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Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 13  |  Issue : 4  |  Page : 631-635  

Comparison of intraoperative glycemic levels in infants with the use of Ringer Lactate with supplemental 1% versus 2% dextrose as maintenance fluid


Department of Anaesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Date of Submission22-Sep-2019
Date of Decision30-Sep-2019
Date of Acceptance10-Oct-2019
Date of Web Publication16-Dec-2019

Correspondence Address:
Sunil Rajan
Department of Anaesthesiology, Amrita Institute of Medical Sciences, Kochi, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aer.AER_128_19

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   Abstract 

Context: There is no consensus regarding the concentration of dextrose supplementation to be used in pediatric patients intraoperatively. Aims: The primary objective was to assess the effect of using Ringer lactate (RL) with 1% versus 2% dextrose as maintenance fluid in infants on intraoperative blood glucose levels. The secondary objectives included assessment of incidence of hyperglycemia and hypoglycemia in both groups. Settings and Design: This was a prospective randomized study conducted in a tertiary care teaching institute. Subjects and Methods: Forty infants undergoing cheiloplasty or palatoplasty were included. All patients fasted 6 h for solids and formula feeds, 4 h for breast milk, and 2 h for clear fluids and received general anesthesia as per standardized protocol. Patients belonging to Group 1 received RL with 1% dextrose supplementation, whereas Group 2 received RL with 2% dextrose added to it as an intraoperative maintenance fluid. Random blood sugar (RBS) was checked preoperatively and then at 60 min and 120 min after induction. Hypoglycemia was defined as RBS <70 mg/dL and hyperglycemia as RBS >150 mg/dL. Statistical Analysis Used: Independent sample ttest and Pearson's Chisquare test were used for statistical analysis. Results: Preoperative RBS was comparable in both groups. RBS at 60 and 120 min was significantly higher in Group 2 compared to Group 1. There was no incidence of hypoglycemia in both groups, and the incidence of hyperglycemia was similar in both groups. Conclusion: Use of RL with 2% dextrose as intraoperative maintenance fluid in infants resulted in significant increase in blood sugar levels as compared to addition of 1% dextrose although the incidence of hyperglycemia remained comparable in both groups.

Keywords: Dextrose, hyperglycemia, hypoglycemia, infants, Ringer lactate


How to cite this article:
Tosh P, Rajan S, Barua K, Kumar L. Comparison of intraoperative glycemic levels in infants with the use of Ringer Lactate with supplemental 1% versus 2% dextrose as maintenance fluid. Anesth Essays Res 2019;13:631-5

How to cite this URL:
Tosh P, Rajan S, Barua K, Kumar L. Comparison of intraoperative glycemic levels in infants with the use of Ringer Lactate with supplemental 1% versus 2% dextrose as maintenance fluid. Anesth Essays Res [serial online] 2019 [cited 2020 Jul 4];13:631-5. Available from: http://www.aeronline.org/text.asp?2019/13/4/631/272974


   Introduction Top


For the prevention of intraoperative hypoglycemia, dextrose is very commonly added to perioperative maintenance fluids. However, there is no consensus regarding the concentration of dextrose for supplementation intraoperatively in pediatric patients. Various practices exist across the globe, and many practitioners follow the age-old norm of adding 2% dextrose to maintenance fluid for infants <10 kg body weight and 1% dextrose for older children of <2 years of age. Conflicting practices do exist, and it is even suggested that there is no need for dextrose supplementation intraoperatively as stress response to surgery itself will result in hyperglycemia and further supplementation may actually worsen the hyperglycemic condition. However, the common practice is the addition of 1% dextrose to maintenance fluids to avoid a catabolic response and also as a safe measure to prevent intraoperative hypoglycemia which has serious sequelae, especially in younger children. The requirement of optimal dextrose concentration and the rate of fluid administration vary according to the type of surgery as well. It has been shown that the use of 1%–2.5% dextrose containing isotonic fluids as maintenance fluid in infants undergoing surgery decreases the incidence of hypoglycemia as well as hyperglycemia.[1]

The primary objective of the present study was to assess the effect of using Ringer lactate (RL) with 1% versus 2% dextrose as maintenance fluid in infants undergoing surgery under general anesthesia without supplemental regional anesthesia on intraoperative blood glucose levels. The secondary objectives included assessment of the incidence of hyperglycemia and hypoglycemia and changes in hemodynamics with the use of these two fluid regimens.


