Preoperative Carbohydrate Drinks Research Articles

Determinants of late recovery following elective colorectal surgery.

Despite the implementation of enhanced recovery protocols, a significant proportion of patients experience delayed recovery. Identifying potential determinants of delayed recovery is crucial for optimizing perioperative protocols and tailoring patient pathways. This study aims to identify possible determinants of delayed recovery. Retrospective observational study based on a prospectively collected dedicated register spanning from 2015 to 2022. Twenty-two Italian hospitals specializing in high-volume colorectal surgery and trained in enhanced recovery protocols. Patients undergoing elective colorectal resection for cancer or benign disease. Recovery status on postoperative day 2. Late recovery was defined as the failure to meet at least two indicators of postoperative recovery (oral feeding, removal of the urinary catheter, cessation of intravenous fluids, and mobilization) on postoperative day 2. A total of 1535 patients were analyzed. The median overall adherence to pre- and intraoperative enhanced recovery protocol items was 75.0% (range: 66.6%-83.3%). Delayed recovery was observed in 487 (31.7%) patients. Multiple regression analysis revealed six enhanced recovery protocol items that independently positively influenced postoperative recovery: pre-admission counseling (adjusted odds ratio [aOR] 2.596), a preoperative carbohydrate drink (aOR 1.948), intraoperative fluid infusions < 7ml/kg/h (aOR 1.662), avoidance of thoracic epidural analgesia (aOR 2.137), removal of nasogastric tube at the end of surgery (aOR 4.939), and successful laparoscopy (aOR 2.341). The rate of delayed recovery progressively decreased with increasing adherence to these six positive items, reaching 13.0% when all items were applied (correlation coefficient [r] = - 0.99, p < 0.001). This study is limited by its retrospective analysis of a register containing data from multiple centers and a diverse patient population. Adherence to specific pre- and intraoperative enhanced recovery protocol items, including counseling, preoperative carbohydrate intake, restrictive intraoperative fluid management, avoidance of thoracic epidural analgesia, early removal of nasogastric tube, and successful laparoscopy, appears crucial for promoting early recovery following elective colorectal resection.

Pre-operative carbohydrate drink in pediatric spine fusion: randomized control trial.

As rapid discharge protocols for pediatric spine fusion shorten stays, gastrointestinal (GI) complications are uncovered and cause delays in discharge. A pre-operative carbohydrate (CHO) drink has been shown to improve perioperative GI symptoms and functional return but has not been examined in pediatric spine patients. We aimed to determine if a preoperative CHO drink is safe in pediatric spine fusion patients, and if it improves their comfort scores and return of bowel function. We prospectively randomized ASA-1 and -2 pediatric spine fusion patients to either a pre-anesthesia carbohydrate drink 2h prior to surgery or to a control group (standard 8h NPO), blinded to surgical team. We documented time to return to flatus, bowel movement, GI symptoms, and comfort scores for 72h post-operatively or until discharge. 62 patients were randomized. There was no significant differences between the groups' pre-operative characteristics, surgical details, nor post-operative morphine dose equivalents, except for EBL (405cc control, 340cc CHO drink, p = 0.044). There were no perioperative complications related to ingestion of the CHO drink. CHO group had a positive trend for earlier return of flatus (21% vs. 3% return at 12h), and comfort scores for anxiety and abdominal pain, but no statistically significant differences. There was no difference in length of stay or time to first bowel movement. There were no complications related to ingestion of a CHO drink 2h prior to pediatric spinal fusion surgery. Further studies are needed to develop a study blinded to the participants with larger sample size. Level of evidenceI.

