Preoperative Carbohydrate Treatment Research Articles

AUGS-IUGA Joint Clinical Consensus Statement on Enhanced Recovery After Urogynecologic Surgery

AUGS-IUGA Joint Clinical Consensus Statement on Enhanced Recovery After Urogynecologic Surgery

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).

Postoperative inflammation and insulin resistance in relation to body composition, adiposity and carbohydrate treatment: A randomised controlled study

SummaryBackground & aimsThe aims of this study were to identify whether differences in distribution of adipose tissue and skeletal muscle in obese and non-obese individuals contribute to the magnitude of the postoperative inflammatory response and insulin resistance, with and without preoperative treatment with carbohydrate drinks.MethodsThirty-two adults (16 obese/16 non-obese) undergoing elective major open abdominal surgery participated in this 2 × 2 factorial, randomised, double-blind, placebo-controlled study. Participants received Nutricia preOp® or placebo (800 ml on the night before surgery/400 ml 2–3 h preoperatively) after stratifying for obesity. Insulin sensitivity was measured using the hyperinsulinaemic-euglycaemic clamp preoperatively and on the 1st postoperative day. Vastus lateralis, omental and subcutaneous fat biopsies were taken pre- and postoperatively and analysed after RNA extraction. The primary endpoint was within subject differences in insulin sensitivity.ResultsMajor abdominal surgery was associated with a 42% reduction in insulin sensitivity from mean(SD) M value of 37.3(11.8) μmol kg−1 fat free mass (FFM) to 21.7(7.4) μmol kg−1 FFM, but this was not influenced by obesity or preoperative carbohydrate treatment. Activation of the triggering receptor expressed on myeloid cells (TREM1) pathway was seen in response to surgery in omental fat samples. In postoperative muscle samples, gene expression differences indicated activation of the peroxisome proliferator-activated receptor (PPAR-α)/retinoid X-receptor (RXR-α) pathway in obese but not in non-obese participants. There were no significant changes in gene expression pathways associated with carbohydrate treatment.ConclusionThe reduction in insulin sensitivity associated with major abdominal surgery was confirmed but there were no differences associated with preoperative carbohydrates or obesity.

An Enhanced Recovery After Surgery (ERAS) Protocol for Ambulatory Anorectal Surgery Reduced Postoperative Pain and Unplanned Returns to Care After Discharge

Ambulatory surgery for anorectal procedures has been proven to be safe and effective. Specific perioperative pathways combining multiple interventions have been shown to optimize recovery and outcomes associated with inpatient colorectal surgery. However, there are no major studies describing and evaluating a standardized protocol for ambulatory anorectal surgery. The purpose of this study was to evaluate the outcomes of a modified enhanced recovery after surgery (ERAS) protocol for ambulatory anorectal surgery. This was a retrospective review of prospectively collected data from 14 Southern California Kaiser Permanente medical centers. An eight-item protocol including: preoperative education, preoperative distribution of prescriptions, preoperative carbohydrate treatment, multimodal analgesia, preferential use of monitored anesthesia care (MAC), routine use of local anesthesia/regional blocks, intraoperative restriction of intravenous fluids, and post-discharge phone call. Postoperative pain scores and preventable returns to the emergency department or urgent care were assessed. Postoperative pain scores were reduced when all eight elements of the protocol were delivered (p=0.005). On multivariate analysis, there was reduced postoperative pain when preoperative carbohydrate treatment was completed (p=0.002), with MAC (p=0.003), and when multimodal analgesia was used (p=0.02). There were decreased preventable returns to the emergency department or urgent care when MAC was used (p=0.03); there were more returns for constipation (p=0.04) but fewer returns for pain (p=0.002) after preoperative carbohydrate treatment. Local anesthesia was associated with fewer returns for constipation (p=0.01). Implementation of a standardized ERAS protocol for ambulatory anorectal surgery decreased postoperative pain and unplanned return visits to emergency care.

Enhanced recovery after surgery (ERAS®) in gynecologic oncology - Practical considerations for program development.

Enhanced recovery after surgery (ERAS®) in gynecologic oncology - Practical considerations for program development.

