Benefits of maltodextrin intake 2 hours before cholecystectomy by laparotomy in respiratory function and functional capacity: a prospective randomized clinical trial

Cost-effectiveness analysis of hernioplasties before and after the implementation of the ACERTO project

OBJECTIVE

to compare hospital costs and clinical outcomes in inguinal and incisional hernioplasty before and after implementation of the ACERTO project in a university hospital.

METHODS

retrospective study of 492 patients undergoing either inguinal hernioplasty (n=315) or incisional hernioplasty (n=177). The investigation involved two phases: between January 2002 and December 2005, encompassing cases admitted before the implementation of the ACERTO protocol (PRE-ACERTO period), and the other phase, with cases operated between January 2006 and December 2011, after the implementation of the protocol (ACERTO period). The main outcome variable was the comparison of the mean hospital costs between the two periods. As secondary endpoints, we analyzed the length of stay, the surgical site infection rate and mortality. We used the cost method suggested by Public Sector Cost Information System.

RESULTS

surgical site infection was higher (p = 0.039) in the first phase of the study for both inguinal hernia operations (2 (1.6%) versus 0 (0%) cases) and incisional hernioplasty (5 (7.6%) versus 3 (2.7%) cases). The length of stay decreased one day after the implementation of the ACERTO protocol (p=0.005). There was a reduction in costs per patient from R$ 4,328.58 per patient in the first phase to R$ 2,885.72 in the second phase (66.7% reduction).

CONCLUSION

there was a reduction in infectious morbidity, length of stay and hospital costs in hernioplasty after the implementation of the ACERTO protocol.

Effects of overnight fasting on handgrip strength in inpatients

Objective:

To investigate the effects of overnight fasting on handgrip strength of adult inpatients.

Methods:

A prospective clinical study enrolling 221 adult patients. The endpoints were handgrip strength obtained by dynamometry in three time points (morning after an overnight fasting, after breakfast and after lunch) and the cumulative handgrip strength (mean of handgrip strength after breakfast and lunch) in the same day. The mean of three handgrip strength measures was considered to represent each time point. A cut-off for the mean overnight fasting handgrip strength at the 50^th percentile (35.5kg for males and 27.7kg for females) was used for comparisons. We registered the age, sex, current and usual weight (kg), weight loss (kg), diagnosis of cancer, nutritional status, elderly frequency, digestive tract symptoms, type of oral diet, and the amount of dinner ingested the night before handgrip strength (zero intake, until 50%, <100% and 100%).

Results:

Handgrip strength evaluated after an overnight fasting (31.2±8.7kg) was lesser when compared with handgrip strength after breakfast (31.6±8.8kg; p=0.01), and with cumulative handgrip strength (31.7±8.8kg; p<0.001). Handgrip strength was greater in patients who ingested 100% (33.2±9.1kg versus 30.4±8.4kg; p=0.03) and above 50% of dinner (32.1±8.4kg versus 28.6±8.8kg; p=0.006). Multivariate analysis showed that ingesting below 50% of dinner, severe malnutrition, and elderly were independent factors for handgrip strength reduction after overnight fasting.

Conclusion:

The muscular function was impaired after an overnight fasting of adult patients hospitalized for medical treatment, especially for those with low ingestion, malnourished and elderly.

A randomized controlled study of preoperative oral carbohydrate loading versus fasting in patients undergoing elective craniotomy

OBJECT

The aim of this study was to evaluate the effect of preoperative oral carbohydrate loading versus fasting on the outcomes of patients undergoing elective craniotomy.

METHODS

In a single-center randomized controlled study, 120 neurosurgical patients who were admitted for elective craniotomy were included and randomized into 2 groups: 58 patients received 400 mL of oral carbohydrate loading 2 h before surgery (intervention group), and 62 patients were fasting for 8 h prior to surgery as routine management (control group). The primary end point was glucose homeostasis. Secondary outcomes included handgrip strength, pulmonary function and postoperative complications.

RESULTS

Better glucose homeostasis (5.6 ± 1.0 mmol/L vs. 6.3 ± 1.2 mmol/L, P = 0.001) was achieved in patients who received preoperative oral carbohydrate loading compared to fasting. Furthermore, patients in the intervention group had better handgrip strength (25.3 ± 7.1 kg vs. 19.9 ± 7.5 kg, P < 0.0001) and pulmonary function (in terms of peak expiratory flow rate) (315.8 ± 91.5 L/min vs. 270.0 ± 102.7 L/min, P = 0.036) compared to the controls postoperatively. The rates of postoperative surgical and non-surgical complications did not differ between the groups. Both postoperative and total hospital length of stay (LOS) reduced significantly in the intervention group (-3d, P < 0.0001 and P = 0.004).

CONCLUSIONS

Oral carbohydrate loading given 2 h before surgery in patients undergoing elective craniotomy seems to improve glucose homeostasis, handgrip strength and pulmonary function as well as decrease LOS without increasing the risk of postoperative complications. Routine use of preoperative oral carbohydrate loading could be suggested in clinical settings, though further evaluation of its safety and efficacy is warranted.

PRE-OPERATIVE FASTING: WHY ABBREVIATE?

INTRODUCTION

Considering the practice of preoperative fasting based on observations on the gastric emptying delay after induction and the time of this fast is closely linked to organic response to trauma, arise the question about preoperative fasting period necessary to minimize such response and support the professional with clinical and scientific evidence.

AIM

To review the aspects related to the abbreviation of preoperative fasting from the metabolic point of view, physiology of gastric emptying, its clinical benefits and the currently recommendations.

METHOD

Literature review was based on articles and guidelines published in English and Portuguese, without restriction of time until January 2017, in PubMed, SciELO and Cochrane with the descriptors: surgery, preoperative fasting, carbohydrate. From the universe consulted, 31 articles were selected.

RESULTS

The literature suggests that the abbreviation of fasting with beverage added carbohydrates until 2 h before surgery, can bring benefits on glycemic and functional parameters, reduces hospitalization, and does not present aspiration risk of healthy patients undergoing elective surgery. Another nutrient that has been added to the carbohydrate solution and has shown promising results is glutamine.

CONCLUSION

The abbreviation of preoperative fasting with enriched beverage with carbohydrates or carbohydrate and glutamine seems to be effective in the care of the surgical patient, optimizing the recovery from of postoperative period.

ACERTO guidelines of perioperative nutritional interventions in elective general surgery

ABSTRACT Objective: to present recommendations based on the ACERTO Project (Acceleration of Total Post-Operative Recovery) and supported by evidence related to perioperative nutritional care in General Surgery elective procedures. Methods: review of relevant literature from 2006 to 2016, based on a search conducted in the main databases, with the purpose of answering guiding questions previously formulated by specialists, within each theme of this guideline. We preferably used randomized controlled trials, systematic reviews and meta-analyzes but also selected some cohort studies. We contextualized each recommendation-guiding question to determine the quality of the evidence and the strength of this recommendation (GRADE). This material was sent to authors using an open online questionnaire. After receiving the answers, we formalized the consensus for each recommendation of this guideline. Results: the level of evidence and the degree of recommendation for each item is presented in text form, followed by a summary of the evidence found. Conclusion: this guideline reflects the recommendations of the group of specialists of the Brazilian College of Surgeons, the Brazilian Society of Parenteral and Enteral Nutrition and the ACERTO Project for nutritional interventions in the perioperative period of Elective General Surgery. The prescription of these recommendations can accelerate the postoperative recovery of patients submitted to elective general surgery, with decrease in morbidity, length of stay and rehospitalization, and consequently, of costs.