The safety of preoperative carbohydrate drinks in extremely elderly patients assessed by gastric ultrasonography: a randomized controlled trial

BackgroundModern perioperative guidelines encourage drinking oral carbohydrates 2 h before management. Nevertheless, research on the safety of preoperative carbohydrate drinks, particularly in extremely elderly patients is lacking. We aimed to evaluate the safety of carbohydrate drinks 2 h before surgery in extremely elderly patients (≥ 80 years) using gastric ultrasonography.MethodsWe conducted a randomized prospective comparative study of 70 patients aged over 80 years who were scheduled for total knee arthroplasty, hip fracture or humerus fracture surgery. These patients were randomly assigned to the carbohydrate group (n = 35), which fasted from midnight, except for drinking 355 mL of a carbohydrate-containing fluid 2 h before surgery, or the fasting group (n = 35), which fasted from midnight and drank no fluid before surgery. The primary outcome of the study was the cross-sectional area (CSA) of the gastric antrum in the right lateral decubitus position (RLDP) before surgery. The secondary outcomes included CSA in the supine position, intraoperative blood glucose levels and their variability coefficients, Perlas grade, and the visual analog scale of subjective feelings.ResultsThe CSA in the RLDP and supine positions revealed no differences between the carbohydrate and fasting groups at 0 h preoperatively (P > 0.05). In the qualitative assessment, preoperative 0-h Perlas grading did not differ significantly between the groups (P > 0.05). From 2 h before surgery to transfer out of the post-anesthesia care unit, the average blood glucose level of patients in the carbohydrate group was significantly higher than that in the fasting group (P < 0.001) but remained within the normal range. Moreover, the blood glucose variability coefficient was significantly lower in the carbohydrate group than in the fasting group (P = 0.009). Oral intake of 355 mL carbohydrates before surgery significantly relieved patients’ feelings (P < 0.001).ConclusionPreoperative consumption of carbohydrate drinks 2 h before surgery is safe in “healthy” extremely elderly patients. In addition, preoperative drinking has potential value in maintaining ideal blood glucose levels and stable blood glucose fluctuations perioperatively and improving subjective perceptions of preoperative preparation. This finding warrants further investigation in clinical practice.Trial registrationChinese Clinical Trial Registry (Registration Number ChiCTR1900024812), first registered on 29/07/2019.

Does a Preoperative Carbohydrate Drink Reduce Postoperative Inflammation? A Systematic Review and Meta-Analysis

Since 1995, it has been known that carbohydrate drinks (CHDs) can be safely consumed two to three hours (2–3 h) preoperatively. Furthermore, preoperative CHDs significantly benefit many outcomes, such as thirst, hunger, and insulin resistance. Patients, however, still fast excessively. This study aimed to determine if a CHD, consumed 2–3 h preoperatively, impacts postoperative inflammation compared to a placebo drink or fasting. This was achieved through analysing the levels of interleukin-6, C-reactive peptide, and serum albumin 10–24 h postoperatively. We conducted a systematic review of randomised control trials. We comprehensively searched the Embase, MEDLINE and Web of Science databases, identified 473 studies, and, after screening, were left with 10 randomised control trials. Our meta-analyses found a significantly lower mean interleukin-6 level of −21.26 pg/mL ((95% CI −33.37, −9.15); p = 0.0006) postoperatively in patients given a preoperative CHD compared to fasting and a significantly higher mean serum albumin level of 2.56 g/L ((95% CI 1.41, 3.71); p &lt; 0.0001) postoperatively in patients given a preoperative CHD compared to a placebo. Our results therefore show that a CHD, consumed 2–3 h preoperatively, lowers proinflammatory cytokine levels and increases serum albumin levels. Thus, our study reinforces guideline recommendations to give patients a CHD 2–3 h preoperatively for improved outcomes.

Preoperative carbohydrate drink in fast-track primary total knee arthroplasty: a randomized controlled trial of 168 patients.

