At T1 and T2, concentrations of KBs in the glucose group were significantly lower than those in the control group (T1, p=0.010; T2, p=0.028). In the glucose group, glucose concentrations decreased significantly at T2 temporarily, but in the control group, glucose concentrations were stable during this study (T2, p<0.001: glucose vs control). CONCLUSIONS: Preoperative intake of glucose (50 g, p.o.) can alleviate ketogenesis for 3 h after consumption but can cause temporary hypoglycaemia after anaesthesia induction.

The Anesthetic Management for a Patient With Trisomy 13.

Trisomy 13 is a chromosomal disorder that occurs in complete or partial mosaic forms. It is characterized by central apnea, mental retardation, seizure and congenital heart disease. The survival of the patients with trisomy 13 is the majority dying before one month. Trisomy 13 is the worst life prognosis among all trisomy syndromes. It is reported the cause of death is central apnea. Special needs patients with mental retardation are recognized to have poorer oral health condition. Oral health related quality of life reflects daily activity and well-being. Dental treatment under general anesthesia is sometimes an option for such patients. This patient had received ventricular septal defect closure surgery at 2-year-old. In addition, he had mental retardation and seizure. Dental treatment had been completed without any cerebral and cardiovascular events under non-invasive monitoring with not only cardiac electric velocimetry, but also epileptogenic activity. In addition, postoperative respiratory condition was maintained stable in room air.

Low-dose carperitide (α-human A-type natriuretic peptide) alleviates hemoglobin concentration decrease during prolonged oral surgery: a randomized controlled study.

PURPOSE: Surgical injury stimulates the renin-angiotensin-aldosterone system (RAAS) and causes antidiuresis, leading to postoperative oliguria. Carperitide (α-human A-type natriuretic peptide) is a cardiac peptide hormone secreted from the atrium. This peptide hormone enhances diuresis by suppressing the RAAS. In our experience, carperitide alleviates decreased hemoglobin (Hb) concentration during elective surgery. In the current study, we investigated the relationship between low-dose carperitide (0.01 µg/kg/min) and Hb concentration during oral surgery. METHODS: Patients (ASA-PS: I-II, 40-80 years old) undergoing oral maxillofacial surgery (duration of operation >8 h) were enrolled in this study. Patients were divided into two groups: the carperitide group received carperitide at 0.01 µg/kg/min and the control group received normal saline. Body fluid water [including total body water (TBW), extracellular water (ECW), and intracellular water (ICW)], urine volume, and chemical parameters such as Hb concentration, PaO2, and serum electrolytes were evaluated every 2 h. RESULTS: In the carperitide group (n = 15), Hb decreased from 12.6 ± 1.1 to 10.8 ± 1.5 g/dl, while it decreased from 12.6 ± 1.4 to 9.5 ± 1.3 g/dl in the control group (n = 15) (p < 0.05). Urine volume (2557.3 ± 983.5 mL) in the carperitide group was significantly more than it was in the control group (1108.8 ± 586.4 mL; p < 0.001). There were no significant differences in clinical characteristics, body fluid water, PaO2, and serum electrolytes between the two groups. In addition, there were no perioperative clinical respiratory and hemodynamic complications in the groups. CONCLUSION: The Hb concentration in the group administered low-dose carperitide at 0.01 µg/kg/min remained higher than that in the control group during surgery. Administration of low-dose carperitide may therefore reduce the risk of blood transfusion during surgery.

Risk Factors for Postoperative Shivering After Oral and Maxillofacial Surgery.

