Role of preoperative carbohydrate loading: a systematic review

Comparison of Gastric Residual Volume After Ingestion of A Carbohydrate Drink and Water in Healthy Volunteers with Obesity: A Randomized Crossover Study

INTRODUCTION

Preoperative carbohydrate intake is essential to enhance postoperative recovery. However, its safety for individuals with obesity remains unclear. This study investigated the safety of preoperative carbohydrate consumption compared to water intake in obese populations through gastric volume assessment.

METHODS

A prospective randomized crossover study enrolled 30 healthy volunteers aged 18-65 years with a body mass index ≥ 30 kg/m2, following a minimum 6-h fast. The participants received either 400 ml of a carbohydrate drink (group C) or water (group W). Gastric ultrasonography, blood glucose level, hunger, and thirst assessments were conducted at baseline (T) and various time points (T2 to T6). The protocol was repeated with reverse interventions at least 1 week later.

RESULTS

Group C had significantly higher gastric volume at T3, T4, and T5 compared to group W, with a prolonged time to empty the gastric antrum (94.4 ± 28.5 vs. 61.0 ± 33.5 min, 95% CI 33.41 [17.06,24.69]). However, glucose levels, degrees of hunger, and thirst showed no significant differences between the groups.

CONCLUSION

Administering 400 ml of preoperative carbohydrates to healthy obese individuals 2 h preoperatively is safe and comparable to water intake. These findings support the integration of carbohydrate loading into perioperative care for obese individuals, consistent with the enhanced recovery after surgery protocols. Further research is warranted to refine preoperative fasting protocols and improve surgical outcomes in this population.

Effect of preoperative oral carbohydrate loading on postoperative insulin resistance, patient-perceived well-being, and surgical outcomes in elective colorectal surgery: a randomized controlled trial

BACKGROUND

Insulin resistance (IR) is one of the independent determinants influencing the length of hospital stay (LOHS) and postoperative complications in colorectal procedures. Preoperative oral carbohydrate loading (OCL) has emerged as a prospective countermeasure for IR. This study aimed to investigate the effects of preoperative carbohydrate loading on postoperative IR, inflammatory parameters, and clinical outcomes in patients undergoing elective colorectal surgery.

METHODS

This was an open-label, parallel arm, superiority randomized controlled trial conducted over 2 years. Participants were assigned to conventional fasting and oral OCL groups. IR, insulin sensitivity, Glasgow Prognostic Score (GPS), and interleukin 6 levels were analyzed on the day of surgery and on the first postoperative day (POD-1) and third POD (POD-3). Clinical parameters, such as thirst, hunger, dry mouth, anxiety, weakness, pain, nausea, and vomiting, were compared in the perioperative period. In addition, surgical clinical outcomes, such as intestinal recovery, time to independent ambulation, postoperative morbidity, and LOHS, were studied.

RESULTS

A total of 72 participants were included, with 36 in each group. In the OCL group, there was a statistically significant decrease in postoperative IR on the day of surgery, POD-1, and POD-3 (P = .0336). Similarly, inflammatory parameters and the GPS were found to be significantly lower in the OCL group (P < .001). Clinical parameters, such as thirst, hunger, and dry mouth, were significantly lower in the intervention group (P =.00), with a shortened LOHS.

CONCLUSION

This study demonstrated that preoperative carbohydrate loading is associated with reduced IR and inflammatory markers, shortened hospital stays, and improved overall clinical outcomes in elective colorectal surgery.

Assessing Full Stomach Prevalence with Ultrasound Following Preoperative Fasting in Diabetic Patients with Dysautonomia: A Comparative Observational Study

BACKGROUND

Traditionally, diabetics have been considered patients with a high risk of aspiration due to having delayed gastric emptying; However, the evidence concerning residual gastric volume (GV) in fasting diabetic patients is inconsistent. This study aimed to compare the fasting GV of diabetic patients with or without dysautonomia with control patients scheduled for elective surgery using gastric ultrasound.

METHODS

This bicentric prospective single-blinded case-control study was conducted at 2 university hospitals in Spain. Patients aged over 18 years, classified as American Society of Anesthesiologists (ASA) physical statuses I to III and having similar fasting statuses, were included in the study. The primary outcome was to compare the prevalence of risk stomach using the Perlas gastric content grading scale evaluated by ultrasound in the 3 groups. Secondary outcomes included the measurement of cross-sectional area (CSA) and GV in the right lateral decubitus (RLD) position, as well as the prevalence of solid gastric residue.

RESULTS

A total of 289 patients were recruited for the study, comprising 145 diabetic patients (83 of whom had dysautonomia) and 144 patients in the control group. The percentage of patients classified as Perlas grade 2 was 13.2% in the control group, 16.1% in diabetic patients without dysautonomia, and 22.9% in diabetic patients with dysautonomia (P = .31). Antral CSA was significantly higher in diabetic patients with dysautonomia (6.5 [4.8-8.4]) compared to the control group (5.4 [4.0-7.2]; P = .04). However, no significant differences were observed between groups in residual GV. Among diabetic patients with dysautonomia, 12% exhibited solid gastric residue, which was twice the percentage observed in diabetic patients without dysautonomia (4.8%) and 3 times higher than that in the control group (3.5%; P = .03). The presence of dysautonomia was associated with an increased odds ratio of solid gastric residue (odds ratio [OR], 3.37; 95% confidence interval [CI], 1.28-8.87; P = .01) after adjusting for confounding factors.

CONCLUSIONS

This study offers insights into the relationship between dysautonomia in patients with diabetes mellitus and the presence of full stomach, underscoring the significance of preoperative gastric ultrasound evaluation in managing perioperative risks in this population.

The awareness of enhanced recovery after surgery (ERAS) cesarean delivery guidelines among anesthesiology and reanimation assistants in Turkey; a questionnaire study

BACKGROUND

To reduce maternal-fetal morbidity and mortality, it is becoming increasingly important for anesthetists to understand and implement enhanced recovery after surgery (ERAS) cesarean delivery guidelines. Our aim was to reveal the knowledge of anesthesia assistants in Turkey about ERAS during cesarean delivery and to increase their awareness of ERAS.

METHODS

This descriptive study was conducted in the city of Isparta, Turkey in 2023. The survey, which was approved by the ethics committee, was distributed to participants across Turkey via e-mail and online messages. The survey comprises of a total of 42 questions evaluating perioperative ERAS recommendations.

RESULTS

Of the 404 participants in our survey, 59.9% were associated with university hospitals and 65.8% had completed three or more years of education. A total of 87.9% of the participants were familiar with ERAS; however, only 42.8% had received ERAS training. Although 93.8% of the participants' institutions performed a cesarean delivery, ERAS recommendations were only implemented at a rate of 48%. This may be due to the absence of an ERAS team, which was identified in our survey at a high rate of 66.6%.

CONCLUSION

Awareness about ERAS was high among the participants, but the implementation rates of some recommendations were low. The reason for this may be the inability to form a multidisciplinary team and inadequate training of participants. For this purpose, we recommend the formation of a multidisciplinary team for ERAS protocol implementation and increased participant training opportunities.

The EUropean PErioperative MEdical Networking (EUPEMEN) project and recommendations for perioperative care in colorectal surgery: a quality improvement study

BACKGROUND

Despite consensus supporting enhanced recovery programs, their full implementation in such a context is difficult due to conventional practices within various groups of professionals. The goal of the EUropean PErioperative MEdical Networking (EUPEMEN) project was to bring together the expertise and experience of national clinical professionals who have previously helped deliver major change programs in their countries and to use them to spread enhanced recovery after surgery protocols (ERAS) in Europe. The specific aim of this study is to present and discuss the key points of the proposed recommendations for colorectal surgery.

MATERIALS AND METHODS

Five partners from university hospitals in four European countries developed the project as partners. Following a non-systematic review of the literature, the European consensus panel generated a list of recommendations for perioperative care in colorectal surgery. A list of recommendations was formulated and distributed to collaborators at each center to allow modifications or additional statements. These recommendations were then discussed in three consecutive meetings to share uniform ERAS protocols to be disseminated.

RESULT

The working group developed (1) the EUPEMEN online platform to offer, free of charge, evidence-based standardized perioperative care protocols, learning activities, and assistance to health professionals interested in enhancing the recovery of their patients; (2) the preparation of the EUPEMEN Multimodal Rehabilitation manuals; (3) the training of the trainers to teach future teachers; and (4) the dissemination of the results in five multiplier events, one for each partner, to promote and disseminate the protocols.

CONCLUSION

The EUPEMEN project allowed the sharing of the expertise of many professionals from four different European countries with the objective of training the new generations in the dissemination of ERAS protocols in daily clinical practice through a new learning system. This project was proposed as an additional training tool for all the enhanced recovery program teams.