A key component in fast-track total knee arthroplasty (TKA) is early mobilization. Preoperative fasting might cause orthostatic hypotension and -intolerance which both can interfere with early mobilization. It was hypothesized that consuming a carbohydrate drink 2-3 hours prior to surgery is a viable option to reduce orthostatic hypotension, and as a result, improve rehabilitation. In this randomized controlled trial, all consecutive unilateral primary TKA patients were reviewed for eligibility. Exclusion criteria were American Society of Anesthesiologists (ASA) class above 3, older than 80 years of age, Diabetes Mellitus, and an insufficient comment of Dutch language. Patients were distributed in two groups. The control group was allowed to eat till 6 hours and drink clear fluids till 2 hours before surgery (standard treatment). The intervention group consumed, additionally to the standard treatment, a carbohydrate drink 2-3 hours before surgery. Blood pressure was measured both lying and standing as a measure for orthostatic hypotension during first time postoperative mobilization on day of surgery. A total of 168 patients were included. Prevalence of orthostatic hypotension in the control- and intervention group was 24 patients (34%) and 14 patients (19%) respectively, (p=0.05). Prevalence of orthostatic intolerance was 13 patients (19%) in the control group and 9 patients (13%) in the intervention group (p=0.32). No drink related adverse events occurred. In conclusion, taking a carbohydrate drink 2-3 hours before TKA significantly lowers the number of patients with orthostatic hypotension in early mobilization. However, the clinical relevance of the carbohydrate drink has to be studied further.

Current Status of and Barriers to the Implementation of Enhanced Recovery After Surgery in 77 Tertiary Hospitals

To investigate the status of and obstacles to the implementation of enhanced recovery after surgery (ERAS) in tertiary-care general hospitals in China. Questionnaire on the Current Status of and Barriers to the Implementation of ERAS in Tertiary-Care Hospitals, a self-developed questionnaire, was used to conduct a survey of 77 tertiary hospitals from 21 provinces across China between May 2022 and June 2022. The participating hospitals were selected by convenience sampling. The questionnaire on the current implementation status of ERAS was mainly focused on the departments involved and the ERAS programs implemented, incorporating a total of 25 items of three dimensions, preoperative, intraoperative, and postoperative. The answer to each question consisted of 5 options from "never" to "always", which corresponded to 1 to 5 points on the scoring scale, with the higher scores indicating better implementation of the program concerned. In the questionnaire on barriers to ERAS implementation and recommendations, 10 items of two dimensions, including hospital management, and patient and caregiver, were concerned with the barriers to implementation. The answer to each question consisted of 5 options from "disagree" to "strongly agree", which corresponded to 1 to 5 points on the scoring scale, with the higher scores indicating the greater importance of the barriers. ERAS programs were implemented in 73 (94.8%) hospitals. The best-implemented items were preoperative education (4.73±0.51), prevention and treatment of deep vein thrombosis (4.55±0.71), and postoperative follow-up (4.40±0.81). The items of poor implementation status were preoperative prehabilitation (2.71±1.40), preoperative oral carbohydrate drinks (3.03±1.49), and early ambulation after surgeries (3.04±1.22). The main obstacles to ERAS implementation included a lack of effective incentive systems, poor motivation among the medical and nursing staffs (3.21±0.93), a lack of disease-specific clinical implementation pathways (3.16±1.06), and a lack of experience in multidisciplinary teamwork (2.98±1.17). There is a high rate of ERAS implementation in tertiary general hospitals in China, but clinical implementation and dissemination are still confronted with many obstacles.

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

In our previous study, hypokalemia incidence was high in patients scheduled for laparoscopic colorectal resection. This trial was conducted to verify the effects of preoperative carbohydrate drinks containing potassium in these patients. A three-arm randomized controlled design was used. Patients were randomly assigned to control, placebo, and treatment groups. In the control group, patients fasted from midnight. In the placebo group, patients fasted from midnight and received carbohydrate drinks 2 to 3 hours before surgery. In the treatment group, patients fasted from midnight and received carbohydrate drinks containing potassium supplementation 2 to 3 hours before surgery. The primary outcome was the incidence and severity of preoperative hypokalemia. Other outcomes included postoperative gastrointestinal function, including the time to postoperative first flatus (FFL) and first feces (FFE), and other complications. The final analysis included 122 participants. The incidence of preoperative hypokalemia in the treatment group was significantly lower than that in the control and placebo groups (50% vs 88.1% vs 77.5%, P < .001). The severity of hypokalemia in the control and placebo groups was greater than that in the treatment group. No regurgitation or aspiration occurred in the three groups. No significant differences were observed among the three groups regarding time to FFL and FFE. Preoperative carbohydrate drinks containing potassium significantly reduced the incidence of preoperative hypokalemia and improved preoperative thirst and hunger, but did not reduce the postoperative time to FFL and FFE or length of hospital stay. However, as part of the enhanced recovery after surgery protocol, preoperative carbohydrate drinks containing potassium should be considered, as early as first admittance to hospital.

