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A multimodal postoperative rehabilitation program in critically ill diabetic patients.

The clinical investigation by Brodner et al. (1) demonstrates the beneficial influence of multimodal perioperative management using combined thoracic epidural blockade with local anesthetic, forced postoperative mobilization, and early enteral nutrition on catabolic responses and reconvalescence after cystectomy and formation of ileal neobladder. The results confirm in a nonrandomized fashion the previous observations of improvement of analgesia and resto- ration of bowel function obtained by using similar multimodal concepts in patients undergoing colorectal surgery (2,3). Notwithstanding the apparent significance of the clinical results presented by Brodner et al. (1), the metabolic endocrine findings in this article deserve further comment. It is interesting to note that the majority of patients who entered the study protocol were diabetic and, more importantly, that all patients in the treatment group were insulin-dependent. This issue has been completely ignored in the discussion part of the manuscript, although the stimulating effect of hyperglycemia on the sympathoadrenergic system (4) and the an- ticatabolic action of insulin are well recognized. Thus, it is crucial to know if and how successful normoglycemia in the three groups was controlled during and after surgery. Furthermore, the validity of nitrogen balance and catecholamine measurements, particularly in diabetic patients with bladder cancer and potentially impaired di-uresis, might have been flawed by several factors such as tumor stage, individual nutritional status, renal and liver dysfunction, and intake of drugs with metabolic impact. Considering the surprisingly large number of critically ill patients with approximately 30% of the subjects classified as ASA grade IV (“incapacitating life-threatening systemic disturbance”) preventive therapy with (cid:2) -blockers (coro-nary artery disease, hypertension) or systemic steroids (COPD) as well as perioperative interventional hemodynamic support