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Zhou J, Zhang P, Tan Z, Li C, Yao L, He T, Hou H, Yin Y. Enhanced recovery after surgery in elective cesarean section patients with gestational diabetes mellitus does not lead to glucose-related maternal and neonatal complications. Front Endocrinol (Lausanne) 2024; 15:1403754. [PMID: 39165509 PMCID: PMC11333357 DOI: 10.3389/fendo.2024.1403754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 07/22/2024] [Indexed: 08/22/2024] Open
Abstract
Objective For elective cesarean section patients with gestational diabetes mellitus (GDM), there is a lack of evidence-based research on the use of enhanced recovery after surgery (ERAS). This study aims to compare the ERAS after-surgery protocol and traditional perioperative management. Research design and methods In this retrospective cohort study, singleton pregnancies with good glucose control GDM, delivered by elective cesarean sections under intravertebral anesthesia at least 37 weeks from January 1 to December 31, 2022, were collected at the Third Affiliated Hospital of Sun Yat-sen University. We divided all enrolled pregnant women and newborns into an ERAS group and a control group (the traditional perioperative management group) based on their adherence to the ERAS protocol. The primary outcome was the preoperative blood glucose level, with an increase of more than 1 mmol/L indicating clinical significance when compared to the control group. The secondary outcome was centered around an adverse composite outcome that affected both mothers and newborns. Results We collected a total of 161 cases, with 82 in the ERAS group and 79 in the control group. Although the mean preoperative blood glucose level in the ERAS group was significantly higher than in the control group (5.01 ± 1.06 mmol/L vs. 4.45 ± 0.90 mmol/L, p<0.001), the primary outcome revealed that the mean glycemic difference between the groups was 0.47 mmol/L (95% CI 0.15-0.80 mmol/L), which was below the clinically significant difference of 1 mmol/L. For the secondary outcomes, the ERAS group had an 86% lower risk of a composite adverse outcome compared to the control group. This included a 73% lower risk of perioperative maternal hypoglycemia and a 92% lower rate of neonatal hypoglycemia, all adjusted by age, hypertensive disorder of pregnancy, BMI, gestational weeks, primigravidae, primary pregnancy, GDM, surgery duration, and fasting glucose. Conclusion Implementing a low-dose carbohydrate ERAS in pregnant women with GDM prior to elective cesarean section, compared to traditional perioperative management, does not lead to clinically significant maternal glucose increases and thus glucose-related maternal or neonatal perioperative complications.
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Affiliation(s)
| | | | | | | | | | | | | | - Yuzhu Yin
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Canelli RJ, Louca J, Gonzalez RM, Rendon LF, Hartman CR, Bilotta F. Trends in preoperative carbohydrate load practice: A systematic review. JPEN J Parenter Enteral Nutr 2024; 48:527-537. [PMID: 38676554 DOI: 10.1002/jpen.2633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/22/2024] [Accepted: 04/05/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND The preoperative carbohydrate load (PCL) is intended to improve surgical outcomes by reducing the catabolic state induced by overnight fasting. However, there is disagreement on the optimal PCL prescription, leaving local institutions without a standardized PCL recommendation. Results from studies that do not prescribe PCL in identical ways cannot be pooled to draw larger conclusions on outcomes affected by the PCL. The aim of this systematic review is to catalog prescribed PCL characteristics, including timing of ingestion, percentage of carbohydrate contribution, and volume, to ultimately standardize PCL practice. METHODS A comprehensive search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized controlled trials were included if they studied at least one group of patients who were prescribed a PCL and the PCL was described with respect to timing of ingestion, carbohydrate contribution, and total volume. RESULTS A total of 67 studies with 6551 patients were included in this systematic review. Of the studies, 49.3% were prescribed PCL on the night before surgery and morning of surgery, whereas 47.8% were prescribed PCL on the morning of surgery alone. The mean prescribed carbohydrate concentration was 13.5% (±3.4). The total volume prescribed was 648.2 ml (±377). CONCLUSION Variation in PCL practices prevent meaningful data pooling and outcome analysis, highlighting the need for standardized PCL prescription. Efforts dedicated to the establishment of a gold standard PCL prescription are necessary so that studies can be pooled and analyzed with respect to meaningful clinical end points that impact surgical outcomes and patient satisfaction.