Prevention of post-operative nausea and vomiting with honey as a pre-operative oral carbohydrate: A randomised controlled pilot trial

Background Post-operative nausea and vomiting (PONV) is the secondmost common post-operative complication. Prolonged pre-operative fasting is common in Australia despite guidelines recommending reduced fasting to improve patient outcomes, such as PONV. Commercially prepared preoperative oral carbohydrate (OC) drinks may be used to reduce fasting time. In this study commercial products were replaced with honey, an inexpensive and common food item. Design Partially blinded, four parallel arms randomised controlled noninferiority trial compared pre-operative OC loading with overnight fasting. Methods Adult elective laparoscopic cholecystectomy and thyroidectomy patients having two or more risk factors for PONV were allocated into intervention and control groups by simple randomisation. The intervention group ingested 60g of honey in 100 ml of water at least two hours before surgery as pre-operative OC loading to reduce PONV. Participants and assessors to the group assignment were blinded to the study outcomes. Early PONV (0–6 hours) was measured with Rhodes index of nausea, vomiting and retching (R-INVR) and a numeric rating scale (NRS). Results The four groups (N = 142) were control and intervention groups of thyroidectomy patients (n = 72: C = 37, I = 35), and control and intervention groups of laparoscopic cholecystectomy patients (n = 70: C = 37, I = 33) and had similar distributions of variables. The estimated effect size was 140 with a 95 percent confidence interval. The PONV incidence (Pearson χ2 = 4.54; df = 1; p = 0.03) and severity were significantly lower in the laparoscopic cholecystectomy intervention group (R-INVR: Mann–Whitney U = 446.5; p = 0.01; NRS: Mann–Whitney U = 444.5; p = 0.01) and results were not conclusive in the thyroidectomy group (NRS: Mann–Whitney U = 629.5; p = 0.95; R-INVR: Mann–Whitney U = 629.5; p = 0.76). Conclusion Honey could be recommended as an inexpensive pre-operative OC to reduce PONV in adult patients receiving general anaesthesia.

Attenuation of metabolic stress response during spinal surgery under general anaesthesia - A comparison between preoperative carbohydrate drink or no carbohydrate load

Background: Surgery is a stress which stimulates the increase of counter regulatory hormones. Pre-operative prolonged fasting increases stress further. Although a pre-operative carbohydrate (CHO) drink has been variably reported to yield benefit in reducing the perioperative stress and is being used frequently for elective surgeries, some recent reports also reports that preoperative CHO loading did not result in increase or decrease in the post-operative complication rates when compared with placebo or fasting group. Aims and Objectives: The present study was designed to determine the stress response in the postoperative period at 24 h in terms of changes in the levels of cortisol and other biomarkers. Materials and Methods: This randomized, parallel group, and double-blind study was conducted in 75 patients aged 18–65 years, of American Society of Anesthesiologists Physical Status Classes I and II, scheduled for elective lumbar spine surgery under general anesthesia. The patients were randomly allocated to receive 300 ml plain water at 9 pm on the day before surgery and 2 h before operation (Group C, control, n=25), or 300 ml plain water at 9 pm on the day before surgery and solution containing 75 grams of glucose dissolved in 300 ml water in the morning 2 h before surgery (Group CHO-1, n=25), or to receive 75 grams of glucose dissolved in 300 ml water at 9 pm in the night before the surgery and again in the morning at 2 h before surgery (Group CHO-2, n=25). In all the three groups, the levels of insulin (C-peptide), lactate, glucose, and cortisol were determined preoperatively (before the induction of anesthesia) and 24 h postoperatively. Results: There was considerable difference between post-operative blood cortisol level among the three groups (583.9 vs. 462.3 vs. 389.6 nMol/L, Control vs., CHO load once or twice, respectively, P&lt;0.0001). A significant difference in post-operative values was also seen with other parameters such as serum lactate, glucose, and C-peptide. Considerable differences were seen in both preoperative and postoperative period in case of cortisol and lactate whereas it was limited to postoperative values in case of glucose and C-peptide. Conclusion: Pre-operative glucose loading showed better efficacy in suppressing perioperative stress response in terms of less rise of serum cortisol and lactate as compared to no CHO load.

