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The Safety of Preoperative Amino Acid (Elental) Loading in Colon Cancer Surgery: Prospective Cohort Study. Int Surg 2021. [DOI: 10.9738/intsurg-d-16-00088.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
The aim of this prospective study was to evaluate the safety of preoperative amino acid plus carbohydrate drink (Elental) loading in colon cancer surgery. Prolonged preoperative fasting increases insulin resistance, and current evidence recommends carbohydrate drinks 2 hours before surgery. We prospectively enrolled consecutive patients with a preoperative diagnosis of colon cancer who underwent surgery. The patients received 600 mL of Elental the night before surgery and 300 mL of Elental 3 hours prior to induction of anesthesia. Primary end point was the safety of preoperative amino acid (Elental) loading in colon cancer surgery. Safety measurement was anastomotic leakage and aspiration pneumonia. Secondary end points were incidence rate of incisional surgical site infection, recovery of bowel movement, length of hospital stay, postoperative nutritional status, and insulin resistance. A total of 80 consecutive patients were enrolled in this study from February 2013 to January 2014. The incidence of anastomotic leakage was 3 patients (3.8%), and there was no aspiration pneumonia. The incidence of incisional surgical site infection was 2 patients (2.5%). The median times of first flatus, defecation after surgery, and postoperative hospital stay were 1 day, 2 days, and 6 days, respectively. The insulin resistance recovered to a preoperative level after 3 days after surgery. The preoperative amino acid plus carbohydrate drink (Elental) loading 3 hours prior to induction of anesthesia in colon cancer surgery is safe, and incisional surgical site infection rate and recovery of bowel movement and insulin resistance are feasible.
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Persing S, Manahan M, Rosson G. Enhanced Recovery After Surgery Pathways in Breast Reconstruction. Clin Plast Surg 2020; 47:221-243. [DOI: 10.1016/j.cps.2019.12.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Multimodal Nutritional Management in Primary Lumbar Spine Surgery: A Randomized Controlled Trial. Spine (Phila Pa 1976) 2019; 44:967-974. [PMID: 30817733 DOI: 10.1097/brs.0000000000002992] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective randomized controlled trial. OBJECTIVE The purpose of this study was to evaluate the clinical effect and safety of a new multimodal nutritional management (MNM) protocol for patients receiving primary lumbar spine surgery. SUMMARY OF BACKGROUND DATA Poor nutritional status is common in the perioperative period in primary lumbar spine surgery, and may impede recovery after surgery. METHODS A total of 187 patients were included in this prospective randomized controlled trial. They were randomly assigned to the MNM group or the control group. Albumin (ALB) infusion, postoperative ALB level, electrolyte disorders, postoperative electrolyte levels, transfusion rate, postoperative hemoglobin level, length of stay (LOS), and complications were compared between the groups. RESULTS Compared with the control group, the rate and the total amount of ALB infusion were lower in the MNM group, and the postoperative level of ALB in the MNM group was higher on the first postoperative day, and the third postoperative day. The incidence of hypokalemia, hyponatremia, and hypocalcemia were lower in the MNM group. In the MNM group, the postoperative levels of sodium, potassium, and calcium were higher than the control group. The transfusion rate was similar between the two groups. The hemoglobin level was similar between the two groups on first postoperative day, but was higher in the MNM group on third postoperative day. LOS in the MNM group was shorter than in the control group. The incidence of wound drainage was lower in the MNM group. No statistical differences were observed regarding surgical complications between the two groups. CONCLUSION The MNM protocol effectively reduced ALB infusion, the incidence of electrolyte disorders, and wound drainage, increased the postoperative levels of ALB, sodium, potassium, and calcium, and reduced the LOS without increasing the rate of postoperative complications. LEVEL OF EVIDENCE 2.
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Helander EM, Webb MP, Menard B, Prabhakar A, Helmstetter J, Cornett EM, Urman RD, Nguyen VH, Kaye AD. Metabolic and the Surgical Stress Response Considerations to Improve Postoperative Recovery. Curr Pain Headache Rep 2019; 23:33. [PMID: 30976992 DOI: 10.1007/s11916-019-0770-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Enhanced recovery pathways are a multimodal, multidisciplinary approach to patient care that aims to reduce the surgical stress response and maintain organ function resulting in faster recovery and improved outcomes. RECENT FINDINGS A PubMed literature search was performed for articles that included the terms of metabolic surgical stress response considerations to improve postoperative recovery. The surgical stress response occurs due to direct and indirect injuries during surgery. Direct surgical injury can result from the dissection, retraction, resection, and/or manipulation of tissues, while indirect injury is secondary to events including hypotension, blood loss, and microvascular changes. Greater degrees of tissue injury will lead to higher levels of inflammatory mediator and cytokine release, which ultimately drives immunologic, metabolic, and hormonal processes in the body resulting in the stress response. These processes lead to altered glucose metabolism, protein catabolism, and hormonal dysregulation among other things, all which can impede recovery and increase morbidity. Fluid therapy has a direct effect on intravascular volume and cardiac output with a resultant effect on oxygen and nutrient delivery, so a balance must be maintained without excessively loading the patient with water and salt. All in all, attenuation of the surgical stress response and maintaining organ and thus whole-body homeostasis through enhanced recovery protocols can speed recovery and reduce complications. The present investigation summarizes the clinical application of enhanced recovery pathways, and we will highlight the key elements that characterize the metabolic surgical stress response and improved postoperative recovery.
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Affiliation(s)
- Erik M Helander
- Department of Anesthesiology, LSU School of Medicine, Room 656, 1542 Tulane Ave., New Orleans, LA, 70112, USA
| | - Michael P Webb
- Department of Anesthesiology, North Shore Hospital, 124 Shakespeare Rd., Takapuna, Auckland, 0620, New Zealand
| | - Bethany Menard
- Department of Anesthesiology, LSU School of Medicine, Room 656, 1542 Tulane Ave., New Orleans, LA, 70112, USA
| | - Amit Prabhakar
- Department of Anesthesiology and Critical Care Medicine, Emory University Hospital, 550 Peachtree St NE, Atlanta, GA, 30308, USA
| | - John Helmstetter
- Department of Anesthesiology, LSU School of Medicine, Room 656, 1542 Tulane Ave., New Orleans, LA, 70112, USA
| | - Elyse M Cornett
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71130, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Viet H Nguyen
- Department of Anesthesiology, LSU School of Medicine, Room 656, 1542 Tulane Ave., New Orleans, LA, 70112, USA
| | - Alan David Kaye
- Department of Anesthesiology, LSU School of Medicine, Room 656, 1542 Tulane Ave., New Orleans, LA, 70112, USA.
