Effects of oral carbohydrate with amino acid solution on the metabolic status of patients in the preoperative period: a randomized, prospective clinical trial

[Effect of preoperative carbohydrates intake on the gastric volume and the risk of reflux aspiration in patients positioning in trendelenburg undergoing gynecological laparoscopic procedures]

OBJECTIVE

To investigate the effect of 300 mL carbohydrates intake two hours before sur-gery on the gastric volume (GV) in patients positioning in trendelenburg undergoing gynecological laparoscopic procedures by using gastric antrum sonography, and further assess the risk of reflux aspiration.

METHODS

From June 2020 to February 2021, a total of 80 patients, aged 18-65 years, body mass index (BMI) 18-35 kg/m2, falling into American Society of Anesthesiologists (ASA) physical status Ⅰ or Ⅱ, scheduled for gynecological laparoscopic procedures positioning in trendelenburg were recruited and divided into two groups: the observation group (n =40) and the control group (n=40). In the observation group, solid food was restricted after 24:00, the patients were required to take 300 mL carbohydrates two hours before surgery. In the control group, solid food and liquid intake were restricted after 24:00 the night before surgery. The cross-sectional area (CSA) of gastric antrum was measured in supine position and right lateral decubitus position before anesthesia. Primary outcome was gastric volume (GV) in each group. Secondary outcome included Perlas A semi-quantitative grading and gastric volume/weight (GV/W). All the patients received assessment of preoperative feeling of thirsty and hunger with visual analogue scale (VAS).

RESULTS

Complete data were available in eighty patients. GV was (58.8±23.6) mL in the intervention group vs. (56.3±22.1) mL in the control group, GV/W was (0.97±0.39) mL/kg vs. (0.95±0.35) mL/kg, respectively; all the above showed no significant difference between the two groups (P > 0.05). Perlas A semi-quantitative grading showed 0 in 24 patients (60%), 1 in 15 patients (37.5%), 2 in 1 patient (2.5%) in the intervention group and 0 in 25 (62.5%), 1 in 13 (32.5%), 2 in 2 (5%) in the control group, the proportion of Perlas A semi-quantitative grading showed no significant difference between the two groups (P > 0.05). A total of 3 patients (1 in the intervention group and 2 in the control group) with Perlas A semi-quantitative grading 2 were treated with special intervention, no aspiration case was observed in this study. The observation group endured less thirst and hunger (P＜0.05).

CONCLUSION

Three hundred mL carbohydrates intake two hours before surgery along with ultrasound guided gastric content monitoring does not increase gastric volume and the risk of reflux aspiration in patients positioning in trendelenburg undergoing gynecological laparoscopic surgery, and is helpful in minimizing disturbance to the patient's physiological needs, therefore leading to better clinical outcome.

2023 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting: Carbohydrate-containing Clear Liquids with or without Protein, Chewing Gum, and Pediatric Fasting Duration-A Modular Update of the 2017 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting

These practice guidelines are a modular update of the "Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures." The guidance focuses on topics not addressed in the previous guideline: ingestion of carbohydrate-containing clear liquids with or without protein, chewing gum, and pediatric fasting duration.

Effects of Preoperative Oral Carbohydrate Electrolyte Drinks on Preoperative Hypokalemia Incidence in Patients Scheduled for Laparoscopic Colorectal Resection: A Three-arm Randomized Clinical Trial

PURPOSE

In our previous study, hypokalemia incidence was high in patients scheduled for laparoscopic colorectal resection. This trial was conducted to verify the effects of preoperative carbohydrate drinks containing potassium in these patients.

DESIGN

A three-arm randomized controlled design was used.

METHODS

Patients were randomly assigned to control, placebo, and treatment groups. In the control group, patients fasted from midnight. In the placebo group, patients fasted from midnight and received carbohydrate drinks 2 to 3 hours before surgery. In the treatment group, patients fasted from midnight and received carbohydrate drinks containing potassium supplementation 2 to 3 hours before surgery. The primary outcome was the incidence and severity of preoperative hypokalemia. Other outcomes included postoperative gastrointestinal function, including the time to postoperative first flatus (FFL) and first feces (FFE), and other complications.

