Preoperative Carbohydrate Loading Research Articles

Enhanced recovery after fetal spina bifida surgery: what is our global practice?

Prenatal spina bifida closure results in improved outcomes for the child compared to postnatal surgery but is associated with significant maternal morbidity. Optimization of the perioperative care for women who underwent fetal spina bifida surgery could improve maternal and pregnancy outcomes. Enhanced Recovery After Surgery (ERAS) protocols are multimodal, evidence-based care plans that have been adopted for multiple surgical procedures to promote faster and better patient recovery and shorter hospitalization. This study aims to explore if fetal centers have implemented ERAS principles in this setting. Furthermore, we provide recommendations for the perioperative management of patients undergoing fetal spina bifida surgery. Fifty-three fetal therapy centers offering prenatal surgery for open spina bifida were identified and invited to complete a digital questionnaire covering their pre-, intra- and postoperative management. An overall score was calculated per center based on the center's compliance with 20 key ERAS principles, extrapolated from ERAS guidelines for cesarean section, gynecologic oncology and colorectal surgery. Each item was scored 1 or 0 when the center did or did not comply with each principle, with a maximum score of 20. The questionnaire was completed by 46 centers in 17 countries (response rate 87%). Twenty-two centers (48%) exclusively perform open fetal surgery (laparotomy and hysterotomy), whereas 14 (30%) offer both open and fetoscopic procedures and 10 (22%) use fetoscopy only. The perioperative management of patients undergoing fetoscopic and open surgery was highly similar. The median ERAS score was 12 (mean 12.5, SD 2.4, range 8-17). Center compliance was the highest for the use of regional anesthesia (98%), avoidance of bowel preparation (96%), and thromboprophylaxis (96%), while the lowest compliance was achieved for preoperative carbohydrate loading (15%), postoperative nausea and vomiting prevention (33%), avoidance of overnight fasting (33%) and a 2-hour fasting period for clear fluids (20%). ERAS scores were similar in centers with a short (2-5 days), medium (6-10 days) and long (≥11 days) hospital stay (12.8 ± 2.4, 12.1 ± 2.0, and 10.3 ± 3.2, respectively, p=0.15). Furthermore, there was no significant association between ERAS score and surgical technique or center volume. The perioperative management of fetal spina bifida surgery is highly variable across fetal therapy centers worldwide. Standardizing protocols according to ERAS principles may improve patient recovery, reduce maternal morbidity, and shorten hospital stay after fetal spina bifida surgery. This article is protected by copyright. All rights reserved.

A feasibility study on preoperative carbohydrate loading in older patients undergoing hip fracture surgery

BackgroundPreoperative carbohydrate loading in Enhanced Recovery After Surgery is an independent predictor of postoperative outcomes. By reducing the impact of surgical stress response, fasting-induced insulin resistance is modulated. As a clear fluid, consuming carbohydrate drink is safe up to 2 h preoperatively. Widely practiced in abdominal surgeries, its implementation in hip fracture surgeries is yet to be recognized. This study aimed to identify the feasibility of preoperative carbohydrate loading in hip fracture surgery and assess its clinical effects.MethodsThis was a randomized controlled, open labelled trial. Patients ≥ 65 years old without diabetes mellitus, has hip fracture were recruited in a tertiary hospital between November 2020 and May 2021. The intervention was carbohydrate loading versus standard preoperative fasting.ResultsThirty-four ASA I-III patients (carbohydrate loading and control, n = 17 each), mean age 78 years (SEM ± 1.5), mean body mass index 23.7 (SEM ± 0.6 kg/m2) were recruited. Analysis for feasibility of carbohydrate loading (n = 17) demonstrated attrition rate of 29% (n = 5). Otherwise, all recruited patients were compliant (100% compliance) with no adverse events reported. There was no significant difference among groups in the postoperative nausea and vomiting, pain score, fatigue level, muscle strength, postoperative infection and length of hospital stay assessed at 24–48 h postoperatively.ConclusionThe implementation of preoperative carbohydrate loading was found to be feasible preoperatively in hip fracture surgeries but requires careful coordination among multidisciplinary teams. An adequately powered randomized controlled study is needed to examine the full benefits of preoperative carbohydrate loading in this group of patients.Trial registrationThis study was registered in ClinicalTrial.gov (ClinicalTrials.gov identifier: NCT04614181, date of registration: 03/11/2020).

Trends in preoperative carbohydrate load practice: A systematic review.