Optimal perioperative care in major head and neck cancer surgery with free flap reconstruction

Importance: Head and cancers often require complex, labor-intensive surgeries, especially when free flap reconstruction is required. Enhanced recovery is important in this patient population but evidence-based protocols on perioperative care for this population are lacking. Objective: To provide a consensus-based protocol for optimal perioperative care of patients undergoing and cancer surgery with free flap reconstruction. Evidence Review: Following endorsement by the Enhanced Recovery After Surgery (ERAS) Society to develop this protocol, a systematic review was conducted for each topic. The PubMed and Cochrane databases were initially searched to identify relevant publications on and cancer surgery from 1965 through April 2015. Consistent key words for each topic included head and surgery, pharyngectomy, laryngectomy, laryngopharyngectomy, neck dissection, parotid lymphadenectomy, thyroidectomy, oral cavity resection, glossectomy, and head and neck. The final selection of literature included meta-analyses and systematic reviews as well as randomized controlled trials where available. In the absence of high-level data, case series and nonrandomized studies in and cancer surgery patients or randomized controlled trials and systematic reviews in non-head and cancer surgery patients, were considered. An international panel of experts in major and cancer surgery and enhanced recovery after surgery reviewed and assessed the literature for quality and developed recommendations for each topic based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. All recommendations were graded following a consensus discussion among the expert panel. Findings: The literature search, including a hand search of reference lists, identified 215 relevant publications that were considered to be the best evidence for the topic areas. A total of 17 topic areas were identified for inclusion in the protocol for the perioperative care of patients undergoing major and cancer surgery with free flap reconstruction. Best practice includes several elements of perioperative care. Among these elements are the provision of preoperative carbohydrate treatment, pharmacologic thromboprophylaxis, perioperative antibiotics in clean-contaminated procedures, corticosteroid and antiemetic medications, short acting anxiolytics, goal-directed fluid management, opioid-sparing multimodal analgesia, frequent flap monitoring, early mobilization, and the avoidance of preoperative fasting. Conclusions and Relevance: The evidence base for specific perioperative care elements in and cancer surgery is variable and in many cases information from different surgerical procedures form the basis for these recommendations. Clinical evaluation of these recommendations is a logical next step and further research in this patient population is warranted.

Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations — Part I

Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations — Part I

Preoperative carbohydrate treatment for enhancing recovery after elective surgery.

Preoperative carbohydrate treatments have been widely adopted as part of enhanced recovery after surgery (ERAS) or fast-track surgery protocols. Although fast-track surgery protocols have been widely investigated and have been shown to be associated with improved postoperative outcomes, some individual constituents of these protocols, including preoperative carbohydrate treatment, have not been subject to such robust analysis. To assess the effects of preoperative carbohydrate treatment, compared with placebo or preoperative fasting, on postoperative recovery and insulin resistance in adult patients undergoing elective surgery. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 3), MEDLINE (January 1946 to March 2014), EMBASE (January 1947 to March 2014), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (January 1980 to March 2014) and Web of Science (January 1900 to March 2014) databases. We did not apply language restrictions in the literature search. We searched reference lists of relevant articles and contacted known authors in the field to identify unpublished data. We included all randomized controlled trials of preoperative carbohydrate treatment compared with placebo or traditional preoperative fasting in adult study participants undergoing elective surgery. Treatment groups needed to receive at least 45 g of carbohydrates within four hours before surgery or anaesthesia start time. Data were abstracted independently by at least two review authors, with discrepancies resolved by consensus. Data were abstracted and documented pro forma and were entered into RevMan 5.2 for analysis. Quality assessment was performed independently by two review authors according to the standard methodological procedures expected by The Cochrane Collaboration. When available data were insufficient for quality assessment or data analysis, trial authors were contacted to request needed information. We collected trial data on complication rates and aspiration pneumonitis. We included 27 trials involving 1976 participants Trials were conducted in Europe, China, Brazil, Canada and New Zealand and involved patients undergoing elective abdominal surgery (18), orthopaedic surgery (4), cardiac surgery (4) and thyroidectomy (1). Twelve studies were limited to participants with an American Society of Anaesthesiologists grade of I-II or I-III.A total of 17 trials contained at least one domain judged to be at high risk of bias, and only two studies were judged to be at low risk of bias across all domains. Of greatest concern was the risk of bias associated with inadequate blinding, as most of the outcomes assessed by this review were subjective. Only six trials were judged to be at low risk of bias because of blinding.In 19 trials including 1351 participants, preoperative carbohydrate treatment was associated with shortened length of hospital stay compared with placebo or fasting (by 0.30 days; 95% confidence interval (CI) 0.56 to 0.04; very low-quality evidence). No significant effect on length of stay was noted when preoperative carbohydrate treatment was compared with placebo (14 trials including 867 participants; mean difference -0.13 days; 95% CI -0.38 to 0.12). Based on two trials including 86 participants, preoperative carbohydrate treatment was also associated with shortened time to passage of flatus when compared with placebo or fasting (by 0.39 days; 95% CI 0.70 to 0.07), as well as increased postoperative peripheral insulin sensitivity (three trials including 41 participants; mean increase in glucose infusion rate measured by hyperinsulinaemic euglycaemic clamp of 0.76 mg/kg/min; 95% CI 0.24 to 1.29; high-quality evidence).As reported by 14 trials involving 913 participants, preoperative carbohydrate treatment was not associated with an increase or a decrease in the risk of postoperative complications compared with placebo or fasting (risk ratio of complications 0.98, 95% CI 0.86 to 1.11; low-quality evidence). Aspiration pneumonitis was not reported in any patients, regardless of treatment group allocation. Preoperative carbohydrate treatment was associated with a small reduction in length of hospital stay when compared with placebo or fasting in adult patients undergoing elective surgery. It was found that preoperative carbohydrate treatment did not increase or decrease postoperative complication rates when compared with placebo or fasting. Lack of adequate blinding in many studies may have contributed to observed treatment effects for these subjective outcomes, which are subject to possible biases.

