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ORIGINAL ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 1  |  Page : 47-51

A comparative study on effect of 4% gelatin and dextran-40 on blood glucose levels during surgery under subarachnoid block - A randomized, prospective study


Department of Anaesthesia, Sri Venkateswara Medical College (SVMC), Tirupati, Andhra Pradesh, India

Date of Submission14-Dec-2019
Date of Decision28-Feb-2021
Date of Acceptance22-Mar-2021
Date of Web Publication19-May-2021

Correspondence Address:
Dr. K G Sreehari
Assistant Professor, Department of Anaesthesia, Sri Venkateswara Medical College (SVMC), Tirupati, Chittor, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JDRNTRUHS.JDRNTRUHS_122_19

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  Abstract 


Background: Stress response to surgery induces hyperglycemia to a limited extent. An additive hyperglycemic response, secondary to the metabolism of intravenous fluids, can thus prove detrimental to the well-being of the patient, if ignored.
Aim and Objectives: Our study aimed to examine and compare the effects of 4% gelatin and dextran-40 on blood glucose levels during surgery under subarachnoid block and their potential to induce hyperglycemia.
Materials and Methods: Sixty ASA grade I and II patients were randomized into two groups, 30 patients in each. Group 1 patients were preloaded with 4% gelatin (10 mL/kg) and Group 2 patients were preloaded with Dextran-40 in normal saline (10 mL/kg), over a period of 30 min. Just prior to preloading, baseline capillary blood glucose (CBG) level was noted this is followed by subsequent readings at 20 min interval until 100 min from baseline reading. All patients received normal saline (0.9%) as a maintenance fluid. Under strict aseptic precautions, subarachnoid block using 15 mg of hyperbaric bupivacaine at L3–L4 or L4–L5 level was given after preloading.
Results: Both groups are comparable in age, weight, sex, age-wise distribution, type and duration of surgery. The CBG levels in both the groups at 20, 40, 60, 80, and 100 min from the baseline were within physiological limits. In group 2, the maximum mean blood glucose level of 98.53 ± 14.57 mg/dL was found at 60 min from onset of preloading, which was found to be statistically significant (P = 0.017) when compared with corresponding blood glucose level (86.50 ± 10.44 mg/dL) in group 1.
Conclusion: Preloading the patients prior to subarachnoid block with 4% gelatin or dextran 40 does not raise CBG levels significantly above the physiological limits.

Keywords: Capillary glucose levels and subarachnoid block, dextran-40, gelatin-4%


How to cite this article:
Sreehari K G, Satyanarayana V, Madhusudan M, Vijay K, Ravi Raj G S. A comparative study on effect of 4% gelatin and dextran-40 on blood glucose levels during surgery under subarachnoid block - A randomized, prospective study. J NTR Univ Health Sci 2021;10:47-51

How to cite this URL:
Sreehari K G, Satyanarayana V, Madhusudan M, Vijay K, Ravi Raj G S. A comparative study on effect of 4% gelatin and dextran-40 on blood glucose levels during surgery under subarachnoid block - A randomized, prospective study. J NTR Univ Health Sci [serial online] 2021 [cited 2021 Dec 6];10:47-51. Available from: https://www.jdrntruhs.org/text.asp?2021/10/1/47/316311




  Introduction Top


Colloids are widely used in fluid resuscitation for hypovolemic shock as an integral part of the acute medical management in critically ill patients in intensive care unit or inside an operating room.[1] Colloids are also used as preloading fluids prophylactically, to limit complications following sympathetic blockade in central neuraxial blockade, especially subarachnoid block.[2] Stress response to surgery and catecholamine release following it is itself known to induce some amount of hyperglycemia, but this remains confined to limited extent. An additive hyperglycemic response, secondary to the metabolism of infused intravenous colloids, especially starches can thus prove detrimental to the well-being of the patient, if ignored.[3] Hyperglycemia is known to potentiate neurological changes and ischemia to the brain spinal cord, heart,[4] and kidneys.[5]