The preoperative carbohydrate load (PCL) is intended to improve surgical outcomes by reducing the catabolic state induced by overnight fasting. However, there is disagreement on the optimal PCL prescription, leaving local institutions without a standardized PCL recommendation. Results from studies that do not prescribe PCL in identical ways cannot be pooled to draw larger conclusions on outcomes affected by the PCL. The aim of this systematic review is to catalog prescribed PCL characteristics, including timing of ingestion, percentage of carbohydrate contribution, and volume, to ultimately standardize PCL practice. A comprehensive search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized controlled trials were included if they studied at least one group of patients who were prescribed a PCL and the PCL was described with respect to timing of ingestion, carbohydrate contribution, and total volume. A total of 67 studies with 6551 patients were included in this systematic review. Of the studies, 49.3% were prescribed PCL on the night before surgery and morning of surgery, whereas 47.8% were prescribed PCL on the morning of surgery alone. The mean prescribed carbohydrate concentration was 13.5% (±3.4). The total volume prescribed was 648.2 ml (±377). Variation in PCL practices prevent meaningful data pooling and outcome analysis, highlighting the need for standardized PCL prescription. Efforts dedicated to the establishment of a gold standard PCL prescription are necessary so that studies can be pooled and analyzed with respect to meaningful clinical end points that impact surgical outcomes and patient satisfaction.

Impact of preoperative carbohydrate loading on postoperative course and morbidity in debulking surgery for epithelial ovarian cancer.

Despite the theoretical benefits, the favorable effect of preoperative carbohydrate loading on postoperative morbidity remains controversial. Most of the outcomes reported in the literature are derived from non-gynecologic surgery data, with only one study involving a limited number of patients specifically in gynecological oncology. The present study aimed to investigate the impact of carbohydrate loading, as a single element of enhanced recovery after surgery protocols, on postoperative course and morbidity in patients undergoing debulking surgery for epithelial ovarian cancer (EOC). The present study was a non-randomized, prospective cohort trial enrolling patients with EOC who underwent surgery between June 2018 and December 2021. An oral carbohydrate supplement with a dose of 50 g was given to patients 2-3 h before anesthesia. Data on postoperative course and morbidity were collected and compared with data of a historical cohort including consecutive patients who underwent surgery without a carbohydrate loading between January 2015 and June 2018. Analyses were performed on a total of 162 patients, including 72 patients in the carbohydrate loading group and 90 patients in the control group. Median length of hospital stay (11 days vs. 11 days; P=0.555), postoperative days 1-7 serum c-reactive protein levels (P=0.213), 30-day readmission (11.6% vs. 11.5%, P=0.985), 30-day relaparotomy (2.8% vs. 3.4%, P=0.809) and 30-day morbidity (48.6% vs. 46.7%; P=0.805) were comparable between the cohorts. No significant differences in grades of morbidities were identified between the cohorts (P=0.511). Multivariate analysis revealed that the sole independent risk factor for any postoperative morbidity was operative time. In conclusion, based on the results of the present study, postoperative course and morbidity seemed to be unaffected by carbohydrate loading in patients undergoing debulking surgery for EOC.

Effects of preoperative and postoperative carbohydrate loading on gastrointestinal function and stress-induced inflammation after radical prostatectomy

Background: Early postoperative oral clear liquid diet has been shown to enhance postoperative recovery. However, the standard strategy for this diet has not been established. The authors’ aim was to investigate the combined effect of preoperative and early postoperative carbohydrate loading on postoperative stress and gastrointestinal function of patients by standardizing the starting time, type, volume, and concentration of carbohydrate drinks. Materials and methods: Fifty-three patients undergoing radical prostatectomy were randomly assigned to two groups. Both groups received a carbohydrate loading of 400 ml (12.5%) overnight and 2 h before surgery. The intervention group (n=29) started a 400 ml (12.5%) carbohydrate loading 6 h after surgery and consumed it within 24 h, while the control group (n=32) drank water. The primary outcomes–postoperative fasting blood glucose, fasting insulin, C-reactive protein (CRP), interleukin-6 levels, and gastrointestinal function–were recorded. Secondary outcomes included subjective comfort assessment, the first postoperative intake of semi-fluid food time, and drainage volume. Results: Compared with the control group, the intervention group had lower CRP levels on postoperative day 1 (POD1)/POD2 and less drainage volume on POD1. The intervention group also experienced shorter times to the first postoperative flatus and the first consumption of semi-fluid foods; their 72-h postoperative protein intake was higher than that of the control group. Conclusion: The results suggest that combined preoperative and postoperative carbohydrate loading can alleviate stress-induced inflammation and promote the recovery of postoperative gastrointestinal function.

