Preoperative Carbohydrate Loading in Enhanced Recovery...

PreoperativeCarbohydrateLoadinginEnhancedRecoveryAfterSurgeryPathwaysisSafeinPatientswithTypeIIDiabetes

StephanieD.TalutisMD,MPH1,SuYeonLeeBS1,DanielChengMD2,PamelaRosenkranzRN,BSN,MEd1,SarahM.AlexanianMD1,DavidMcAnenyMD,FACS1

1DepartmentofSurgery,BostonUniversitySchoolofMedicine,Boston,MA,2DepartmentofSurgery,UniversityofNevada,LasVegas,NV

AIM • TheobjectiveofthisstudyistodeterminethesafetyofpreoperativecarbohydrateloadinginpatientswithDMII

• Demonstratenosigni<icantdifferenceinbloodglucoselevels,insulinrequirements,inpatientendocrineconsultations,hypoglycemicepisodes,andpostoperativecomplicationsinpatientswithDMIIduringthe<irstyearofERASprogramatBMC

METHODS

• IRB-approvedretrospectivechartreview

• Analyzedpatientsduringthe<irstyearofERAS(10/1/15–9/30/16)

• Exclusioncriteria•  Diet-controlledDMII•  ThosewithoutdocumentedconsumptionofCHO•  TypeIDiabetes

• AdditionalgroupconsistedofhistoricalpatientswithDMII

• Statistics:•  Demographic and perioperative variables were

comparedamongthethreegroupsusingANOVA•  Differences between groups of patients with DMII

wereevaluatedusingChisquaretestforcategoricalvariables and Kruskal Wallis test for continuousvariables

•  Signi<icancede<inedasp<0.05

RESULTS

CONCLUSIONS ERASpatientswithDMIIsafelytolerateCHOaspartofanERASpathwaywithoutanincreaseininsulinrequirementsorincreaseincomplications

NEXT STEPS •  ThereisnoconsensuswithintheERASliteraturewithregardtothetypeorquantityofpreoperativeCHObeverages.

•  Futurestudiescaninvestigatespeci<icCHOcompositionforpatientswithandwithoutDMIItoassessanyimpactonperioperativeglucoselevels,insulinrequirements,andotheroutcomes.

•  TheERASprogramatBostonMedicalCentercontinuestoincludcarbohydrateloadingpatientswithDMII

BACKGROUND• Enhanced Recovery After Surgery (ERAS) pathways involve evidencebasedprotocolstominimizethestressresponsetosurgery1

• ERAS efforts include education, reduced IV <luids, and decreasednarcotics1

• InmanyERASmodels,patientsdrinkapreoperativecarbohydrateload(CHO)2 hours prior to surgery,which improvesnitrogenbalance anddecreasesnauseaandileus1-3

• TherearelimiteddataregardingthesafetyofcarbohydrateloadinginpatientswithTypeIIDiabetes(DMII)3

• SincetheinceptionoftheERASprogramatBostonMedicalCenter,wehaveintentionallyincludedcarbohydrateloadingpatientswithDMII

RESULTS

Table1:DemographicsTable1:Demographics

ERASPatients ERASPatients HistoricalPatientswithoutDMII withDMII withDMII pValue(n=275) (n=80) (n=89)

Medianageinyears(range) 43(21-89) 48(20-86) 51(25-93) 1.000Female% 74.9%(206/275) 78.8%(63/80) 74.2%(66/89) 0.743MedianBMI(range) 39.5(16.7-81.4) 38.6(19.8-69.5) 40.5(20.7-59.3) 0.367OperativeDuration,hours 3.02(1.50-11.10) 3.18(1.67-10.80) 2.7(1.70-11.60) 0.085(range)Specialty% 0.200Bariatric 62.9%(173/275) 71.3%(57/80) 67.4%(60/89)Colorectal 25.8%(71/275) 13.8%(11/80) 23.6%(21/89)SurgicalOncology 11.3%(31/275) 15%(12/80) 9.0%(8/89)

Laparoscopic% 83.6%(230/275) 90%(72/80) 93.3%(83/89) 0.078ASA 1.0001 0.4%(1/275) 0%(0/80) 0%(0/89)2 51.6%(142/275) 22.5%(18/80) 38.2%(34/89)3 47.6%(131/275) 67.3%(61/80) 60.7%(54/89)4 0.4%(1/275) 1.3%(1/80) 1.1%(1/89)