Impact of oral or enteral nutritional support on clinical outcomes of patients subjected to cardiac surgery: A systematic review.

Cardiovascular diseases represent the leading cause of death worldwide, in addition to having a direct negative impact on quality of life, functional capacity and nutritional status. Studies show high prevalence of malnutrition in patients undergoing cardiac surgery. It is known that cardiac surgery can also lead to changes in nutritional status, through surgical trauma, systemic inflammation and, often, delay in the initiation of nutritional support. On the other hand, the role of nutritional support as a driver of clinical outcomes in different surgical populations is well described in the literature. To review the literature in order to assess the effect of perioperative oral or enteral nutritional support on clinical outcomes of cardiac patients undergoing cardiac surgery. The search was conducted in February 2021 in the following databases: EMBASE, PubMed/MEDLINE, Scopus and Web of Science. Randomized clinical trials (RCT) and retrospective studies were selected, carried out with patients with heart disease, undergoing cardiac surgery and aged 18 years or over. The Outcomes of interest were: length of hospital stay, length of stay in the ICU, time on ventilatory support, mortality rate, clinical complications and use of vasoactive drugs in the postoperative period. Ten studies were included in this systematic review, of which 7 were RCTs and 3 were cohorts. The most prevalent surgery was myocardial revascularization. Six studies evaluated oral nutritional support, two enteral nutritional support and two analyzed both. Two studies found a significant reduction in the length of hospital and ICU staying associated with preoperative intake of carbohydrate-based beverages. Only one study observed a significant reduction in the requirement for ventilatory support after cardiac surgery, after preoperative carbohydrate-based drinks and early postoperative enteral nutrition. There was no influence of nutritional support on mechanical ventilation length and mortality. Most studies showed that nutritional support did not reduce hospital and ICU staying. Nutritional support benefits were demonstrated in studies that offered preoperative oral carbohydrate drinks. No association was observed between nutritional support and duration of mechanical ventilation or mortality rate. Most studies did not find any influence of nutritional support on the need and/or dosage of vasoactive drugs in the postoperative period of cardiac surgery.

Effect of Preoperative Oral Carbohydrates on Insulin Resistance in Older Adults Who Underwent Total Hip or Knee Arthroplasty: A Prospective Randomized Trial.

Preoperative carbohydrate drinks are recommended to reduce fasting time before surgery. Older adults are at risk of pulmonary aspiration and hyperglycemia after consuming carbohydrate drinks because of increased insulin resistance and delayed gastric emptying. We investigated the effects of oral carbohydrate drinks on perioperative insulin resistance, metabolic responses, and gastric volume in older adults. Fifty-six patients (aged more than 65 years) were randomly assigned to the control or carbohydrate (CHO) group. The CHO group received 400 mL of a carbohydrate drink 2 to 3 hours before anesthesia. The control group was allowed clear fluid intake 2 hours before anesthesia. Blood glucose and insulin levels were measured before intake of the carbohydrate drink and 1 hour postoperatively. Gastric volume was measured before spinal anesthesia. Insulin resistance was calculated using the homeostasis model assessment for insulin resistance. Homeostasis model assessment for insulin resistance was not different between the control and CHO groups preoperatively (2.5 versus 3.3, P = 0.156) or postoperatively (2.6 versus 2.4, P = 0.817). Preoperative gastric volume was comparable between the control and CHO groups (35.5 versus 30.8 mL, P = 0.696). Preoperative oral consumption of carbohydrates did not affect insulin resistance or gastric volume in older adults undergoing total knee or hip arthroplasty. Preoperative carbohydrate loading is safe in older adults undergoing total knee or hip arthroplasty. The data that support the findings of this study are available from the corresponding author on reasonable request. ClinicalTrials.gov (No. NCT04206189).