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.

Role of preoperative carbohydrate loading for prevention of perioperative ketoacidosis in elective cesarean delivery

Abstract Background and Aims: Starvation of long duration during third trimester of pregnancy is undesirable as it is associated with accelerated fasting leading to hypoglycemia, raised plasma free fatty acid (FFA) levels, and increased plasma/urinary ketones. Carbohydrate (CHO)-rich drinks given preoperatively may ameliorate these deleterious effects. The enhanced recovery after surgery (ERAS) guidelines for perioperative care recommend that oral CHO fluid supplementation 2 h before cesarean delivery may be offered to nondiabetic pregnant women. The aim of the study was to evaluate the role of preoperative oral CHO loading for the prevention of perioperative ketoacidosis in elective cesarean deliveries. Material and Methods: One hundred and twenty American Society of Anesthesiologists (ASA) II/III parturients undergoing elective cesarean section under subarachnoid block (SAB) were divided into two groups of 60 each after they gave written informed consent. Group A parturients received 400 ml of filtered water 2 h before surgery. Group B parturients received 400 ml of nonparticulate CHO drink 2 h before surgery. The primary outcome was the incidence of ketonuria studied by the dipstick method. Secondary outcomes included hunger and thirst scores, anxiety score, dominant hand grip strength, and the quality of recovery score. Results: The urine ketone levels were positive (+1) in 8.3% parturients in group A and 1.7% parturients in the CHO group (P value- 0.094). The hunger and thirst scores as well as the modified Beck’s anxiety scores were significantly lower in the CHO group (P value- 0.002). Dominant hand grip strength was preserved in both the groups (P value- 0.827). The quality of recovery score was significantly improved in the CHO group (P value- 0.002). No serious adverse effects were noted in either group. Conclusion: Oral CHO drink is safe when administered 2 h before uncomplicated elective cesarean deliveries. It may have a positive influence on a wide range of perioperative markers of clinical outcome.

EFFECTS OF NUTRITION STATUS AND PERIOPERATIVE NUTRITION SUPPLEMENT COMPLETION ON POSTOPERATIVE OUTCOMES IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE UNDERGOING SURGERY

Abstract BACKGROUND Malnutrition is common in inflammatory bowel disease, (IBD) and is associated with poor disease activity, greater hospital length of stay (LOS), higher 30-day readmission rates, and increased risk of postoperative complications. Structured, multimodal prehabilitation including nutrition counseling improves various outcomes after elective cancer and orthopedic surgeries. We examined the effects of malnutrition and perioperative nutrition supplementation on surgical outcomes in IBD patients participating in a multimodal prehabilitation program. METHODS This was a retrospective study of patients aged 18-80 enrolled in a 10-week prehabilitation program undergoing surgery for IBD. Beginning 4 weeks prior to surgery, patients met with a multidisciplinary team including a nurse practitioner, physical therapist and registered dietitian. Patients were provided 3 preoperative carbohydrate loading oral nutrition supplements (ONS) 48 hours prior to surgery, and 20 perioperative immunonutrition ONS. Malnutrition was defined using the Global Leadership in Malnutrition criteria as moderate or severe. We used Fisher’s exact test to determine associations between malnutrition, ONS use, and postoperative complications (defined by the comprehensive complication index (CCI, with CCI scores >20 classified as severe)), and 30-day readmission. Logistic and linear regression were used to analyze length of stay (LOS), opioid use (defined as morphine milligram equivalents, MME), nutrition status, and ONS completion. RESULTS 25 patients (48% female, mean age 44, 18 (72%) with Crohn’s disease) completed the prehabilitation program between 05/2022 and 10/2023. 10 patients (40%) met criteria for malnutrition (of these, 50% were moderate and 50% severe). Malnutrition was not significantly associated with CCI severity (p=0.07), LOS (p =0.07), opioid use (p=0.07) or 30 day readmission rates (0.06). Higher ONS use for carbohydrate loading and immunonutrition were more likely to have a LOS<5 days (p=0.05 and p=0.03 respectively). CONCLUSION ONS for preoperative carbohydrate loading and perioperative immunonutrition may shorten LOS after surgery among patients with IBD. In our study, higher amounts of ONS consumption led to a shorter LOS. Larger, controlled studies will help to further clarify the effects of malnutrition, carbohydrate loading, and immunonutrition among patients with IBD preparing for surgery.