Effect of Preoperative Oral Carbohydrate Intake on Perioperative Hyperglycemia in Indian Patients Undergoing Hip Fracture Fixation

Objective

Preoperative fasting leads to a catabolic state aggravated by surgical stress. This leads to poor patient outcomes. This study aimed to determine the effect of preoperative oral carbohydrate administration on perioperative hyperglycemia and patient comfort.

Methods

This prospective, randomized study was conducted on 60 adult American Society of Anesthesiologist I/II patients undergoing hip fracture fixation after obtaining institutional ethical committee clearance. Patients were randomly kept conventionally fasted before surgery (group F, n = 30) or were given oral carbohydrate 2 h before surgery (group C, n = 30). Under all aseptic precautions, a combined spinal epidural block was administered, and surgery was allowed. The primary outcome was blood glucose, and secondary outcomes included incidence of postoperative hyperglycemia, insulin level, blood urea, hunger, thirst, and anxiety.

Results

Blood glucose levels were not statistically different between the two groups at baseline (T0; P=0.400), immediately after surgery (T1; P=0.399) and 24h after surgery (T2; P=0.619). The incidence of postoperative hyperglycemia was significantly higher in group F than in group C (P=0.045) at T2. Insulin levels, blood urea levels, and hunger scores were also not statistically different between the groups. The thirst and anxiety scores were lower at T0 and T1 in group C.

Conclusion

Preoperative oral carbohydrate administration does not prevent perioperative increases in blood glucose levels. However, it reduces the incidence of perioperative hyperglycemia and decreases perioperative thirst and anxiety, thereby improving the quality of perioperative patient care.

Is Intravenous Dextrose Infusion During Emergence From Anesthesia Effective in Improving the PONV in Gynecologic Laparoscopy? A Randomized Controlled Trial

STUDY OBJECTIVE

This study aimed to explore the relationship between intravenous 5% dextrose infusion during emergence from anesthesia to postoperative nausea and vomiting (PONV) in patients after gynecologic laparoscopic surgery.

DESIGN

This was a double-blind randomized controlled trial. Participants were randomized into the experimental group and control group using a computer-generated random number generator. Intervenors and measurers were blinded to group assignments of the study.

SETTING

A single academic tertiary medical center.

PATIENTS

Patients undergoing gynecologic laparoscopic surgery.

INTERVENTIONS

On completion of surgery, participants were randomized into the test group (receive 5% dextrose) and control group (receive Ringer's lactate solution).

MEASUREMENTS AND MAIN RESULTS

The primary outcome of the present study was the incidence of PONV. Other outcomes included postoperative rescue analgesic and rescue antiemetic, postoperative pain response, and recovery time of postanesthesia care unit. Baseline characteristics were statistically similar between the 2 groups of participants. There were 49 of 105 patients experienced PONV within 24 hours postoperatively. The overall incidence of PONV within 24 hours postoperatively was not significantly different (45.5% vs 48%; relative risk [RR], 0.95; 95% confidence interval [CI], 0.67-1.37; p = .794). However, fewer patients experienced PONV in the test group than in the control group during 0 to 1 hours (6.0% vs 20.0%; RR, 0.85; 95% CI, 0.73-0.99; p = .024) and 1 to 3 hours (14.5% vs 32.0%; RR, 0.80; 95% CI, 0.64-0.99; p = .033) postoperatively. In addition, recovery time in the postanesthesia care unit was less in the test group (17.07 ± 6.36 vs 22.04 ± 7.33; mean difference, -4.97; 95% CI, -7.62 to -2.32; p <.001) and pain score was lower in the test group during 0 to 0.5 hours postoperatively (2.29 ± 1.74 vs 3.08 ± 1.64; mean difference, -0.79; 95% CI, -1.45 to -0.13; p = .019).

CONCLUSION

In patients after gynecologic laparoscopic surgery, postanesthesia 5% dextrose infusion may be useful in improving the early management of PONV and pain response and may warrant further study.

Enhanced recovery after surgery: Preoperative carbohydrate loading and insulin management in type 2 diabetes

We assessed our institutional practice of individualized insulin dosing for patients with type 2 diabetes receiving preoperative carbohydrate loading (CHO-L) within an enhanced recovery after surgery (ERAS®) protocol. Patients enrolled in an ERAS® protocol with concomitant type 2 diabetes received rapid acting insulin (Novolog®[insulin aspart]) prior to 50 g CHO-L on the day of surgery. Following CHO-L and the administration of insulin, no hypoglycemic episodes occurred with preoperative POC glucose values between 6.8 and 12.3 mmol/L (123 and 221 mg/dL). Our experience demonstrates that administering rapid acting insulin prior to CHO-L in patients with type 2 diabetes is feasible and targets the potentially negative influence CHO-L may impose on preoperative glycemia in this population. Important considerations of this approach are highlighted and an insulin dosing algorithm designed for non-specialty providers is suggested.

Short-term hypercaloric carbohydrate loading increases surgical stress resilience by inducing FGF21

Dietary restriction promotes resistance to surgical stress in multiple organisms. Counterintuitively, current medical protocols recommend short-term carbohydrate-rich drinks (carbohydrate loading) prior to surgery, part of a multimodal perioperative care pathway designed to enhance surgical recovery. Despite widespread clinical use, preclinical and mechanistic studies on carbohydrate loading in surgical contexts are lacking. Here we demonstrate in ad libitum-fed mice that liquid carbohydrate loading for one week drives reductions in solid food intake, while nearly doubling total caloric intake. Similarly, in humans, simple carbohydrate intake is inversely correlated with dietary protein intake. Carbohydrate loading-induced protein dilution increases expression of hepatic fibroblast growth factor 21 (FGF21) independent of caloric intake, resulting in protection in two models of surgical stress: renal and hepatic ischemia-reperfusion injury. The protection is consistent across male, female, and aged mice. In vivo, amino acid add-back or genetic FGF21 deletion blocks carbohydrate loading-mediated protection from ischemia-reperfusion injury. Finally, carbohydrate loading induction of FGF21 is associated with the induction of the canonical integrated stress response (ATF3/4, NF-kB), and oxidative metabolism (PPARγ). Together, these data support carbohydrate loading drinks prior to surgery and reveal an essential role of protein dilution via FGF21.

Impact of Enhanced Recovery Protocols on Short-Term Outcomes in Esophagectomy: A Retrospective Cohort Study from Cancer Research Institute, Uttarakhand, India

OBJECTIVE

Surgery for esophageal cancer is associated with high mortality and morbidity, especially in low and middle-income countries. The recent enhanced recovery after surgery guidelines for esophagectomy (2018) which attempt to reduce complications and length of stay (LOS) have rarely been validated in these settings. This study aimed to analyse the effect of this protocol on short-term outcomes in our subset of patients.

METHODS

A retrospective review was conducted to investigate the outcomes of enhanced recovery protocol (ERP) compared to standard pre-protocol care (PP) in patients who underwent esophagectomy for cancer (31 in ERP vs 61 in PP group) at Cancer Research Institute, Uttarakhand, India. The main outcomes measured were 30-day mortality, morbidity and LOS. Risk assessment was stratified as per Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) systems while complications were classified as per the Clavien-Dindo scale.

RESULTS

Preoperative clinical characteristics were similar between groups. Though the predicted POSSUM mortality and morbidity were significantly higher in the ERP group (p = 0.007), 30-day morbidity (19.35% vs 42.62%, p = 0.027) as well as median LOS (12 vs 15 days, p < 0.001) was significantly lower in ERP group. The PP group reported 4 deaths within 30 days as compared to none in the ERP group (p = 0.296). Furthermore, the ERP group reported lower occurrence of pulmonary complications (6.4%vs24.6%,p = 0.046), hemodynamic instability (0%vs14.75%,p = 0.026) as well as need for prolonged postoperative ventilation (> 24 h; 0% vs 11.48%, p = 0.004). Both minor and major complications as assessed by the Clavien-Dindo scale were lower in the group ERP though these differences were not statistically significant (0.059).

CONCLUSIONS

Implementation of ERP improved short-term outcomes; hence can be strongly recommended in patients undergoing esophagectomy.

Enhanced Recovery After Surgery: Exploring the Advances and Strategies

Enhanced recovery after surgery (ERAS) has emerged as a paradigm-shifting approach in perioperative care, aimed at optimizing patient outcomes, accelerating recovery, and minimizing hospital stays. This review delves into the latest advances and strategies within the field of ERAS, encompassing a comprehensive examination of preoperative, intraoperative, and postoperative interventions. By analyzing an array of clinical studies, meta-analyses, and implementation experiences, this review highlights the multifaceted elements contributing to the success of ERAS programs. Key components such as preoperative patient education, minimally invasive surgical techniques, tailored anesthesia protocols, judicious fluid management, optimized pain control, early ambulation, and structured nutritional support are thoroughly explored. Furthermore, the review delves into the intricacies of ERAS implementation across diverse surgical specialties, emphasizing the significance of multidisciplinary collaboration, protocol customization, and sustained quality improvement initiatives. The analysis not only showcases the tangible benefits of ERAS, including reduced complication rates, shortened hospital stays, and enhanced patient satisfaction, but also underscores the challenges and barriers that medical professionals encounter during program adoption. By synthesizing the current state of ERAS research and practice, this review provides clinicians, administrators, and researchers with valuable insights into the evolving landscape of perioperative care, fostering a deeper understanding of ERAS as a holistic approach that transcends traditional surgical pathways.