Preoperative Carbohydrate Drink Intake Increases Glycemic Variability in Patients with Type 2 Diabetes Mellitus in Total Joint Arthroplasty: A Prospective Randomized Trial

Preoperative carbohydrate treatment attenuates insulin resistance and improves metabolism to an anabolic state. Despite these benefits, impaired glycemic control and aspiration risk related to gastroparesis represent concerns for patients with diabetes undergoing surgery. This randomized controlled trial investigated the effects of oral carbohydrate therapy on perioperative glucose variability, metabolic responses, and gastric volume in diabetic patients undergoing elective total hip or knee arthroplasty. Fifty diabetic patients scheduled to undergo elective total knee or hip arthroplasty during August 2019-October 2020 were randomly assigned to a control or carbohydrate therapy (CHO) group. CHO group of patients received a 400-mL carbohydrate drink 2-3h before anesthesia; control group of patients underwent overnight fasting from midnight, one night before surgery. Blood glucose levels were measured before intake of the carbohydrate drink, before spinal anesthesia, preoperatively, immediately postoperatively, and 1h postoperatively. Insulin level and gastric volume were measured before spinal anesthesia. The glucose variability of patients in the CHO group was significantly higher than that of those in the control group (16.5 vs. 10.1%, P = 0.008). Similarly, insulin resistance was higher in the CHO group than in the control group (8.5 vs. 2.7, P < 0.001). The gastric volume did not differ significantly between the groups (61.3 vs. 15.2ml, P = 0.082). Preoperative oral carbohydrate therapy increases glucose variability and insulin resistance in diabetic patients. Therefore, carbohydrate beverages should be cautiously administered to diabetic patients, considering metabolic and safety aspects. Trial registration number ClinicalTrials.gov (No. NCT04013594).

A Review of Current Literature of Interest to the Office-Based Anesthesiologist

A Review of Current Literature of Interest to the Office-Based Anesthesiologist

Potential causes of the preoperative increase in the rectosigmoid cyclic motor pattern: A high-resolution manometry study.

BackgroundCyclic motor patterns (CMPs) are the most common motor pattern in the distal colon. This study used high‐resolution (HR) colonic manometry to quantify trends in distal colonic motor activity before elective colonic surgery, determine the effect of a preoperative carbohydrate load, and compare this with a meal response in healthy controls.MethodsFiber‐optic HR colonic manometry (36 sensors, 1 cm intervals) was used to investigate distal colonic motor activity in 10 adult patients prior to elective colonic surgery, 6 of whom consumed a preoperative carbohydrate drink (200 kCal). Data were compared with nine healthy volunteers who underwent HR colonic manometry recordings while fasted and following a 700 kCal meal. The primary outcome was the percentage of recording occupied by CMPs, defined as propagating contractions at 2–4 cycles per minute (cpm). Secondary outcomes included amplitude, speed, and distance of propagating motor patterns.ResultsThe occurrence of CMPs progressively increased in time periods closer to surgery (p = 0.001). Consumption of a preoperative drink resulted in significantly increased CMP occurrence (p = 0.04) and propagating distance (p = 0.04). There were no changes in amplitude or speed of propagating motor patterns during the preoperative period. The increase in activity following a preoperative drink was of similar magnitude to the colonic meal response observed in healthy controls, despite the lesser caloric nutrient load.ConclusionDistal colonic CMP increased in occurrence prior to surgery, amplified by ingestion of preoperative carbohydrate drinks. We hypothesize that anxiety, which is also known to rise with proximity to surgery, could play a contributing role.

Preoperative oral carbohydrate loading: Effects on intraoperative blood glucose levels, post-operative nausea and vomiting, and intensive care unit stay.