MULTIMODAL PREHABILITATION MAY IMPROVE SURGICAL OUTCOMES FOR PATIENTS WITH INFLAMMATORY BOWEL DISEASE

Abstract BACKGROUND Surgery is associated with loss of lean body mass and physical deconditioning, which can delay healing and lead to complications. Multimodal prehabilitation (PH) with nutrition optimization and physical therapy improves outcomes after cancer surgery. However, the effects of prehabilitation for inflammatory bowel disease (IBD) surgery are not established. We aimed to assess surgical outcomes among IBD patients exposed to prehabilitation relative to no prehabilitation. METHODS We conducted a case-controlled study of the impact of prehabilitation in patients with IBD who underwent major abdominal surgery for Crohn’s disease (CD) or ulcerative colitis (UC) between May 1st, 2022 and June 6th, 2023 at a tertiary care center. Cases were defined as those who participated in a multimodal PH program that included nutrition counseling (weight optimization, preoperative carbohydrate loading and perioperative immunonutrition), medication management, physical therapy, and psychosocial evaluation beginning 4 weeks prior to surgery; controls received standard of care (SOC) written preoperative surgical instructions without PH. We assessed postoperative complications (defined by the comprehensive complications index (CCI)), severe complications (CCI>20), reoperation rate, 30-day readmission, post operative length of stay (LOS) and post-operative opioid use (defined by daily morphine milligram equivalents (MME)). Statistical tests included linear and logistic regression, Mann-Whitney U test, Chi-Square test, and Fisher’s exact test, as appropriate. RESULTS A total of 68 patients were identified, including 20 PH (cases) and 48 SOC (controls). Among PH, 75% had CD with the remainder UC; surgeries included ileocecal resection (45%), colectomy with ileostomy (25%), ileal pouch-anal anastomosis (25%), and small bowel resection (5%). Among SOC, 31% had CD with the remainder UC, and surgeries included colectomy with ileostomy (60%), stage 2 IPAA (29%), and small bowel (6%) or ileal (4%) resections. Age, sex, race, and ethnicity was similar between groups. Overall and severe complication rates were similar between PH and SOC (mean CCI scores 13.42 PH vs 11.25 SOC (p = 0.58), and CCI > 20 in 40% PH patients vs 29% SOC (p = 0.56)). Median post-operative LOS was shorter among PH vs SOC (3.0 vs 3.5d, p=0.02), and median post-operative opioid use was lower among PH vs SOC (19.5 vs 20.8 MME, p = 0.04). Readmission within 30 days occurred in 30% of PH and 17% of SOC (p = 0.22). Reoperation within 30 days occurred in 5% of PH and 17% of SOC (p = 0.37). CONCLUSION: Multimodal prehabilitation may improve select surgical outcomes in IBD, including length of stay and opioid use after surgery. Larger, prospective, controlled studies may help to further clarify the impact of PH on surgical outcomes for IBD, including complications, readmissions, and functional status. Table 1. Patient Characteristics and Outcomes by Prehabilitation Exposure Status

Randomized Controlled Trial Comparing the Effects of Preoperative Carbohydrate and Non-carbohydrate Loading on Gastric Emptying in Diabetic and Non-diabetic Patients Posted for Elective Surgery.

Background Preoperative fasting for six hours and accepting clear fluids till two hours of surgery is followed as a regular practice. Carbohydrate-rich fluids antagonize catabolism and are claimed to be tolerated better. This study aims to compare the effect of carbohydrate-rich drinks on gastric volume and blood sugar control in diabetic and non-diabetic patients undergoing elective surgery with plain water. Methods Two hundred forty patients aged 40 to 65 undergoing elective surgery under regional anesthesia were randomized into diabetic control, diabetic study, non-diabetic control, and non-diabetic study. Control groups were given 400 ml of plain water, while the study group received 50 grams of dextrose dissolved in 400 ml of water two hours prior to surgery. Gastric volume was evaluated using USG, and thirst and discomfort were assessed using the Likert scale. Perioperatively, blood sugar values were monitored and kept under control using insulin. Results Mean gastric volume (ml) in diabetic control (35.3±12.95 ml), diabetic study (31.2±11.75 ml), non-diabetic control (29±11.42 ml), and non-diabetic study (30.4±9.12 ml) showed no statistically significant difference (p>0.05). Capillary blood glucose (CBG) values two hours post fluid intake showed a significant increase in CBG levels in the diabetic study (183.2±28.67 mg/dl) compared to the diabetic control group (138.66±15.81 mg/dl). The values returned to baseline within six hours. Thirst and discomfort were significantly lower in the study group of diabetic and non-diabetic populations. Conclusion We conclude that carbohydrate loading does not affect gastric volume in diabetics and non-diabetics. However, the sugar values do increase which may warrant hourly checking and administration ofinsulin in diabetics.