It also impairs wound healing, by interfering with white blood cells.[6] These colloids are harmful in fluid resuscitation of uncontrolled diabetes, during neurosurgical procedures and in the event of cardiopulmonary resuscitation. Dextrans and hydroxyethyl starches produce significant levels of free glucose residues following metabolism. Dextrans are polysaccharides that are normally broken down completely to carbon dioxide and water by the enzyme dextranase, at a rate approaching 70 mg/kg, every 24 h. However, under stressful conditions, or as a result of catecholamine response to shock, these dextrans are likely to elevate blood glucose levels to potentially harmful limits following intravenous administration, as a response to the rapid degradation of the glucose polymers to free glucose residues.[7],[8]

Similar to dextrans, hydroxyethyl starches, which are made up of large ethylated starch or glucose polymers, are metabolized by serum amylases to produce smaller molecules of starch polymers and free glucose residues. Even these carry a potential to accelerate blood glucose levels, subsequent to intravenous administration, under stressful conditions.[3] Considering these potential ill-effects of hyperglycemia, in the peri-operative period, on well-being of patients and on the outcome of surgery, we carried out the following study, with an objective to examine and compare the effects of 4% gelatin and dextran-40 on blood sugar levels during subarachnoid block.


  Materials and Methods Top


A prospective, randomized nonblinded study was conducted after approval from the Institutional Ethics and Dissertation committee in the Department of Anesthesiology and Critical Care to compare the effect of 4% gelatin and dextran-40 on blood glucose levels during surgery under subarachnoid block. Informed written consent was obtained from each patient participating in the study. Sixty patients of American Society of Anesthesiologists (ASA) physical status I and II, nondiabetic patients, 20–60 years of age, weighing between 40 and 70 kg and undergoing elective lower limb or lower abdominal surgical procedures, which were anticipated to last for at least one hour, were included in the study.

Ethical Clearance

SVIMS- Ethical committee approval obtained on 12-6-2012.

Patients on drugs that cause hyperglycemia (steroids), patients who are diabetic, those requiring blood transfusion, low hematocrit (packed cell volume <30), patients who develop allergic reactions to study fluids, uncontrolled hypertension, pregnant women and lactating mothers, patients with renal and hepatic diseases, patients who are not willing to participate in the study were excluded from study.

Randomization sequence was generated before the start of the study. Patients were selected and randomized by computer and opaque sealed envelope technique, into two groups i.e., Groups 1 and 2, 30 patients in each group. Group 1 patients were preloaded with 4% Gelatin [Gelofusine-4%] (10 mL/kg) and Group 2 patients were preloaded with Dextran-40 in normal saline [Microspan 40] (10 mL/kg), over a period of 30 min, prior to spinal anesthesia, through an 18-gauge intravenous cannula. Preloading was done under vigilant monitoring of vital parameters-heart rate, blood pressure and SPO2 at 10-min interval. Preloading was immediately interrupted on evidence of any allergic reaction and symptomatic treatment was given and the patient was excluded from the study.

Throughout the procedure, capillary blood glucose levels were measured at 20-min intervals using an SD-CHECK GOLD glucometer (Accuchek) (CAT NO-01GM10). Glucometer reading was validated against peripheral venous blood glucose measurement periodically once in 60 tests. Just prior to preloading, baseline capillary blood glucose level was noted and followed by subsequent readings at 20, 40, 60, 80, and 100 min from baseline reading. Following preloading, all the patients received normal saline (0.9%) as a maintenance fluid. Under strict aseptic precautions, subarachnoid block using 15 mg of hyperbaric (0.5%) bupivacaine at L3–L4 or L4–L5 level was administered immediately after completion of the preloading. Sensory block was noted after fixation of the drug.

Hypotension was defined as more than 25% fall in mean arterial pressure and was treated with fluid boluses (normal saline) and injection ephedrine 6 mg IV.

Bradycardia was defined as heart rate less than 50 beats/min and treated with injection atropine 0.6 mg IV.

Patient data variables were summarized as mean and standard deviation (SD). Comparison between two groups with respect to continuous variables such as age, weight, duration of surgery, maximum level of sensory blockade, and capillary blood glucose levels were compared with Student's t test (t). Categorical variables such as gender distribution and type of surgical procedures were analyzed by Chi-square test (χ[2]). All statistical analysis was done by using EPI INFO 3.5.4 version (Epidemiological Information) software. A value of P (probability) of <0.05 was considered as statistically significant.