FINDINGS

The final analysis included 122 participants. The incidence of preoperative hypokalemia in the treatment group was significantly lower than that in the control and placebo groups (50% vs 88.1% vs 77.5%, P < .001). The severity of hypokalemia in the control and placebo groups was greater than that in the treatment group. No regurgitation or aspiration occurred in the three groups. No significant differences were observed among the three groups regarding time to FFL and FFE.

CONCLUSIONS

Preoperative carbohydrate drinks containing potassium significantly reduced the incidence of preoperative hypokalemia and improved preoperative thirst and hunger, but did not reduce the postoperative time to FFL and FFE or length of hospital stay. However, as part of the enhanced recovery after surgery protocol, preoperative carbohydrate drinks containing potassium should be considered, as early as first admittance to hospital.

Impact of preoperative carbohydrate loading on gastric volume in patients with type 2 diabetes

BACKGROUND

Enhanced recovery after surgery advocates that consuming carbohydrates two hours before anesthesia is beneficial to the patient's recovery. Patients with diabetes are prone to delayed gastric emptying. Different guidelines for preoperative carbohydrate consumption in patients with diabetes remain controversial due to concerns about the risk of regurgitation, aspiration and hyperglycemia. Ultrasonic gastric volume (GV) assessment and blood glucose monitoring can comprehensively evaluate the safety and feasibility of preoperative carbohydrate intake in type 2 diabetes (T2D) patients.

AIM

To evaluate the impact of preoperative carbohydrate loading on GV before anesthesia induction in T2D patients.

METHODS

Patients with T2D receiving surgery under general anesthesia from December 2019 to December 2020 were included. A total of 78 patients were randomly allocated to 4 groups receiving 0, 100, 200, or 300 mL of carbohydrate loading 2 h before anesthesia induction. Gastric volume per unit weight (GV/W), Perlas grade, changes in blood glucose level, and risk of reflux and aspiration were evaluated before anesthesia induction.

RESULTS

No significant difference was found in GV/W among the groups before anesthesia induction (P > 0.05). The number of patients with Perlas grade II and GV/W > 1.5 mL/kg did not differ among the groups (P > 0.05). Blood glucose level increased by > 2 mmol/L in patients receiving 300 mL carbohydrate drink, which was significantly higher than that in groups 1 and 2 (P < 0.05).

CONCLUSION

Preoperative carbohydrate loading < 300 mL 2 h before induction of anesthesia in patients with T2D did not affect GV or increase the risk of reflux and aspiration. Blood glucose levels did not change significantly with preoperative carbohydrate loading of < 200 mL. However, 300 mL carbohydrate loading may increase blood glucose levels in patients with T2D before induction of anesthesia.

Effects of preoperative oral carbohydrate on postoperative discomfort in patients undergoing elective surgery: a meta-analysis of randomized controlled trials

PURPOSE

Fasting is a standard preoperative procedure performed to prevent vomiting and pulmonary aspiration during anaesthesia and surgery. However, fasting can cause postoperative physical and psychological discomfort. Intake of oral carbohydrate (CHO) may mimic the intake of food, which prevents postoperative discomfort. We conducted a meta-analysis to evaluate the effect and safety of preoperative oral CHO in adult surgical patients.

METHODS

Randomized controlled trials (RCTs) were searched for in the PubMed, EMBASE, and Cochrane Library databases. A meta-analysis was performed to calculate a pooled effect size by using random-effects models. The satisfaction outcomes were mouth dryness, hunger, thirst, pain severity, duration of hospitalization, homeostatic model assessment for insulin resistance (HOMA-IR), and the incidence of postoperative nausea and vomiting. The safety outcomes were the incidence of aspiration and infection.