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Serrano PE, Parpia S, Nair S, Ruo L, Simunovic M, Levine O, Duceppe E, Rodrigues C. Perioperative Optimization With Nutritional Supplements in Patients Undergoing Gastrointestinal Surgery for Cancer (PROGRESS): Protocol for a Feasibility Randomized Controlled Trial. JMIR Res Protoc 2018; 7:e10491. [PMID: 30381282 PMCID: PMC6257881 DOI: 10.2196/10491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 07/03/2018] [Accepted: 07/03/2018] [Indexed: 01/27/2023] Open
Abstract
Background Postoperative morbidity following gastrointestinal tract major surgery ranges between 40% and 60%. Malnutrition, poor protein intake, and surgery-related impairment of the immune system and its function have been associated with postoperative infections. Supplemental perioperative nutrition may improve nutrition by increasing protein intake to influence cell-mediated immunity, thereby reducing the rate of postoperative infectious complications. Objective The primary objective of our trial is to determine the proportion of eligible patients randomized in an 18-month period. The primary feasibility outcome will be to (1) stop, main study not feasible: estimated proportion of randomized patients <40.0% (40/100); (2) continue with protocol modifications: estimated proportion of randomized patients 40.0% (40/100) to 59.0% (50/100); or (3) continue without modification: estimated proportion of randomized patients ≥60.0% (60/100). The secondary objectives are to evaluate compliance with the nutritional supplements and to estimate differences in postoperative complications, global health-related quality of life (QoL), and median length of hospital stay between the groups. Methods This is a double-blind randomized placebo-controlled feasibility trial. The intervention comprises three nutritional supplements: a protein isolate powder (ISOlution); immunomodulation (INergy-FLD), formulated liquid diet; and carbohydrate loading (PreCovery). Patients will consume 1 serving of the protein supplement per day from the randomization time up to 6 days before surgery (30 days in total). The immunomodulation, a solution that contains arginine, protein isolate, omega-6 fatty acids, and RNA, aims to attenuate excessive inflammatory responses and to replenish nutrients. This solution will be consumed as 3 doses per day for 5 days before and after surgery. Carbohydrate loading helps to reduce the stress from surgery by decreasing insulin resistance. Patients will have 2 servings the evening before surgery and 1 serving 2-3 hours before surgery. To be eligible, patients must have a resectable gastrointestinal cancer for which an elective operation is planned. Patients will be stratified according to nutritional status. The operation should occur within 4 weeks from enrollment. Results We expect to screen 165 eligible patients; 60.6% (100/165) of them will be randomized to either intervention or placebo. Assuming a two-sided alpha of .05, this will give us a 95% CI around the estimate of 53%-68%. A sample size of 50 per group will enable us to estimate the treatment effect and corresponding variance of the complication rate and QoL measures with adequate precision. The success is defined as the proportion of eligible patients randomized as ≥60.0% (60/100). Patients’ compliance is defined as an intake of at least 70% (41/58) sachets of the intervention volume. Conclusions The results will help to determine the feasibility of a larger randomized controlled trial to implement a perioperative nutritional supplement program for patients undergoing gastrointestinal surgery for cancer. Trial Registration ClinicalTrials.gov NCT03445260; https://clinicaltrials.gov/ct2/show/NCT03445260 (Archived by WebCite at http://www.webcitation.org/72CAmMzgP) International Registered Report Identifier (IRRID) PRR1-10.2196/10491
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Affiliation(s)
- Pablo Emilio Serrano
- Department of Surgery, McMaster University, Hamilton, ON, Canada.,Department of Oncology, Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
| | - Sameer Parpia
- Department of Oncology, Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada.,Department of Oncology, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Saeda Nair
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Leyo Ruo
- Department of Surgery, McMaster University, Hamilton, ON, Canada.,Department of Oncology, Ontario Clinical Oncology Group, McMaster University, Hamilton, ON, Canada
| | - Marko Simunovic
- Department of Surgery, McMaster University, Hamilton, ON, Canada.,Department of Oncology, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Oren Levine
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Emmanuelle Duceppe
- Department of General Internal Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Carol Rodrigues
- Juravinski Hospital, Hamilton Health Sciences, Hamilton, ON, Canada
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Hamamoto H, Yamamoto M, Masubuchi S, Ishii M, Osumi W, Tanaka K, Okuda J, Uchiyama K. The impact of preoperative carbohydrate loading on intraoperative body temperature: a randomized controlled clinical trial. Surg Endosc 2018; 32:4393-4401. [DOI: 10.1007/s00464-018-6273-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 06/07/2018] [Indexed: 12/20/2022]
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Dardevet D, Mosoni L, David J, Polakof S. Fructose Feeding during the Postabsorptive State Alters Body Composition and Spares Nitrogen in Protein-Energy-Restricted Old Rats. J Nutr 2018; 148:40-48. [PMID: 29378055 DOI: 10.1093/jn/nxx028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 10/27/2017] [Indexed: 11/12/2022] Open
Abstract
Background Fructose feeding in the context of high energy intake is recognized as being responsible for metabolic dysregulation. However, its consumption in the postabsorptive state might contribute to reducing the use of amino acids (AAs) as energy substrates and thus spare nitrogen resources, which could be beneficial during catabolic states. Objective We hypothesized that fructose feeding during a catabolic situation corresponding to protein-energy restriction (PER) in older rats would reduce AA utilization for energy purposes, thus slowing down the loss of body weight (BW) and improving body composition. Methods For 45 d, 22-mo-old male Wistar rats (average weight: 716 g) were fed a control ration (13% protein) either at normal (20 g/d), restricted (PER: 10 g/d), or at PER levels supplemented with glucose (3 g/d) or fructose (3 g/d) and then studied in the postabsorptive state. We measured BW, body composition, and enzyme activities and metabolite concentrations related to glucose, fructose, and AA metabolism. Results Both glucose and fructose feeding reduced PER-induced loss of BW and lean mass (-27% compared with PER), but only fructose reduced the loss of fat mass (-28% compared with PER). Fructose feeding prevented the PER-induced loss of muscle and intestinal mass. Fructose feeding also reduced circulating branched-chain AA concentrations by 50% (compared with PER) and increased those of alanine (+65% compared with PER). A reduction in hepatic enzymes related to AA catabolism was also observed during fructose feeding (compared with PER), whereas glycogen concentrations were enhanced in both intestine (+300%) and muscle (+21%). Conclusions We showed that in PER older rats, fructose feeding improved body composition and the weight of several organs by reducing AA catabolism and utilization for energy production and liver autophagy potential. This could be advantageous in sparing body proteins, particularly during catabolic states, such as those related to malnutrition during aging.
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Affiliation(s)
- Dominique Dardevet
- Université Clermont Auvergne, INRA, UNH, Unité de Nutrition Humaine, CRNH Auvergne, Clermont-Ferrand, France
| | - Laurent Mosoni
- Université Clermont Auvergne, INRA, UNH, Unité de Nutrition Humaine, CRNH Auvergne, Clermont-Ferrand, France
| | - Jérémie David
- Université Clermont Auvergne, INRA, UNH, Unité de Nutrition Humaine, CRNH Auvergne, Clermont-Ferrand, France
| | - Sergio Polakof
- Université Clermont Auvergne, INRA, UNH, Unité de Nutrition Humaine, CRNH Auvergne, Clermont-Ferrand, France
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Ali ZS, Ma TS, Ozturk AK, Malhotra NR, Schuster JM, Marcotte PJ, Grady MS, Welch WC. Pre-optimization of spinal surgery patients: Development of a neurosurgical enhanced recovery after surgery (ERAS) protocol. Clin Neurol Neurosurg 2017; 164:142-153. [PMID: 29232645 DOI: 10.1016/j.clineuro.2017.12.003] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 11/21/2017] [Accepted: 12/02/2017] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Despite surgical, technological, medical, and anesthetic improvements, patient outcomes following elective neurosurgical procedures can be associated with high morbidity. Enhanced recovery after surgery (ERAS) protocols are multimodal care pathways designed to optimize patient outcomes by addressing pre-, peri-, and post-operative factors. Despite significant data suggesting improved patient outcomes with the adoption of these pathways, development and implementation has been limited in the neurosurgical population. METHODS/RESULTS This study protocol was designed to establish the feasibility of a randomized controlled trial to assess the efficacy of implementation of an ERAS protocol on the improvement of clinical and patient reported outcomes and patient satisfaction scores in an elective inpatient spine surgery population. Neurosurgical patients undergoing spinal surgery will be recruited and randomly allocated to one of two treatment arms: ERAS protocol (experimental group) or hospital standard (control group). The experimental group will undergo interventions at the pre-, peri-, and post-operative time points, which are exclusive to this group as compared to the hospital standard group. CONCLUSIONS The present proposal aims to provide supporting data for the application of these specific ERAS components in the spine surgery population and provide rationale/justification of this type of care pathway. This study will help inform the design of a future multi-institutional, randomized controlled trial. RESULTS of this study will guide further efforts to limit post-operative morbidity in patients undergoing elective spinal surgery and to highlight the impact of ERAS care pathways in improving patient reported outcomes and satisfaction.
