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Carb Loading Prior to Surgery

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by

Lauryn Richert

on 29 April 2014

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Transcript of Carb Loading Prior to Surgery

Length of Hospital Stay
Postoperative Insulin Resistance (PIR)
In adults undergoing elective surgery, does carbohydrate loading with a liquid beverage 3 hours prior to surgery decrease the length of stay, decrease nausea and vomiting, and decrease insulin resistance compared to those who do not carbohydrate load?

Problem Statement
Identify the Problem
Identify the Problem
34% of adult Americans have insulin resistance, or metabolic syndrome (WebMD, 2012)
Excessive fasting period creates the potential for poor glycemic control (Dhatariya, 2011).
Hyperglycemia is associated with prolonged wound healing and arterial hypotension (Hahn, 2013).


In major surgical procedures, up to 90% of patients have stress induced hyperglycemia (Ljungqvist, 2010).
An increase in insulin resistance by 50% post surgery raise the risk of major complications 5 to 6 times (Ljungqvist, 2010).

Average length of stay
colorectal surgery: 10 days
(Abraham, 2011)
open liver resection: 6-7 days
(Jones, 2013)
CABG: 22 days
(Brewer, 2006)
"An increase in insulin resistance by 50% after surgery increased the risk……..for a severe infection by more than 10-fold," increasing the length of hospital stay (Ljungqvist, 2010, p. 4217).


University of Oklahoma
College of Nursing
Research shows....
Does it effect patient outcomes?
Postoperative Nausea & Vomiting (PONV)
Identify the Problem
Postoperative Insulin Resistance (PIR)

30% of Patients experience PONV (Smith, 2012).
The overall incidence of PONV in surgical patients is 25-30%, but among high risk patients in can be as high as 70-80% (Doubravska, 2010).
PONV may increase perioperative cost, perioperative morbidity, and increase readmissions (Smith, 2012).
Anesthesia studies from France suggest that approximately 30% of surgical patients developed PONV symptoms, totaling 2 million patients with PONV (Tramer, 2004).

Carbohydrate Loading Prior to Surgery

by Shey Beene, Ashley McWilliams, Lauryn Richert & Steven Wingfield
The lack of carbohydrate loading in elective preoperative surgical patients increases the risk of post operative nausea and vomiting, increases insulin resistance in non-diabetic patients, and contributes to an increased length of stay.

PICO Question

No cases of apparent or suspected pulmonary aspiration (Wang, 2010)
Improved hand grip strength (Lidder, 2012)
Improved pulmonary function (Lidder, 2012)
Quicker return of bowel function (Jones, 2011)
Lower risk of postop complications (Gustafsson, 2011)

Decreased LOS in carbohydrate drink group.
91 patients, Open Liver Resection: 3 days less RCT (Jones, 2013)
743 patients, Colorectal Surgery: 3.5 days less Systematic Review (Jones, 2011)
240 patients colorectal surgery: 3 days less Retrospective Analysis (Keane, 2011)
No significant difference in LOS in either group.
1578 patients, Elective surgery, Systematic Review (Li, 2012)
160 patients, CABG, Double Blind (Breuer, 2006)
Decrease PONV in carbohydrate drink group
743 patients, Colorectal Surgery, Systematic Review (Jones, 2011)
40 patients, Lap Chole Surgery, Randomized Single Blind (Yilmaz, 2013)
No significant PONV difference in either group.
1578 patients, Elective surgery, Systematic Review (Li, 2012)

Surgeries Performed in 2013
Scope of Local Impact
St Francis Medical Center: 27,000
St. John’s Medical Center: 18,454
Hillcrest Medical Center: 14,330
Oklahoma State University Medical Center: 3,704


Important Information
Literature Review
References
Postoperative insulin was decreased in the preoperative carbohydrate group.
48 patients. Colorectal Surgery. Double Blind RCT (Wang, 2010)
120 patients. Colorectal Surgery. Double Blind RCT (Lidder, 2012)
1445 patients. Elective surgery. Systematic Review (Bilku, 2014)
No significant difference in glucose levels or requirements in groups.
160 diabetic type 2 patients. CABG. RCT (Breuer, 2006)