RESULTS

In total, 57 RCTs involving 5606 patients were included. The outcomes of mouth dryness, thirst, hunger, and pain were assessed by a 10-point visual analogue scale (0 = best, 10 = worst). The severity of mouth dryness (weighted mean difference [WMD]: -1.26, 95% CI: -2.36 to -0.15), thirst (WMD: -1.36, 95% CI: -2.05 to -0.67), hunger (WMD: -1.66, 95% CI: -2.53 to -0.80), pain (WMD: -0.68, 95% CI: -1.01 to -0.35), duration of hospitalization (WMD: -0.39 day, 95% CI: -0.66 to -0.12), and HOMA-IR (WMD: -1.80, 95% CI: -2.84 to -0.76) were significantly lower in the CHO group than in the control group. The incidence of postoperative nausea and vomiting did not differ between the CHO and control groups. No aspiration was recorded in any of the groups.

CONCLUSIONS

Preoperative CHO can alleviate patient's discomfort without safety concerns. Surgeons and anaesthesiologists should strongly promote preoperative CHO as a strategy to enhance recovery after surgery protocols.

Preoperative Fasting Abbreviation With Whey Protein Reduces the Occurrence of Postoperative Complications in Patients With Head and Neck Cancer: A Randomized Clinical Trial

BACKGROUND

Surgery has become the treatment of choice for head and neck cancer (HNC) in most cases. Preoperative fasting abbreviation and nutrition screening have been suggested to reduce the occurrence of postoperative complications. This study aimed to evaluate the addition of whey protein in the preoperative fasting abbreviation and to analyze the association of nutrition status on postoperative complications in patients with HNC.

METHODS

A randomized, single-blind clinical trial was performed. Patients recruited from March to November 2018 at a national cancer reference center in Brazil were divided into 2 groups: intervention group (clear fluids with carbohydrate plus whey protein [CHO-P]) and control group (clear fluids with carbohydrate only [CHO]). All patients were evaluated by the Patient-Generated Subjective Global Assessment (PG-SGA) and body mass index. Logistic regression analyses were performed to assess associations between the studied variables, generating odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

A total of 49 patients met the eligibility criteria and enrolled in the study. A PG-SGA score of 4-8, indicating moderate malnutrition (OR, 10.91; 95% CI, 1.05-112.91), was an independent factor that increased the risk of postoperative complication, whereas the CHO-P group (OR, 0.04; 95% CI, 0.01-0.26) was found to be an independent factor in reducing such risk.

CONCLUSION

The addition of whey protein to clear fluids (CHO-P group) was associated with a reduced risk of postoperative complications compared with the CHO group. Furthermore, moderate malnourishment was associated with an increased risk of postoperative complications for patients with HNC.

Improvement in the Quality of Early Postoperative Course After Endoscopic Transsphenoidal Pituitary Surgery: Description of Surgical Technique and Outcome

Objective: The endoscopic transsphenoidal pituitary surgery has gained popularity and has shown excellent results with a more comfortable postoperative course. However, the quality of the early postoperative course is not well-established in endoscopic transsphenoidal pituitary surgery. We hypothesized that the quality of the early postoperative course would be improved when an enhanced recovery after surgery (ERAS) protocol and minimally invasive endoscopic transsphenoidal pituitary surgery is implemented.

Methods: We implemented a perioperative management ERAS protocol for endoscopic transsphenoidal pituitary surgery by an experienced surgeon (Yuehui Ma) in our department from January 2018. From then the endoscopic transsphenoidal pituitary surgery was implemented with a minimally invasive technique, such as bony sella reconstruction and partial nasal packing. We compared the results of 78 endoscopic transsphenoidal pituitary surgery cases during the initiation of the ERAS protocol and minimally invasive technique implementation: 37 cases in the control group and 41 cases in the ERAS group. Outcomes assessed included the effectiveness and security of surgery, postoperative hospital length of stay (LOS), and postoperative status on postoperative day 1 (POD1).