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Affiliation(s)
- Zarina S Ali
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Tracy S Ma
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
| | - Ali K Ozturk
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Neil R Malhotra
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - James M Schuster
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Paul J Marcotte
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - M Sean Grady
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - William C Welch
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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Fawcett WJ, Ljungqvist O. Starvation, carbohydrate loading, and outcome after major surgery. BJA Educ 2017. [DOI: 10.1093/bjaed/mkx015] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Consensus Review of Optimal Perioperative Care in Breast Reconstruction: Enhanced Recovery after Surgery (ERAS) Society Recommendations. Plast Reconstr Surg 2017; 139:1056e-1071e. [PMID: 28445352 DOI: 10.1097/prs.0000000000003242] [Citation(s) in RCA: 190] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Enhanced recovery following surgery can be achieved through the introduction of evidence-based perioperative maneuvers. This review aims to present a consensus for optimal perioperative management of patients undergoing breast reconstructive surgery and to provide evidence-based recommendations for an enhanced perioperative protocol. METHODS A systematic review of meta-analyses, randomized controlled trials, and large prospective cohorts was conducted for each protocol element. Smaller prospective cohorts and retrospective cohorts were considered only when higher level evidence was unavailable. The available literature was graded by an international panel of experts in breast reconstructive surgery and used to form consensus recommendations for each topic. Each recommendation was graded following a consensus discussion among the expert panel. Development of these recommendations was endorsed by the Enhanced Recovery after Surgery Society. RESULTS High-quality randomized controlled trial data in patients undergoing breast reconstruction informed some of the recommendations; however, for most items, data from lower level studies in the population of interest were considered along with extrapolated data from high-quality studies in non-breast reconstruction populations. Recommendations were developed for a total of 18 unique enhanced recovery after surgery items and are discussed in the article. Key recommendations support use of opioid-sparing perioperative medications, minimal preoperative fasting and early feeding, use of anesthetic techniques that decrease postoperative nausea and vomiting and pain, use of measures to prevent intraoperative hypothermia, and support of early mobilization after surgery. CONCLUSION Based on the best available evidence for each topic, a consensus review of optimal perioperative care for patients undergoing breast reconstruction is presented. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.
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Effect of Hypoglycemia on the Incidence of Revision in Total Knee Arthroplasty. J Arthroplasty 2017; 32:499-502. [PMID: 27554778 DOI: 10.1016/j.arth.2016.07.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 06/09/2016] [Accepted: 07/11/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND It is well established that diabetic patients undergoing total knee arthroplasty (TKA) are more susceptible to infection, problematic wound healing, and overall higher complication rates. However, a paucity in current literature exists. The purpose of this study was to determine the effect of hypoglycemia on TKA revision (rTKA) incidence by analyzing a national private payer database for procedures performed between 2007 and 2015 Q1 Q2. METHODS A retrospective review of a national private payer database within the PearlDiver Supercomputer application for patients undergoing TKA with blood glucose levels from 20 to 219 mg/mL, in 10-mg/mL increments, was conducted. Patients who underwent TKA were identified by Current Procedural Terminology (CPT) and International Classification of Disease (ICD) codes. Glucose ranges were identified by filtering for Logical Observation Identifiers Names and Codes within the PearlDiver database. Patients with diagnosed diabetes mellitus type I or II were excluded by using ICD-9 codes 250.00-250.03, 250.10-250.13, and 250.20-250.21. rTKA causes including mechanical loosening, failure/break, periprosthetic fracture, osteolysis, infection, pain, arthrofibrosis, instability, and trauma were identified with CPT and ICD-9 codes. Statistical analysis was primarily descriptive. RESULTS Our query returned 264,824 TKAs, of which 12,852 (4.9%) were revised. Most TKAs were performed with a glucose of 70-99 mg/mL (26.1%), followed by 100-109 mg/mL (18.5%). Patients with TKAs performed with glucose 20-29 mg/mL had the highest rate of revision (17.2%; P < .001). Infection was the most common cause of revision among all glucose ranges (P < .001). CONCLUSION Infection remains one of the most common causes of rTKA irrespective of glucose level. Our results suggest that hypoglycemia may increase revision rates among TKA patients. Tight glycemic control before and during surgery may be warranted.
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Ljungqvist O, Nygren J, Hausel J, Thorell A. Preoperative nutrition therapy - novel developments. ACTA ACUST UNITED AC 2016. [DOI: 10.3402/fnr.v44i0.1773] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Olle Ljungqvist
- Karolinska Institutet at Huddinge University Hospital and Ersta Hospital, Centre of Gastrointestinal Disease, Stockholm, Sweden
| | - Jonas Nygren
- Karolinska Institutet at Huddinge University Hospital and Ersta Hospital, Centre of Gastrointestinal Disease, Stockholm, Sweden
| | - Jonatan Hausel
- Karolinska Institutet at Huddinge University Hospital and Ersta Hospital, Centre of Gastrointestinal Disease, Stockholm, Sweden
| | - Anders Thorell
- Karolinska Institutet at Huddinge University Hospital and Ersta Hospital, Centre of Gastrointestinal Disease, Stockholm, Sweden
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Abstract
An enhanced recovery after surgery strategy will be increasingly adopted in the era of value-based care. The various elements in each enhanced recovery after surgery protocol are likely to add value to the overall patient surgical journey. Although the evidence varies considerably based on type of surgery and patient group, the team-based approach of care should be universally applied to patient care. This article provides an overview of up-to-date techniques and methodology for enhanced recovery, including an overview of value-based care, delivery, and the evidence base supporting enhanced recovery after surgery.
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Affiliation(s)
- Arvind Chandrakantan
- Department of Anesthesiology, Stony Brook Medicine, HSC Level 4, Room 060, Stony Brook, NY 11794-8480, USA
| | - Tong Joo Gan
- Department of Anesthesiology, Stony Brook University School of Medicine, Stony Brook University, HSC Level 4, Room 060, Stony Brook, NY 11794-8480, USA.
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Schricker T, Lattermann R. Perioperative catabolism. Can J Anaesth 2015; 62:182-93. [PMID: 25588775 DOI: 10.1007/s12630-014-0274-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 11/07/2014] [Indexed: 01/08/2023] Open
Abstract
PURPOSE This article reviews the pathophysiology, clinical relevance, and therapy of the catabolic response to surgical stress. PRINCIPLE FINDINGS The key clinical features of perioperative catabolism are hyperglycemia and loss of body protein, both metabolic consequences of impaired insulin function. Muscle weakness and (even moderate) increases in perioperative blood glucose are associated with morbidity after major surgery. Although the optimal glucose concentration for improving clinical outcomes is unknown, most medical associations recommend treatment of random blood glucose > 10 mmol·L(-1). Neuraxial anesthesia blunts the neuroendocrine stress response and enhances the anabolic effects of nutrition. There is evidence to suggest that the avoidance of preoperative fasting prevents insulin resistance and accelerates recovery after major abdominal surgery. CONCLUSIONS Current anticatabolic therapeutic strategies include glycemic control and perioperative nutrition in combination with optimal pain control and the avoidance of preoperative starvation. All these elements are part of Enhanced Recovery After Surgery (ERAS) programs.
