Anaesthesia and pancreatic surgery: Techniques, clinical practice and pain management

Table 1 Risk-reduction strategies

Preoperative

Encourage cessation of cigarette smoking for at least 8 wk

Treat airflow obstruction in patients with chronic obstructive pulmonary disease or asthma

Administer antibiotics and delay surgery if respiratory infection is present

Begin patient education regarding lung-expansion maneuvers

Intraoperative

Limit duration of surgery to less than 3 h

Use epidural or blended anesthesia

Use laparoscopic procedures when possible

Substitute less ambitious procedure for upper abdominal or thoracic surgery when possible

Postoperative

Use deep-breathing exercises or incentive spirometry

Use continuous positive airway pressure

Use epidural analgesia

Use intercostal nerve blocks

Table 2 Continuous insulin infusion protocol

Initiating CII:

Prepare solution: 1 unit per 1 mL of 0.9% normal saline

Start CII when blood glucose level ≥ 140 mg/dL (x 2)

Patients with known diabetes treated with insulin can start CII when blood glucose ≥ 70 mg/dL

Initial rate: divide blood glucose level (mg/dL) by 100, then round to nearest 0.5 UI

Insulin infusion rate change:

BG (mg/dL) instructions:

> 200 ↑ rate by 2 UI/h

> 160-200 ↑ rate by 1.0 UI/h

> 120-160 ↑ rate by 0.5 UI/h

80-120 No change in rate

60-80 If < 10% lower BG, rate by 1 UI/h

Check BG within 30 min

If > 10% lower BG, 2 rate by 50%

Check BG within 30 min

< 60 Stop infusion (give IV dextrose 12.5 g IV bolus)

Check BG within 30 min. When BG > 100 mg/dL, restart infusion at 50% of previous rate

Patient monitoring:

Check capillary blood glucose every hour until it is within goal range for 2 h, and then decrease to every 2 h

Hourly monitoring may be indicated for critically ill patients even if they have stable blood glucose

If a patient is eating, hourly blood glucose monitoring is necessary for at least 3 h after eating

Decrease insulin infusion rate by 50% if nutritional therapy (e.g., total parenteral nutrition or tube feeds) are discontinued or significantly reduced

CII: Continuous insulin infusion; UI: 1 unit; BG: Blood glucose.