Results: Postoperative status on POD1, such as nasal ventilation, out of bed, headache score, and liquid supplement, had significant improvement (P < 0.05). The median postoperative LOS decreased from 8 days in the control group to 3 days in the ERAS group (P < 0.05). The ERAS group had better economic benefit with fewer hospital charges (P < 0.05). There was no difference in the early postoperative diabetes insipidus and 30-day readmission for epistaxis, hyponatremia, or other complications between the two groups.

Conclusion: The quality of the early postoperative course was improved when a neurosurgical ERAS protocol and minimally invasive endoscopic transsphenoidal pituitary surgery with partially nasal packing were implemented. Endoscopic transsphenoidal pituitary day surgery could be recommended in some classes of patients though further evaluation in large case studies is warranted.

The effect of 1% glucose loading on metabolism in the elderly patients during remifentanil-induced anesthesia: a randomized controlled trial

Background

Previous studies showed that remifentanil-induced anesthesia can inhibit surgical stress response in non-diabetic adult patients and that low-dose glucose loading during anesthesia may attenuate fat catabolism. However, little is known about the influence of glucose loading on metabolism in elderly patients, whose condition may be influenced by decreased basal metabolism and increased insulin resistance. We hypothesized that, in elderly patients, intraoperative low glucose infusion may attenuate the catabolism of fat without causing harmful hyperglycemia during remifentanil-induced anesthesia.

Methods

Elderly, non-diabetic patients scheduled to undergo elective surgery were enrolled and randomized to receive no glucose (0G group) or low-dose glucose infusion (0.1 g/kg/hr. for 1 h followed by 0.05 g/kg/hr. for 1 h; LG group) during surgery. Glucose, adrenocorticotropic hormone (ACTH), 3-methylhistidine (3-MH), insulin, cortisol, free fatty acid (FFA), creatinine (Cr), and ketone body levels were measured pre-anesthesia, 1 h post-glucose infusion, at the end of surgery, and on the following morning.

Results

A total of 31 patients (aged 75–85) were included (0G, n = 16; LG, n = 15). ACTH levels during anesthesia decreased significantly in both groups. In the LG group, glucose levels increased significantly after glucose loading but hyperglycemia was not observed. During surgery, ketone bodies and FFA were significantly lower in the LG group than the 0G group. There were no significant differences in insulin, Cr, 3-MH, and 3-MH/Cr between the two groups.

Conclusion

Remifentanil-induced anesthesia inhibited surgical stress response in elderly patients. Intraoperative low-dose glucose infusion attenuated catabolism of fat without inducing hyperglycemia.

Trial registration

This study has been registered with the University hospital Medical Information Network Center (http://www.umin.ac.jp/english/). Trial registration number: UMIN000016189. The initial registration date: January 12th 2015.

Effects of preoperative oral carbohydrate intake on catabolism, nutrition and adipocytokines during minor surgery: A randomized, prospective, controlled clinical phase II trial

BACKGROUND

We investigated the effects of preoperative oral carbohydrate loading on intraoperative catabolism, nutritional parameters, and adipocytokine levels during anesthesia.

METHODS

Study participants were randomized to two groups who were allowed to consume either no more than 250 mL of 18% oral carbohydrate solution (Arginaid Water: AW group) or no more than 500 mL of plain water (PW group) within the 2 hours before surgery, with no intraoperative glucose administration. Percentage changes from preoperative values of resting metabolic rate (RMR) and total body water (TBW), determined by bioelectrical impedance analysis (BIA), were compared. Blood levels of serum ketone bodies, free fatty acids (FFAs), insulin, 3-methyl histidine, blood glucose, retinol binding protein, adiponectin, and leptin were measured. BIA measurement and blood sampling were performed on entry to the operating room (M1) and 2 hours after the induction of anesthesia (M2). Chi squared test, Mann-Whitney U test, and Wilcoxon's test were used for comparisons of parameters. P values less than 0.05 constituted a significant difference.