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Affiliation(s)
- Thomas Schricker
- Department of Anesthesia, Royal Victoria Hospital, McGill University, 687 Pine Avenue West, Room C5.20, Montreal, QC, H3A 1A1, Canada,
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Improving outcomes and cost-effectiveness of colorectal surgery. J Gastrointest Surg 2014; 18:1944-56. [PMID: 25205538 DOI: 10.1007/s11605-014-2643-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 08/25/2014] [Indexed: 02/08/2023]
Abstract
In order to truly make an impact on improving the cost effectiveness, and most importantly, the outcomes of patients undergoing colorectal surgery, all aspects of care need to be scrutinized, re-evaluated, and refined. To accomplish this, everything from the way we train surgeons to the adoption of a minimally invasive approach for colorectal disease, along with the use of adjunct intraoperative measures to decrease morbidity and mortality, may all need to be incorporated within an ERAS program. Only then will this approach lead the provider to a patient-centric care plan which can successfully reduce metrics such as morbidity, mortality, and length of stay (even with the obligatory readmission rate) and provide it all at a lower cost of care.
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Scott MJ, Fawcett WJ. Oral carbohydrate preload drink for major surgery - the first steps from famine to feast. Anaesthesia 2014; 69:1308-13. [DOI: 10.1111/anae.12921] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- M. J. Scott
- University of Surrey; Department of Anaesthesia; Royal Surrey County Hospital; Guildford Surrey UK
| | - W. J. Fawcett
- University of Surrey; Department of Anaesthesia; Royal Surrey County Hospital; Guildford Surrey UK
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Huang HH, Wu PC, Kang SP, Wang JH, Hsu CW, Chwang LC, Chang SJ. Postoperative Hypocaloric Peripheral Parenteral Nutrition With Branched-Chain-Enriched Amino Acids Provides No Better Clinical Advantage Than Fluid Management in Nonmalnourished Colorectal Cancer Patients. Nutr Cancer 2014; 66:1269-78. [DOI: 10.1080/01635581.2014.956248] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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KAMBE N, TANAKA K, KAKUTA N, KAWANISHI R, TSUTSUMI YM. The influence of glucose load on metabolism during minor surgery using remifentanil-induced anesthesia. Acta Anaesthesiol Scand 2014; 58:948-54. [PMID: 24780066 DOI: 10.1111/aas.12335] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND During perioperative fasting, lipid metabolism gradually increases, resulting in free fatty acids (FFA) and/or ketone bodies. Suppression of surgical stress by remifentanil may allow the safe administration of glucose infusions, avoiding both hyperglycemia and ketogenesis. The effects of glucose infusion on glucose and lipid metabolism were therefore investigated in patients undergoing minor surgery with remifentanil anesthesia. METHODS Thirty-four patients were randomized 1 : 1 to receive no glucose (0G group) or low-dose glucose (0.1 g/kg/h for 1 h followed by 0.05 g/kg/h for 1 h; LG group). The concentrations of glucose, adrenocorticotropic hormone (ACTH), 3-methylhistidine (3-MH), insulin, cortisol, FFA, creatinine (Cr), and ketone bodies were measured before anesthetic induction, 1 and 2 h after glucose infusion, at the end of surgery, and the next morning. RESULTS The concentrations of cortisol and ACTH decreased during surgery in both groups when compared with the concentrations before anesthesia and at the end of surgery (P < 0.05). Glucose and insulin concentrations were significantly higher in the LG than in the 0G group at 1 and 2 h after infusion. No patient experienced hyperglycemia. The concentrations of FFA and ketone bodies were lower in the LG than in the 0G group during surgery, but there were no significant between group differences in 3-MH/Cr. CONCLUSION Infusion of low-dose glucose attenuated fat catabolism without causing hyperglycemia, indicating that infusion of low-dose glucose during remifentanil-induced anesthesia may be safe for patients.
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Affiliation(s)
- N. KAMBE
- Department of Anesthesiology; Institute of Health Biosciences; University of Tokushima Graduate School; Tokushima Japan
| | - K. TANAKA
- Department of Anesthesiology; Institute of Health Biosciences; University of Tokushima Graduate School; Tokushima Japan
| | - N. KAKUTA
- Department of Anesthesiology; Institute of Health Biosciences; University of Tokushima Graduate School; Tokushima Japan
| | - R. KAWANISHI
- Department of Anesthesiology; Institute of Health Biosciences; University of Tokushima Graduate School; Tokushima Japan
| | - Y. M. TSUTSUMI
- Department of Anesthesiology; Institute of Health Biosciences; University of Tokushima Graduate School; Tokushima Japan
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Smith MD, McCall J, Plank L, Herbison GP, Soop M, Nygren J. Preoperative carbohydrate treatment for enhancing recovery after elective surgery. Cochrane Database Syst Rev 2014; 2014:CD009161. [PMID: 25121931 PMCID: PMC11060647 DOI: 10.1002/14651858.cd009161.pub2] [Citation(s) in RCA: 141] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND 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. OBJECTIVES 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. SEARCH METHODS 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. SELECTION CRITERIA 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 COLLECTION AND ANALYSIS 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. MAIN RESULTS 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. AUTHORS' CONCLUSIONS 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.
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Affiliation(s)
- Mark D Smith
- Southland HospitalDepartment of General SurgeryKew RoadInvercargillNew Zealand9840
| | - John McCall
- Dunedin School of Medicine, University of OtagoDepartment of Surgical SciencesPO Box 913DunedinNew Zealand9054
| | - Lindsay Plank
- University of AucklandDepartment of SurgeryPrivate Bag 92019AucklandNew Zealand1142
| | - G Peter Herbison
- Dunedin School of Medicine, University of OtagoDepartment of Preventive & Social MedicinePO Box 913DunedinNew Zealand9054
| | - Mattias Soop
- Salford Royal NHS Foundation TrustDepartment of SurgeryStott LaneSalfordUK
| | - Jonas Nygren
- Institution of Clinical Sciences at Danderyds HospitalCentre for Gastrointestinal Disease, Ersta Hospital and Karolinska InstitutetStockholmSweden
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Abstract
There is increasing recognition of the deleterious effects of poor nutrition on health care outcomes. Older patients appear particularly vulnerable to the effects of undernutrition. This includes both low intake as patients and chronic preadmission undernutrition. This study investigates nutrition during a critical intervening period when patients present to a hospital emergency department (ED) in the first half of the day. One third of observed patients sustained periadmission fasts in excess of 18 hours. This fasting period showed significant positive correlation to age (correlation coefficient = 0.34, P < 0.05). Analysis of the results by gender showed that men who were older than the average cohort age of 53.6 years fasted for a significantly longer period in the hospital than their younger counterparts (P < 0.02). This comparison did not reach significant levels for female patients (P > 0.05). This study raises the question as to whether food should be routinely provided in the ED unless there is reason to withhold it. Particular care should be taken to avoid unnecessary delays in offering food to older patients. There may also be a need to ensure that geriatric care indicators are considered individually for each gender.