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Affiliation(s)
- Robert J Canelli
- Department of Anesthesiology, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Joseph Louca
- Department of Anesthesiology, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Rafael M Gonzalez
- Department of Anesthesiology, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA
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Shi H, Zheng C, Zhu B. Effects of Preoperative Oral Carbohydrate on Perioperative Maternal Outcomes Undergoing Cesarean Section: A Systematic Review and Meta-Analysis. Anesthesiol Res Pract 2024; 2024:4660422. [PMID: 38586152 PMCID: PMC10999288 DOI: 10.1155/2024/4660422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/18/2024] [Accepted: 03/23/2024] [Indexed: 04/09/2024] Open
Abstract
Purpose Preoperative oral carbohydrate (CHO) is a rapid postoperative rehabilitation protocol that improves perioperative outcomes and is widely used in adult surgical patients. However, pregnant women are excluded because of the possibility of aspiration due to delayed gastric emptying. This meta-analysis was conducted to evaluate the efficacy of preoperative oral CHO in elective cesarean section. Methods PubMed, Embase, Web of Science, and the Cochrane Library were searched from inception to July 2023. Randomized controlled trials were included. The risk of bias was assessed using the Cochrane tool. Risk ratios and 95% confidence intervals were calculated. Meta-analysis was performed using random-effects models to estimate risk ratios and mean differences (MDs) with 95% confidence intervals (CIs). The outcomes included thirst and hunger scores, incidence of vomiting and nausea, time to flatus, and homeostatic model assessment of insulin resistance (HOMA-IR). Results A total of nine studies with 1211 patients were included in the analysis. The levels of thirst and hunger were evaluated using a 10-point visual analog scale, with 0 representing the best and 10 representing the worst. The severity of hunger (weighted mean difference (WMD: -2.34, 95% CI: -3.13 to -1.54), time to flatus (WMD: -3.51 hours, 95% CI: -6.85 to -0.17), and HOMA-IR (WMD: -1.04, 95% CI: -1.31 to -0.77) were significantly lower in the CHO group compared to the control group. However, there were no significant differences in the severity of thirst or the incidence of vomiting and nausea between the CHO and control groups. Conclusion Preoperative oral CHO during cesarean section alleviates thirst and hunger, shortens the time of postoperative flatus, and reduces HOMA-IR. However, the available evidence is insufficient to reach a clear consensus on the benefits or harms of preoperative oral CHO during cesarean section. Therefore, it is premature to make a definitive recommendation for or against its routine use.
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Affiliation(s)
- Haibin Shi
- Department of Anesthesiology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang, China
| | - Caihong Zheng
- Department of Anesthesiology, Hangzhou Women's Hospital, Hangzhou, Zhejiang, China
| | - Bin Zhu
- Department of Anesthesiology, Hangzhou Women's Hospital, Hangzhou, Zhejiang, China
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Sánchez-García JC, Saraceno López-Palop I, Piqueras-Sola B, Cortés-Martín J, Mellado-García E, Muñóz Sánchez I, Rodríguez-Blanque R. Advancements in Nutritional Strategies for Gestational Diabetes Management: A Systematic Review of Recent Evidence. J Clin Med 2023; 13:37. [PMID: 38202044 PMCID: PMC10779518 DOI: 10.3390/jcm13010037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 12/14/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
Gestational diabetes mellitus (GDM) is defined as hyperglycaemia first detected at any time during pregnancy with values lower than those determined by the WHO for diabetes diagnosis in adults. This pathology, with a worldwide prevalence of 13.4%, causes significant maternal and foetal risks. The first line of treatment consists of maintaining normo-glycaemia through an adequate diet and lifestyle changes. The aim is to synthesize the scientific evidence updating the nutritional recommendations for the effective management of GDM. A systematic review of the scientific literature was conducted following the PRISMA guidelines. Randomized clinical trials published within the last five years and providing information on nutritional recommendations to achieve an effective management of gestational diabetes were selected. The databases searched were PubMed, the WOS Core Collection, SCOPUS, and CINAHL, using the MeSH terms: "Diabetes, Gestational"; "Nutrition Assessment (nutrition*)"; "Diet"; "Eating"; and "Food"; with the Boolean operators "AND" and "OR". The PEDro scale (Physiotherapy Evidence Database) was used to assess the scientific quality of the studies, with a mean score of 8.9, indicating an average good scientific quality. Results: A total of 809 papers were collected, of which, after applying the inclusion and exclusion criteria, 14 randomized clinical trials were selected. Probiotic supplementation and co-supplementation with vitamin D have been found to be the most beneficial options for both mothers with GDM and neonates, but the most effective regimens are not known. Diets enriched with extra virgin olive oil (EVOO) and oat bran, as well as some recommendations focused on carbohydrates also seem effective, as well as diets designed for this group of women with GDM such as "CHOICE". Conclusions: Although there are numerous proposals that have been published in recent years focused on the diet of women with GDM in order to improve their results and those of their children, it is the supplementation with probiotics and the co-supplementation with vitamin D that is most agreed upon as beneficial; however, more research is needed into which protocols are most effective. Other proposals that could also be beneficial should be further studied.