RESULTS

Seventeen patients per group (34 patients total) were enrolled. RMR and TBW values did not differ between M1 and M2 measurements. Participants in the AW group had lower blood ketone body and FFA levels and higher insulin levels at M1. However, their ketone body and FFA levels rose and insulin levels fell after 2 hours, although ketone body and FFA levels in the AW group were still lower than those in the PW group. Although retinol binding protein, adiponectin, and leptin levels were not different in terms of preoperative oral carbohydrate loading, the levels of these substances in both groups were lower after 2 hours compared with levels on operating room entry.

CONCLUSIONS

Preoperative oral carbohydrate loading without intraoperative glucose administration appears to suppress catabolism for 2 hours after the start of surgery.

Ultrasound dynamics of gastric content volumes after the ingestion of coconut water or a meat sandwich. A randomized controlled crossover study in healthy volunteers

Background

Adequate preoperative fasting is critical in preventing pulmonary aspiration of gastric content. We proposed to study the sonographic gastric content dynamics after the ingestion of liquid or solid food in healthy volunteers and confront it with current guidelines for preoperative fasting times.

Methods

We performed a prospective, crossover, evaluator-blinded study involving 17 healthy volunteers of both sexes. Each participant fasted for 10 h and was subjected to a baseline gastric ultrasound, intake of 400 mL of coconut water or a 145 g, 355 kcal meat sandwich, and sonographic gastric evaluations after 10 min and every hour until the stomach was completely empty.

Results

At baseline, all subjects had an empty stomach. At 10 min, gastric content [mean + standard deviation (SD)] was 240.4 + 69.3 and 248.2 + 119.2 mL for liquid and solid foods, respectively (p > 0.05). Mean + SD gastric emptying times were 2.5 + 0.7 and 4.5 + 0.9 h for liquid and solid foods, respectively (p < 0.001). For the drink, the stomach was completely empty in 59% and 100% of the subjects after two and four hours, and for the sandwich, 65% and 100% of the subjects after four and seven hours, respectively.

Conclusions

Sonographic gastric dynamics for coconut water and a meat sandwich resulted in complete gastric emptying times higher and lower, respectively, than those suggested by current guidelines for preoperative fasting.

[Ultrasound dynamics of gastric content volumes after the ingestion of coconut water or a meat sandwich. A randomized controlled crossover study in healthy volunteers]

BACKGROUND

Adequate preoperative fasting is critical in preventing pulmonary aspiration of gastric content. We proposed to study the sonographic gastric content dynamics after the ingestion of liquid or solid food in healthy volunteers and confront it with current guidelines for preoperative fasting times.

METHODS

We performed a prospective, crossover, evaluator-blinded study involving 17 healthy volunteers of both sexes. Each participant fasted for 10h and was subjected to a baseline gastric ultrasound, intake of 400mL of coconut water or a 145g, 355kcal meat sandwich, and sonographic gastric evaluations after 10min and every hour until the stomach was completely empty.

RESULTS

At baseline, all subjects had an empty stomach. At 10min, gastric content [mean + standard deviation (SD)] was 240.4 + 69.3 and 248.2 + 119.2mL for liquid and solid foods, respectively (p>0.05). Mean + SD gastric emptying times were 2.5 + 0.7 and 4.5 + 0.9h for liquid and solid foods, respectively (p<0.001). For the drink, the stomach was completely empty in 59% and 100% of the subjects after two and four hours, and for the sandwich, 65% and 100% of the subjects after four and seven hours, respectively.

CONCLUSIONS

Sonographic gastric dynamics for coconut water and a meat sandwich resulted in complete gastric emptying times higher and lower, respectively, than those suggested by current guidelines for preoperative fasting.

Safety and efficacy of a novel neurosurgical enhanced recovery after surgery protocol for elective craniotomy: a prospective randomized controlled trial

OBJECTIVE

Although enhanced recovery after surgery (ERAS) programs have gained acceptance in various surgical specialties, no established neurosurgical ERAS protocol for patients undergoing elective craniotomy has been reported in the literature. Here, the authors describe the design, implementation, safety, and efficacy of a novel neurosurgical ERAS protocol for elective craniotomy in a tertiary care medical center located in China.