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Tran S, Wolever TMS, Errett LE, Ahn H, Mazer CD, Keith M. Preoperative Carbohydrate Loading in Patients Undergoing Coronary Artery Bypass or Spinal Surgery. Anesth Analg 2013; 117:305-13. [DOI: 10.1213/ane.0b013e318295e8d1] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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25
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Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, McNaught CE, Macfie J, Liberman AS, Soop M, Hill A, Kennedy RH, Lobo DN, Fearon K, Ljungqvist O. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS(®)) Society recommendations. World J Surg 2013; 37:259-84. [PMID: 23052794 DOI: 10.1007/s00268-012-1772-0] [Citation(s) in RCA: 804] [Impact Index Per Article: 73.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Nygren J, Thacker J, Carli F, Fearon KCH, Norderval S, Lobo DN, Ljungqvist O, Soop M, Ramirez J. Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS(®)) Society recommendations. World J Surg 2013; 37:285-305. [PMID: 23052796 DOI: 10.1007/s00268-012-1787-6] [Citation(s) in RCA: 303] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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27
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Parenteral nutrition and preOp preparation in prevention of post-operative insulin resistance in gastrointestinal carcinoma. Adv Med Sci 2013; 58:150-5. [PMID: 23612677 DOI: 10.2478/v10039-012-0059-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE The aim was to compare preventive effect of total parenteral nutrition (TPN) and oral nutrition (preOp) on the perioperative insulin resistance prevention in surgical gastrointestinal cancer patients. MATERIAL/METHODS The study was conducted in a group of 75 elective gastric and large intestine cancer patients. Patients were randomly divided into 3 study groups, 25 patients each: group I (NIL) - no preparations influencing tissue sensitivity to insulin, group II (TPN) - total parenteral nutrition in its preoperative stage and group III (TPN + preOp) parenteral nutrition and preOp in the preoperative phase. RESULTS Immediately after the surgery, no statistically significant differences in insulin resistance level between groups were observed. During the first 6 postoperative hours, a statistically significant decrease of insulin resistance level in the TPN+ preOp group in comparison to others, was observed. During the first 24 postoperative hours, the NIL group was the only one to keep the insulin resistance level the same as in the preoperative phase. CONCLUSIONS Application of TPN in the preoperative phase leads to shortening of perioperative insulin resistance time. Combining TPN with oral application of carbohydrate before surgical procedure is an effective and the best method in postoperative insulin resistance syndrome prevention.
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The anabolic effect of perioperative nutrition depends on the patient's catabolic state before surgery. Ann Surg 2013; 257:155-9. [PMID: 22878551 DOI: 10.1097/sla.0b013e31825ffc1f] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE We tested the hypothesis that the anabolic effect of hypocaloric, isonitrogenous nutrition in patients undergoing colorectal surgery depends on the patient's preoperative catabolic state. BACKGROUND Although there is evidence to suggest that total parenteral nutrition more effectively spares protein in depleted than in nondepleted cancer patients, the influence of preoperative catabolism on the anabolic effects of hypocaloric nutrition in patients undergoing elective surgery is unknown. METHODS Seventeen patients undergoing colorectal surgery received intravenous infusion of glucose with amino acids. Feeding was administered over 72 hours, from 24 hours before until 48 hours after surgery. Glucose provided 50% of the patient's measured resting energy expenditure. Amino acids provided 20% of the resting energy expenditure. Whole-body leucine balance (difference between the incorporation of leucine into protein = protein synthesis and endogenous leucine release = proteolysis) was determined using L-[1-(13)C]leucine kinetics before and 2 days after surgery. We analyzed the association between the postoperative increase in leucine balance and the following factors: preoperative leucine balance, protein breakdown, weight loss, oxygen consumption, circulating concentrations of glucose, free fatty acids, insulin, glucagon, cortisol, albumin, age, duration of surgery, and blood loss. RESULTS Of 6 potentially relevant variables, 4 (weight loss, protein breakdown, albumin, and cortisol) were removed because they were not significant during the stepwise linear regression procedure. Leucine balance and age were the remaining 2 factors that remained with the final regression model: Δleucine balance = 19.1 - (0.20 × age [years]) - (0.58) × leucine balance(preOP)). CONCLUSIONS We demonstrate a significant association between the degree of preoperative catabolism, the patient's age, and the anabolic effect of hypocaloric nutrition (ClinicalTrials.gov registration ID: NCT01414946).
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Yildiz H, Gunal SE, Yilmaz G, Yucel S. Oral Carbohydrate Supplementation Reduces Preoperative Discomfort in Laparoscopic Cholecystectomy. J INVEST SURG 2013; 26:89-95. [DOI: 10.3109/08941939.2012.699998] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Huseyin Yildiz
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Kahramanmaras Sutcu Imam University,
Kahramanmaras, Turkey,
| | - Solmaz Eruyar Gunal
- Ministry of Health Ankara Training and Research Hospital, Clinics of Anesthesiology and Reanimation,
Ankara, Turkey,
| | - Gulsen Yilmaz
- Department of Clinical Biochemistry, Ministry of Health Ankara Training and Research Hospital, Clinics of Anesthesiology and Reanimation,
Ankara, Turkey
| | - Safak Yucel
- Ministry of Health Ankara Training and Research Hospital, Clinics of Anesthesiology and Reanimation,
Ankara, Turkey,
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Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, McNaught CE, MacFie J, Liberman AS, Soop M, Hill A, Kennedy RH, Lobo DN, Fearon K, Ljungqvist O. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr 2012; 31:783-800. [PMID: 23099039 DOI: 10.1016/j.clnu.2012.08.013] [Citation(s) in RCA: 441] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 08/19/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND This review aims to present a consensus for optimal perioperative care in colonic surgery and to provide graded recommendations for items for an evidenced-based enhanced perioperative protocol. METHODS Studies were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts. For each item of the perioperative treatment pathway, available English-language literature was examined, reviewed and graded. A consensus recommendation was reached after critical appraisal of the literature by the group. RESULTS For most of the protocol items, recommendations are based on good-quality trials or meta-analyses of good-quality trials (quality of evidence and recommendations according to the GRADE system). CONCLUSIONS Based on the evidence available for each item of the multimodal perioperative-care pathway, the Enhanced Recovery After Surgery (ERAS) Society, International Association for Surgical Metabolism and Nutrition (IASMEN) and European Society for Clinical Nutrition and Metabolism (ESPEN) present a comprehensive evidence-based consensus review of perioperative care for colonic surgery.
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Affiliation(s)
- U O Gustafsson
- Department of Surgery, Ersta Hospital, Stockholm, Sweden.
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31
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Nygren J, Thacker J, Carli F, Fearon KCH, Norderval S, Lobo DN, Ljungqvist O, Soop M, Ramirez J. Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr 2012; 31:801-16. [PMID: 23062720 DOI: 10.1016/j.clnu.2012.08.012] [Citation(s) in RCA: 254] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 08/19/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND This review aims to present a consensus for optimal perioperative care in rectal/pelvic surgery, and to provide graded recommendations for items for an evidenced-based enhanced recovery protocol. METHODS Studies were selected with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohorts. For each item of the perioperative treatment pathway, available English-language literature was examined, reviewed and graded. A consensus recommendation was reached after critical appraisal of the literature by the group. RESULTS For most of the protocol items, recommendations are based on good-quality trials or meta-analyses of good-quality trials (evidence grade: high or moderate). CONCLUSIONS Based on the evidence available for each item of the multimodal perioperative care pathway, the Enhanced Recovery After Surgery (ERAS) Society, European Society for Clinical Nutrition and Metabolism (ESPEN) and International Association for Surgical Metabolism and Nutrition (IASMEN) present a comprehensive evidence-based consensus review of perioperative care for rectal surgery.