The effect of pre-endoscopy maltodextrin beverage on gastric residual volume and patient’s well-being: a randomised controlled trial

Prolonged fasting prior to oesophagogastroduodenoscopy (OGDS) could be noxious to patients’ well-being. Strict fasting protocol has been used prior to OGDS with the concern of reduced visibility or suboptimal endoscopic assessment. Maltodextrin beverages were also commonly used as the pre-operative carbohydrate loading in enhanced recovery after surgery (ERAS) protocol. Our study aimed to look for the effects of maltodextrin beverage 2 h before OGDS on gastric residual volume and patient’s well-being scores. This was a single-blinded, stratified randomised controlled trial, comparing control group (A, received 400 ml of plain water) and carbohydrate loading group (B, received 400 ml of Carborie). The primary objectives were to measure the gastric residual volume (GRV) and patient’s well-being scores using visual analogue scale (VAS) scores for hunger, thirst, anxiety, tiredness and general discomfort. Of 80 randomised patients, 78 completed the study (38 received plain water and 40 Carborie). The median (IQR) GRV was not significantly different between group A and B (5.0 ml (20) vs 4.0 ml (19), p = 0.777). Both groups showed significant reduction in VAS scores in all five parameters (p ≤ 0.001). There were no complications attributed to endoscopy in either group. Pre-endoscopy maltodextrin beverage is as safe as clear water with improved patient’s well-being in both groups.Clinical Trial Registration: NCT05106933.

Effect of Preoperative Oral Carbohydrate Loading on Perioperative Hemodynamic in Patients Undergoing Laparoscopic Cholecystectomy: A Randomized Controlled Study

Background: Conventional preoperative fasting is associated with intravascular volume contraction, increased stress, hyperglycaemia in the perioperative period. Recently, the concept of preoperative carbohydrate loading is introduced. This study was conducted to reveal the relation between use of carbohydrate-rich fluid and perioperative hemodynamic, perfusion index, and glucose control of the patients, who were undergoing elective laparoscopic cholecystectomy under general anesthesia. Methods: This study is a double-blinded prospective randomized control study. The patients, who met the inclusion criteria were randomly divided into 2 groups of 43 each with the help of computer-generated randomization method. Patients who received preoperative carbohydrate loading and patients who follow conventional preoperative fasting for surgery were labelled as Group E and Group S respectively. Incidence of hypotension was the primary outcome; variation in blood pressure, heart rate, perfusion index, and blood glucose level were the secondary outcomes. Results: Intraoperative hypotensive episodes were significantly lower in the carbohydrate loading group in comparison to the conventional fasting group, p=0.023. The systolic, diastolic blood pressure and perfusion index were significantly lower in the conventional fasting group. Also, the heart rate was significantly higher in the conventional fasting group. Numeric rating scale, the score for pain taken at 1 hour postoperatively was significantly lower in the carbohydrate loading group. Blood glucose level postoperatively after 24 hours was significantly more in the conventional fasting group. Conclusion: The carbohydrate loading group has better hemodynamic stability and optimal intravascular volume after induction and intraoperatively. Also, the carbohydrate loading group had better glycaemic control and better pain relief postoperatively.

GLIOMA-07 E.R.A.S. IN NEURO-ONCOLOGY

Abstract BACKGROUND We performed a retrospective study assesses the efficacy and safety of a protocol for the enhanced recovery after surgery for supratentorial gliomas and metastasis.The protocol applied to the Ca' Foncello Hospital in Treviso starts from the recommendations on the subject that the medical literature reported up to December 2018.Briefly, three main sections:1) preoperative functional status evaluation, preoperative oral carbohydrate loading; 2) minimally invasive surgery, scalp incision anesthesia, nonopioid analgesia; 3) early urinary-catheter removal, standing and feeding resumption within 3-4 hours from surgery. METHODS We analyzed data on 28 patients operated on ERAS protocol and compared them to a control group (22 patients). The main clinical variables are: age, ASA and Charlson comorbidity index; times urinary-catether removal, adherence ambulation, taking food by mouth; hospital long of stay (LOS). We also collected studies from 2016 to 2020 describing data about ERAS and craniotomy and we pooled these into a meta-analysis. RESULTS Postoperative pain was significantly lower in the ERAS group (2.47 vs. 3.95, p-value=0.0007)) as long as time to removal of urinary catheter (3.1 vs. 25.0 hours, p-value < 0.001), adherence to ambulation (4 vs. 25 hours, p-value < 0.001), and first oral solid food intake (5.3 hours vs. 23.7 hours, p-value < 0.001). The mean LOS was 2.9 days in the ERAS group and 4.8 days in the control group (p-value < 0.001), and no differences in terms of surgical and medical complications, 30 days readmission rate, and time between surgery and RT were found. Our data are in line with those reported in the literature as highlighted by our meta-analysis, where hospital LOS and moderate to severe postoperative pain rates (> 4 points on NPRS) were significantly lower in ERAS patients. CONCLUSIONS Our protocol for ERAS in neuro-oncology appears to have significant benefits over conventional management: it may accelerate functional recovery and decrease length of stay

