Preoperative carbohydrate loading in diabetic patients

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The Collaborative Learning Community: EBP Identification of Clinical Question assignment is due.

Prepare for your upcoming Topic 5 assignment, Collaborative Learning Community: EBP Literature Search/Appraisal of Evidence. Remember to record all communication in the CLC Forum.

Use the evidence hierarchy pyramid provided in Figure 2.1 in the Nursing Research: Generating and Assessing Evidence for Nursing Practice textbook as a guide for the levels of evidence in your reference list.

Locate case studies, relevant clinical articles written by experts, research articles, evidence-based guidelines, protocols, and theories that may guide the identification of appropriate solutions. This can include the articles reviewed in Topic 3. Note: Not all theories will have research that allows them to have a level assigned to them. This does not mean they are not good theories. A true proposal would require a comprehensive review of the literature and inclusion of all relevant works.

Appraise the evidence using the guidelines provided in the Nursing Research: Generating and Assessing Evidence for Nursing Practice textbook. Use these guidelines to discard references that are untrustworthy or irrelevant. Box 2.2 can help with this decision-making process. Chapter 5 provides guidance on how to synthesize the article findings.

Use the assigned Topic Material, “CLC EBP Research Table,” to consolidate and present the findings. Limit the articles to no more than 10 (two per student in the CLC group would be reasonable). Choose one group member to submit the completed assignment by the end of Topic 5.

A ll patients undergoing colorectal surgery must be provided with evidence-based care (Nursing and Midwifery Council (NMC), 2015); with the current gold standard being the enhanced recovery pathway (Gustafsson et al, 2013). This

research-based care pathway includes a variety of elements to result in a quicker recovery after surgery; associated with fewer complications (Larson et al, 2014). One of the elements of enhanced recovery is the use of preoperative carbohydrate loading. This is done through the use of a specially formulated drink taken orally prior to the operation to optimise the surgical process and minimise postoperative insulin resistance.

Enhanced recovery pathway The enhanced recovery pathway (ERP) has many different names including ‘fast track’ and ERAS (Enhanced Recovery After Surgery). The ERP encompasses a variety of preoperative, perioperative and postoperative research-based elements and can be used for patients of all ages (Burch, 2012). The basis of this care pathway began in colorectal surgery but it has been successfully adapted to many other surgical specialities such as gynaecological (Sjetne et al, 2009; Nelson et al, 2016) and urological surgery (Cerantola et al, 2013). More than 10 years ago Henrik Kehlet looked at the surgical research; amalgamating the evidence and formulating a care pathway (Kehlet and Wilmore, 2002). The Department of Health (DH) has realised the benefits of, and supported, this initiative; publishing a document on the Enhanced Recovery Partnership Programme (DH, 2011).

The elements of the ERP There are a number of elements related to the ERP. An important part of the pathway is a preoperative assessment, which includes nutritional screening and encouragement of patients to be involved in their care (Fearon et al, 2005). All information provided verbally is also written in a booklet that patients receive in the preassessment clinic. There are examples of such booklets on the ERAS society website (www.erassociety.org).

Preoperatively patients are not starved for prolonged periods. Food and milk are allowed until 6 hours prior to surgery, water

ABSTRACT The enhanced recovery pathway is an evidence-based surgical care pathway that includes preoperative, perioperative and postoperative care and results in fewer complications and a shorter length of stay in hospital. There are a variety of elements associated with this pathway and one is the use of a preoperative carbohydrate-loading drink. The consumption of this drink, which is specifically designed to be safely consumed a few hours before surgery, is discussed with a review of the literature on the topic.

Key words: Surgery ■ Fast track ■ Nutrition ■ Diabetes ■ Insulin resistance

Jennie Burch, Enhanced Recovery Nurse, St Mark’s Hospital, Harrow, London

Accepted for publication: June 2016

is permitted until a few hours prior to the operation. To prevent insulin resistance a carbohydrate-rich drink is given (Anderson et al, 2003) and consumed before the operation; just prior to being strictly nil by mouth for 2 hours. Moreover colorectal patients do not routinely have mechanical bowel preparation prior to surgery (Gustafsson et al, 2013). Historically it was thought to be safer to have a clean colon prior to bowel surgery; however, it has been shown that the use of bowel preparation can result in dehydration and electrolyte imbalance without any clinical benefit (Fearon et al, 2005). Therefore, not only is the preoperative patient fed and hydrated, but they are also kept in a more physiologically normal state through the avoidance of bowel preparation.