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Affiliation(s)
- J Nygren
- Department of Surgery, Ersta Hospital, Karolinska Institutet, Stockholm, Sweden.
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32
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Affiliation(s)
- Olle Ljungqvist
- Örebro University Hospital & Karolinska Institutet, Örebro, Sweden
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33
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Melnyk M, Casey RG, Black P, Koupparis AJ. Enhanced recovery after surgery (ERAS) protocols: Time to change practice? Can Urol Assoc J 2011; 5:342-8. [PMID: 22031616 DOI: 10.5489/cuaj.11002] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Radical cystectomy with pelvic lymph node dissection remains the standard treatment for patients with muscle invasive bladder cancer. Despite improvements in surgical technique, anesthesia and perioperative care, radical cystectomy is still associated with greater morbidity and prolonged in-patient stay after surgery than other urological procedures. Enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care pathways designed to achieve early recovery after surgical procedures by maintaining preoperative organ function and reducing the profound stress response following surgery. The key elements of ERAS protocols include preoperative counselling, optimization of nutrition, standardized analgesic and anesthetic regimens and early mobilization. Despite the significant body of evidence indicating that ERAS protocols lead to improved outcomes, they challenge traditional surgical doctrine, and as a result their implementation has been slow.The present article discusses particular aspects of ERAS protocols which represent fundamental shifts in surgical practice, including perioperative nutrition, management of postoperative ileus and the use of mechanical bowel preparation.
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Affiliation(s)
- Megan Melnyk
- Department of Urological Sciences, University of British Columbia, Gordon & Leslie Diamond Health Care Centre, Vancouver, BC
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Yamasaki K, Inagaki Y, Mochida S, Funaki K, Takahashi S, Sakamoto S. Effect of intraoperative acetated Ringer's solution with 1% glucose on glucose and protein metabolism. J Anesth 2010; 24:426-31. [PMID: 20300778 DOI: 10.1007/s00540-010-0926-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2009] [Accepted: 02/16/2010] [Indexed: 01/04/2023]
Abstract
PURPOSE To investigate the effects of the intraoperative administration of Ringer's solution with 1% glucose on the metabolism of glucose, lipid and muscle protein during surgery. METHODS Thirty-one adult patients, American Society of Anesthesiologists physical status I or II, undergoing elective otorhinolaryngeal, head and neck surgeries were randomly assigned to one of two patient groups: those receiving acetated Ringer's solution with 1% glucose (Group G) or those receiving acetated Ringer's solution without glucose (Group R) throughout the surgical procedure. Plasma glucose was measured at anesthetic induction (T0), artery 1 h (T1), 2 h (T2), 3 h after anesthetic induction (T3) and at the end of surgery (T4). Plasma ketone bodies, insulin and 3-methylhistidine were measured at T0 and T4. RESULTS The intravenous infusion for patients in Group G and R was 6.1 + or - 0.8 and 6.3 + or - 1.7 ml/kg/h, respectively, with Group G patients receiving a dose of 4.1 g/h glucose. Plasma glucose levels were significantly higher in Group G than in Group R patients at T1, T2, T3 and T4; however, plasma glucose remained <150 mg/dl in both groups. The plasma concentration of ketone bodies was significantly higher (P < 0.05) in Group R than in Group G patients at T4. Changes in plasma 3-methylhistidine concentration was significantly lower in Group G than in Group R patients. These results indicate that acetated Ringer's solution with 1% glucose decreased protein catabolism without hyperglycemia among the Group G patients. CONCLUSION The infusion of a small dose of glucose (1%) during minor otorhinolaryngeal, head and neck surgeries may suppress protein catabolism without hyperglycemia and hypoglycemia.
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Affiliation(s)
- Kazumasa Yamasaki
- Department of Anesthesiology and Critical Care Medicine, Tottori University Faculty of Medicine, 36-1 Nishi-cho, Yonago 683-8504, Japan.
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Mathur S, Plank LD, McCall JL, Shapkov P, McIlroy K, Gillanders LK, Merrie AEH, Torrie JJ, Pugh F, Koea JB, Bissett IP, Parry BR. Randomized controlled trial of preoperative oral carbohydrate treatment in major abdominal surgery. Br J Surg 2010; 97:485-94. [DOI: 10.1002/bjs.7026] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Abstract
Background
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.
Methods
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.
Results
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).
Conclusion
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. Registration number: ACTRN012605000456651 (http://www.anzctr.org.au).
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Affiliation(s)
- S Mathur
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - L D Plank
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - J L McCall
- New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland, New Zealand
| | - P Shapkov
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - K McIlroy
- Nutrition Services, Auckland City Hospital, Auckland, New Zealand
| | - L K Gillanders
- Nutrition Services, Auckland City Hospital, Auckland, New Zealand
| | - A E H Merrie
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - J J Torrie
- Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand
| | - F Pugh
- Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand
| | - J B Koea
- Hepatobiliary and Upper Gastrointestinal Unit, Auckland City Hospital, Auckland, New Zealand
| | - I P Bissett
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - B R Parry
- Department of Surgery, University of Auckland, Auckland, New Zealand
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Ljungqvist O. Modulating postoperative insulin resistance by preoperative carbohydrate loading. Best Pract Res Clin Anaesthesiol 2010; 23:401-9. [PMID: 20108579 DOI: 10.1016/j.bpa.2009.08.004] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The concept of preoperative overnight fasting was challenged and proved to have no benefits over allowing patients to drink clear fluids up until 2 h before surgery. This led to changes in the guidelines for preoperative fasting in many countries around the world. This concept has more recently been developed further. Mounting evidence indicates that instead of being operated in the traditional overnight fasted state, undergoing surgery in the carbohydrate-fed state has many clinical benefits. Many of these clinical effects can be related to reduced postoperative insulin resistance by preoperative carbohydrate loading. This article summarises the present understanding of the mechanisms behind the positive clinical effects and gives an overview of the information available regarding the clinical effects of this treatment. Finally, the article summarises the most recently published national guidelines on preoperative fasting routines where preoperative carbohydrates are recommended for use before a major surgery. These are to be considered for all patients allowed to drink clear fluids and undergoing elective surgery.
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Affiliation(s)
- Olle Ljungqvist
- Karolinska Institutet, CLINTEC, Division of Surgery, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden.
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Wang ZG, Wang Q, Wang WJ, Qin HL. Randomized clinical trial to compare the effects of preoperative oral carbohydrate versus placebo on insulin resistance after colorectal surgery. Br J Surg 2010; 97:317-27. [PMID: 20101593 DOI: 10.1002/bjs.6963] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Abstract
Background
Preoperative oral carbohydrate (OCH) reduces postoperative insulin resistance (PIR). This randomized trial investigated whether this effect is related to insulin-induced activation of the phosphatidylinositol 3-kinase (PI3K)/protein kinase B (PKB) signalling pathway.