Postoperative Nausea & Vomiting (PONV)
Length of Hospital Stay (LOS)
Other Potential Benefits
Although the majority of current literature includes an Enhanced Recovery After Surgery (ERAS) protocol, and impacts cannot be exclusively linked to carbohydrate loading, early studies focused only on carbohydrate loading.
5
Carbohydrate Liquid Beverage
Intervention
Hypo-osmolar 12.5% carbohydrate drink
Not to be given to high risk patients
Loading dose: 800ml the evening before surgery
Final dose: 400ml in the morning up to 3 hr before anesthesia

Preoperative Carbohydrate Loading
Practice Guidelines
Preoperative oral carbohydrate loading should be administered to all non-diabetic patients (Nygern, 2013)
Prescribe a carbohydrate-rich beverage to be consumed two to three hours before scheduled procedure. (Crenshaw, 2011)
Patients be allowed to drink clear liquids until 2 hours before surgery. (Kratzing, 2011)
Use of pre-operative carbohydrate-loading drinks has been identified as a key factor in enabling enhanced recovery following elective surgery. (Burch, 2012)


Preoperative Carbohydrate Loading
Barriers to Implementation
PreOp drink not approved in United States.
Flexible Surgical Schedules
Lack of Education
-Perceived Risk of Aspiration
Inclusion Population
-Only applies to low risk surgical patients.



Abraham, A., Albayati, S. (2011). Enhanced recovery after surgery programs hasten recovery after colorectal resections. World Journal of Gastrointestinal Surgery, 3(1), 1-6.
Bilku, D. K., Dennison, A. R., Hall, T. C., Metcalfe, M. S., & Garcea, G. (2014). Role of preoperative carbohydrate loading: a systematic review . Annals of the Royal College of Surgeons of England, 96(1), 15-22.
Breuer, J. P., Dossow, V. V., Heymann, C. V. Griesbach, M., von Schickfus, M., Mackh, E., Hacker, C., Elgeti, U., Konertz, W., Wemecke, K. D., Spies, C. D. (2006). Preoperative Oral Carbohydrate Administration to ASA III-IV Patients Undergoing Elective Cardiac Surgery.
Burch, J. (2012). Enhanced recovery for patients following colorectal surgery. Nursing Standard. 27(2), 37- 43.
Crenshaw, J. T. (2011). Preoperative fasting: will the evidence ever be put into practice?. The American Journal of Nursing, 111(10), 38-43.
Dhatariya, K., Flanagan, D., Hilton, L., Kilvert, A., Levy, N., Rayman, G., Watson, B. (2011). Management of adults with diabetes undergoing surgery and elective procedures: improving standards. Retrieved March 25, 2014, from NHS Trust: www.diabetes.nhs.uk
Gustafsson U. O., Hausel, J., Thorell, A., Ljungqvist, O., Soop, M., & and Nygren, J.(2011). Adherence to the Enhanced Recovery After Surgery Protocol Outcomes After Colorectal Cancer Surgery. Arch Surg, 146(5), 571-577.
Hahn, R.G., & Ljunggren, S. (2013). Preoperative insulin resistance reduces complications after hip replacement surgery in non-diabetic patients. BMC Anesthesiology. 13(39).

Jones, C., Bader, S.A., Hannon, R. (2011). The role of carbohydrate drinks in pre-operative nutrition for elective colorectal surgery. Advancing Surgical Standards, 93, 504-507.
Jones, C., Kelliher, L., Dickinson, M., Riga, A., Worthington, T., Scott, M. J., ... Karanjia, N. (2013). Randomized clinical trial on enhanced recovery versus standard care following open liver resection. British Journal of Surgery, 100(), 1015-1024.
Keane, C., Savage, S., McFarlane, K., Seigne, R., Robertson, G. & Eglington, T. (2011). Enhanced recovery after surgery versus conventional care in colonic and rectal surgery. ANZ Journal of Surgery, 82, 697-703.
Kratzing, C. (2011). Symposium 3: Nutrition is the cutting edge in surgery: peri-operative feeding, Pre-operative nutrition and Carbohydrate Loading. Proceedings of the Nutrition Society Conference on ‘Malnutrition matters,’ 70, 311-315.
Lee, J. M., Okumura, M. J., Davis, M. M., Herman, W. H., & Gurney, J. G. (January 01, 2006). Prevalence and determinants of insulin resistance among U.S. adolescents: a population-based study. Diabetes Care, 29, 11, 2427-32.