During surgery the infusion of intravenous fluids is controlled to prevent fluid and sodium overload. New surgical techiques including laparoscopic surgery result in less intraoperative blood loss and also reduced insensible losses (through sweat, breathing, and evaporation from the surgery site).

In the postoperative period patients do not have a nasogastric tube and are allowed to drink as soon as they can sit up in bed. Patients also can eat on the day of surgery if they feel able; in line with the evidence that a low-residue diet is better than clear fluids in the postoperative period (Lau et al, 2014). In the postoperative period patients are assisted until they are able to manage alone to get out of bed, mobilise in the ward and sit in the chair; this is usually achieved on the day after the operation. Anecdotally, walking after surgery is achieved by nearly all patients on the day after major colorectal surgery. Patients have their urinary catheter removed soon after surgery; as a result of this and other interventions, the risk of complications such as a urinary or chest infection are reduced (Gustafsson et al, 2013). Thus patients are in a better physical condition than with traditional care when they are discharged home.

Preoperative carbohydrate loading in the enhanced recovery pathway Jennie Burch

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The benefits of the ERP The ERP results in fewer complications and a shorter hospital stay following colorectal resections (Gustafsson et al, 2013); reducing lengths of stay from 10-14 days to 4 days for a colonic resection (Faiz et al, 2008). The ERP is reported as having high patient satisfaction (Polle et al, 2007; Khan et al, 2010); patients also report there is less time away from their families (Taylor and Burch, 2011). Furthermore it saves money through fewer bed days (Sammour et al, 2010) and lower rate of infection complications such as hospital-acquired pneumonia. Additionally, Jakobsson et al (2014) reported that recovery following colonic surgery produces rapid improvement in the patient’s condition during the first month at home.

Stress response and insulin resistance As a result of injury humans react to protect themselves with hormonal and metabolic changes. This reaction is termed the stress response with endocrine changes including insulin resistance. In modern surgery this ‘protective’ response is unnecessary for survival; the use of intraoperative medications can be used to dramatically these effects (Desborough, 2000) as can other interventions. Reducing the stress response enables an improved postoperative recovery.

Postoperative insulin resistance may result after surgery; despite insulin being produced; the body cells become resistant to insulin; resulting in hyperglycaemia (Lui et al, 2010). Insulin resistance is associated with an increased risk of postoperative morbidity and mortality (Kratzing, 2011)

and occurs in patients who are not known to have diabetes as well as patients who are. Through the avoidance of prolonged preoperative and postoperative fasting there is a reduction in the postoperative insulin resistance; this can be achieved by preoperative carbohydrate loading with a carbohydrate-rich drink such as preOp or PreLoad (Nygren et al, 1998).

Preoperative carbohydrate loading Carbohydrate loading results in a reduction in the postoperative insulin resistance (Thorell et al, 1999), which improves the postoperative glycaemic control; although the exact reason for this is uncertain (Yuill et al, 2005; Svanfeldt et al, 2007) and reduces the effects of metabolic stress (Kaška et al, 2010). Carbohydrate loading is achieved by consuming a clear drink that is passed through the stomach in 90 minutes (Nygren et al, 1995); so it does not increase the risk of aspiration during the surgical procedure (Kaška et al, 2010). In the meta-analysis by Li et al (2012) there were no reported aspirations associated with preoperative carbohydrate loading.