Insulin sensitivity and beta-cell function after carbohydrate oral loading in hip replacement surgery: A double-blind, randomised controlled clinical trial

Surgery initiates a series of physiological stress processes in the body, inducing transient insulin resistance. Preoperative carbohydrate treatment can reduce the latter phenomenon. We investigated the effects of carbohydrate loading on insulin sensitivity and beta-cell function after elective hip replacement. Twenty-three nondiabetic patients (mean age of 68 years) who underwent elective hip replacement surgery participated in this double-blind controlled study. The patients were randomised to a nutrition group, which ingested a carbohydrate-rich fluid (50 kcal/100 ml) (Preop(®)), or a control group (tap water flavoured with lemon) 800 ml + 400 ml before the surgery. The insulin response (beta-cell function) and the insulin sensitivity were measured with an intravenous glucose tolerance test (IVGTT) and a hyperinsulinaemic euglycaemic glucose clamp, respectively, one day before and two days after the surgery. Insulin sensitivity decreased by 51% (median; 25-75th percentiles 35-61) after ingesting Preop(®) and by 39% (21-51) after ingesting in the control group (n.s.). The postoperative IVGTT in the nutrition group was followed by a significantly larger area under the curve (AUC) for plasma insulin (+54% versus the preoperative IVGTT) compared to the control group (+7%). This difference was already apparent during the first phase (0-10 min) of insulin secretion (+20 and -21%, respectively; P < 0.05). The patients randomised to the carbohydrate oral fluid or the water prior to the surgery demonstrated a significant but similar decrease in insulin sensitivity. The carbohydrates increased the beta-cell function as a compensatory response to the disposition index, resulting in a smaller reduction in surgery-induced insulin resistance compared to the tap water. The study was registered at http://www.clinicaltrials.gov (NCT01774084).

A meta-analysis of randomised controlled trials on preoperative oral carbohydrate treatment in elective surgery