Knowledge, Implementation, and Perception of Enhanced Recovery After Surgery Amongst Surgeons in Pakistan: A Survey Analysis.

An increasing shift towards non-communicable diseases and an existing high surgical burden of disease in low-middle-income countries (LMICs), such as Pakistan, has driven the need for implementing Enhanced Recovery After Surgery (ERAS), a safe and cost-effective surgical service aimed at improving patient recovery and reducing post-operative complications. Despite countless benefits, there are few ERAS programs throughout Pakistan andsparse literature on healthcare professionals' views regarding ERAS. Without a deep understanding of healthcare professionals' perspectives on ERAS, underlying barriers and facilitators to a long-term ERAS implementation cannot be addressed and improved upon.Therefore, the purpose of this study is to better understand the knowledge, implementation, and perception of ERAS from the perspective of healthcare professionals across Pakistan. Upon receiving ethical approval from the McGill University Health Center (MUHC), a previously validated questionnaire was modified and a 29-question survey was developed and disseminated to healthcare professionals practising in Pakistan. Quantitative data was analyzed using descriptive statistics and potential correlations that exist between the implementation of ERAS and the participants' gender, employment setting, and surgical specialty were investigated using the chi-squared analysiswith a p-value of 0.05 as the cutoff. A total of 49 participants responded to this survey of whom 34 (69%) worked at a tertiary care teaching hospital whereas 15 (31%) worked at a private hospital. Surprisingly, 42 (85%) participants expressed being aware of the ERAS guidelines with only 30 (61%) either strongly agreeing or agreeing to successfully implementing ERAS into practice. The largest discrepancies in implementation were seen when discussing specific elements of the ERAS guidelines such as preoperative carbohydrate loading, practicing prolonged preoperative fasting, performing mechanical bowel preparation, performing active patient warming, and early postoperative removal of Foley's catheter. Surgeons employed at a private institution were more likely to discuss postoperative pain management and control, less likely to utilize prolonged fasting, more likely to perform regular body temperature monitoring, more likely to practice providing chewing gum to patients postoperatively, and more likely to perform early removal of the Foley's catheter. An understanding of ERAS, the implementation of various elements, and a positive attitude toward its benefits definitely seem to be prevalent among healthcare professionals in Pakistan. However, key barriers and enablers specific to the underlying healthcare environment seem to be hindering the long-term successful implementation of ERAS across Pakistan. It is crucial for future studies to explore these barriers in further detail and involve theperspective of these key stakeholders to help enhance long-term ERAS adoption.

Effect of Carbohydrate Loading in Diabetic Patients Undergoing Laparoscopic Cholecystectomy: A Randomized Controlled Trial.

Investigations of preoperative oral carbohydrate (CHO) loading have primarily examined benefits among patients without diabetes. Preoperative CHO-rich beverages in general populations have resulted in reductions in insulin resistance after surgery, protein loss, metabolic derangements, and immune dysfunction. The aim of this study was to assess the effect of CHO loading in diabetic patients undergoing laparoscopic cholecystectomy. Diabetic patients controlled on oral hypoglycemic agent were randomly divided into two groups: (1) Group T- this group will be given 50 g of maltodextrin before two hours of surgery; (2) Group C- this group will be kept nil per oral as per standard protocol. Blood sugar, serum insulin, serum cortisol, and insulin requirement were compared in both groups. Blood sugar levels of Group C were found to be significantly higher than that of Group T at six hours and 24 hours. In Group T, a rise in baseline serum insulin (8.94 ± 3.43 mIU/l) was observed at 24 hours (13.23 ± 5.71 mIU/l). A change of 4.29 ± 3.00 mIU/l in serum insulin level was observed. The change in baseline serum insulin levels was 47.99%. In Group C too, a rise in baseline serum insulin (6.27 ± 1.74 mIU/l) was observed at 24 hours (18.00 ± 5.34 mIU/l). A change of 11.73 ± 4.97 mIU/l in serum insulin level was observed. The change in baseline HOMA-IR (homeostatic model assessment for insulin resistance) levels in Group T was 53.66%. A rise (4.39 ± 1.63) in baseline HOMA-IR of Group C (1.65 ± 0.45) was observed at 24 hours (6.04 ± 1.76). The change in baseline HOMA-IR levels in Group C was 266.06%. CHO loading is observed to be beneficial in diabetic patients undergoing laparoscopic cholecystectomy. No adverse effects or an increased riskof aspiration were observed in the intervention group during the study period.