  Results Top


Sixty-two patients were recruited into the study. Two cases were excluded from study; one case was excluded due to failed spinal and the other due to inadequate level of block. In our study, no anaphylactic reactions were observed to study fluids (4% gelatin and Dextran-40). All the patients were hemodynamically stable during preloading and intraoperative period. The patients in both groups were compared in respect to age, sex, weight, duration of surgery, maximum sensory blockade level, and type of surgical procedure carried out in the study.

No significant (P > 0.05) difference was observed in mean age, mean weight, and sex distribution [Table 1]. The types of surgical procedures carried out in two groups were comparable [Table 2]. The mean duration of surgery, which was taken as time from surgical incision to skin closure, and the mean of the maximum level of sensory blockade achieved after spinal anesthesia (T8) were also comparable in two groups [Table 3].
Table 1: Comparison Of Demographic Data

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Table 2: Comparison of Type of Surgical Procedures in Two Groups

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Table 3: Duration of Surgical Procedure and Level of Sensory Blockade

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The baseline mean capillary blood glucose levels (mg/dL) at onset of preloading in two groups were 90.58 + 11.03 in group 1 and 89.45 + 11.27 in group 2, which were comparable (P = 0.69).

In group 1 (gelatin), the maximum mean blood glucose level of 92.76 ± 14.77 mg/dL was found at 100 min from the onset of preloading, which was found to be statistically not significant from the corresponding blood glucose level 89.66 ± 14.15 mg/dL (100 min) in group 2.

In group 2 (dextran), the maximum mean blood glucose level of 98.53 ± 14.57 mg/dL was found at 60 min from the onset of preloading, which was found to be statistically significant (P = 0.017), when compared with corresponding (60 min) blood glucose level 86.50 ± 10.44 mg/dL in group 1 [Graph 1].



The mean capillary blood glucose levels at 20, 40, 80, and 100 min from onset of preloading, in two groups were comparable and statistically not significant (P < 0.05).

The capillary blood glucose levels in both the groups at 20, 40, 60, 80, and 100 min were within the physiological limit [Table 4].
Table 4: Differences in Mean Capillary Blood Glucose Levels (MG/DL) Between Two Groups

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  Discussion Top


A prospective, randomized study was conducted in the Department of Anesthesiology and Critical Care to compare the effect of 4% Gelatin and Dextran-40 on blood sugar levels during surgery under subarachnoid block. A majority of the studies conducted on starch solutions and dextrans have evaluated their volume expansion properties and their impact on blood coagulation.

Very few studies have examined the possibility of starches and dextrans producing hyperglycemia, in spite of their pharmacodynamic potential to cause the same. In our study, spinal anesthesia was used as the technique of choice in all the patients, so as to standardize the stress response due to anesthesia and surgery in two groups. Stress response to surgery and catecholamine release following it is itself known to induce some amount of hyperglycemia, but this remains confined to a limited extent.[9]

For similar reasons, only normal saline was used in all the patients, as the subsequent intravenous fluid intra-operatively. Ringer's Lactate has been shown to possibly cause hyperglycemia, due to the conversion of lactate to glucose via the Cori's cycle.[10]

Murty et al., in 2004, studied the effects of 6%Hestar-450, Pentastarch 200 and Ringer's Lactate as preloading fluids in spinal anesthesia, on blood sugar levels. They concluded that both the starches significantly elevated the blood sugar levels (P < 0.05), which were within physiological limits and peaks at the end of 2 h with Hestar6%-450 and at the end of 3 h with pentastarch 6%–200. However, in their study, Ringer's Lactate did not significantly elevate blood sugar level.

Abhiruchipatki et al., 2010, studied the effect of 6% hydroxyethyl starch-450 and low molecular weight dextran on blood sugar levels during surgery under subarachnoid block and demonstrated a sustained and statistically significant rise (P < 0.05) in blood sugar levels from the baseline, with the infusion of both Ringer's lactate and hydroxyethyl starch 6%- 450, which peaked at the end of 45 min and at the end of one hour, respectively. On the contrary, Dextran-40 demonstrated a steep and statistically highly significant (above physiological limit) rise (P < 0.001) in mean capillary blood glucose levels from the mean baseline reading, which peaked at 45 min.

