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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 3  |  Page : 140-144

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


1 Department of Anaesthesiology, Sri Venkateswara Medical College, Tirupati, Andhra Pradesh, India
2 Department of Anaesthesiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India

Date of Submission27-Sep-2020
Date of Decision01-Feb-2021
Date of Acceptance17-Feb-2021
Date of Web Publication13-Sep-2021

Correspondence Address:
Sreehari Kunichetty Gajula
Assistant Professor, Department of Anaesthesia, Sri Venkateswara Medical College, Chittor, Tirupati 517 507, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JCSR.JCSR_85_20

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  Abstract 


Background: Stress response to surgery induces hyperglycaemia to limited extent. An additive hyperglycaemic response, secondary to the metabolism of intravenous fluids, can thus prove detrimental to the well-being of the patient, if ignored.
Methods: We compared the effects of 4% gelatin and dextran-40 on blood glucose levels during surgery under subarachnoid block and their potential to induce hyperglycaemia. Sixty American Society of Anesthesiologists grade I and II patients were randomised 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, base line capillary blood glucose (CBG) level was noted this is followed by subsequent readings at 20 min interval until 100 min from base line 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: The CBG levels in both the groups at 20, 40, 60, 80 and 100 min from base line were within physiological limits. In group 2, the maximum CBG level was found at 60 min from onset of preloading (P = 0.017), when compared with corresponding CBG level in Group 1. Preloading the patients prior to subarachnoid block with 4% gelatin or dextran 40 do not raise CBG levels significantly above the physiological limits.

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


How to cite this article:
Gajula SK, Bhadri S, Mukkara M. A comparative study on effect of 4% gelatin and dextran-40 on blood glucose levels during surgery under subarachnoid block – A randomised, prospective study. J Clin Sci Res 2021;10:140-4

How to cite this URL:
Gajula SK, Bhadri S, Mukkara M. A comparative study on effect of 4% gelatin and dextran-40 on blood glucose levels during surgery under subarachnoid block – A randomised, prospective study. J Clin Sci Res [serial online] 2021 [cited 2021 Nov 30];10:140-4. Available from: https://www.jcsr.co.in/text.asp?2021/10/3/140/325824




  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],[2] Colloids are also used as preloading fluids prophylactically, to limit complications following sympathetic blockade in central neuraxial blockade, especially subarachnoid block.[3] Stress response to surgery and catecholamine release following it, is itself known to induce some amount of hyperglycaemia,[4],[5] but this remains confined to limited extent. An additive hyperglycaemic response, secondary to the metabolism of infused intravenous (IV) colloids, especially starches can thus prove detrimental to the well-being of the patient, if ignored.[6] Hyperglycaemia is known to potentiate neurological changes and ischemia to the brain, spinal cord, heart and kidneys.[7],[8]

It also impairs wound healing, by interfering with white blood cells.[9] These more 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 result of catecholamine response to shock, these Dextrans are likely to elevate blood glucose levels to potentially harmful limits following IV administration, as a response to the rapid degradation of the glucose polymers to free glucose residues.[10],[11]

Similar to dextrans, hydroxyethyl starches, which are made up of large ethylated starch or glucose polymers, are metabolised 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 IV administration, under stressful conditions. Considering these potential ill-effects of hyperglycaemia, in the perioperative 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 glucose levels during subarachnoid block.


  Material and Methods Top


A prospective, randomised study was conducted after approval from Institutional Ethics and Dissertation committee in the Department of Anaesthesiology 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 with American Society of Anesthesiologists physical status I and II, who were in the age-group 20–60 years, who did not have diabetes mellitus, weighing between 40 and 70 kg and undergoing elective lower limb or lower abdominal surgical procedures, which were anticipated to last for at least 1 h, were included in the study.

Patients on drugs that cause hyperglycaemia, patients with diabetes mellitus, those requiring blood transfusion, low haematocrit (packed cell volume <0), 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.

Randomisation sequence was generated before the start of the study. Patients were selected and randomised by computer and opaque sealed envelope technique, into two groups i.e., Group 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 anaesthesia, through an 18-gauge IV cannula. Preloading was done under vigilant monitoring of vital parameters - Heart rate, Blood pressure and SPO2 at 10 min (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. Comparison of composition of the study fluids is shown in [Table 1].
Table 1: Comparison of composition of the study fluids

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Throughout the procedure, capillary blood glucose (CBG) levels were measured at 20 min intervals using a glucometer (Accuchek) (CAT NO-01GM10). Just prior to preloading, base line CBG level was noted and followed by subsequent readings at 20, 40, 60, 80 and 100 min from base line 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 <50 beats/min and treated with injection atropine 0.6 mg IV.