Comparison of Enhanced Recovery After Surgery (ERAS) Pathway Versus Standard Care in Patients Undergoing Elective Stoma Reversal Surgery- A Randomized Controlled Trial

BackgroundPractices such as prolonged preoperative fasting, bowel preparation, delayed ambulation and resumption of orals result in morbidity in 15-20% of stoma reversal cases which can be improved by Enhanced Recovery After Surgery (ERAS) pathways. AimTo evaluate the safety, feasibility and efficacy of ERAS pathway in patients undergoing elective loop ileostomy or colostomy reversal surgery MethodsThis was an open-labeled, superiority randomized controlled trial in which patients undergoing loop ileostomy or colostomy reversal were randomized to standard or ERAS care. Patients with ASA class ≥3, needing laparotomy for stoma reversal, cardiac, renal and neurological illnesses were excluded. Components of ERAS protocol included pre-operative carbohydrate loading, avoidance of mechanical bowel preparation, goal directed fluid therapy, avoidance of long-acting opioid anesthetics or analgesics, avoidance of drains, urinary catheter or nasogastric tube, early mobilization and early enteral feeding. The primary outcome was length of stay (LOS) while the secondary outcomes were postoperative recovery and morbidity parameters. ResultsForty patients each were randomized to standard care and ERAS. Demographic and laboratory parameters between the two groups were comparable. ERAS group patients had significantly reduced LOS (5.3±0.3 vs 7 ± 2.6; mean difference: 1.73 ± 0.98; p=0.0008). Functional recovery was earlier in the ERAS group compared to the standard care group, such as early resolution of ileus (median-2 days; p<0.001), time to first stool (median-3 days; p=0.0002), time to the resumption of liquid diet (median-3 days; p<0.001) and solid diet (median-4 days; p<0.001). Surgical site infections (SSI) were significantly lesser in ERAS group (12.5% vs 32.5%; p=0.03) while postoperative nausea/vomiting (p=0.08), pulmonary complications (p=0.17) and urinary tract infections (p=0.56) were comparable in both groups. ConclusionERAS pathways are feasible, safe and significantly reduces LOS in patients undergoing elective loop ileostomy or colostomy reversal surgery.

Enhanced Recovery After Surgery (ERAS®) Society Guidelines for Gynecologic Oncology: Addressing Implementation Challenges - 2023 Update

ABSTRACT Implementation of the Enhanced Recovery after Surgery (ERAS) Society Guidelines in 2016 has resulted in an approximate decrease in hospital length of stay (LOS), reduction in complications and readmission, and cost saving. Recent publications however have demonstrated that barriers and gaps in understanding may result in many ERAS recommendations being poorly adhered to in gynecologic oncology patients. The aims of this second update to the ERAS Society Guidelines for gynecologic oncology is to summarize and update the evidence investigating specific implementation challenges to increase ERAS uptake and improve clinical outcomes for patients. A literature search was conducted for topics specified to 9 ERAS implementation challenges identified: perioperative oral intake safety, preoperative medication importance, penicillin allergies, intraoperative analgesia, how to manage urinary drainage, venous thromboembolism prophylaxis, postoperative opioid prescription practices, same-day discharge programs, and how can I overcome barriers to ERAS implementation. The quality of evidence and recommendations was evaluated, and recommendations graded as strong or weak based on quality, balance between desirable and undesirable effects on holistic clinical outcomes, and on values and preferences of practitioners. Regarding perioperative oral intake safety, patients should be encouraged to consume clear liquids in 2 hours before surgery and preoperative carbohydrate loading improves satisfaction and comfort. Optimal preoperative medications include nonsteroidal anti-inflammatory drugs, acetaminophen, and gabapentinoids. Patients with penicillin allergies should receive standard surgical antibiotic prophylaxis. For intraoperative analgesia, wound infiltration with local anesthetic and TAP block are preferred over thoracic epidural analgesia. Indwelling bladder catheters should be removed as early as possible in the postoperative period such as on the day of surgery for minimally invasive procedures and no later than postoperative day 1 for laparotomy. Patients at increased risk of venous thromboembolism should receive dual prophylaxis with compression and medications, and extended chemoprophylaxis should be prescribed to those with high-risk criteria or after laparotomy. Multimodal opioid-reduction is critical for all patients, and decreased postdischarge opioid proscribing is improved with a team approach and does not affect pain control or patient satisfaction. Patient controlled analgesia is a last resort for those requiring repeated treatment with intravenous opioids. Multidisciplinary same-day discharge programs should be considered in minimally invasive surgeries, and implementation requires a multidisciplinary team approach with patient education, case selection, and ERAS principles. Overcoming barriers to ERAS principles is more successful with changes at the management level and education. Communication of the economic benefits of ERAS to administrators may be a strong incentive to garner support. Although the evidence level varied between moderate and strong for each of these recommendations, the recommendation grade for each was strong. This updated ERAS guideline focuses on addressing implementation challenges and controversial aspects of ERAS defined by a stakeholder clinician group and offers suggestions based on objective data for overcoming these barriers.

