Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Dec 2009
ReviewModulating postoperative insulin resistance by preoperative carbohydrate loading.
The concept of preoperative overnight fasting was challenged and proved to have no benefits over allowing patients to drink clear fluids up until 2 h before surgery. This led to changes in the guidelines for preoperative fasting in many countries around the world. This concept has more recently been developed further. ⋯ This article summarises the present understanding of the mechanisms behind the positive clinical effects and gives an overview of the information available regarding the clinical effects of this treatment. Finally, the article summarises the most recently published national guidelines on preoperative fasting routines where preoperative carbohydrates are recommended for use before a major surgery. These are to be considered for all patients allowed to drink clear fluids and undergoing elective surgery.
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Best Pract Res Clin Anaesthesiol · Dec 2009
ReviewHow to weigh the current evidence for clinical practice.
This article presents a template for judging trials of tight glucose control in critically ill patients. It reviews threats to both internal validity and generalisability using examples from the current literature. ⋯ These may relate to the setting, the patients or the practical delivery of tight glucose control or other interventions. Once identified, a judgement must be made for each difference of whether it is likely to modify the effect of tight glucose control.
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Best Pract Res Clin Anaesthesiol · Dec 2009
ReviewTight glycaemic control: clinical implementation of protocols.
Implementation of tight glycaemic control in hospitalised patients presents a huge challenge. It concerns many patients, there are many interfering factors and many health-care professionals are involved. The current literature provides little practical guidance. ⋯ An effective, safe and user-friendly algorithm for intravenous insulin administration is presented that can be executed by regular nurses and used in many situations. Practical advice is offered for the use of subcutaneous basal-bolus insulin, for fasting orders and for transition to discharge care. The main safety considerations are discussed.
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Best Pract Res Clin Anaesthesiol · Dec 2009
ReviewClinical benefits of tight glycaemic control: effect on the kidney.
Acute kidney injury is a frequent and life-threatening complication of critical illness. Prevention of this condition is crucial. Two randomized single center trials in critically ill patients have shown a decrease in acute kidney injury by tight glycaemic control, an effect that appears most pronounced in surgical patients. ⋯ This apparent contradiction is likely explained by methodological differences between studies, including different patient populations, insufficient patient numbers, comparison with a different control group, use of inaccurate blood glucose analyzers, and differences in the degree of reaching the target blood glucose level. The optimal glycaemic target for renoprotection in critical illness remains to be defined. Possible mechanisms underlying the renoprotective effect of tight glycaemic control are prevention of glucose overload and toxicity and the associated mitochondrial damage, an anti-inflammatory or anti-apoptotic effect, prevention of endothelial dysfunction, and an improvement of the lipid profile.