Background and Aims:Preoperative fasting imparts safety to patients from aspiration of gastric contents, but undue fasting may predispose to hypoglycemia and dehydration. Preoperative carbohydrate drink reduces postoperative nausea and vomiting (PONV). Primary objective of the present study was to assess effect of carbohydrate drink given 2h before surgery on intraoperative blood glucose levels as compared to those who did not receive it. Secondary objectives included assessment of incidence and severity of PONV and duration of Intensive Care Unit (ICU) stay.Material and Methods:It was a prospective randomized study done in 52 non-diabetic patients undergoing thyroidectomy. Group A received 39gm of carbohydrate in 250 mL of apple juice (tetrapack) and Group B patients were given equivalent volume of plain water 2 h prior to surgery. Random blood glucose (RBS) levels were checked before fluid administration, preinduction, 1 h postinduction, and at the end of surgery. PONV was assessed using PONV Impact Scale Score (ISS) and rescue drugs, if needed, were noted. Paired t-test, sample t-test, Mann–Whitney U test, and Fisher’s exact test were used as applicable.Results:The fasting, preinduction, and postoperative RBS values were comparable in both groups. Group B had significantly higher RBS at 1h intraoperatively. Group A patients had less vomiting, dry retching, or nausea and required less rescue therapy compared to Group B.Conclusion:Compared to patients who received carbohydrate drink 2 h before surgery, those who did not receive it had significantly higher blood glucose values intraoperatively with a higher incidence and severity of PONV and comparable ICU stay.

An international assessment of the adoption of enhanced recovery after surgery (ERAS®) principles across colorectal units in 2019-2020.

The Enhanced Recovery After Surgery (ERAS®) Society guidelines aim to standardize perioperative care in colorectal surgery via 25 principles. We aimed to assess the variation in uptake of these principles across an international network of colorectal units. An online survey was circulated amongst European Society of Coloproctology members in 2019-2020. For each ERAS principle, respondents were asked to score how frequently the principle was implemented in their hospital, from 1 ('rarely') to 4 ('always'). Respondents were also asked to recall whether practice had changed since 2017. Subgroup analyses based on hospital characteristics were conducted. Of hospitals approached, 58% responded to the survey (195/335), with 296 individual responses (multiple responses were received from some hospitals). The majority were European (163/195, 83.6%). Overall, respondents indicated they 'most often' or 'always' adhered to most individual ERAS principles (18/25, 72%). Variability in the uptake of principles was reported, with universal uptake of some principles (e.g., prophylactic antibiotics; early mobilization) and inconsistency from 'rarely' to 'always' in others (e.g., no nasogastric intubation; no preoperative fasting and carbohydrate drinks). In alignment with 2018 ERAS guideline updates, adherence to principles for prehabilitation, managing anaemia and postoperative nutrition appears to have increased since 2017. Uptake of ERAS principles varied across hospitals, and not all 25 principles were equally adhered to. Whilst some principles exhibited a high level of acceptance, others had a wide variability in uptake indicative of controversy or barriers to uptake. Further research into specific principles is required to improve ERAS implementation.

Incidence of urinary ketosis and the effect of carbohydrate drink supplementation during fasting for elective caesarean section: Audit.

Elective lower segment caesarean section patients are routinely instructed to fast from food for 6h before surgery, with clear fluids up until 2h before surgery. We conducted an audit examining the true fasting times of mothers undergoing an elective caesarean section and the incidence of urinary ketones before and after introducing a preop carbohydrate drink (Nutricia preOp 400ml) to be administered to all patients at 6am on the day of surgery. We audited 50 patients prior to introducing the preop carbohydrate drink and 54 patients after the introduction of a carbohydrate drink. We found the mean fasting time from last caloric intake was reduced from 13h 35min to 5h 5min after the introduction of a preoperative carbohydrate drink. We found that the incidence of urinary ketones was 40.4% prior to the introduction of a preoperative carbohydrate drink and 38.3% after the introduction of a preop drink (p = 1). If fasting times were limited to under 4h, the incidence of urinary ketones is 10%. Our audit demonstrates that reducing preoperative fasting times is possible and preventing metabolic derangements may be possible, requiring an approach targeted at keeping fasting times to a minimum.