Shanley (2009) undertook a literature review, reporting that there were several, non-statistical benefits linked with carbohydrate loading; including a reduction in the length of hospital stay and improving patient wellbeing. The postoperative benefits of carbohydrate loading include reduced postoperative nausea and vomiting for patients undergoing a laparoscopic cholecystectomy (Hausel et al, 2005). Of note, postoperative nausea and vomiting after colorectal surgery may also be the result of a postoperative ileus; Ljungqvist (2010) suggested that there are also fewer postoperative complications such as infections, Currie et al (2015) concurred. Lui et al (2010), in their small study of elderly patients undergoing orthopaedic surgery following a fracture, reported a shorter length of hospital stay and 50% fewer readmissions. Noblett et al (2006) reported that there was a significantly reduced length of hospital stay for people having preoperative carbohydrate loading compared with people having water or prolonged fasting, and postoperative passage of flatus also occurred sooner.

Furthermore preoperative carbohydrate loading is associated with improved muscle strength, retention of lean body mass and a reduction in the loss of postoperative grip strength (Yuill et al, 2005; Svanfeldt et al, 2007). Carbohydrate loading has also been used in spinal anaesthesia where it results in less postoperative discomfort (Yagmurdur, 2011). These studies suggest that patients are physically in a better condition after surgery as a result of the carbohydrate loading. In tests in rats, carbohydrate loading has been shown to accelerate and improve the consumption of food in the postoperative period (Luttikhold, 2013). In practice, patients are generally able to resume solid food the day after surgery. Shanley (2009) considered that preoperative carbohydrate loading was not associated with any adverse effects and thus suggested overnight fasting should no longer be enforced. Furthermore, within the ERP it is accepted that the benefits outweigh any risks and the practice has received the support of the DH (2010).

Preoperative carbohydrate loading and diabetes Patients with diabetes are at risk of impaired glycaemic control

Figure 1. The human digestive system

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in the postoperative period. However, there are concerns that preoperative carbohydrate loading may adversely affect people with diabetes; with fears of slow gastric emptying and impaired control of blood glucose (Park and Camilleri, 2006). Interestingly Gustafsson et al (2008) performed a study on 25 people with well-controlled type 2 diabetes and reported that there was not a delay in gastric emptying compared with healthy controls. It should be noted that the peak glucose levels were delayed from 30 to 60 minutes for people with diabetes. Reassuringly the increased glucose levels after consuming the carbohydrate loading drink returned to normal after 2 or 3 hours for people without and with diabetes respectively. They concluded that as patients with type 2 diabetes showed no signs of delayed gastric emptying, it could be suggested that a carbohydrate loading drink may be safely administrated 3 hours before anaesthesia without risk of hyperglycaemia or aspiration. In clinical practice it can be seen that although preoperative blood glucose rises that there were no complications encountered in a case study of two patients (Box 1). However, on such a small patient sample it can only be suggested that carbohydrate loading is safe and further studies are necessary.

Relevance to clinical practice It can be seen that preoperative carbohydrate loading drinks are safely used prior to surgery and there is also evidence that there are a variety of benefits associated with their use; such as less postoperative insulin resistance resulting in a reduction in stress response. There are also data, albeit limited, to suggest that carbohydrate loading can be safely given to non-insulin dependent diabetics (patients with type 2 diabetes) prior to colorectal surgery; with careful review and control of blood glucose in the perioperative period.

Conclusion Using the ERP there is good evidence that patients will encounter fewer complications than with traditional care. Prolonged preoperative starvation is detrimental to recovery after surgery. The use of preoperative carbohydrate loading is safe for people without diabetes and probably with type 2 diabetes, although further research is needed. Further work is needed to establish if preoperative carbohydrate loading is safe for people with insulin-controlled diabetics. Benefits associated with preoperative carbohydrate loading include less postoperative insulin resistance, which can result in fewer postoperative infections. BJN

Declaration of interest: none

Anderson AD, McNaught CE, MacFie J, Tring I, Barker P, Mitchell CJ (2003) Randomized clinical trial of multimodal optimization and standard perioperative surgical care. Br J Surg 90(12): 1497-504

Burch J (2012) Enhanced recovery and nurse-led telephone follow-up post surgery. Br J Nurs 21(16 suppl): S24-S29. doi: 10.12968/bjon.2012.21. Sup16.S24

Cerantola Y, Valerio M, Persson B et al (2013) Guidelines for perioperative care after radical cystectomy for bladder cancer: Enhanced Recovery After Surgery (ERAS®) Society Recommendations. Clin Nutr 32(6): 879-87. doi: 10.1016/j.clnu.2013.09.014