METHODS

A multidisciplinary neurosurgical ERAS protocol for elective craniotomy was developed based on the best available evidence. A total of 140 patients undergoing elective craniotomy between October 2016 and May 2017 were enrolled in a randomized clinical trial comparing this novel protocol to conventional neurosurgical perioperative management. The primary endpoint of this study was the postoperative hospital length of stay (LOS). Postoperative morbidity, perioperative complications, postoperative pain scores, postoperative nausea and vomiting, duration of urinary catheterization, time to first solid meal, and patient satisfaction were secondary endpoints.

RESULTS

The median postoperative hospital LOS (4 days) was significantly shorter with the incorporation of the ERAS protocol than that with conventional perioperative management (7 days, p < 0.0001). No 30-day readmission or reoperation occurred in either group. More patients in the ERAS group reported mild pain (visual analog scale score 1-3) on postoperative day 1 than those in the control group (79% vs. 33%, OR 7.49, 95% CI 3.51-15.99, p < 0.0001). Similarly, more patients in the ERAS group had a shortened duration of pain (1-2 days; 53% vs. 17%, OR 0.64, 95% CI 0.29-1.37, p = 0.0001). The urinary catheter was removed within 6 hours after surgery in 74% patients in the ERAS group (OR 400.1, 95% CI 23.56-6796, p < 0.0001). The time to first oral liquid intake was a median of 8 hours in the ERAS group compared to 11 hours in the control group (p < 0.0001), and solid food intake occurred at a median of 24 hours in the ERAS group compared to 72 hours in the control group (p < 0.0001).

CONCLUSIONS

This multidisciplinary, evidence-based, neurosurgical ERAS protocol for elective craniotomy appears to have significant benefits over conventional perioperative management. Implementation of ERAS is associated with a significant reduction in the postoperative hospital stay and an acceleration in recovery, without increasing complication rates related to elective craniotomy. Further evaluation of this protocol in large multicenter studies is warranted.Clinical trial registration no.: ChiCTR-INR-16009662 (chictr.org.cn).

Patient-Reported Outcomes Are Associated With Enhanced Recovery Status in Patients With Bladder Cancer Undergoing Radical Cystectomy

BACKGROUND

Bladder cancer is a disease of the elderly that is associated with high morbidity in those treated with radical cystectomy. In this observational study of patients with bladder cancer undergoing radical cystectomy, we analyzed and compared patient-reported outcomes from those treated with Enhanced Recovery After Surgery (ERAS) methods versus those who received traditional perioperative care.

METHODS

We enrolled patients who underwent radical cystectomy at a high-volume tertiary care referral center from November 2013 to December 2016, when the ERAS concept was being introduced into postoperative care at our institution. Patients reported symptom outcomes using the MD Anderson Symptom Inventory preoperatively and on postoperative days 1 to 5. Mann-Whitney U tests were used to compare symptom burden between the ERAS and traditional-care groups. General linear mixed-effects models were used for longitudinal data; linear regression models were used for multivariable analysis.

RESULTS

Patients (N = 383) reported dry mouth, disturbed sleep, drowsiness, fatigue, pain, and lack of appetite as the most severe symptoms. Compared with the traditional-care group, the ERAS group had significantly less pain (est. = -0.98, P = .005), drowsiness (est. = -0.91, P = .009), dry mouth (est. = -1.21, P = .002), disturbed sleep (est. = -0.97, P = .01), and interference with functioning (est. = -0.70, P = .022) (adjusted for age, sex, surgical technique, and neoadjuvant chemotherapy status).

CONCLUSIONS

These results suggest that ERAS practice significantly reduced immediate postoperative symptom burden in bladder cancer patients recovering from radical cystectomy, supporting the use of patient-reported symptom burden as an outcome measure in perioperative care.