Abbreviated Perioperative Fasting Management for Elective Fresh Fracture Surgery: Guideline Adherence Analysis

BackgroundLong-term fasting for elective surgery has been proven unnecessary based on established guidelines. Instead, preoperative carbohydrate loading 2 hours before surgery and recommencing oral nutrition intake as soon as possible after surgery is recommended. This study was performed to analyze the compliance with and effect of abbreviated perioperative fasting management in patients undergoing surgical repair of fresh fractures based on current guidelines.MethodsPatients with fresh fractures were consecutively enrolled from May 2019 to July 2019 at our hospital. A carbohydrate-enriched beverage was recommended up to 2 hours before surgery for all surgical patients except those with contraindications. Postoperatively, oral clear liquids were allowed once the patients had regained full consciousness, and solid food was allowed 1 to 2 hours later according to the patients’ willingness. The perioperative fasting time was recorded and the patients’ subjective comfort with respect to thirst and hunger was assessed using an interview-assisted questionnaire.ResultsIn total, 306 patients were enrolled in this study. The compliance rate of preoperative carbohydrate loading was 71.6%, and 93.5% of patients began ingestion of oral liquids within 2 hours after surgery. The median (interquartile range) preoperative fasting time for liquids and solids was 8 (5.2–12.9) and 19 (15.7–22) hours, respectively. The median postoperative fasting time for liquids and solids was 1 (0.5–1.9) and 2.8 (2.2–3.5) hours, respectively. A total of 70.3% and 74.2% of patients reported no thirst or hunger during the perioperative period. Logistic regression analysis showed that the preoperative fasting time for liquids was an independent risk factor for perioperative hunger. No adverse events such as aspiration pneumonia or gastroesophageal reflux were observed.ConclusionsIn this study of a real clinical practice setting, abbreviated perioperative fasting management was carried out with high compliance in patients with fresh fractures. The preoperative fasting time should be further shortened to further improve patients’ subjective comfort.

P-OGC07 The Role of Carbohydrate Loading on Lactate and Glucose Levels in Upper GI Cancer Surgery

Background Surgical stress is a significant factor in metabolic dysregulation in the perioperative setting. Its impact on insulin resistance is regarded as one of the most detrimental effects, contributing to post-operative complications and poor outcomes. Clinical markers of this include glucose and lactate levels, with hyperglycaemia and hyperlactataemia the predicted responses by the body. One way of minimising the impact of surgical stress is pre-operative carbohydrate loading, which in theory will provide more substrate for metabolism. Our aim was to investigate whether carbohydrate loading had any impact on lactate and glucose levels in patients undergoing upper gastrointestinal cancer resections. Methods A retrospective observational feasibility study was performed looking at 42 patients who had undergone either an oesophagectomy or gastrectomy. Patients were divided depending on whether they received pre-operative carbohydrate loading. Lactate and glucose levels both intra-operatively and post-operatively were collected. Mean difference was compared between the two groups at 4 hours intra-operatively, 2 hours post-operatively and 12 hours post-operatively using unpaired t tests, with significance at P < 0.05. Variance between the two groups was analysed. Secondary outcomes included analysis based on type of operation, anastomotic leaks, and post-operative intravenous fluid use in the first 24 hours. Results There was no statistically significant difference in lactate levels between the two test groups at any time point. Mean difference at intra-operative 4 hours 0.0408mmol/L (+/- 0.2537, P = 0.8731); post-operative 2 hours 0.2697mmol/L (+/- 0.3008, P = 0.3754); post-operative 12 hours 0.2327mmol/L (+/- 0.2368, P = 0.3318). Glucose levels at the same time points were not significantly different: intra-operative 4 hours 0.068mmol/L (+/- 0.5322, P = 0.5746); post-operative 2 hours -0.2649mmol/L (+/- 0.4679, P = 0.5746); post-operative 12 hours 0.3773mmol/L (+/- 0.3629, P = 0.305). Secondary outcomes did not show any statistically significant differences between analysed groups. Conclusions Pre-operative carbohydrate loading does not seem to influence lactate or glucose levels in these patients either intra-operatively or post-operatively. The lack of significant differences between the two cohorts may be due to underpowering of the sample size, as this is a small feasibility study. We assume that carbohydrate loading would reduce insulin resistance and therefore lactate and glucose levels. However, could it be that carbohydrate loading is not having as much of an effect on patient metabolism as we think? A larger prospective study is recommended to investigate its impact on clinical biochemistry and patient outcomes.