Preoperative immunonutrition and carbohydrate loading associated with improved bowel function after radical cystectomy.

Preoperative malnourishment has been consistently associated with poor outcomes after radical cystectomy and other major abdominal surgeries. Most enhanced recovery after surgery (ERAS) studies have examined preoperative nutrition and its relationship to outcomes after gastrointestinal surgery. Although numerous studies have demonstrated the benefits of using an ERAS protocol, this study in unique in comparing 2 ERAS protocols, with and without a nutrition component. A formalized preoperative nutrition protocol (PNP) recommending use of preoperative immunonutrition and carbohydrate drink was introduced in June 2018. A total of 78 consecutive patients who drank both beverages were compared with 92 historical controls. Multivariable logistic regression analyses were sequentially performed to determine if preoperative nutrition was associated with binary outcome variables (30-day complication, infectious complication, and readmission within 30 days). The preoperative nutrition group and control group were statistically similar in distribution of age, sex, American Society of Anesthesiologists physical status classification, clinical stage, and body mass index. Return of bowel function was found to occur earlier in the preoperative nutrition group than in the control group (3.12 vs 3.74 days; relative risk, 0.82; CI, 0.73-0.93; P = .0029). Complications within 30 days were similar in both groups (63.6% vs 55.4%; P = 0.36). Infectious complications (42.9% vs 37%; P = .53) and readmission within 30 days (22.1% vs 15.2%; P = .34) were also similar in both groups. Use of a PNP including immunonutrition and carbohydrate drink may be associated with earlier return of bowel function after radical cystectomy.

The influence of preoperative carbohydrate loading on postoperative outcomes in bariatric surgery patients: a randomized, controlled trial.

Preoperative carbohydrate loading is a component of Enhanced Recovery After Surgery (ERAS) protocols, but there is limited literature in bariatric surgery patients. The objective of this study was to characterize the impact of preoperative carbohydrate loading on postoperative bariatric surgery outcomes. University Hospital. Patients undergoing a primary minimally invasive Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) between 2018 and 2020 were randomized to standard management or intervention. Standard management patients were nothing by mouth (NPO) after midnight prior to surgery. Intervention patients consumed 2 carbohydrate drinks: 1 the night before and another 3 hours prior to surgery. Primary outcomes analyzed included postoperative nausea and vomiting (PONV), length of stay, and overall complications. In total, 134 patients were analyzed: 64 intervention (47.8%) and 70 (52.2%) standard. In the end, 7% and 15% of patients were lost to follow-up at 6-weeks and 3-months, respectively. There was no statistically significant difference in length of stay (2.0 ± 1.2 vs 2.1 ± .9 d; P = .65) or postoperative outcomes between the 2 groups. There were no episodes of aspiration among the intervention group. Among RYGB patients, intervention patients had a shorter duration of nausea compared with standard patients. There was no significant difference in glycemic control among patients with and without diabetes. Preoperative carbohydrate drinks can be administered to bariatric surgery patients without significant risks. Carbohydrate loading preoperatively can decrease the duration of PONV in RYGB patients. Carbohydrate drinks can be safely included in bariatric ERAS protocols for patients with and without diabetes, although the benefits remain unknown.

Gastric Emptying of Carbohydrate Drinks in Term Parturients Before Elective Cesarean Delivery: An Observational Study

(Int J Obstet Anesth. 2020;41:29–34) Most enhanced recovery after surgery programs now opt to use preoperative carbohydrate (CHO) drinks as a standard part of their protocol. Preoperative fasting guidelines set by the American Society of Anesthesiologists (ASA) state that moderate amounts of clear fluids up to 2 hours before anesthesia are allowed for uncomplicated patients undergoing elective surgery. Most research regarding clear liquid consumption before anesthesia has been performed in nonpregnant patients although recent data found gastric emptying of water was not delayed in nonlaboring parturients. The rate of gastric emptying of CHO drinks in a pregnant population has yet to be studied, however. The aim of this study was to investigate gastric emptying of 400 mL of a CHO drink up to 2 hours before elective cesarean delivery.