PURPOSE: Postoperative shivering is a frequent complication of anesthesia. However, there are few reports about postoperative shivering in oral and maxillofacial surgery. Postoperative shivering in patients after osteotomy was observed from April 2008 to September 2015. This retrospective study investigated the risk factors of postoperative shivering in oral and maxillofacial surgery. PATIENTS AND METHODS: Anesthesia records of patients who underwent an osteotomy of the maxilla or mandible were checked. A patient's background (gender, age, height, and weight), anesthesia time, operative time, fentanyl, remifentanil, fluid volume, urine volume, blood loss volume, agent for anesthetic maintenance, rectal temperature at the end of surgery, and type of surgery were recorded in addition to the occurrence of postoperative shivering. In the univariate analysis, the Fisher exact test and the χ2 test were used, and a multivariable analysis was performed using stepwise logistic regression to determine risk factors of postoperative shivering. RESULTS: In this study, 233 cases were investigated, and 24 patients (11.5%) had postoperative shivering. The occurrence of postoperative shivering was correlated with blood loss volume (shivering group, 633.9 ± 404.8 mL; nonshivering group, 367.0 ± 312.6 mL; P < .01) and core temperature at the end of surgery (shivering group, 37.2 ± 0.6°C; nonshivering group, 37.5 ± 0.5°C; P < .01). Two variables were associated with postoperative shivering. Rectal temperature at the end of surgery was the highest risk factor (odds ratio = 2.560277; 95% confidence interval, 1.236774-5.327362), and blood loss volume was the next highest risk factor (odds ratio = 0.997733; 95% confidence interval, 0.999-0998). CONCLUSION: Clinicians should pay attention to postoperative shivering not only in patients with hypothermia but also in patients with substantial blood loss.

Body composition and hemodynamic changes in patients with special needs.

BACKGROUND: Some patients with special needs exhibit intellectual disability, including deficits in cognitive skills and decreased quality of life. The purpose of this study was to retrospectively compare changes in body composition and hemodynamics during general anesthesia in patients with and without special needs. METHODS: The backgrounds of patients who underwent oral maxillofacial surgery under general anesthesia were recorded from medical records. Intracellular water (ICW), extracellular water (ECW), stroke volume variation (SVV), and heart rate (HR) were recorded for 3 h after the start of anesthesia. Categorical data were compared using an unpaired t-test, and a P-value of less than 0.05 was regarded as significant. Numerical data were compared using the Bonferroni correction, and a P-value of less than 0.0125 was regarded as significant. RESULTS: A total of 21 patients were included in the study: 10 patients without special needs (non-S-group) and 11 patients with special needs (S-group). There were no significant differences in patients' backgrounds, except with regard to height (P = 0.03). In both groups, ICW and ECW were maintained, although they were lower in the S-group compared to the non-S-group. SVV was maintained in both groups, although it was higher in the S-group than the non-S-group. HR was significantly lower in the S-group 1 h after induction of anesthesia (P < 0.003). CONCLUSIONS: Changes in hemodynamics due to body fluid imbalance should be monitored during general anesthesia, especially for patients with special needs.

Intra-operative administration of low-dose IV glucose attenuates post-operative insulin resistance.

BACKGROUND & AIMS: Insulin sensitivity often decreases after surgery in spite of normal insulin secretion, and may worsen the outcome. This post-operative insulin resistance increases according to the magnitude of surgical invasion. However, supplementation of carbohydrates before surgery attenuates the post-operative insulin resistance. This study aimed to investigate the effect of intra-operative administration of low-dose glucose on the post-operative insulin resistance. METHODS: Patients undergoing maxillofacial surgery were randomly assigned to two groups throughout the surgical procedure: The glucose group receiving acetated Ringer solution with 1.5% glucose and the control group receiving acetated Ringer solution without glucose. Insulin resistance quantified by the mean glucose infusion rate (the glucose infusion rate) was evaluated by glucose clamp using the STG-22TM instrument on the previous day and on the next day of surgery. Blood glucose level was monitored continuously during surgery. In addition, serum insulin, ketone bodies and 3-methylhistidine were measured during perioperative period. RESULTS: Patients in the glucose group (n=11) received 0.15 ± 0.06 g/kg/h of glucose during surgery, while patients in the control group (n=11) received no glucose. In both groups, however, the mean blood glucose levels were maintained stable at less than 150 mg/dL during and after surgery. The serum ketone bodies significantly increased after surgery in the control group (p=0.0035), while it decreased significantly in the glucose group (p=0.043). The reduction rate in the glucose infusion rate was significantly lower in the glucose group, 43.3 ± 20.7%, than that in the control group, 57.7 ± 9.3% (p=0.041). CONCLUSIONS: Intra-operative small-dose of glucose administration may suppress ketogenesis and attenuate the post-operative insulin resistance without causing hyperglycemia.