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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.