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Affiliation(s)
- Juan Carlos Sánchez-García
- Research Group CTS-1068, Andalusia Research Plan, Junta de Andalucía, 18014 Granada, Spain; (J.C.S.-G.); (B.P.-S.); (E.M.-G.); (R.R.-B.)
- Department of Nursing, Faculty of Health Sciences, University of Granada, 18071 Granada, Spain;
| | | | - Beatriz Piqueras-Sola
- Research Group CTS-1068, Andalusia Research Plan, Junta de Andalucía, 18014 Granada, Spain; (J.C.S.-G.); (B.P.-S.); (E.M.-G.); (R.R.-B.)
- Virgen de las Nieves University Hospital, 18014 Granada, Spain
| | - Jonathan Cortés-Martín
- Research Group CTS-1068, Andalusia Research Plan, Junta de Andalucía, 18014 Granada, Spain; (J.C.S.-G.); (B.P.-S.); (E.M.-G.); (R.R.-B.)
- Department of Nursing, Faculty of Health Sciences, University of Granada, 18071 Granada, Spain;
| | - Elena Mellado-García
- Research Group CTS-1068, Andalusia Research Plan, Junta de Andalucía, 18014 Granada, Spain; (J.C.S.-G.); (B.P.-S.); (E.M.-G.); (R.R.-B.)
- Costa del Sol Health District, 29640 Fuengirola, Spain
| | | | - Raquel Rodríguez-Blanque
- Research Group CTS-1068, Andalusia Research Plan, Junta de Andalucía, 18014 Granada, Spain; (J.C.S.-G.); (B.P.-S.); (E.M.-G.); (R.R.-B.)
- Department of Nursing, Faculty of Health Sciences, University of Granada, 18071 Granada, Spain;
- San Cecilio University Hospital, 18071 Granada, Spain
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Kotfis K, Wojciechowska A, Zimny M, Jamioł-Milc D, Szylińska A, Kwiatkowski S, Kaim K, Dołęgowska B, Stachowska E, Zukowski M, Pankowiak M, Torbé A, Wischmeyer P. Preoperative Oral Carbohydrate (CHO) Supplementation Is Beneficial for Clinical and Biochemical Outcomes in Patients Undergoing Elective Cesarean Delivery under Spinal Anaesthesia-A Randomized Controlled Trial. J Clin Med 2023; 12:4978. [PMID: 37568381 PMCID: PMC10419905 DOI: 10.3390/jcm12154978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/25/2023] [Accepted: 07/27/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Preoperative fasting and surgery cause metabolic stress, insulin resistance with ketosis, and postoperative nausea and vomiting (PONV). Oral carbohydrate loading strategy (CHO) improves outcomes in labor and general surgery. We aimed to compare the effectiveness of CHO with standard fasting in patients undergoing elective cesarean delivery (CD) under spinal anesthesia. METHODS A single-center, parallel, prospective randomized controlled trial (RCT) was conducted in a tertiary university obstetrics department at Pomeranian Medical University in Szczecin, Poland. Patients were randomly assigned (1:1 ratio) to the CHO group (oral carbohydrate 2 h before elective CD, n = 75) or the SF group (control-standard fasting, n = 73). The main outcome measures were incidence and severity of PONV at 6 and 24 h after CD, time to the first peristalsis, time to first bowel movement, and biochemical parameters indicating ketosis in mothers and their children. RESULTS A total of 148 adult females with singleton pregnancies undergoing elective CD under spinal anesthesia (ASA I and II) were included in the final analysis. At 24 h after CD, 8.0% from the CHO group vs. 20.55% reported three or more episodes of vomiting or dry retching as compared to patients in the SF group (p = 0.041). Preoperative CHO supplementation decreased preoperative feelings of hunger (p < 