Table2:PerioperativeDiabeticVariablesTableII:PerioperativeDiabeticVariables

ERASPatients HistoricalPatients

withDMII withDMII pValue

(n=80) (n=89)

HemoglobinA1Cmedian(range) 7(5-12.5) 7.4(5.5-12.6) 0.432

HomeDiabetesMedications 1.000

OralAgent 90%(72/80) 92.1%(82/89)

Insulin 28.8%(23/80) 23.6%(21/89)

NumberofAgents 0.698

1 57.8%(47/80) 66.3%(59/89)

2 25%(20/80) 22.5%(20/89)

3 7.5%(6/80) 9.0%(8/89)

4 3.8%(3/80) 2.2%(2/89)

HomeInsulinDosing,medianunits(range) 36(6-178) 39(6-200) 0.760

MedianGlucose(range)

Preoperative(HoldingArea) 142(66-392) 129.5(82-316) 0.017*

OperatingRoom 158(95-286) 174.8(100-279.5) 0.913

1stPostoperative 159(102-309) 173(96-295) 0.231

DailyMedian

PostoperativeDay0 184.5(106-320) 175(86-350) 0.145

PostoperativeDay1 152(84-323) 137.5(86-279) 0.004*

PostoperativeDay2 135.3(82-223) 131(82-240) 0.446

PostoperativeDay3 134(67-207) 134.8(78-220.5) 0.634

PostoperativeDay4 135.5(81-232) 138.3(89.5-201.5) 0.787

PostoperativeDay5 135(85-171.5) 146(79-220) 0.438

IntraoperativeInsulinInfusion 11.3%(9/80) 14.6%(13/89) 0.648

Insulin,medianunits(range)

OR 0(0-16.5) 0(0-19.2) 0.625

PostoperativeDay0 2(0-62) 2(0-75.83) 0.669

PostoperativeDay1 4(0-75) 0(0-79) 0.094

PostoperativeDay2 0(0-53) 0(0-41) 0.187

PostoperativeDay3 4(0-47) 0(0-50) 0.995

PostoperativeDay4 4(0-54) 2(0-45) 0.767

PostoperativeDay5 2(0-37) 0(0-55) 0.765

Table3:OutcomesTable3-Outcomes

ERASPatients ERASPatients HistoricalPatients

withoutDMII withDMII withDMII pValue

(n=275) (n=80) (n=89)

%Hypoglycemia - 7.5%(6/80) 5.6%(5/89) 0.758

%InpatientEndocrineConsultation - 41.3%(33/80) 37.1%(33/89) 0.637

Clavien-DindoClassification 0.651

NoComplication 78.9%(217/275) 80%(64/80) 73.0%(65/89)

GradeI 7.6%(21/275) 12.5%(10/80) 14.6%(13/89)

GradeII 8.7%(24/275) 5%(4/80) 7.9%(7/89)

GradeIIIa 2.5%(7/275) 2.5%(2/80) 2.2%(2/89)

GradeIIIb 2.2%(6/275) 0%(0/80) 2.2%(2/89)

AntiemeticDoses,median(range) 0(0-9) 0(0-5) 1(0-13) 1.000

LengthofStay,median(range) 2(0-37) 2(2-33) 2(1-14) 0.383

Table4:BinaryLogisticRegression–RiskofAnyComplication

OddsRatio 95%ConfidenceInterval pValueLower Upper

HemoglobinA1C 0.482 0.197 1.179 0.11NumberofHypoglycemicMedications 1.316 0.489 3.537 0.587PreoperativeInsulinDosing 0.983 9.58 1.009 0.192PreoperativeGlucoseMeasurement 1.008 0.993 1.024 1.008

References 1. NygrenJ,SoopM,ThorellA,EfendicS,NairKS,LjungqvistO.Preoperativeoralcarbohydrateadministrationreducespostoperativeinsulinresistance.ClinNut,1998;17(2):65-71.2. BlixtC,AhlstedtC,LjungqvistO,IsakssonB,KalmanS,RooyackersO.Theeffectofperioperativeglucosecontrolonpostoperativeinsulinresistance.ClinlNutr,2012;31(5):676.3. GustafssonUO,NygrenJ,ThorellA,etal.Pre-operativecarbohydrateloadingmaybeusedintype2diabetespatients.ActaAnaesthScand.2008;52(7):946-951.