   Subjects and Methods Top


The present study was a prospective randomized study conducted after obtaining institutional ethical committee clearance and consent from parents of the study participants. Forty infants undergoing cheiloplasty or palatoplasty belonging to the American Society of Anesthesiologists physical status Class 1 were included in the study. Infants of diabetic mothers, those with diabetes, those on intravenous fluids, and those getting glucose supplements orally were excluded from the study.

Following a detailed preanesthetic evaluation, patients were recruited into the study and were kept fasting 6 h for solids and formula feeds, 4 h for breast milk, and 2 h for clear fluids. On the day of surgery, they were randomly allotted to either Group 1 or Group 2 based on computer-generated random sequence of numbers, and concealment of allocation was ensured by using sequentially numbered opaque sealed envelopes. Each group comprised twenty patients. Syrup triclofos 75 mg.kg-1 body weight was given to children aged above 6 months, 2 h prior to the induction. All patients received general anesthesia as per a standardized protocol. Patients belonging to Group 1 received RL with 1% dextrose supplementation, whereas those belonging to Group 2 received RL with 2% dextrose added to it as intraoperative maintenance fluid.

After attaching standard pre-induction monitors such as pulse oximeter, electrocardiograph, and noninvasive blood pressure monitors, all infants were induced with 8% sevoflurane in oxygen using a Jackson–Rees circuit, and a peripheral intravenous line was secured. The first random blood sugar (RBS) reading was taken soon after induction, before initiating intravenous fluid administration. All blood sugar values were checked using a standard glucometer (FreeStyle Optium H System, Copyright© 2015 Abbott Laboratories. Abbott Park, Illinois, USA) with test strips. If the fasting RBS reading was below 70 mg/dL, 25% dextrose at 1 mL.kg-1 was administered intravenously (IV) as a bolus to correct hypoglycemia and those infants were ousted from the study.

All patients were given midazolam 0.05 mg.kg-1 body weight, glycopyrrolate 5 μg.kg-1 body weight, and fentanyl 3 μg.kg-1 body weight IV. An additional bolus of 1 mg.kg-1 of propofol was given followed by suxamethonium 2 mg.kg-1 body weight, and the patients were intubated with appropriate-sized, south pole-facing, uncuffed, preformed endotracheal tubes. Intraoperatively, the patients were ventilated with 50% air, 50% oxygen, and isoflurane 1%–1.5% with gas flow rates of 1 L/min using a closed circuit. After intubation, atracurium 0.5 mg.kg-1 body weight was given IV. Intraoperatively, mechanical ventilation was done at the rate of 20–24 breaths per min with a tidal volume of 8–10 mL.kg-1 body weight to maintain end-tidal carbon dioxide between 30 and 35 mmHg.

Intraoperatively, RBS was checked hourly using capillary blood samples for 2 h. Hypoglycemia[2] was defined as RBS <70 mg/dL and hyperglycemia[3] as RBS >150 mg/dL. At any point during the study, in both the groups, if the RBS reading was <70 mg/dL, 25% dextrose at 1 mL.kg-1 was given as IV bolus to correct hypoglycemia. No intervention was done for RBS values up to 200 mg/dL. If the levels exceeded >200 mg/dL, dextrose-containing solution was changed to plain RL. Intraoperative maintenance fluid was administered according to body weight based on the Holliday and Segar formula.[4] Any losses requiring fluid bolus to be administered were corrected using RL. Blood loss exceeding 10% of the estimated blood volume was replaced with packed red blood cells.

Measurements of heart rate (HR), systolic blood pressure (SBP), and mean arterial pressure were noted at different time intervals starting from pre-induction and then at 15 min intervals for 2 h. At the end of surgery, neuromuscular blockade was reversed with neostigmine and glycopyrrolate, and the patients were extubated on table when awake with return of airway reflexes. The total volume of intravenous fluid used as well as the volume and the number of times 25% dextrose bolus was administered to correct hypoglycemia, if required, were also noted.

Independent sample t-test was used to analyze and compare the baseline blood sugar values and values at 60 min and 120 min between the two groups. Pearson's Chi-square test was used to calculate the incidence of hyper- and hypoglycemia. Statistical analysis was done using IBM SPSS Statistics 20 for Windows 8 (SPSS Inc., Chicago, Illinois, USA).