Preoperative considerations for patients with diabetes

INTRODUCTION

Patients undergoing surgery require a thorough assessment preoperatively. Hyperglycemia is associated with poor outcomes, and stability of glucose levels is an important factor in preoperative management. Diabetes presents a particular challenge since patients are often on multiple medications encompassing glycemic management and cardiovascular therapies.

AREAS COVERED

A PubMed search of published data and reviews on preoperative approaches in diabetes was conducted. Consensus opinion drives most of the guidelines and recommendations for management of diabetes in surgical patients. Pathophysiology is often complex with varying levels of glucose and surgical stress. Establishing well-controlled diabetes prior to surgical intervention should be standard practice in non-emergent procedures. We review the best practices for implementing preoperative assessment, with diabetes with a focus on diabetes medications.

EXPERT OPINION

The management of a patient preoperatively varies by region and country. Institutions differ in approaches to preoperative evaluation and the establishment of consistent approaches would provide a platform for monitoring patient outcomes. Multidisciplinary teams and pre-assessment clinics for preoperative evaluation can enhance patient care for those undergoing surgery.

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

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.

Preoperative carbohydrate load to reduce perioperative glycemic variability and improve surgical outcomes: A scoping review

The detrimental effects of both diabetes mellitus (DM) and hyperglycemia in the perioperative period are well established and have driven extensive efforts to control blood glucose concentration (BGC) in a variety of clinical settings. It is now appreciated that acute BGC spikes, hypoglycemia, and high glycemic variability (GV) lead to more endothelial dysfunction and oxidative stress than uncomplicated, chronically elevated BGC. In the perioperative setting, fasting is the primary approach to reducing the risk for pulmonary aspiration; however, prolonged fasting drives the body into a catabolic state and therefore may increase GV. Elevated GV in the perioperative period is associated with an increased risk for postoperative complications, including morbidity and mortality. These challenges pose a conundrum for the management of patients typically instructed to fast for at least 8 h before surgery. Preliminary evidence suggests that the administration of an oral preoperative carbohydrate load (PCL) to stimulate endogenous insulin production and reduce GV in the perioperative period may attenuate BGC spikes and ultimately decrease postoperative morbidity, without significantly increasing the risk of pulmonary aspiration. The aim of this scoping review is to summarize the available evidence on the impact of PCL on perioperative GV and surgical outcomes, with an emphasis on evidence pertaining to patients with DM. The clinical relevance of GV will be summarized, the relationship between GV and postoperative course will be explored, and the impact of PCL on GV and surgical outcomes will be presented. A total of 13 articles, presented in three sections, were chosen for inclusion. This scoping review concludes that the benefits of a PCL outweigh the risks in most patients, even in those with well controlled type 2 DM. The administration of a PCL might effectively minimize metabolic derangements such as GV and ultimately result in reduced postoperative morbidity and mortality, but this remains to be proven. Future efforts to standardize the content and timing of a PCL are needed. Ultimately, a rigorous data-driven consensus opinion regarding PCL administration that identifies optimal carbohydrate content, volume, and timing of ingestion should be established.

An analysis of enhanced recovery pathways for bariatric surgery-preoperative fasting, carbohydrate loading, and aspiration risk: a position statement from the International Society for the Perioperative Care of Patients with Obesity

Enhanced recovery pathways (ERPs) and recommendations have become widely accepted for metabolic and bariatric surgery, including recommendations for preoperative carbohydrate loading and duration of fasting status. There is still a lack of consensus regarding such protocols and the underlying issues of gastric emptying time, resting gastric volume and pH, and risk of aspiration in patients with severe obesity and in patients undergoing bariatric surgery. The goal of this position statement by the International Society for the Perioperative Care of Patients with Obesity (ISPCOP) is to provide an analysis of available data on preoperative fasting and loading with oral complex clear carbohydrate drinks as well its potential effects on perioperative risk of aspiration in the context of Enhanced Recovery Pathways for Metabolic and Bariatric Surgery (ERAMBS).

The Effect of Preoperative Oral Carbohydrate on the Incidence of Complications in PACU After General Anesthesia: A Prospective Cohort Study

PURPOSE

This study aimed to investigate the effect of preoperative oral carbohydrate (POC) loading on the occurrence of complications in the postanesthesia care unit (PACU) after general anesthesia.

DESIGN

Prospective observational cohort study METHODS: Patients who were scheduled for abdominal surgery under general anesthesia at our institution were divided into the POC group and control group based on whether they drank carbohydrate solution 2 hours before surgery. POC loading of the patients was decided by the responsible surgeon. In PACU, the occurrence of postoperative complications including delayed emergence, emergence agitation, hypoxemia, hypertension, hypotension, moderate to severe postoperative pain, nausea and vomiting, hypothermia, shivering, and time to awakening, time to extubation, length of PACU stay were recorded.

FINDINGS

Data from 307 patients (n = 154 in POC group and n = 153 in control group) were included in the final analysis. Compared to the control group, POC led to a near-significant reduction in the overall incidence of complications in PACU after surgery (37.0% vs 47.7%, P = .058). The POC group had a lower incidence of hypothermia and shorter mean time to awakening when compared to control group (6.5% vs 16.3%, P = .007 and 19 min vs 21 min, P = .007, respectively). No statistical differences were detected in other outcome measurements between the POC group and the control group.

CONCLUSIONS

POC is associated with a trend to decrease the overall incidence of complications during recovery period after general anesthesia in patients who underwent abdominal surgery. Moreover, POC could reduce the risk of hypothermia in PACU and shorten the time to awakening.

Implementation of enhanced recovery in cardiac surgery: An experimental study with the control group

INTRODUCTION

The Enhanced Recovery After Cardiac Surgery protocol is the most recent addition to cardiac treatment. In this paper, we aimed to test the safety and viability of this protocol in our hospital to improve our standard of care.

METHODS

This study was conducted as an experimental study with a historical control at the Maritime Heart Center, Halifax, Nova Scotia, Canada. In order to quantify the success of this protocol, we measured the postoperative Length of Hospital Stay and three intensive care unit variables: time to extubation, time to ambulation, and opioid consumption. In the study, 100 patients were in the Enhanced Recovery After Cardiac Surgery group, and 103 patients were used as historic controls-selected by strenuous chart review and selection criteria.

RESULTS

The primary outcome (Length of Hospital Stay) was reduced from a mean of 8.88 ± 3.50 days in the control group to a mean of 5.13 ± 1.34 days in the Enhanced Recovery After Cardiac Surgery group (p < 0.001). Likewise, we observed a significant reduction in intensive care unit variables: time to extubation was reduced from 10.54 ± 7.83 h in the control group to 6.69 ± 1.63 in the Enhanced Recovery After Cardiac Surgery group (p < 0.01), and time to ambulation was reduced from 36.27 ± 35.21 h in the control group to 9.78 ± 2.03 in the Enhanced Recovery After Cardiac Surgery group (p < 0.01) and opioid consumption was reduced from 50.58 ± 11.93 milligram morphine equivalent in the control group to 11.58 ± 4.43 milligram morphine equivalent in the Enhanced Recovery After Cardiac Surgery group (p < 0.01).

CONCLUSION

Enhanced Recovery After Cardiac Surgery protocols were seamlessly integrated into selected cardiac surgical patients, contingent on a high level of interprofessional communication and collaboration.

A national survey on enhanced recovery for renal transplant recipients: current practices and trends in the UK

INTRODUCTION

Enhanced recovery after surgery (ERAS) is well established in many specialties but has not been widely adopted in renal transplantation. The aim of this survey was to understand current national practices and sentiment concerning ERAS for renal transplant recipients in the UK.

METHODOLOGY

A national web-based survey was sent to consultant surgeons at all 23 UK adult renal transplant units. Completed questionnaires were collected between May and July 2020. Data were analysed according to individual responses and grouped according to the existence of formal ERAS pathways within units.

RESULTS

All transplant units were represented in this survey. Three units had a formal ERAS pathway for all recipients. Of the remaining units, 65.9% considered implementing an ERAS pathway in the near future. The most commonly perceived barrier to ERAS implementation was 'embedded culture within transplant units' (54.8% of respondents). A fifth of respondents insert surgical drains selectively and 11.7% routinely discontinue patient-controlled analgesia on postoperative day 1. Most respondents routinely remove urinary catheters on day 5 (70%) and ureteric stents 4-6 weeks post-transplantation (81.7%). Median length of stay for deceased donor kidney transplant recipients was lower in units with ERAS programmes (5-7 days versus 8-10 days, respectively). The main cited barriers for discharge were 'suboptimal fluid balance' and 'requirement of treatment for rejection'.