Whilst preoperative carbohydrate treatment (PCT) results in beneficial physiological effects, the effects on postoperative clinical outcomes remain unclear and were studied in this meta-analysis. Prospective studies that randomised adult non-diabetic patients to either PCT (≥50 g oral carbohydrates 2-4 h pre-anaesthesia) or control (fasted/placebo) were included. The primary outcome was length of hospital stay. Secondary outcomes included development of postoperative insulin resistance, complications, nausea and vomiting. Methodological quality was assessed using GRADEpro® software. Twenty-one randomised studies of 1685 patients (733 PCT: 952 control) were included. No overall difference in length of stay was noted for analysis of all studies or subgroups of patients undergoing surgery with an expected hospital stay ≤2 days or orthopaedic procedures. However, patients undergoing major abdominal surgery following PCT had reduced length of stay [mean difference, 95% confidence interval: -1.08 (-1.87 to -0.29); I² = 60%, p = 0.007]. PCT reduced postoperative insulin resistance with no effects on in-hospital complications over control (risk ratio, 95% confidence interval, 0.88 (0.50-1.53), I² = 41%; p = 0.640). There was significant heterogeneity amongst studies and, therefore, quality of evidence was low to moderate. PCT may be associated with reduced length of stay in patients undergoing major abdominal surgery, however, the included studies were of low to moderate quality.

PP011-SUN A META-ANALYSIS OF RANDOMISED CONTROLLED TRIALS ON PREOPERATIVE ORAL CARBOHYDRATE TREATMENT IN ELECTIVE SURGERY

summary Background & aims: Whilst preoperative carbohydrate treatment (PCT) results in beneficial physiological effects, the effects on postoperative clinical outcomes remain unclear and were studied in this metaanalysis. Methods: Prospective studies that randomised adult non-diabetic patients to either PCT (� 50 g oral carbohydrates 2e4 h pre-anaesthesia) or control (fasted/placebo) were included. The primary outcome was length of hospital stay. Secondary outcomes included development of postoperative insulin resistance, complications, nausea and vomiting. Methodological quality was assessed using GRADEpro software. Results: Twenty-one randomised studies of 1685 patients (733 PCT: 952 control) were included. No overall difference in length of stay was noted for analysis of all studies or subgroups of patients undergoing surgery with an expected hospital stay � 2 days or orthopaedic procedures. However, patients undergoing major abdominal surgery following PCT had reduced length of stay [mean difference, 95% confidence interval: � 1.08 (� 1.87 to � 0.29); I 2 ¼ 60%, p ¼ 0.007]. PCT reduced postoperative insulin resistance with no effects on in-hospital complications over control (risk ratio, 95% confidence interval, 0.88 (0.50e1.53), I 2 ¼ 41%; p ¼ 0.640). There was significant heterogeneity amongst studies and, therefore, quality of evidence was low to moderate. Conclusions: PCT may be associated with reduced length of stay in patients undergoing major abdominal surgery, however, the included studies were of low to moderate quality.

Jonathan E. Rhoads Lecture 2011

This lecture reviews the current understanding of how insulin resistance, as a marker of the metabolic stress, is involved in recovery after major surgery. Insulin resistance develops as a graded response related to the magnitude of the operation. It lasts for weeks after medium-size surgery and affects all parts of body metabolism. Although hyperglycemia develops, muscle and fat uptake is reduced and other non-insulin-sensitive cells have an increase in glucose uptake as a result of the elevated glucose levels. Reduced glucose uptake and storage in muscle along with loss of lean body mass help explain reduced muscle function that will impair mobilization. The increased uptake of glucose in non-insulin-sensitive cells is involved in the development of several of the most common postoperative complications, including infections and cardiovascular problems. Many of the perioperative treatments in use are outdated, and modern care involves a multimodal approach with several treatments, such as preoperative carbohydrate treatment instead of overnight fasting, continuous epidural anesthesia for postoperative pain care, early feeding, and mobilization, all of which affect insulin by reducing the stress and enhancing recovery. Most of the previous mandatory catabolic responses to surgery can be avoided, resulting in substantially faster recovery and fewer complications. Methods to implement these modern treatments have been developed and used in Europe, resulting in improved care and shorter length of stay.