   Results Top


Forty patients were included in the study [Table 1]. The mean age, weight, and distribution of gender were comparable in both groups [Table 2]. Preoperative RBS was comparable in both groups. RBS measured at 60 and 120 min was significantly higher in Group 2 compared to Group 1 [Figure 1] and [Table 3]. There was no incidence of hypoglycemia in both groups throughout the study period, and no patient in either group required administration of 25% dextrose. Volume of RL used and the incidence of hyperglycemia (RBS >150 mg/dL) were similar in Groups 1 and 2 during the study period [20% and 30%, respectively, [Table 4]. HR and SBP were comparable in both groups throughout the study period [Table 5].
Table 1: CONSORT flow diagram

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Table 2: Comparison of age, weight, and gender

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Figure 1: Changes in random blood sugar

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Table 3: Comparison of RBS between the Group R and Group D

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Table 4: Mean volume of Ringer lactate used and incidence of hyperglycemia

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Table 5: Comparison of heart rate and mean arterial pressure

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   Discussion Top


Intraoperative hypoglycemia is a major concern for anesthetists as it may result in seizures and brain damage, which lead to developmental delays, physical and learning disabilities, and its extreme manifestations can even lead to death[5],[6],[7],[8],[9] if not recognized on time and corrected promptly. The clinical manifestations of hypoglycemia under anesthesia may be blunted or could be easily misinterpreted as response to inadequate depth of general anesthesia. The rationale for the addition of glucose to the intraoperative maintenance fluids of pediatric patients is based on the fact that glucose is required as approximately 20% of the normal caloric needs are provided by it. Therefore, glucose supplementation becomes necessary to prevent starvation ketoacidosis and protein degradation in patients who are kept fasting prior to surgery.[10] This practice, in turn, would limit postoperative energy deficit and hyperglycemia, provide substrate for energy requirements, and thereby avoid perioperative hypoglycemia.[11]

Under general anesthesia, due to stress response of anesthesia and surgery, usually a catecholamine surge happens, which results in a relative insulin resistance and glycogenolysis manifesting as elevated blood sugar levels. Increased levels of cortisol and catecholamines augment glucose production because of increased hepatic glycogenolysis and gluconeogenesis along with reduced peripheral utilization of glucose.[12],[13]

Dubois et al.[11] found that blood glucose levels had increased postoperatively in patients who received 1% and 2.5% dextrose and also in the group that did not receive dextrose with RL. However, they were of the opinion that a concentration of 1% dextrose was advantageous over higher concentrations as near-normal blood sugar values were seen intraoperatively. They concluded that 1% dextrose in RL resulted in moderate postoperative hyperglycemia but avoided any perioperative hypoglycemic events.

In another study by Barua et al.[14] where plain RL was compared with the addition of 2% dextrose to RL, it was shown that the use of RL with 2% dextrose supplementation intraoperatively resulted in significant hyperglycemia in infants undergoing facial cleft surgeries. Berleur et al.[15] investigated the use of RL solution with low dextrose concentration and had recommended RL with 0.9% or 1% dextrose for intraoperative fluid therapy in pediatric patients, as that concentration was found to reduce the risk of hyponatremia as well as hypoglycemia.

Hyperglycemia in children also has detrimental effects such as intraventricular hemorrhage, osmotic diuresis, impaired immunity, delayed wound healing, renal injury, and neuronal lactic acidosis.[16],[17],[18],[19],[20],[21],[22] Although in our study it was shown that addition of both 1% and 2% dextrose to RL resulted in intraoperative hyperglycemia, use of RL alone in pediatric patients should be practiced only with regular monitoring of blood sugar levels. In circumstances where regular RBS monitoring is not immediately available, use of RL with 1% dextrose supplementation seems to be a safer practice.

The major drawback of our study was that the blood glucose estimation was done using capillary blood with glucometer with test strips. Use of blood glucose measurements with arterial blood gas analyzers would have yielded more accurate results. As arterial lines are not usually put in facial cleft surgeries and obtaining arterial blood sample intraoperatively was difficult in our patients as the infants were almost fully covered with surgical drapes, we opted for capillary sample for the estimation of blood glucose levels.


   Conclusion Top


Use of RL with 2% dextrose as intraoperative maintenance fluid in infants resulted in a significant increase in blood sugar levels as compared to addition of 1% dextrose although the incidence of hyperglycemia remained comparable in both groups during the study period.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Murat I, Dubois MC. Perioperative fluid therapy in pediatrics. Paediatr Anaesth 2008;18:363-70.  Back to cited text no. 1
    
2.
Wintergerst KA, Buckingham B, Gandrud L, Wong BJ, Kache S, Wilson DM. Association of hypoglycemia, hyperglycemia, and glucose variability with morbidity and death in the pediatric intensive care unit. Pediatrics 2006;118:173-9.  Back to cited text no. 2
    