CONCLUSIONS

Despite slow uptake of ERAS in kidney transplantation, appetite appears to be increasing, particularly in the post-COVID-19 era. The current practice and opinions of transplant specialists highlighted in this survey may help to establish nationally agreed ERAS guidelines in this field.

Pilot study on the impact of a carbohydrate loading drink on postprandial glycemic responses and gastric emptying in adults with prediabetes and type 2 diabetes mellitus

BACKGROUND

Preoperative carbohydrate (CHO) loading improves patient outcomes but is not extensively studied in individuals with diabetes mellitus (DM), resulting in limited professional recommendations. This study examined postprandial glycemic responses and gastric emptying rates following consumption of a CHO drink in adults with and without DM.

METHODS

A single-arm, nonrandomized pilot trial was conducted in adults without DM (non-DM) (47.5 ± 2.5 years), with pre-DM (55.8 ± 3.0 years), and with type 2 DM (56.2 ± 2.5 years). Following an overnight fast, participants consumed a 50 g CHO drink followed by 1.5 g liquid paracetamol. Venous blood samples were collected at baseline (ie, t = 0 min) and 15, 30, 45, 60, 90, 120, 150, 180, 210, and 240 min for plasma glucose and serum insulin and paracetamol concentrations to assess gastric emptying.

RESULTS

Participants with DM were older and had a higher body mass index than non-DM participants (31.2 ± 0.9 vs 28.2 ± 0.9). Fasting glucose and hemoglobin A1c levels differed significantly across groups (non-DM: 95.4 ± 3.6 mg/dl and 5.2% ± 0.1%; pre-DM: 111.6 ± 3.6 mg/dl and 5.8% ± 0.1%; DM: 167.4 ± 3.6 mg/dl and 7.2% ± 0.1%). Compared with the non-DM group, DM had increased glucose responses at 30-180 min. Glucose returned to baseline at 150 min in the non-DM and pre-DM groups compared with 210 min in the DM group. Paracetamol concentrations were not significantly different between the non-DM and DM groups.

CONCLUSION

Blood glucose returned to baseline within ~2.5 h in non-DM and pre-DM groups and ~3.5 h in participants with DM following ingestion of a CHO drink. No consistent differences in gastric emptying rates were observed between participants with and without DM.

Optimizing Perioperative Care in Transsphenoidal Pituitary Surgery: Considerations for Enhanced Recovery After Surgery

OBJECTIVE

To identify key recommendations for maximizing the efficiency and efficacy of perioperative care in transsphenoidal pituitary surgery.

METHODS

The authors performed a comprehensive literature search of Enhanced Recovery After Surgery protocols implemented for patients undergoing transsphenoidal adenomectomy (TSA); individual recommendations were abstracted, and the evidence base thoroughly reviewed.

RESULTS

The authors identified 19 individual recommendations pertinent to the care of patients undergoing TSA, which were subdivided into preoperative (n=6), intraoperative (n=6), and postoperative (n=7) interventions. Key factors recommended for minimizing length of stay, preventing readmission, and improving patient outcomes included comprehensive patient education, multidisciplinary evaluation, avoidance of routine lumbar drain placement and nasal packing, and rigorous postoperative monitoring of pituitary function and salt-water imbalances. The overall level of evidence for 7/19 (37%) implemented recommendations was found to be low, suggesting a need for continued research in this patient population.

CONCLUSION

Several key interventions should be considered in the development of Enhanced Recovery After Surgery protocols for TSA, which may aid in further decreasing length of stay and promoting positive patient outcomes.

The use of the ERAS protocol in malnourished and properly nourished patients undergoing elective surgery: a questionnaire study

INTRODUCTION

Enhanced recovery after surgery (ERAS) is a modern approach to perioperative management. This study aimed to evaluate compliance with certain aspects of the ERAS protocol in malnourished and properly nourished patients undergoing elective surgery.

MATERIAL AND METHODS

A questionnaire study was conducted among 197 patients undergoing elective surgery at the university hospital. We divided patients into two groups according to nutritional status.

RESULTS

The study's results showed that 67 patients (34%) lost weight before admission (the weight-loss group). Twenty-five participants (37%) in the weight-loss group and 15 patients (12%) in the preserved-weight group underwent surgery due to cancer ( P < 0.001). More patients in the weight loss group (45 of 67) than in the preserved-weight group (40 of 129, P < 0.001) limited their food intake a week before the surgery. The preserved-weight group participants were mobilized earlier than the weight-loss group ( P = 0.04). The median number of hours since drinking their last fluids and eating their last meals before the surgery were 12.2 hours and 25.4 hours for both groups, respectively. Only eight patients received preoperative carbohydrate loading. We found higher serum protein concentrations in the preserved-weight group (7.10 [0.5] vs. 6.92 [0.71], P = 0.023); however, white blood cell count was higher in the weight-loss group (7.85 (2.28) vs.7.10 (0.50), P = 0.04). Both groups were highly satisfied with their hospital treatments.

CONCLUSIONS

Our study revealed relatively high malnutrition in patients undergoing elective surgery. As a standard of perioperative care in the studied centre, the ERAS protocol implementation level is low.

Enhanced Recovery Protocols Reduce Mortality Across Eight Surgical Specialties at Academic and University-affiliated Community Hospitals

OBJECTIVE

To determine if implementation of a simplified ERP across multiple surgical specialties in different hospitals is associated with improved short and long-term mortality. Secondary aims were to examine ERP effect on length of stay, 30-day readmission, discharge disposition, and complications.

SUMMARY BACKGROUND DATA

Enhanced recovery after surgery and various derivative ERPs have been successfully implemented. These protocols typically include elaborate sets of multimodal and multidisciplinary approaches, which can make implementation challenging or are variable across different specialties. Few studies have shown if a simplified version of ERP implemented across multiple surgical specialties can improve clinical outcomes.

METHODS

A simplified ERP with 7 key domains (minimally invasive surgical approach when feasible, pre-/intra-operative multimodal analgesia, postoperative multimodal analgesia, postoperative nausea and vomiting prophylaxis, early diet advancement, early ambulation, and early removal of urinary catheter) was implemented in 5 academic and community hospitals within a single health system. Patients who underwent nonemergent, major orthopedic or abdominal surgery including hip/knee replacement, hepatobiliary, colorectal, gynecology oncology, bariatric, general, and urological surgery were included. Propensity-matched, retrospective case-control analysis was performed on all eligible surgical patients between 2014 and 2017 after ERP implementation or in the 12 months preceding ERP implementation (control population).

RESULTS

A total of 9492 patients (5185 ERP and 4307 controls) underwent ERP eligible surgery during the study period. Three thousand three hundred sixty-seven ERP patients were matched by surgical specialty and hospital site to control non-ERP patients. Short and long-term mortality was improved in ERP patients: 30 day: ERP 0.2% versus control 0.6% ( P = 0.002); 1-year: ERP 3.9% versus control 5.1% ( P < 0.0001); 2-year: ERP 6.2% versus control 9.0% ( P < 0.0001). Length of stay was significantly lower in ERP patients (ERP: 3.9 ± 3.8 days; control: 4.8 ± 5.0 days, P < 0.0001). ERP patients were also less likely to be discharged to a facility (ERP: 11.3%; control: 14.8%, P < 0.0001). There was no significant difference for 30-day readmission. All complications except venous thromboembolism were significantly reduced in the ERP population (P < 0.02).

CONCLUSIONS

A simplified ERP can uniformly be implemented across multiple surgical specialties and hospital types. ERPs improve short and long-term mortality, clinical outcomes, length of stay, and discharge disposition to home.

Residual gastric volume after 3 h of the ingestion of an oral supplement containing carbohydrates alone or associated with whey protein: a randomized crossover pilot study

BACKGROUND

New formulas including a nitrogenous source to maltodextrin have been reported as preoperative beverages 2-3 h before anesthesia in the elective procedure. Whey protein is a potential candidate for the composition of this clear oral supplement. This study aimed to investigate the gastric residual volume (GRV) of healthy volunteers 3 h after the ingestion of an oral supplement containing carbohydrates (CHO) alone or combined with whey protein (WP).

METHODS

This crossover clinical trial design includes young, healthy male volunteers with normal body mass index. Magnetic resonance imaging (MRI) scan of the upper abdomen to measure the GRV was performed in the participants in three phases: (1) after a fasting period of 8 h; (2) immediately after the ingestion of 200 mL of a clear supplement containing: (2a) 10 g of WP and 54 g of CHO (74% glucose and 26% maltodextrin)-WP + CHO group or (2b) 12.5% maltodextrin (25 g)-CHO group; and (3) after 3 h of the ingestion of both types of supplements. A week interval was programmed between phases 2a and 2b.