0.001) and thirst (p < 0.001). Laboratory results in the CHO group showed higher plasma pH (p = 0.001) and glucose (p < 0.001), lower F2-isoprostane in plasma (p = 0.049) and urine (p = 0.018), lower urine F2-isoprostane/creatinine ratio (p = 0.045) than in the SF group. HOMA-IR (p < 0.001) and lactate (p < 0.001) were higher in the CHO group than in the control group. CONCLUSIONS There was no significant difference in the incidence or severity of early PONV at 6 h. The incidence of vomiting or dry retching at 24 h after cesarean delivery was lower in the CHO group as compared to standard starvation, but the combined results of PONV frequency and severity on the Wengritzky scale did not differ between the two study groups. Preoperative CHO supplementation decreased preoperative feelings of hunger and thirst, enhancing the comfort of pregnant women. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT04069806.
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Affiliation(s)
- Katarzyna Kotfis
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, 70-111 Szczecin, Poland; (K.K.); (M.Z.); (M.P.)
| | - Arleta Wojciechowska
- Department of Obstetrics and Gynecology, Pomeranian Medical University in Szczecin, 70-111 Szczecin, Poland; (A.W.); (M.Z.); (S.K.); (A.T.)
| | - Małgorzata Zimny
- Department of Obstetrics and Gynecology, Pomeranian Medical University in Szczecin, 70-111 Szczecin, Poland; (A.W.); (M.Z.); (S.K.); (A.T.)
| | - Dominika Jamioł-Milc
- Department of Human Nutrition and Metabolomics, Pomeranian Medical University, 71-460 Szczecin, Poland; (D.J.-M.); (E.S.)
| | - Aleksandra Szylińska
- Department of Medical Rehabilitation and Clinical Physiotherapy, Pomeranian Medical University in Szczecin, 71-210 Szczecin, Poland;
| | - Sebastian Kwiatkowski
- Department of Obstetrics and Gynecology, Pomeranian Medical University in Szczecin, 70-111 Szczecin, Poland; (A.W.); (M.Z.); (S.K.); (A.T.)
| | - Karolina Kaim
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, 70-111 Szczecin, Poland; (K.K.); (M.Z.); (M.P.)
| | - Barbara Dołęgowska
- Department of Microbiology, Immunology and Laboratory Medicine, Pomeranian Medical University in Szczecin, 70-111 Szczecin, Poland;
| | - Ewa Stachowska
- Department of Human Nutrition and Metabolomics, Pomeranian Medical University, 71-460 Szczecin, Poland; (D.J.-M.); (E.S.)
| | - Maciej Zukowski
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, 70-111 Szczecin, Poland; (K.K.); (M.Z.); (M.P.)
| | - Maria Pankowiak
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, 70-111 Szczecin, Poland; (K.K.); (M.Z.); (M.P.)
| | - Andrzej Torbé
- Department of Obstetrics and Gynecology, Pomeranian Medical University in Szczecin, 70-111 Szczecin, Poland; (A.W.); (M.Z.); (S.K.); (A.T.)
| | - Paul Wischmeyer
- Department of Anesthesiology and Surgery, Duke University School of Medicine, Durham, NC 27710, USA;
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Joshi GP, Abdelmalak BB, Weigel WA, Harbell MW, Kuo CI, Soriano SG, Stricker PA, Tipton T, Grant MD, Marbella AM, Agarkar M, Blanck JF, Domino KB. 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. Anesthesiology 2023; 138:132-151. [PMID: 36629465 DOI: 10.1097/aln.0000000000004381] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
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.
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