Methods
Patients with colorectal cancer scheduled for elective open resection were randomly assigned to preoperative OCH, fasting or placebo. Preoperative general well-being, insulin resistance before and immediately after surgery, and postoperative expression of PI3K, PKB, protein tyrosine kinase (PTK) and glucose transporter 4 (GLUT4) in rectus abdominis muscle were evaluated.
Results
Patient and operative characteristics did not differ between groups. Subjective well-being was significantly better in OCH and placebo groups than in the fasting group, primarily because of reduced thirst (P = 0·005) and hunger (P = 0·041). PIR was significantly greater in fasting and placebo groups (P < 0·010). By the end of surgery, muscle PTK activity as well as PI3K and PKB levels were significantly increased in the OCH group compared with values in fasting and placebo groups (P < 0·050), but GLUT4 expression was unaffected.
Conclusion
PIR involves the PI3K/PKB signalling pathway. Preoperative OCH intake improves preoperative subjective feelings of hunger and thirst compared with fasting, while attenuating PIR by stimulation of the PI3K/PKB pathway. Registration number: NCT00755729 (http://www.clinicaltrials.gov).
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Affiliation(s)
- Z G Wang
- Department of General Surgery, Shanghai Chang Zheng Hospital, Second Military Medical University, Shanghai, China
| | - Q Wang
- Department of General Surgery, Shanghai Chang Zheng Hospital, Second Military Medical University, Shanghai, China
| | - W J Wang
- Department of General Surgery, Shanghai Chang Zheng Hospital, Second Military Medical University, Shanghai, China
| | - H L Qin
- Department of General Surgery, Shanghai Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
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Gastric emptying of three liquid oral preoperative metabolic preconditioning regimens measured by magnetic resonance imaging in healthy adult volunteers: A randomised double-blind, crossover study. Clin Nutr 2009; 28:636-41. [DOI: 10.1016/j.clnu.2009.05.002] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2008] [Revised: 04/13/2009] [Accepted: 05/02/2009] [Indexed: 12/15/2022]
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40
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Gustafsson UO, Thorell A, Soop M, Ljungqvist O, Nygren J. Haemoglobin A1c as a predictor of postoperative hyperglycaemia and complications after major colorectal surgery. Br J Surg 2009; 96:1358-64. [DOI: 10.1002/bjs.6724] [Citation(s) in RCA: 129] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
Background
Hyperglycaemia following major surgery increases morbidity, but may be improved by use of enhanced-recovery protocols. It is not known whether preoperative haemoglobin (Hb) A1c could predict hyperglycaemia and/or adverse outcome after colorectal surgery.
Methods
Some 120 patients without known diabetes underwent major colorectal surgery within an enhanced-recovery protocol. HbA1c was measured at admission and 4 weeks after surgery. All patients received an oral diet beginning 4 h after operation. Plasma glucose was monitored five times daily. Patients were stratified according to preoperative levels of HbA1c (within normal range of 4·5–6·0 per cent, or higher).
Results
Thirty-one patients (25·8 per cent) had a preoperative HbA1c level over 6·0 per cent. These had higher mean(s.d.) postoperative glucose (9·3(1·5) versus 8·0(1·5) mmol/l; P < 0·001) and C-reactive protein (137(65) versus 101(52) mg/l; P = 0·008) levels than patients with a normal HbA1c level. Postoperative complications were more common in patients with a high HbA1c level (odds ratio 2·9 (95 per cent confidence interval 1·1 to 7·9)).
Conclusion
Postoperative hyperglycaemia is common among patients with no history of diabetes, even within an enhanced-recovery protocol. Preoperative measurement of HbA1c may identify patients at higher risk of poor glycaemic control and postoperative complications.
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Affiliation(s)
- U O Gustafsson
- Centre for Gastrointestinal Disease, Ersta Hospital, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - A Thorell
- Department of Surgery, Ersta Hospital, Stockholm, Sweden
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
| | - M Soop
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - O Ljungqvist
- Karolinska Institute, Clintec, Division of Surgery, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - J Nygren
- Department of Surgery, Ersta Hospital, Stockholm, Sweden
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
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Braga M, Ljungqvist O, Soeters P, Fearon K, Weimann A, Bozzetti F. ESPEN Guidelines on Parenteral Nutrition: surgery. Clin Nutr 2009; 28:378-86. [PMID: 19464088 DOI: 10.1016/j.clnu.2009.04.002] [Citation(s) in RCA: 373] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Accepted: 04/01/2009] [Indexed: 12/15/2022]
Abstract
In modern surgical practice it is advisable to manage patients within an enhanced recovery protocol and thereby have them eating normal food within 1-3 days. Consequently, there is little room for routine perioperative artificial nutrition. Only a minority of patients may benefit from such therapy. These are predominantly patients who are at risk of developing complications after surgery. The main goals of perioperative nutritional support are to minimize negative protein balance by avoiding starvation, with the purpose of maintaining muscle, immune, and cognitive function and to enhance postoperative recovery. Several studies have demonstrated that 7-10 days of preoperative parenteral nutrition improves postoperative outcome in patients with severe undernutrition who cannot be adequately orally or enterally fed. Conversely, its use in well-nourished or mildly undernourished patients is associated with either no benefit or with increased morbidity. Postoperative parenteral nutrition is recommended in patients who cannot meet their caloric requirements within 7-10 days orally or enterally. In patients who require postoperative artificial nutrition, enteral feeding or a combination of enteral and supplementary parenteral feeding is the first choice. The main consideration when administering fat and carbohydrates in parenteral nutrition is not to overfeed the patient. The commonly used formula of 25 kcal/kg ideal body weight furnishes an approximate estimate of daily energy expenditure and requirements. Under conditions of severe stress requirements may approach 30 kcal/kg ideal body weights. In those patients who are unable to be fed via the enteral route after surgery, and in whom total or near total parenteral nutrition is required, a full range of vitamins and trace elements should be supplemented on a daily basis.
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Affiliation(s)
- M Braga
- Department of Surgery, San Raffaele University, Milan, Italy
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Gustafsson UO, Nygren J, Thorell A, Soop M, Hellström PM, Ljungqvist O, Hagström-Toft E. Pre-operative carbohydrate loading may be used in type 2 diabetes patients. Acta Anaesthesiol Scand 2008; 52:946-51. [PMID: 18331374 DOI: 10.1111/j.1399-6576.2008.01599.x] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Post-operative insulin resistance and hyperglycaemia are associated with an impaired outcome after surgery. Pre-operative oral carbohydrate loading (CHO) reduces post-operative insulin resistance with a reduced risk of hyperglycaemia during post-operative nutrition. Insulin-resistant diabetic patients have not been given CHO because the effects on pre-operative glycaemia and gastric emptying are unknown. METHODS Twenty-five patients (45-73 years) with type 2 diabetes [glycated haemoglobin (HbA1c) 6.2 +/- 0.2%, mean +/- SEM] and 10 healthy control subjects (45-72 years) were studied. A carbohydrate-rich drink (400 ml, 12.5%) was given with paracetamol 1.5 g for determination of gastric emptying. RESULTS Peak glucose was higher in diabetic patients than in healthy subjects (13.4 +/- 0.5 vs. 7.6 +/- 0.5 mM; P<0.01) and occurred later after intake (60 vs. 30 min; P<0.01). Glucose concentrations were back to baseline at 180 vs. 120 min in diabetic patients and healthy subjects, respectively (P<0.01). At 120 min, 10.9 +/- 0.7% and 13.3 +/- 1.2% of paracetamol remained in the stomach in diabetic patients and healthy, subjects respectively. Gastric half-emptying time (T50) occurred at 49.8 +/- 2.2 min in diabetics and at 58.6 +/- 3.7 min in healthy subjects (P<0.05). Neither peak glucose, glucose at 180 min, gastric T50, nor retention at 120 min differed between insulin (HbA1c 6.8 +/- 0.7%)- and non-insulin-treated (HbA1c 5.6 +/- 0.4%) patients. CONCLUSIONS Type 2 diabetic patients showed no signs of delayed gastric emptying, suggesting that a carbohydrate-rich drink may be safely administrated 180 min before anaesthesia without risk of hyperglycaemia or aspiration pre-operatively.