RESULTS

There was no significant difference (p = 0.91; within-group comparison) of the mean ± SD of the GRV between phase 1 (WP + CHO: 23.45 ± 14.01; CHO: 25.03 ± 15.17 cm³; p = 0.78; between-groups comparison) and phase 3 (WP + CHO: 25.66 ± 9.31; CHO: 23.45 ± 13.58 cm³, p = 0.86; between-groups comparison). The GRV of phase 2 (WP + CHO: 206.43 ± 23; CHO: 203.99 ± 12.18 cm³; p = 0.82; between-groups comparison) was significantly greater (p < 0.01; within-group comparison) than both other two phases.

CONCLUSION

The GRV after 3 h of the ingestion of either WP + CHO or CHO oral supplement returns to basal fast condition implying that gastric emptying after this interval of time is significantly completed.

TRIAL REGISTRATION

Registered and posted on the ClinicalTrials.gov public website with Identifier: NCT05573854.

Preoperative carbohydrate loading before colorectal surgery: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

Preoperative carbohydrate loading has been introduced as a component of many enhanced recovery after surgery programs. Evaluation of current evidence for preoperative carbohydrate loading in colorectal surgery has never been synthesized.

METHODS

MEDLINE, Embase, and CENTRAL were searched until May 2021. Randomized controlled trials (RCTs) comparing patients undergoing colorectal surgery with and without preoperative carbohydrate loading were included. Primary outcomes were changes in blood insulin and glucose levels. A pairwise meta-analysis was performed using inverse variance random effects.

RESULTS

The search yielded 3656 citations, from which 12 RCTs were included. In total, 387 patients given preoperative carbohydrate loading (47.2% female, age: 62.0 years) and 371 patients in control groups (49.4% female, age: 61.1 years) were included. There was no statistical difference for blood glucose and insulin levels between both patient groups. Patients receiving preoperative carbohydrate loading experienced a shorter time to first flatus (SMD: - 0.48 days, 95% CI: - 0.84 to - 0.12, p = 0.008) and stool (SMD: - 0.50 days, 95% CI: - 0.86 to - 0.14, p = 0.007). Additionally, length of stay was shorter in the preoperative carbohydrate loading group (SMD: - 0.51 days, 95% CI: - 0.88 to - 0.14, p = 0.007). There was no difference in postoperative morbidity and patient well-being between both groups.

CONCLUSIONS

Preoperative carbohydrate loading does not significantly impact postoperative glycemic control in patients undergoing colorectal surgery; however, it may be associated with a shorter length of stay and faster return of bowel function. It merits consideration for inclusion within colorectal enhanced recovery after surgery protocols.

A review of the current ERAS guidelines for liver resection, liver transplantation and pancreatoduodenectomy

In perioperative care after liver resection, transplantation and pancreatoduodenectomy, ERAS (Enhanced Recovery After Surgery) recommendations are based on the reducing invasiveness of procedures and the severity of the surgical stress, which results in decreasing complications and enhanced recovery. Recommendations for all three operations can be classified into five groups: recommended for all patients, recommended for special patient groups, rejected for all patients, controversial recommendations, specific recommendations for all three operations. Preoperative counselling and psychological support, nutritional support, smoking and alcohol cessation, pre- and intraoperative antibiotic prophylaxis, thrombosis prevention, limiting of preoperative hunger and thirst to 4 and 6 h, preoperative intaking carbohydrate rich drink, alcohol-based antiseptics for skin preparation, a goal-directed infusion therapy, providing normothermia, early removal of the drainage tube, glycemic control, dual antiemetic therapy, multimodal analgesia strategies, early oral feeding and activation, audit recommend for all patients. Postoperative antibiotic prophylaxis, enteral and parenteral nutrition, short-acting anxiolytics are recommended for individual patients. It is recommended to avoid Mercedes type incision, use of long-acting anxiolytics and postoperative nasogastric tube. The benefits of preoperative physical exercise, immunonutrition and probiotics are controversial. There are no specific recommendations for thoracic epidural anesthesia, preventing delayed gastric emptying and intestinal paresis in liver surgery.

Risk Factor-Driven Prehabilitation Prior to Abdominal Wall Reconstruction to Improve Postoperative Outcome. A Narrative Review

All abdominal wall reconstructions find themselves on a scale, varying between simple to highly complex procedures. The level of complexity depends on many factors that are divided into patient comorbidities, hernia characteristics, and wound characteristics. Preoperative identification of modifiable risk factors provides the opportunity for patient optimization. Because this so called prehabilitation greatly improves postoperative outcome, reconstructive surgery should not be scheduled before all modifiable risk factors are optimized to a point where no further improvement can be expected. In this review, we discuss the importance of preoperative risk factor recognition, identify modifiable risk factors, and utilize options for patient prehabilitation, all aiming to improve postoperative outcome and therewith long-term success of the reconstruction.

Gastric Emptying of Maltodextrin versus Phytoglycogen Carbohydrate Solutions in Healthy Volunteers: A Quasi-Experimental Study

Preoperative carbohydrate beverages have been shown to be beneficial in improving patient outcomes. There have been several investigations into the safety of maltodextrin as a preoperative carbohydrate. Although alternative preoperative carbohydrate sources have been proposed, there have been few investigations into the safety and gastric emptying of novel carbohydrate beverages. The present study aimed to compare the gastric emptying of phytoglycogen and maltodextrin to evaluate safety for use as presurgical carbohydrate beverages. In a quasi-experimental design, ten healthy participants orally consumed either a 12.5% maltodextrin or a 12.5% phytoglycogen solution. Gamma scintigraphy was used to evaluate gastric emptying at baseline at 45, 90, and 120 min. Serum insulin and serum glucose were measured at baseline at 15, 30, 45, 60, 90, and 120 min. Gastric volume was significantly lower in the phytoglycogen group at 45 min (p = 0.01) and 90 min (p = 0.01), but this difference lost significance at 120 min (p = 0.17). There were no significant differences between treatments for serum insulin or serum glucose at any time point. This study indicates that the gastric emptying of phytoglycogen is comparable to maltodextrin at 120 min after ingestion, opening the opportunity for the study of alternative carbohydrates for utilization as preoperative carbohydrates.

The effect of pre-operative carbohydrate loading in femur fracture: a randomized controlled trial

BACKGROUND

Femur fracture is a major burden among elderly people, leading patients to be bedridden for a long time in the hospital. The body is more likely to be in a catabolic state as a result of the prolonged fasting period required for surgery, leading to an increase in insulin resistance. Pre-operative carbohydrate loading has been shown to improve postoperative outcomes in several countries. The study aimed to evaluate the effect of pre-operative carbohydrate loading in femur fracture surgery.

METHODS

This study was single-center, hospital-based, open-label, parallel-group randomized controlled trial conducted between August 2020 and November 2021. A total of 66 participants, aged 50 years and above having femur fractures planned for surgery were included in this study and assigned to the control (n = 33) and study (n = 33) groups through computer-generated random numbers. The control group was kept fasting from midnight to the next morning as in existence while the study group was intervened with carbohydrate loading according to the Enhanced Recovery After Surgery (ERAS) protocol. The pre-operative nutritional status was identified and the postoperative outcomes were measured using the Visual Analogue Score (VAS), Cumulative Ambulatory Score (CAS), and Modified Barthel Index (MBI) scoring systems. Statistical analyses were performed using the Chi-square test and the Student's two-sample t-test to compare the outcomes between the two groups.

RESULTS

All the participants completed the study. There was a significant reduction in the average postoperative pain in the carbohydrate loading group (VAS: 4.8 (SD ± 1.8), 95% CI: 4.7-5.4) as compared to the control group (VAS: 6.1 (SD ± 2.1), 95% CI: 5.3-6.8). The average CAS showed a significant improvement in regaining the mobility function of participants in the study group (CAS: 8.1 (SD ± 2.8), 95% CI: 7.1-9.1) than that of the control group (CAS: 6.8 (SD ± 2.8), 95% CI: 5.8-7.8). The mean MBI score of the participants at the time of discharge from the hospital was higher in the study group (MBI:13.1 (SD ± 2.3), 95% CI: 12.2-13.9) compared to the control group (MBI: 11.8 (SD ± 3.1), 95% CI:10.6-12.9). Similarly, the length of hospital stay after surgery had decreased in the study group than in the control group.

CONCLUSIONS

The uptake of carbohydrate loading showed reduced post-operative pain, enhanced functional mobility, and decreased length of hospital stay. This study warrants larger trials to show the effect of pre-operative carbohydrate loading in a clinical setting.

TRIAL REGISTRATION

NCT04838366, first registered on 09/042021 ( https://clinicaltrials.gov/ct2/show/NCT04838366 ).