3.
Datta PK, Aravindan A. Glucose for children during surgery: Pros, cons, and protocols: A Postgraduate educational review. Anesth Essays Res 2017;11:539-43.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
PA Consensus Guideline on Perioperative Fluid Management in Children v 1.1 September 2007 © APAGBI; 2010. https://www.apagbi.org.uk/sites/default/files/inline-files/Perioperative_Fluid_Management_2007.pdf. [Last accessed on 2017 Dec 25].  Back to cited text no. 4
    
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Edge JA, Ford-Adams ME, Dunger DB. Causes of death in children with insulin dependent diabetes 1990-96. Arch Dis Child 1999;81:318-23.  Back to cited text no. 5
    
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Reichard P, Pihl M. Mortality and treatment side-effects during long-term intensified conventional insulin treatment in the Stockholm diabetes intervention study. Diabetes 1994;43:313-7.  Back to cited text no. 6
    
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Hannonen R, Tupola S, Ahonen T, Riikonen R. Neurocognitive functioning in children with type-1 diabetes with and without episodes of severe hypoglycaemia. Dev Med Child Neurol 2003;45:262-8.  Back to cited text no. 7
    
8.
Lord K, Radcliffe J, Gallagher PR, Adzick NS, Stanley CA, De León DD, et al. High risk of diabetes and neurobehavioral deficits in individuals with surgically treated hyperinsulinism. J Clin Endocrinol Metab 2015;100:4133-9.  Back to cited text no. 8
    
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Cryer PE. Hypoglycemia, functional brain failure, and brain death. J Clin Invest 2007;117:868-70.  Back to cited text no. 9
    
10.
Greenbaum L. Maintenance and replacement therapy. In: Kliegman RM, Stanton B, Geme JS, Schor NF, editors. Nelson Essentials of Pediatrics. 18th ed., Vol. 1. Philadelphia, PA: Elsevier Saunders; 2007. p. 309-13.  Back to cited text no. 10
    
11.
Dubois M, Gouyet L, Murat I, Saint Maurice C. Lactated ringer with 1% dextrose: An appropriate solution for perioperative fluid therapy in children. Pediatr Anesth 1992;2:99-104.  Back to cited text no. 11
    
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Desborough JP. The stress response to trauma and surgery. Br J Anaesth 2000;85:109-17.  Back to cited text no. 12
    
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Burton D, Nicholson G, Hall G. Endocrine and metabolic response to surgery. Contin Anaesth Crit Care Pain 2004;4:144-7.  Back to cited text no. 13
    
14.
Barua K, Rajan S, Paul J, Tosh P, Padmalayan A, Kumar L. Effect of using ringer's lactate, with and without addition of dextrose, on intra-operative blood sugar levels in infants undergoing facial cleft surgeries. Anesth Essays Res 2018;12:297-301.  Back to cited text no. 14
[PUBMED]  [Full text]  
15.
Berleur MP, Dahan A, Murat I, Hazebroucq G. Perioperative infusions in paediatric patients: Rationale for using ringer-lactate solution with low dextrose concentration. J Clin Pharm Ther 2003;28:31-40.  Back to cited text no. 15
    
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Kao LS, Morris BH, Lally KP, Stewart CD, Huseby V, Kennedy KA. Hyperglycemia and morbidity and mortality in extremely low birth weight infants. J Perinatol 2006;26:730-6.  Back to cited text no. 16
    
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Duckrow RB, Beard DC, Brennan RW. Regional cerebral blood flow decreases during chronic and acute hyperglycemia. Stroke 1987;18:52-8.  Back to cited text no. 17
    
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Hays SP, Smith EO, Sunehag AL. Hyperglycemia is a risk factor for early death and morbidity in extremely low birth-weight infants. Pediatrics 2006;118:1811-8.  Back to cited text no. 18
    
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Heimann K, Peschgens T, Kwiecien R, Stanzel S, Hoernchen H, Merz U. Are recurrent hyperglycemic episodes and median blood glucose level a prognostic factor for increased morbidity and mortality in premature infants Back to cited text no. 19
    
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Sinclair JC, Bottino M, Cowett RM. Interventions for prevention of neonatal hyperglycemia in very low birth weight infants. Cochrane Database Syst Rev 2011;(10):CD007615.  Back to cited text no. 20
    
21.
Stonestreet BS, Rubin L, Pollak A, Cowett RM, Oh W. Renal functions of low birth weight infants with hyperglycemia and glucosuria produced by glucose infusions. Pediatrics 1980;66:561-7.  Back to cited text no. 21
    
22.
Louik C, Mitchell AA, Epstein MF, Shapiro S. Risk factors for neonatal hyperglycemia associated with 10% dextrose infusion. Am J Dis Child 1985;139:783-6.  Back to cited text no. 22
    


    Figures

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    Tables

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



 

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