A review of perioperative glucose control in the neurosurgical population

Abstract

Significant fluctuations in serum glucose levels accompany the stress response of surgery or acute injury and may be associated with vascular or neurologic morbidity. Maintenance of euglycemia with intensive insulin therapy (IIT) continues to be investigated as a therapeutic intervention to decrease morbidity associated with derangements in glucose metabolism. Hypoglycemia is a common side effect of IIT with potential for significant morbidity, especially in the neurologically injured patient. Differences in cerebral versus systemic glucose metabolism, the time course of cerebral response to injury, and heterogeneity of pathophysiology in neurosurgical patient populations are important to consider in evaluating the risks and benefits of IIT. While extremes of glucose levels are to be avoided, there are little data to support specific use of IIT for maintenance of euglycemia in the perioperative management of neurosurgical patients. Existing data are summarized and reviewed in this context.

Figure 1.

Perfusion-weighted imaging, diffusion-weighted imaging, and MRI spectra in patient A imaged at 2.5 h and 3 days and in patient B imaged at 3 h and 3 days. Patients A and B both had large areas of acute perfusion-weighted-imaging–diffusion-weighted-imaging mismatch or at-risk tissue. Acute blood glucose was 5.9 mmol/liter for patient A and 12.1 mmol/liter for patient B. At 3 days, patient A had no increase in lactate level and major penumbral salvage. In contrast, patient B had a large increase in lactate level, and much of the at-risk tissue progressed to infarction. Copyright 1996; reprinted with permission of John Wiley & Sons, Inc.