Establishing a recommended duration of blood glucose monitoring in nondiabetic patients following orthopaedic surgery

Previous studies have demonstrated that blood glucose (BG) levels should be monitored for at least 1 week after orthopaedic surgery in diabetic patients, but no study has determined how long nondiabetic patients should be monitored. As postoperative elevations in BG have deleterious effects, determining a duration for monitoring the BG of nondiabetic patients after major orthopaedic surgery is needed to detect hyperglycemic events, create comprehensive protocols for nondiabetic orthopaedic patients, and reduce adverse outcomes. A retrospective study was conducted including consecutive patients who underwent a major orthopaedic surgery at a community hospital. A BG level of 150 mg/dl was the cutoff used to define hyperglycemia according to our institutional guidelines. A χ² , analysis of variance, and subgroup analysis were performed separately. Greater than 67% of nondiabetic patients experienced a high BG level (>150 mg/dl) after surgery. We found that nondiabetic patients reached their postoperative maximum BG level at 20 h, which was sooner compared to diabetic patients. We discovered more than 92% of nondiabetic patients reached a maximum BG levels within the first 72 h of hospitalization, while the BG levels after this period were found to be within normal limits in greater than 87% of cases. We propose that BG management be instituted in nondiabetics from the preoperative period to 72 h after surgery, including patients who are same-day discharges. There may not be a need to continue inpatient BG monitoring beyond the first 72 h for nondiabetic hospitalized patients with extended hospitalizations.

Feasibility study of a randomised controlled trial of preoperative and postoperative nutritional supplementation in major lung surgery

OBJECTIVES

Malnutrition and weight loss are important risk factors for complications after lung surgery. However, it is uncertain whether modifying or optimising perioperative nutritional state with oral supplements results in a reduction in malnutrition, complications or quality of life.

DESIGN

A randomised, open label, controlled feasibility study was conducted to assess the feasibility of carrying out a large multicentre randomised trial of nutritional intervention. The intervention involved preoperative carbohydrate-loading drinks (4×200 mL evening before surgery and 2×200 mL the morning of surgery) and early postoperative nutritional protein supplement drinks two times per day for 14 days compared with the control group receiving an equivalent volume of water.

SETTING

Single adult thoracic centre in the UK.

PARTICIPANTS

All adult patients admitted for major lung surgery. Patients were included if were able to take nutritional drinks prior to surgery and give written informed consent. Patients were excluded if they were likely unable to complete the study questionnaires, they had a body mass index <18.5 kg/m², were receiving parenteral nutrition or known pregnancy.

RESULTS

All patients presenting for major lung surgery were screened over a 6-month period, with 163 patients screened, 99 excluded and 64 (41%) patients randomised. Feasibility criteria were met and the study completed recruitment 5 months ahead of target. The two groups were well balanced and tools used to measure outcomes were robust. Compliance with nutritional drinks was 97% preoperatively and 89% postoperatively; 89% of the questionnaires at 3 months were returned fully completed. The qualitative interviews demonstrated that the trial and the intervention were acceptable to patients. Patients felt the questionnaires captured their experience of recovery from surgery well.

CONCLUSION

A large multicentre randomised controlled trial of nutritional intervention in major lung surgery is feasible and required to test clinical efficacy in improving outcomes after surgery.

TRIAL REGISTRATION NUMBER

ISRCTN16535341.

Efficacy of the Oral Administration of Maltodextrin Fructose Before Major Abdominal Surgery: A Prospective, Multicenter Clinical Study

Background

To study the efficacy of the oral administration of maltodextrin and fructose before major abdominal surgery (MAS).

Methods

This prospective, multicenter, parallel-controlled, double-blind study included patients aged 45–70 years who underwent elective gastrectomy, colorectal resection, or duodenopancreatectomy. The intervention group (IG) was given 800 mL and 400 mL of a maltodextrin and fructose beverage at 10 h and 2 h before MAS, respectively, and the control group (CG) received water under the same experimental conditions. The primary endpoint was insulin resistance index (IRI), and the secondary endpoints were fasting blood glucose, fasting insulin, insulin secretion index, insulin sensitivity index, intraoperative blood glucose, subjective comfort score, and clinical outcome indicators.

Results

A total of 240 cases were screened, of which 231 cases were randomly divided into two groups: 114 in the IG and 117 in the CG. No time-treatment effect was detected for any endpoint. The IRI and fasting insulin were significantly lower in the IG than CG after MAS (p = 0.02 & P = 0.03). The scores for anxiety, appetite, and nausea were significantly lower in the IG than CG at 1 h before MAS. Compared with baseline, the scores for appetite and nausea decreased in the IG but increased in the CG.

Conclusion

The oral administration of maltodextrin and fructose before MAS can improve preoperative subjective well-being and reduce postoperative insulin resistance without increasing the risk of gastrointestinal discomfort.

Enhanced recovery after surgery strategy to shorten perioperative fasting in children undergoing non-gastrointestinal surgery: A prospective study

BACKGROUND

Enhanced recovery after surgery strategies are increasingly implemented to improve the management of surgical patients.

AIM

To evaluate the effects of new perioperative fasting protocols in children ≥ 3 mo of age undergoing non-gastrointestinal surgery.

METHODS

This prospective pilot study included children ≥ 3 mo of age undergoing non-gastrointestinal surgery at the Children’s Hospital (Zhejiang University School of Medicine) from January 2020 to June 2020. The children were divided into either a conventional group or an ERAS group according to whether they had been enrolled before or after the implementation of the new perioperative fasting strategy. The children in the conventional group were fasted using conventional strategies, while those in the ERAS group were given individualized fasting protocols preoperatively (6-h fasting for infant formula/non-human milk/solids, 4-h fasting for breast milk, and clear fluids allowed within 2 h of surgery) and postoperatively (food permitted from 1 h after surgery). Pre-operative and postoperative fasting times, pre-operative blood glucose, the incidence of postoperative thirst and hunger, the incidence of perioperative vomiting and aspiration, and the degree of satisfaction were evaluated.

RESULTS

The study included 303 patients (151 in the conventional group and 152 in the ERAS group). Compared with the conventional group, the ERAS group had a shorter pre-operative food fasting time [11.92 (4.00, 19.33) vs 13.00 (6.00, 20.28) h, P < 0.001), shorter preoperative liquid fasting time [3.00 (2.00, 7.50) vs 12.00 (3.00, 20.28) h, P < 0.001], higher preoperative blood glucose level [5.6 (4.2, 8.2) vs 5.1 (4.0, 7.4) mmol/L, P < 0.001], lower incidence of thirst (74.5% vs 15.3%, P < 0.001), shorter time to postoperative feeding [1.17 (0.33, 6.83) vs 6.00 (5.40, 9.20), P < 0.001], and greater satisfaction [7 (0, 10) vs 8 (5, 10), P < 0.001]. No children experienced perioperative aspiration. The incidences of hunger, perioperative vomiting, and fever were not significantly different between the two groups.

CONCLUSION

Optimizing fasting and clear fluid drinking before non-gastrointestinal surgery in children ≥ 3 mo of age is possible. It is safe and feasible to start early eating after evaluating the recovery from anesthesia and the swallowing function.

Effect of a carbohydrate-rich beverage on rate of cesarean delivery in primigravidae with epidural labor analgesia: a multicenter randomized trial

BACKGROUND

Labor represents a period of significant physical activity. Inefficient energy supply may delay labor process and even lead to cesarean delivery. Herein we investigated whether ingestion of a carbohydrate-rich beverage could reduce cesarean delivery in laboring women with epidural analgesia.

METHODS

This multicenter randomized trial was conducted in obstetrician-led maternity units of nine tertiary hospitals in China. Primigravidae with single term cephalic pregnancy who were preparing for vaginal birth under epidural analgesia were randomized to intake a carbohydrate-rich beverage or commercially available low-carbohydrate beverages during labor. The primary outcome was the rate of cesarean delivery. Secondary outcomes included maternal feeling of hunger, assessed with an 11-point scale where 0 indicated no hunger and 10 the most severe hunger, and maternal and neonatal blood glucose after childbirth.

RESULTS

Between 17 January 2018 and 20 July 2018, 2008 women were enrolled and randomized, 1953 were included in the intention-to-treat analysis. The rate of cesarean delivery did not differ between the two groups (11.3% [111/982] with carbohydrate-rich beverage vs. 10.9% [106/971] with low-carbohydrate beverages; relative risk 1.04, 95% CI 0.81 to 1.33; p = 0.79). Women in the carbohydrate-rich beverage group had lower subjective hunger score (median 3 [interquartile range 2 to 5] vs. 4 [2 to 6]; median difference - 1; 95% CI - 1 to 0; p < 0.01); their neonates had less hypoglycemia (1.0% [10/968] vs. 2.3% [22/956]; relative risk 0.45; 95% CI 0.21 to 0.94; p = 0.03) when compared with those in the low-carbohydrate beverage group. They also had higher rates of maternal hyperglycemia (6.9% [67/965] vs. 1.9% [18/953]; p < 0.01) and neonatal hyperglycemia (9.2% [89/968] vs. 5.8% [55/956]; p < 0.01), but none required special treatment.