Statistical analysis

The sample size was calculated using the G*power 3 free[12] software and the findings of the previous study. The effect size was assumed according to the Cohen's guidelines for the social sciences and we selected a medium effect size of 0.3.[13],[14] Using α = 0.05 with a power of 80%, the sample size per each group was calculated as 27 for statistical analysis of 6 consecutive time points measurement of blood glucose level between different factors with correlation of 0.5. After assuming a 10% dropout rate, 30 patients were allocated to each group.

Patient data variables were summarised as mean and standard deviation. Comparison between two groups with respect to continuous variables such as age, weight, duration of surgery, maximum level of sensory blockade and CBG levels were compared with Student's t-test. Categorical variables like gender distribution and type of surgical procedures were analysed by Chi-square test. All statistical analysis was done using Epi InfoTM version 3.5.4, Centers for Disease Control and Prevention, Atlanta, USA software. A P value < 0.05 was considered as statistically significant.


  Results Top


Sixty-two patients were recruited in to the study. Two cases were excluded from study; one case was excluded due to failed spinal and 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.

There is no significant (P > 0.05) difference in mean age, mean weight and sex distribution [Table 2]. The types of surgical procedures carried out in two groups were comparable [Table 3]. The mean duration of surgery, which was taken as time from surgical incision to skin closure and mean of the maximum level of sensory blockade achieved after spinal anaesthesia (T8) were also comparable in two groups [Table 4].
Table 2: Comparison of demographic data

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Table 3: Comparison of type of surgical procedures

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Table 4: Duration of surgical procedure and level of sensory blockade

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The baseline mean CBG 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 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 [Figure 1]. The mean CBG levels at 20, 40.80 and 100 min from onset of preloading, in two groups were comparable and statistically not significant (P < 0.05).
Figure 1: Consort Flow Diagram

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The CBG levels in both the groups at 20, 40, 60, 80, 100 min were within physiological limit [Table 5].
Table 5: Comparison of mean capillary blood glucose levels (mg/dL) at baseline and different time points

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  Discussion Top


In our study, spinal anaesthesia was used as the technique of choice in all the patients, so as to standardise the stress response due to anaesthesia and surgery in two groups. Stress response to surgery and catecholamine release following it, is itself known to induce some amount of hyperglycaemia, but this remains confined to limited extent. For similar reasons, only normal saline was used in all the patients, as the subsequent IV fluid intra-operatively. Ringer's Lactate, has been shown to possibly cause hyperglycaemia, due to the conversion of lactate to glucose via the Cori's cycle.

In a study[6] the effects of 6% Hestar-450, Pentastarch 200 and Ringer's Lactate were studied as preloading fluids in spinal anaesthesia, on blood glucose levels. The authors[6] concluded that both the starches significantly elevated the blood glucose levels (P < 0.05), which were within physiological limits and peaks at the end of 2 h with Hestar 6%-450 and at the end of 3 h with pentastarch 6%-200. However, in their study, Ringer's Lactate did not significantly elevate blood glucose level.

Another study[15] evaluated the effect of 6% hydroxyethyl starch-450 and low molecular weight dextran on blood glucose levels during surgery under subarachnoid block and demonstrated a sustained and statistically significant rise (P < 0.05) in blood glucose 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 1 h, respectively. Dextran 40, on the other hand, demonstrated a steep and statistically highly significant (above physiological limit) rise (P < 0.001) in mean CBG levels from the mean baseline reading, which peaked at 45 min.

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 CBG levels at 20, 40, 80 and 100 min from onset of preloading, in two groups were comparable (P = 0.41). The CBG levels in both the groups were within physiological limits.

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

Our study has a few limitations, though; 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.

Financial support and sponsorship

Nil.

Conflicts of interest

Madhusudan Mukkara is an Associate Editor of Journal of Clinical and Scientific Research. The article was subject to the journal's standard procedures, with double blinded-peer review handled independently of this Associate editor and his research groups.



 
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2.
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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. 6
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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. 8
    
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Nohe B, Johannes T, Reutershan J, Rothmund A, Haeberle HA, Ploppa A. Synthetic colloids attenuate leukocyte-endothelial interactions by inhibition of integrin function. Anesthesiology 2005;103:759-67.  Back to cited text no. 9
    
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Kaye AD, Kucera IJ. Intravascular fluid and electrolyte physiology. In: Miller RD, editor. Text book of Miller's Anesthesia. 6th ed. Philadelphia: Churchill Livingstone; 2005. p. 1763-98.  Back to cited text no. 10
    
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Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 2007;39:175-91.  Back to cited text no. 12
    
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Cohen J. A power primer. Psychol Bull 1992;112:155-9.  Back to cited text no. 13
    
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Jung KT, Shim SB, Choi WY, An TH. Effect of hydroxyethyl starch on blood glucose levels. Korean J Anesthesiol 2016;69:350-6.  Back to cited text no. 14
    
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Patki A, Shelgaonkar V. 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. 15
[PUBMED]  [Full text]  


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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