Lenka Doubravska, K. D. (2010, January 27). Incidence of Postoperative Nausea and Vomiting in Patients at a University Hospital. Where are we Today? Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. , 69-76.
Li, L., Wang, Z., Ying, X., Tian, J., Sun, T., Yi, K., Zhang, P., Yang, K. (2012). Preoperative carbohydrate loading for elective surgery: a systematic review and meta-analysis. Surgery Today, 42, 7, 613-24.
Lidder, P., Thomas, S., Fleming, S., Hosie, K., Shaw, S., & Lewis, S. (2012). A randomized placebo controlled trial of preoperative carbohydrate drinks and early postoperative nutritional supplement drinks in colorectal surgery. The Association of Coloproctology of Great Britain and Ireland, 15, 737–746.
Ljungqvist, O. (January 01, 2010). Insulin resistance and outcomes in surgery. The Journal of Clinical Endocrinology and Metabolism, 95, 9, 4217-9.
Moghissi ES, Korytkowski MT, Dinardo MM, Hellman R, Hirsch IB, Inzucchi S et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care 2009;32:1119-31.
Nygren, J., Thacker, J., Carli, F., Fearon, K.C.H., Norderval, S., Lobo, D.N., Ljungqvist, O., Soop, M., & Ramirez, J. (2012). Guidelines for perioperative care in elective rectal/pelvic surgery. World Journal of Surgery. 37, 285-305.
Smith, H. S., Smith, E. J., Smith, B.R. (2012). Postoperative nausea and vomiting. Annals of Palliative Medicine, 1(2), 94-102 
Tramer, M. R. (2004). Strategies for postoperative nausea and vomiting. Best Practice & Research Clinical Anaesthesiology, 18(4), 693-701. Retrieved Google.com
Wang, Z. G., Wang, Q., Wang, W. J., & Qin, H. L. (March 01, 2010). Randomized clinical trial to compare the effects of preoperative oral carbohydrate versus placebo on insulin resistance after colorectal surgery. British Journal of Surgery, 97(3), 317-327
WebMD (2012, May 15). Insulin Resistance Syndrome (Metabolic Syndrome) Symptoms, Treatments. Retrieved from http://www.webmd.com/diabetes/guide/insulin-resistance-syndrome
Yilmaz, N., Cekmen, N., Bilgin, F., Erten, E., Ozhan, M. O. & Cosar, A. (2013). Preoperative carbohydrate nutrition reduces postoperative nausea and vomiting compared to preoperative fasting. Journal of Research in Medical Sciences, 18, 827–832.

Preoperative Carbohydrate Loading
Evaluation on Effectiveness
Track monthly rates of nausea and vomiting via patient report and use of anti emetics, insulin resistance via finger stick glucometer readings, and length of stay.
Evaluate trends in rates of increase or decrease in outcome parameters.
Make recommendations for continuing or changing protocol as trends dictate.



Preoperative Carbohydrate Loading
Further Study Suggestions
Pediatric Patients
Diabetic Patients
Patients With Delayed Gastric Emptying


Patients With Renal Insufficiency
Obese Patients
Preoperative Carbohydrate Loading
Future Study Questions
Does the relevance of gastric acidity to the digestion of the CHO drink make a difference?
Does the CHO drink alone with no other postoperative interventions have the same effects on patient outcome?
Does a CHO drink help any surgical patients, such as c-section, emergency surgery, gastrointestinal, thyroidectomy, etc?
Full transcript