CONCLUSIONS

For laboring primigravidae with epidural analgesia, ingestion of a carbohydrate-rich beverage compared with low-carbohydrate beverages did not reduce cesarean delivery, but relieved maternal hunger and reduced neonatal hypoglycemia at the expense of increased hyperglycemia of both mothers and neonates. Optimal rate of carbohydrate supplementation remains to be determined.

TRIAL REGISTRATION

www.chictr.org.cn ; identifier: ChiCTR-IOR-17011994 ; registered on 14 July 2017.

Perioperative parameters to consider for enhanced recovery in surgery (ERS) in gynecology (excluding breast surgery)

The current review explores the Enhanced Rehabilitation in Surgery (ERS) approach in the specific context of gynecological surgery. Implementation of an ERS protocol in gynecological surgery reduces postoperative complications and length of stay without increasing morbidity. An ERS approach is based on maintaining an adequate diet and hydration before the operation, according to the recommended time frame, to reduce the phenomenon of insulin resistance, and to optimize patient comfort. On the other hand, the use of anxiolytic treatment as premedication is not recommended. Systematic preoperative digestive preparation, a source of patient discomfort, is not associated with an improvement in the postoperative functional outcome or with a reduction in the rate of complications. A minimally invasive surgical approach is preferrable in the context of ERS. Prevention of surgical site infection includes measures such as optimized antibiotic prophylaxis, skin disinfection with alcoholic chlorhexidine, reduction in the use of drainage of the surgical site, and prevention of hypothermia. Early removal of the bladder catheter is associated with a reduction in the risk of urinary tract infection and a reduction in the length of hospital stay. Prevention of postoperative ileus is based on early refeeding, and prevention of postoperative nausea-vomiting in a multimodal strategy to be initiated during the intraoperative period. Intraoperative hydration should be aimed at achieving euvolemia. Pain control is based on a multimodal strategy to spare morphine use and may include locoregional analgesia. Medicines should be administered orally during the postoperative period to hasten the resumption of the patient's autonomy. The prevention of thromboembolic risk is based on a strategy combining drug prophylaxis, when indicated, and mechanical restraint, as well as early mobilization. However, the eclectic nature of the implementation of these measures as reported in the literature renders their interpretation difficult. Furthermore, beyond the application of one of these measures in isolation, the best benefit on the postoperative outcome is achieved by a combination of measures which then constitutes a global strategy allowing the objectives of the ERS to be met.

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyzes, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

Dex® carbohydrate drinks in trauma patients fasting preoperatively – A patient satisfaction study

Introduction

Dex® is an alkaline carbohydrate (CHO) drink used preoperatively in patients fasting for elective surgery. Its utilisation in patients awaiting emergency surgery is yet to be ascertained. We undertook a study assessing patient satisfaction relating to the introduction of Dex® in trauma patients in a Level 1 adult trauma centre.

Methods

Patients fasting for surgery, and able to receive clear fluids in compliance with local guidelines, were eligible for inclusion. Patient satisfaction scores for predetermined variables were recorded via an interval observer scale prior to and following the introduction of Dex® to the trauma unit.

Results

Prior to the introduction of Dex® 14 satisfaction evaluations were completed. A further 13 evaluations were returned after Dex® was made available. Post-traumatic amnesia accounted for some patients being unable to complete the evaluation. Patients who completed the satisfaction evaluations after Dex® was introduced reported higher satisfaction in all but two variables (‘Headache’ and ‘Staff Annoyance’). ‘Hunger’ median scores were 7 (95% CI, 5–8) prior to the introduction of Dex® and 3 (95% CI, 2–6) after its’ introduction ( p = .004). ‘Thirst’ median scores were 7.5 (95% CI, 6–10) and 4 (95% CI, 3–8) prior to and after Dex® introduction, respectively ( p = .018).

Conclusion

No adverse events or theatre timing related issues were associated with the use of Dex®. A larger randomised study of CHO drink supplementation in trauma patients fasting preoperatively is warranted to further evaluate these satisfaction endpoints as well as the other variables investigated in this study. Postoperative evaluation of these markers should also be considered.

Preoperative carbohydrate loading with individualized supplemental insulin in diabetic patients undergoing gastrointestinal surgery: A randomized trial

BACKGROUND

Preoperative carbohydrate drink is used to improve patients' comfort and recovery, but evidence remains limited in diabetic patients. Herein we investigated the effects of preoperative carbohydrate loading with individualized supplemental insulin regimen in diabetic patients undergoing gastrointestinal surgery.

METHODS

A total of 63 adult patients with type 2 diabetes mellitus undergoing major gastrointestinal surgery were randomized to receive either carbohydrate loading with individualized supplemental insulin (Carbohydrate group) or routine management (Control group). The primary outcome was time to first flatus after surgery. Among secondary outcomes, subjective feelings of thirsty, hunger and fatigue were assessed with the Visual Analogue Scale (scores range from 0 to 100, where 0 indicate no discomfort and 100 the most severe discomfort) before and after surgery. Adverse events were monitored until 24 h after surgery.

RESULTS

All patients were included in the intention-to-treat analysis. Time to first flatus did not differ between groups (median 41 h [IQR 18-69] in the Control group vs. 43 h [27-54] in the Carbohydrate group; hazard ratio 1.24 [95% CI 0.74-2.07]; P = 0.411). The VAS score of preoperative subject feeling of thirsty (median difference -33 [95% CI -50 to -15], P < 0.001), hunger (-25 [-40 to -10], P < 0.001), and fatigue (-5 [-30 to 0], P = 0.004), as well as postoperative subject feeling of thirsty (-50 [-60 to -30], P < 0.001), hunger (-20 [-40 to 0], P = 0.003), and fatigue (0 [-20 to 0], P = 0.020) were all significantly lower in the Carbohydrate group than in the Control group. Intraoperative hypotension (40.6% [13/32] vs. 16.1% [5/31], P = 0.031) and postoperative nausea and vomiting within 24 h (31.3% [10/32] vs. 9.7% [3/31], P = 0.034) occurred less in patients given carbohydrate drink.

CONCLUSION

In diabetic patients undergoing gastrointestinal surgery, preoperative carbohydrate loading with individualized supplemental insulin did not promote gastrointestinal recovery but improved perioperative well-being.

SHORTEN PREOPERATIVE FASTING AND INTRODUCING EARLY EATING ASSISTANCE IN RECOVERY AFTER GASTROJEJUNAL BYPASS?

Rational:

The metabolic response to surgical trauma is enhanced by prolonged preoperative fasting, contributing to increased insulin resistance. This manifestation is more intense on the 1^st and 2^nd postoperative days and is directly proportional to the size of the operation.

Aim:

To compare whether preoperative fasting abbreviation and early postoperative refeeding associated with intraoperative and postoperative fluid restriction interfere in the evolution of patients undergoing gastrojejunal bypass.

Methods:

Eighty patients indicated for Roux-en-Y gastrojejunal bypass were selected. They were randomly divided into two groups: Ringer Lactate (RL) group, who underwent a 6 hours solids fasting, with the administration of 50 g of maltodextrin in 100 ml of mineral water 2 hours before the beginning of anesthesia; and Physiologic Solution (PS) group, who underwent a 12 hours solids and liquids fasting. Anesthesia was standardized for both groups. During the surgical procedure, 1500 ml of ringer lactate solution was administered in the RL and 2500 ml of physiological solution (0.9% sodium chloride) in the PS. In both groups, the occurrence of bronchoaspiration was analyzed during intubation, and the residual gastric volume was measured after opening the abdominal cavity. In the postoperative period in Group RL, patients started a liquid diet 24 hours after the end of the operative procedure; whilst for PS group, fasting was maintained for the first 24 hours, it was prescripted 2000 ml of physiological solution and a restricted liquid diet after 36 hours. Each patient underwent CPK, insulin, sodium, potassium, urea, creatinine, PaCO2, pH and bicarbonate dosage in the immediate postoperative period, and 48 hours later, the exams were repeated.

Results:

There were no episodes of bronchoaspiration and gastrojejunal fistulas in either group. In the analysis of the residual gastric volume of the PS and RL groups, the mean volumes were respectively 16.5 and 8.8, which shows statistical significance between the groups. In laboratory tests, there was no difference between groups in sodium; PS group showed a higher level of serum potassium (p=0.029); whilst RL group showed a higher urea and creatinine values; CPK values were even for both; PS group demonstrated a higher insulin level; pH was higher in PS group; sodium bicarbonate showed a significant difference at all times; PaCO2 values in RL group was higher than in PS. In the analysis of the incidence of nausea and flatus, no statistical significance was observed between the groups.

Conclusions:

The abbreviation of preoperative fasting and early postoperative refeeding of Roux-en-Y gastrojejunal bypass with the application of ERAS or ACERTO Project accelerated the patient’s recovery, reducing residual gastric volume and insulin level, and do not predispose to complications.

