Battlestar Metabolica

A recent case exemplified the future of hospital practice. She was 66 year old, 110 kg, hypertensive despite therapy, was on a statin (the lipid levels ere unknown) and watched her diet because she had been told she had a bit of the sugar diabetes. She was scheduled for abdominal hysterectomy for endometrial carcinoma. 

The "metabolic syndrome" of visceral obesity, hypertension, diabetes and hypercholesterolaemia afflicts more than a third of the Australian population. It is a cause of cardiovascular disease and probably several cancers including endometrial. The weight of the obesity wears out the skeleton. Metabolic syndrome patients with vascular disease, cancer and worn out joints will be filling Australian operating theatres for years to come. If anaesthesiology is to do anything with perioperative medicine it has to be with the metabolic syndrome.

After reviewing the recent consensus papers of the American colleges of cardiologists and endocrinologists I think the key points we need to be aware of in dealing with these patients are:

•  Nearly all will warrant intravenous insulin infusions to a target of glucose 6 to 8 mmol/l. Subcutaneous actrapid insulin scales are useless if not harmful. Even moderate perioperative hyperglycemia increases infenction and cardiac risk. Glucose should be checked at induction and then hourly.
  
• Perioperative statins should be considered (until the next Big Multicentre RCT is published!). If they are already prescribed they must be continued immediately postoperatively to minimise a rebound prothrombotic effect.
  
• Beta-blockers will probably be only recommended for those already hypertensive, and even relative hypotension should be avoided so to avoid ischaemic stroke.
  
• Aspirin should be initiated for perioperative care and for ongoing primary prophylaxis.
  

Obese, dysmetabolic patients are going to be the order of the day. We bettter get our heads around it.