Perioperative perturbations in carnitine metabolism are attenuated by preoperative carbohydrate treatment: Another mechanism by which preoperative feeding may attenuate development of postoperative insulin resistance

Fasting increases lipid flux into mitochondria causing excessive β-oxidation, carnitine acylation and impaired cellular glucose uptake. Preoperative carbohydrate treatment (PCT) attenuates postoperative insulin resistance, but mechanisms underlying this and the effects on carnitine metabolism remain largely unknown. Pre-, intra- and-postoperative (day 1) plasma, and intraoperative rectus muscle mitochondrial free (FC), acyl (AC) and total (TC) carnitine concentrations were determined radioenzymatically in non-diabetic patients undergoing laparoscopic cholecystectomy in a post hoc analysis of a randomised double-blind study (NCT00662376). Patients received 600 ml of a carbohydrate-based drink (ONS, Fresenuis Kabi, N = 15, 50 g carbohydrate, 15 g glutamine and antioxidants/300 ml) or placebo (N = 15, 0 g carbohydrate) the evening before surgery, and 300 ml 3-4 h pre-anaesthesia. No intra- or intergroup differences occurred in pre- or intraoperative plasma FC, TC or AC concentrations. Postoperatively, plasma TC and FC concentrations increased in the placebo group (p = 0.005 and p = 0.013). In the ONS group, postoperative increases occurred in plasma TC (p = 0.048). Increases in postoperative plasma TC and FC concentrations were attenuated in the ONS group (p = 0.013 and p = 0.044, respectively). No intergroup differences occurred in intraoperative mitochondrial carnitine concentrations. Preventing excessive/incomplete mitochondrial β-oxidation, characterised by perturbed carnitine metabolism, may be a mechanism by which PCT attenuates the reduction in postoperative insulin sensitivity.

Anesthesia Literature Review

Anesthesia Literature Review

Randomized controlled trial of preoperative oral carbohydrate treatment in major abdominal surgery

Major surgery is associated with postoperative insulin resistance which is attenuated by preoperative carbohydrate (CHO) treatment. The effect of this treatment on clinical outcome after major abdominal surgery has not been assessed in a double-blind randomized trial. Patients undergoing elective colorectal surgery or liver resection were randomized to oral CHO or placebo drinks to be taken on the evening before surgery and 2 h before induction of anaesthesia. Primary outcomes were postoperative length of hospital stay and fatigue measured by visual analogue scale. Sixty-nine and 73 patients were evaluated in the CHO and placebo groups respectively. The groups were well matched with respect to surgical procedure, epidural analgesia, laparoscopic procedures, fasting period before induction and duration of surgery. Postoperative changes in fatigue score from baseline did not differ between the groups. Median (range) hospital stay was 7 (2-35) days in the CHO group and 8 (2-92) days in the placebo group (P = 0.344). For patients not receiving epidural blockade or laparoscopic surgery (20 CHO, 19 placebo), values were 7 (3-11) and 9 (2-48) days respectively (P = 0.054). Preoperative CHO treatment did not improve postoperative fatigue or length of hospital stay after major abdominal surgery. A benefit is not ruled out when epidural blockade or laparoscopic procedures are not used. ACTRN012605000456651 (http://www.anzctr.org.au).

Preoperative oral carbohydrate treatment attenuates endogenous glucose release 3 days after surgery

Background & aims: Postoperative metabolism is characterised by insulin resistance and a negative whole-body nitrogen balance. Preoperative carbohydrate treatment reduces insulin resistance in the first day after surgery. We hypothesised that preoperative oral carbohydrate treatment attenuates insulin resistance and improves whole-body nitrogen balance 3 days after surgery. Methods: Fourteen patients undergoing total hip replacement were double-blindly randomised to preoperative oral carbohydrate treatment (12.5%, 800+400 ml, n=8) or placebo ( n=6). Glucose kinetics (6,6-D 2-glucose), substrate utilisation (indirect calorimetry) and insulin sensitivity (hyperinsulinaemic-euglycaemic clamp) were measured preoperatively and on the third day after surgery. Nitrogen losses were monitored for 3 days after surgery. Values are mean (SEM). Analysis of variance (ANOVA) statistics were used. Results: Endogenous glucose release during insulin infusion increased after surgery in the placebo group. Preoperative carbohydrate treatment, as compared to placebo, significantly attenuated postoperative endogenous glucose release (0.69 (0.07) vs. 1.21 (0.13) mg kg −1·min −1, P<0.01), while whole-body glucose disposal and nitrogen balance were similar between groups. Conclusions: While insulin resistance in the first day after surgery has previously been characterised by reduced glucose disposal, enhanced endogenous glucose release was the main component of postoperative insulin resistance on the third postoperative day. Preoperative carbohydrate treatment attenuated endogenous glucose release on the third postoperative day.