The application of enhanced recovery after surgery (ERAS) protocol in radical cystectomy and urinary diversion using bowel segment reduces the length of stay: A multicenter comparative study in Indonesia

Link of Video Abstract: https://youtu.be/GvdRCXyJmuk Introduction: Radical cystectomy is one of the most invasive urological procedures, with high difficulty and various complications. The Enhanced Recovery After Surgery (ERAS) protocol was created to improve patient outcomes after such surgery, including radical cystectomy. This study aims to evaluate the application of ERAS on radical cystectomy in Indonesia. Methods: This was a multicenter study (Jakarta, Yogyakarta, Bandung, and Medan) from July 2016 to April 2021. This study compared the postoperative length of stay, diet intake, bowel movement, and mobilization pattern of the subject receiving ERAS protocol with the non-ERAS subject. Curtailed, fast preoperative carbohydrate loading was administered to patients. There was no mechanical bowel preparation except one day before in selected cases. Postoperative patterns after surgery and the length of stay were analyzed. Results: We collected 128 subjects in this study, with 74 (60 %) subjects enrolled with ERAS protocol and 54 (40 %) with non-ERAS. There were statistically significant differences in length of stay with a median of 11 days vs. 16 (p: 0.001), intensive care unit admission duration with a median of 2 days vs. 3 (p: 0.004) and time to sit after radical cystectomy with a mean of 2.14 days vs 2.89 (p-: 0.004) in subject with ERAS protocol compared to non-ERAS protocol. Conclusion: This multicenter study found that ERAS was demonstrated to be efficacious in decreasing the duration of hospital stay, the duration of intensive care unit admission, and the time for the subject to sit after the radical cystectomy.

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.

Effects of a Preoperative Carbohydrate Load on Postoperative Recovery in Children: A Randomised, Double-Blind, Placebo-Controlled Trial

BackgroundNausea and vomiting are common causes for prolonged postoperative length of hospital stay (LOS) in children. A preoperative carbohydrate load may reduce postoperative nausea and vomiting by improving the perioperative metabolic state. The aim of this study was to determine if a preoperative carbohydrate-containing drink would lead to an improvement in the perioperative metabolic state and consequently reduce the incidence of postoperative nausea, vomiting and LOS in children undergoing day-case surgical procedures. MethodRandomised, double-blind, placebo-controlled trial involving children aged 4 to 16-years undergoing day-case surgical procedures. Patients were randomised to receive a carbohydrate-containing drink or a placebo. During the induction of anaesthesia, a venous blood gas, and blood glucose and ketone levels were measured. Postoperatively, the incidence of nausea, vomiting, and LOS were documented. Results120 patients were randomised with 119/120 (99.2%) undergoing analysis. Blood glucose level was higher in the carbohydrate group; 5.4 mmol/L [3.3–9.4] versus 4.9 mmol/L [3.6–6.5] (p = 0.01). Blood ketone level was lower in the carbohydrate group; 0.2 mmol/L versus 0.3 mmol/L (p = 0.003). The incidence of nausea and vomiting was not different (p > 0.9 and p = 0.8, respectively). LOS in the carbohydrate group was 26 min shorter than the placebo group (p = 0.02). ConclusionAlthough a preoperative carbohydrate load may provide a more stable metabolic state at the induction of anaesthesia, we did not find a reduction in postoperative nausea and vomiting. A preoperative carbohydrate load has also minimal effects on the postoperative LOS. Type of studyRandomised clinical trial. Level of evidenceI.