Hofer et al.[11] studied the effect of hydroxyethyl starch solutions on blood glucose concentrations in diabetic and nondiabetic rats and concluded that all though there existed a strong possibility for hydroxyethyl starches to cause hyperglycemia, neither hetastarch nor pentastarch infusions significantly altered blood glucose values over the 3-h study period, regardless of whether the rats were diabetic or nondiabetic. They assumed that the data collected from the study on rats are transferable to humans and hence they concluded that hydroxyethyl starch solutions could be used in diabetic and nondiabetic patients without raising the blood sugar levels.

Our study demonstrated that in group 1 (Gelatin), the maximum mean blood glucose level was found at 100 min from onset of preloading, which was found to be statistically not significant from baseline mean blood glucose level. In group 2 (Dextran), the maximum mean blood glucose level was found at 60 min from onset of preloading, which was found to be statistically significant (P = 0.017), when compared with corresponding (60 min) blood glucose level in group 1. The mean capillary blood glucose levels at 20, 40, 80, and 100 min from onset of preloading, in two groups were comparable (P = 0.41). The capillary blood glucose levels in both the groups were within physiological limits.


  Conclusion Top


We conclude that preloading the patients prior to subarachnoid block with 4% gelatin or dextran 40 in normal saline does not raise capillary blood glucose levels significantly above the physiological limits.

Our study has a few limitations, although we included 4% gelatin and Dextran-40, as study infusions, primarily because of their relatively easier availability in our institution, leaving scope for inclusion of other starches with different molecular weights and different compositions in future studies.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Boldt J. Volume replacement in the surgical patient— does the type of solution make a difference? Br J Anaesth 2000;84:783-93.  Back to cited text no. 1
    
2.
Buggy D, Higgins P, Moran C, O Brein D, Frances O. Donovan, Maire McCarrroll. Prevention of spinal anaesthesia induced hypotension in the elderly: Comparison between preanaesthetic administration of crystalloid, colloid and no prehydration. Anesth Analg 1997;84:106-10.  Back to cited text no. 2
    
3.
Murty SS, Kamath SK, Chaudhari LS. Effects of hydroxyethyl starches on blood sugar levels: A randomised double blind study. Indian J Anaesth 2004;48:196-200.  Back to cited text no. 3
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4.
McAlister FA, Amad H, Man J, Tandon P, Bistritz L. Diabetes and coronary artery bypass surgery. An examination of perioperative glycemic control and outcomes. Diabetes Care 2003;26:1518-24.  Back to cited text no. 4
    
5.
Judith AM. Impact of hyperglycemia on the rennin angiotensin system in early human type 1 diabetes Mellitus. J Am Soc Nephrol 1999;10:1778-85.  Back to cited text no. 5
    
6.
Nohé B, Johannes T, Reutershan J, Rothmund A, Haeberle HA, Ploppa A, et al. Synthetic colloids attenuate leukocyte-endothelial interactions by inhibition of integrin function. Anesthesiology 2005;103:759-67.  Back to cited text no. 6
    
7.
Kirby R. Colloids: Those Magic Fluids. IVECCS VI Proceedings, San Antonio; 1994. p. 648.  Back to cited text no. 7
    
8.
Abhiruchi P, Shelgaonkar VC. Effect of 6% hydroxyethyl starch-450 and low molecular weight dextran on blood sugar levels during surgery under subarachnoid block: A prospective randomised study. Indian J Anaesth 2010;54:448-52.  Back to cited text no. 8
    
9.
Desborough JP. The stress response to trauma and surgery. Br J Anaesth 2000;85:109-17.  Back to cited text no. 9
    
10.
Tayek JA, Katz J. Glucose production, recycling, Cori cycle and gluconeogenesis in humans: Relationship to serum cortisol. Am J Physiol 1997;272:E476-84.  Back to cited text no. 10
    
11.
Hofer RE, Lanier WL. Effect of hydroxyethyl starch solutions on blood glucose concentrations in diabetic and nondiabetic rats. Crit Care Med 1992;20:211-5.  Back to cited text no. 11
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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