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

ObjectivesMalnutrition and weight loss are important risk factors for complications after lung surgery. However, it is uncertain whether modifying or optimising perioperative nutritional state with oral supplements results in a reduction in malnutrition, complications, and quality of life.DesignA randomised, open label, controlled feasibility study was conducted to assess the feasibility of carrying out a large multicentre randomised trial of nutritional intervention. The intervention consisted of preoperative carbohydrate-loading drinks (4x 200mls evening before surgery and 2x 200mls the morning of surgery), and early postoperative nutritional protein supplement drinks twice a day for 2 weeks following surgery compared to the control group receiving an equivalent volume of water. Qualitative interviews were conducted with participants to help determine the acceptance of the study.SettingSingle adult thoracic centre in the UK.ParticipantsAll patients admitted for major lung surgery. Participants were included if were able to take nutritional drinks prior to surgery and were able to give written informed consent. Patients were excluded if they were likely unable to comply with completion of the study questionnaires, they had a body mass index (BMI) < 18.5 kg/m2, were receiving parenteral nutrition or known pregnancy.ResultsAll patients presenting for major lung surgery were screened over a 6-month period, with 163 patients screened, 99 excluded and 64 (41%) patients randomised. Feasibility criteria were met and the study completed recruitment 5 months ahead of target. The 2 groups were well balanced, and tools used to measure outcomes were robust. 97% of patients were compliant with pre-surgery nutritional drinks and 89% of the questionnaires at 3 months were returned fully completed. The qualitative interviews demonstrated that the trial and the intervention were acceptable to patients. Patients felt the questionnaires used captured their experience of recovery from surgery well.ConclusionA large multicentre randomised controlled trial of nutritional intervention in major lung surgery is feasible. It is possible to randomise eligible patients and follow up with high fidelity. A pre-op carbohydrate-loading and post-surgery supplementation is highly acceptable to patients with good compliance to both intervention and trial measures. A large multi-centre clinical trial is required to test clinical efficacy in improving outcomes after surgery.Trial registration numberISRCTN16535341Strengths and limitation of this studyThis randomised, feasibility study had pre-planned feasibility to assess whether a larger randomised trial would be feasible.The study included a large regional thoracic surgical centre and cohort of patients undergoing major lung surgery predominantly for cancer, which would be representative of full trial national recruitment.The study was not designed and powered to be large enough to provide conclusive evidence to support the use of nutritional intervention in major lung surgery, but provided evidence that a larger, substantive randomised controlled trial is feasible.

Satisfactory Rapid Response to Xultophy Associated with Meal Tolerance Test (MTT) by Carbohydrate Loading

The case is a 69-year-old male patient with Type 2 Diabetes Mellitus (T2DM) for 21 years. His diabetic control was not so satisfactory, and his HbA1c value increased in spring 2021. Then, he started Xultophy (IDegLira), which includes a fixed ratio of two agents of basal degludec and liraglutide. Just after providing Xultophy, the daily profile of blood glucose decreased from 179-400 mg/dL to 112-171 mg/dL, with remarkable clinical efficacy. He usually takes 80g of carbohydrates in breakfast, and the meal tolerance test (MTT) was challenged. As carbohydrate loading was given 100-75-50-0%, postprandial hyperglycemia at 60-min showed 277-219-159-133 mg/dL, respectively.

Preoperative carbohydrate loading and intraoperative goal-directed fluid therapy for elderly patients undergoing open gastrointestinal surgery: a prospective randomized controlled trial

Background The effect of a combination of a goal-directed fluid protocol and preoperative carbohydrate loading on postoperative complications in elderly patients still remains unknown. Therefore, we designed this trial to evaluate the relative impact of preoperative carbohydrate loading and intraoperative goal-directed fluid therapy versus conventional fluid therapy (CFT) on clinical outcomes in elderly patients following gastrointestinal surgery. Methods This prospective randomized controlled trial with 120 patients over 65 years undergoing gastrointestinal surgery were randomized into a CFT group (n = 60) with traditional methods of fasting and water-deprivation, and a GDFT group (n = 60) with carbohydrate (200 ml) loading 2 h before surgery. The CFT group underwent routine monitoring during surgery, however, the GDFT group was conducted by a Vigileo/FloTrac monitor with cardiac index (CI), stroke volume variation (SVV), and mean arterial pressure (MAP). For all patients, demographic data, intraoperative parameters and postoperative outcomes were recorded. Results Patients in the GDFT group received significantly less crystalloids fluid (1111 ± 442.9 ml vs 1411 ± 412.6 ml; p < 0.001) and produced significantly less urine output (200 ml [150–300] vs 400 ml [290–500]; p < 0.001) as compared to the CFT group. Moreover, GDFT was associated with a shorter average time to first flatus (56 ± 14.1 h vs 64 ± 22.3 h; p = 0.002) and oral intake (72 ± 16.9 h vs 85 ± 26.8 h; p = 0.011), as well as a reduction in the rate of postoperative complications (15 (25.0%) vs 29 (48.3%) patients; p = 0.013). However, postoperative hospitalization or hospitalization expenses were similar between groups (p > 0.05). Conclusions Focused on elderly patients undergoing open gastrointestinal surgery, we found perioperative fluid optimisation may be associated with improvement of bowel function and a lower incidence of postoperative complications. Trial registration ChiCTR, ChiCTR1800018227. Registered 6 September 2018 - Retrospectively registered.