Enhanced recovery after surgery: anesthesia-related components

Background: Enhanced recovery after surgery (ERAS) is a multidisciplinary and multimodal evidence-based approach aimed at improving the recovery of surgical patients. Successful implementation of ERAS protocols requires proper perioperative communication and collaboration among surgeons, anesthesiologists, nurses, and other medical personnel.Current Concepts: The anesthesiologist is the clinical leader responsible for the ERAS program. Preoperative patient evaluation, optimization, and patient education are essential components of the ERAS program. The program also involves preoperative fasting and carbohydrate loading to minimize catabolic effects. Selection of an appropriate anesthetic regimen, fluid and temperature management, avoidance of intra/postoperative nausea and vomiting, and multimodal pain management are the key components of ERAS for which the anesthesiologist is responsible.Discussion and Conclusion: Factors that enable the successful implementation of ERAS include the willingness to change to ERAS, formation of multidisciplinary teams to improve cooperation, and support from the hospital management, as well as standardization of order sets and care processes and the appropriate use of audits. As the leader of the ERAS team, the anesthesiologist should be actively involved in comprehensive management of the patient during the perioperative period.

Effects of Preoperative Carbohydrate Intake on Inflammatory Markers and Clinical Outcomes in Elderly Patients Undergoing Radical Prostatectomy: A Single-Centre, Double-Blind Randomised Controlled Trial

Background: This study aimed to analyse the effects of carbohydrate (CHO) intake on inflammatory markers, comfort, and clinical outcomes in elderly patients undergoing open radical prostatectomy.

Methods: Patients aged ≥65 years who underwent open radical prostatectomy were randomly divided into CHO, drinking water, and fasting groups. A total of 90 patients were enrolled in this study (CHO group, n = 28; placebo group, n = 30 and fasting group, n = 32). Patients in the CHO group were given 800 and 400 ml of carbohydrates 8 and 2–3 h before surgery, respectively. Patients in the placebo group were given 800 and 400 ml of water 8 and 2–3 h before surgery, respectively. Patients in the fasting group did not consume any liquids. The main result is levels of inflammation markers. Secondary results included cellular immunity, comfort, body weight, grip index, and clinical results.

Results: Compared with the fasting group, the CHO group exhibited a decrease in interleukin 6 (IL-6) levels on days 1 and 7 (75.47 and 7.06 pg/mL, respectively), IL-8 levels on day 1 (274.61 pg/mL) and tumour necrosis factor (TNF) levels on days 1, 3, and 7 (11.16, 9.55, and 9.67 pg/mL, respectively). The placebo group exhibited a decrease in IL-8 (390.26 pg/mL) and TNF levels (13.99 pg/mL) on day 1. Compared with the placebo group, the CHO group exhibited a decrease in IL-6 levels on day 1 and TNF levels on day 3. In the CHO and placebo groups, the thirst and hunger scores decreased on the morning of surgery.

Conclusion: Preoperative CHO and drinking water are associated with decreased levels of IL-6, IL-8, and TNF. CHO and water can also reduce thirst and hunger scores. Therefore, we recommend that patients without contraindications should be given 200–400 ml of fluid 2–3 h before surgery, preferably CHO.

Clinical Trial Registration:http://www.chictr.org.cn/edit.aspx?pid=21783&htm=4; ChiCTR-INR-17012867.

Patient periprocedural stress in cardiovascular medicine: friend or foe?

Stress, a disruption of homeostasis, is an unavoidable part of everyday life. In medical procedures, stress profoundly affects both operators and patients. Although the stress reaction has evolved to aid survival of physical trauma, it may also be harmful, by aggravating the baseline medical condition and/or creating new stress-related medical problems. Stress responses comprise several protective mechanisms that are particularly relevant in the clinical setting (e.g., a procoagulatory state and blood loss counteraction, preservation of blood perfusion pressure, prevention of hypoglycemia, enhanced immune response). Beneficial psychological effects prevent recurrence of traumatic memories, and promote patient compliance and positive lifestyle changes. In contrast, overt acute stress responses may lead to severe pathological conditions such as cytokine storm, post-traumatic stress disorder, takotsubo syndrome, deep venous thrombosis and pulmonary embolism, myocardial infarction, life-threatening arrhythmias and sudden cardiac death. There is also evidence that stress exposure may promote atherosclerosis and reduce long-term benefits from the intervention (increase in major adverse clinical events, in-stent restenosis, etc.). Insights into the role of stress on the operator’s performance have recently led to the introduction of counteractive measures such as simulation training. Conversely, very little is known about the effect of the patient’s periprocedural stress on the outcomes of cardiovascular procedures. Recent data show that the patient periprocedural stress affects the well-being of whole families. This review, focused on topics particularly relevant to cardiovascular interventions, provides a mechanistic insight into beneficial and harmful effects of periprocedural patient stress, including the array of available stress-relieving measures.

Gastric emptying of preoperative carbohydrate in elderly assessed using gastric ultrasonography: A randomized controlled study

BACKGROUND

Preoperative carbohydrate loading enhances postoperative recovery and reduces patient discomfort. However, gastric emptying of liquids can be delayed in elderly populations. Therefore, this study aimed to evaluate the gastric emptying of 400 mL of a carbohydrate drink ingested 2 hours before surgery in elderly patients.

METHODS

In this prospective, randomized controlled study, patients aged >65 years were allocated to either fast from midnight (nil per os [NPO] group, n = 29) or drink 400 mL of a carbohydrate drink 2 hours before surgery (carbohydrate group, n = 29). The gastric antrum was assessed using ultrasonography in the supine position, followed by the right lateral decubitus (RLD) position. The gastric antrum was graded as grade 0 (fluid not seen in both positions), grade 1 (fluid only seen in the RLD position), and grade 2 (fluid seen in both positions). The gastric antral cross-sectional area (CSA) and aspirated residual gastric volume were measured.

RESULTS

In 58 patients, the incidence of grade 2 stomach was 13.8% in NPO group and 17.2% in carbohydrate group (P = .790). The gastric antral CSA in the supine position was larger in carbohydrate group than in NPO group (4.42 [3.72-5.18] cm2 vs 5.31 [4.35-6.92] cm2, P = .018). The gastric antral CSA in the RLD position was not different in NPO and carbohydrate groups (P = .120). There was no difference in gastric volume (2 [0-7.5] vs 3 [0-13.4], P = .331) in NPO group versus carbohydrate group.

CONCLUSION

The incidence of grade 2 stomach was not different between NPO group and carbohydrate group in elderly patients.

Paradigm shift in gastrointestinal surgery − combating sarcopenia with prehabilitation: Multimodal review of clinical and scientific data

A growing body of evidence has demonstrated the prognostic significance of sarcopenia in surgical patients as an independent predictor of postoperative complications and outcomes. These included an increased risk of total complications, major complications, re-admissions, infections, severe infections, 30 d mortality, longer hospital stay and increased hospitalization expenditures. A program to enhance recovery after surgery was meant to address these complications; however, compliance to the program since its introduction has been less than ideal. Over the last decade, the concept of prehabilitation, or “pre-surgery rehabilitation”, has been discussed. The presurgical period represents a window of opportunity to boost and optimize the health of an individual, providing a compensatory “buffer” for the imminent reduction in physiological reserve post-surgery. Initial results have been promising. We review the literature to critically review the utility of prehabilitation, not just in the clinical realm, but also in the scientific realm, with a resource management point-of-view.

The Effect of Reducing the Fasting Time on Postoperative Pain in Orthopaedic Patients: A Randomized Controlled Trial

Background

Patients undergoing orthopedics surgery experience the most severe postoperative pain. The fasting time is a factor that affects this complication. The aim of this study was to investigate the impact of fasting time reduction by using oral carbohydrate on postoperative pain and analgesic consumption in orthopedic patients.

Materials and Methods

This randomized control trial was conducted between November 2017 and December 2018. Sixty-four patients were randomly assigned into the intervention (which consumed 200 mL of the 12.50% carbohydrate, 2 h before the surgery) and the control group (which was fasted from midnight). Postoperative pain was measured by visual analog scale; the amount of the consumed analgesics was also recorded. The data were analyzed by using Chi-square and t-test.

Results

The mean (SD) of the pain scores in the control group immediately and 2, 4, 6, 12 and 24 h after consciousness were 7.19 (2.64), 6.69 (2.17), 6.31 (2.05), 6.16 (2.08), 6.06 (2.24), and 5.38 (1.86), respectively. These scores for the intervention group were 7.44 (1.48), 6.31 (1.25), 5.72 (1.17), 5.59 (1.43), 5.25 (1.13), and 4.97 (1.57). The mean of the pain scores between two groups was not different (p > 0.05). The amount of the consumed morphine (t ₆₁= -2.10, p = 0.039), pethidine (t ₆₂= -2.25, p = 0.028), and diclofenac (t ₆₂= -2.51, p = 0.015) were significantly different between the two groups.

Conclusions

The pain intensity in the patients with shortened fasting time was lower, but it was not statistically significant. Moreover, reducing fasting time by using carbohydrate significantly reduced the use of analgesics.