Can pre-operative carbohydrate loading be used in diabetic patients undergoing colorectal surgery?

Abstract

The introduction of enhanced recovery after surgery (ERAS) has been associated with shortening post-operative recovery. It achieves such outcomes by minimizing the physical and physiological trauma of surgery. Benefits include superior pain control, reduced duration of ileus, improved pulmonary function and a reduction in thromboembolic and cardiac events. Within the ERAS approach the role of oral carbohydrate supplements is based on dealing with insulin resistance which characterizes periods of stress. Aggressive control of blood glucose levels has been shown to benefit both diabetic and non-diabetic patients admitted to intensive care units, however original studies in this area have not been consistently reproducible. The development of low osmolality carbohydrate drinks during the mid 1990s opened up the possibility of extending these benefits to surgical patients by providing them with a carbohydrate load two to three hours prior to anaesthesia. The benefits of the ERAS approach to colorectal surgery has been confirmed in several reports. However, its role in diabetic patients has, as yet, received limited attention. This review examines this limited number of publications and considers the potential benefit of preoperative carbohydrate loading in all diabetic patients. Br J Diabetes Vasc Dis 2014;14:102-104

The efficacy of enhanced recovery protocol from anesthesia in diabetic patients undergoing radical cystectomy

“…ERAS includes 22 components of pre-, intra-and postoperative care, with all being described as "Strong" recommendations as per the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework [10] Whether diabetic patients should be included in ERAS has been a contentious issue [11], resulting in varying clinical observations and guideline recommendations [12].…”

Enhanced Recovery after Surgery (ERAS®) Outcomes in Patients with Prior Diagnosis of Diabetes

“…The published randomized controlled trials that support ERAS interventions have excluded patients with DM or have included them only in very small numbers. 7 , 8 A guideline from the United Kingdom recommended the exclusion of patients with a history of diabetes from ERAS programmes, particularly because of the lack of data among patients with diabetes who have undergone ERAS surgery. 9 However, ERAS consensus statements recommend that patients with diabetes may be included provided that their conditions are optimized to international standards.…”

“…The interventions of the ERAS protocol that raise concerns for patients with DM are preoperative carbohydrate loading and routine prophylaxis for postoperative nausea and vomiting (PONV) with steroids. 5 - 7 , 9 …”

“…The interventions of the ERAS protocol that raise concerns for patients with DM are preoperative carbohydrate loading and routine prophylaxis for postoperative nausea and vomiting (PONV) with steroids. [5][6][7]9 In the ERAS protocol, preoperative carbohydrate loading is the administration of a 100 g carbohydrate drink on the night prior to surgery and a 50 g carbohydrate drink 2 hours prior to surgery. Among patients without diabetes, preoperative carbohydrate loading is associated with a small reduction in postoperative length of hospital stay among patients undergoing colorectal surgery.…”

Enhanced Recovery After Surgery (ERAS®) in Individuals with Diabetes: A Systematic Review

“…Whether patients with diabetes should be included in ERAS ® has been a contentious issue [22, 23], resulting in varying clinical practice and guideline recommendations [17, 22, 24, 25]. There are hypothetical risks to carbohydrate loading (one of the key preoperative elements of ERAS ® ) in individuals with diabetes (such as aspiration pneumonia due to delayed gastric emptying, and hyperglycemia and its sequelae) and it is uncertain whether this may negate any beneficial effects from the other elements of ERAS ® .…”