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Affiliation(s)
- U O Gustafsson
- Department of Clinical Science, Intervention and Technology, Centre for Gastrointestinal Disease, Ersta Hospital, Karolinska Institutet, Stockholm, Sweden
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Kranke P, Redel A, Schuster F, Muellenbach R, Eberhart LH. Pharmacological interventions and concepts of fast-track perioperative medical care for enhanced recovery programs. Expert Opin Pharmacother 2008; 9:1541-64. [DOI: 10.1517/14656566.9.9.1541] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Are there any benefits from minimizing fasting and optimization of nutrition and fluid management for patients undergoing day surgery? Curr Opin Anaesthesiol 2008; 20:540-4. [PMID: 17989547 DOI: 10.1097/aco.0b013e3282f15493] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE OF REVIEW As a result of advances in anaesthesia and surgery, an increasing number of surgical procedures are currently possible in the ambulatory setting. Nausea/vomiting and sedation/drowsiness are often associated with delayed discharge and readmission. These symptoms are also related to pharmacological treatment as well as dehydration and fasting. The evidence that preoperative fasting and dehydration not only reduces preoperative well being, but may also affect postoperative recovery is currently being reviewed. RECENT FINDINGS In association with minor surgical procedures, rehydration with approximately 1 l fluid, and in cases with a moderate degree of surgery, such as laparoscopic surgery, 1-3 l fluid, given perioperatively will improve postoperative well being and recovery. Administration of a carbohydrate-rich beverage not only provides fluid but also counteracts the negative effects of preoperative fasting, which in turn reduces preoperative hunger and improves well being. Postoperatively, this treatment reduces insulin resistance, which may be relevant in surgery with significant postoperative stress response. Two studies on laparoscopic cholecystectomy demonstrate different results regarding effects on postoperative outcome and nausea/vomiting and further evaluation is required. SUMMARY When preoperative dehydration is corrected, postoperative well being and clinical outcome improves. Avoiding preoperative fasting by administration of carbohydrate-rich beverages improves preoperative well being while effects on postoperative recovery in patients undergoing ambulatory surgery need to be further evaluated.
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Yagci G, Can MF, Ozturk E, Dag B, Ozgurtas T, Cosar A, Tufan T. Effects of preoperative carbohydrate loading on glucose metabolism and gastric contents in patients undergoing moderate surgery: A randomized, controlled trial. Nutrition 2008; 24:212-6. [DOI: 10.1016/j.nut.2007.11.003] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2007] [Revised: 11/12/2007] [Accepted: 11/13/2007] [Indexed: 11/29/2022]
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Ljungqvist O, Soop M, Hedström M. Why metabolism matters in elective orthopedic surgery: a review. Acta Orthop 2007; 78:610-5. [PMID: 17966019 DOI: 10.1080/17453670710014293] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
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Svanfeldt M, Thorell A, Hausel J, Soop M, Rooyackers O, Nygren J, Ljungqvist O. Randomized clinical trial of the effect of preoperative oral carbohydrate treatment on postoperative whole-body protein and glucose kinetics. Br J Surg 2007; 94:1342-50. [PMID: 17902094 DOI: 10.1002/bjs.5919] [Citation(s) in RCA: 139] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Abstract
Background
Preoperative oral carbohydrate (CHO) reduces postoperative insulin resistance. In this randomized trial, the effect of CHO on postoperative whole-body protein turnover was studied.
Methods
Glucose and protein kinetics ([6,62H2]D-glucose, [2H5]phenylalanine, [2H2]tyrosine and [2H4]tyrosine) and substrate oxidation (indirect calorimetry) were studied at baseline and during hyperinsulinaemic normoglycaemic clamping before and on the first day after colorectal resection. Fifteen patients were randomized to receive a preoperative beverage with high (125 mg/ml) or low (25 mg/ml) CHO content.
Results
Three patients were excluded after the intervention, leaving six patients in each group. After surgery whole-body protein balance did not change in the high oral CHO group, whereas it was more negative in the low oral CHO group after surgery at baseline (P = 0·003) and during insulin stimulation (P = 0·005). Insulin-stimulated endogenous glucose release was similar before and after surgery in the high oral CHO group, but was higher after surgery in the low oral CHO group (P = 0·013) and compared with the high oral CHO group (P = 0·044).
Conclusion
Whole-body protein balance and the suppressive effect of insulin on endogenous glucose release are better maintained when patients receive a CHO-rich beverage before surgery.
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Affiliation(s)
- M Svanfeldt
- Division of Surgery, Karolinska Institute, Karolinska University Hospital Huddinge, Sweden.
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A Randomized Controlled Trial of the Anticatabolic Effect of Epidural Analgesia and Hypocaloric Glucose. Reg Anesth Pain Med 2007. [DOI: 10.1097/00115550-200705000-00009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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LJUNGQVIST OLLE, HAUSEL JONATAN, NYGREN JONAS, THORELL ANDERS, SOOP MATTIAS. Preoperative patient preparation for enhanced recovery after surgery. ACTA ACUST UNITED AC 2007. [DOI: 10.1111/j.1778-428x.2007.00045.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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van Hoorn DEC, Nijveldt RJ, Boelens PG, Hofman Z, van Leeuwen PAM, van Norren K. Effects of preoperative flavonoid supplementation on different organ functions in rats. JPEN J Parenter Enteral Nutr 2006; 30:302-8. [PMID: 16804127 DOI: 10.1177/0148607106030004302] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Previously it has been reported that preoperative feeding preserves heart function in rats after intestinal ischemia-reperfusion. To further improve postoperative organ function, bioactive nutrition compounds were selected in vitro against the xanthine oxidase radical cascade, an enzyme suggested to play a key role in the induction of single- or multiple-organ dysfunction. METHODS Flavonoids were selected in vitro for their capacity to (1) inhibit xanthine oxidase, (2) scavenge superoxide, and (3) scavenge peroxylradicals. The most bioactive flavonoids were added to the preoperative nutrition to study their effect on postintestinal ischemia-reperfusion organ function. RESULTS A combination of flavonoids selected on basis of effective flavonoid xanthine oxidase inhibition and superoxide scavenging resulted in increased superoxide scavenging. In vivo, the selected flavonoid mixture significantly lowered postischemic intestinal apoptosis and intestinal oxidative stress indicated by malondialdehyde concentration when compared with ischemia-reperfusion fasted and sham-fasted animals. Moreover, this flavonoid mixture significantly lowered plasma creatinine and urea concentration, both indicating a better postoperative kidney function. Furthermore, oxidative stress measured as this flavonoid mixture when compared with control significantly lowered plasma malondialdehyde concentration in fed rats. CONCLUSIONS Coadministration of bioactive flavonoid mixture to preoperative nutrition, in contrast to fasting, attenuates ischemia-reperfusion injury by preserving kidney function in the rat and decreasing apoptosis in the intestine.
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