Currie A, Burch J, Jenkins JT et al for ERAS Compliance Group (2015) The impact of enhanced recovery protocol compliance on elective colorectal cancer resection: results from an international registry. Ann Surg 261(6):1153-9. doi: 10.1097/SLA.0000000000001029

Desborough JP (2000) The stress response to trauma and surgery. Br J Anaesth. 85(1): 109-17

Department of Health (2010) Delivering enhanced recovery: Helping patients to get better sooner after surgery. http://tinyurl.com/j9fofuj (accessed 15 June 2016)

Department of Health (2011) Enhanced Recovery Partnership Programme. http://tinyurl.com/j8tveo6 (accessed 15 June 2016)

Faiz O, Brown T, Colucci G, Kennedy RH (2008) A cohort study of results following elective colonic and rectal resection within an enhanced recovery programme. Colorectal Dis 11(4): 366-72. doi: 10.1111/j.1463- 1318.2008.01604.x

Fearon KCH, Ljungqvist O, Von Meyenfeldt M et al (2005) Enhanced recovery after surgery: A consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 24(3): 466-77

Gustafsson UO, Nygren J, Thorell A et al (2008) Pre-operative carbohydrate loading may be used in type 2 diabetes patients. Acta Anaesthesiol Scand 52(7):946-51. doi: 10.1111/j.1399-6576.2008.01599.x

Gustafsson UO, Scott MJ, Schwenk W et al (2013) Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations. World J Surg 37(2):259-84. doi: 10.1007/s00268-012-1772-0

Hausel J, Nygren J, Thorell A, Lagerkranser M, Ljungqvist O (2005) Randomised clinical trial of the effects of oral preoperative carbohydrates on postoperative nausea and vomiting after laparoscopic cholecystectomy. Br J Surg 92(5): 415-21

Jakobsson J, Idvall E, Wann-Hansson (2014) Patient-reported recovery after enhanced colorectal cancer surgery: a longitudinal six-month follow-up study. Int J Colorectal Dis 29(8):989-98. doi: 10.1007/s00384-014-1939-2

Kaška M, Grosmanová T, Havel E et al (2010) The impact and safety of preoperative oral or intravenous carbohydrate administration versus fasting in colorectal surgery – a randomized controlled trial. Wien Klin Wochenschr 122(1-2):23-30. doi: 10.1007/s00508-009-1291-7

Kehlet H, Wilmore DW (2002) Multimodal strategies to improve surgical outcomes. Am J Surg 183(6): 630-41

Khan S, Wilson T, Ahmed J, Owais A, MacFie J (2010) Quality of life and patient satisfaction with enhanced recovery protocols. Colorectal Dis 12(12): 1175-82. doi: 10.1111/j.1463-1318.2009.01997.x

Kratzing C (2011) Pre-operative nutrition and carbohydrate loading. Proc Nutr Soc 70(3):311-5. doi: 10.1017/S0029665111000450

Larson DW, Lovely JK, Cima RR et al (2014) Outcomes after implementation of a multimodal standard care pathway for laparoscopic colorectal surgery. Br J Surg 101(8):1023-30. doi: 10.1002/bjs.9534

Lau C, Phillips E, Bresee C, Fleshner P (2014) Early use of low residue diet is superior to clear liquid diet after elective colorectal surgery: a randomized controlled trial. Ann Surg 260(4):641-7. doi: 10.1097/ SLA.0000000000000929

Li L, Wang Z, Ying X et al (2012) Preoperative carbohydrate loading for elective surgery: a systematic review and meta-analysis. Surg Today

KEY POINTS ■■ The enhanced recovery pathway is evidence-based care that results in

fewer complications associated with surgery

■■ Preoperative carbohydrate drinks given before surgery have a number of benefits for patients such as better postoperative glycaemic control

■■ If consumed as directed there are no reported aspirations associated with preoperative carbohydrate loading

Box 1. Two case studies to illustrate preoperative carbohydrate loading in patients with diabetes

Female, aged 75. Diabetes controlled with tablets, on pioglitazone and metformin 15/850. Her preoperative blood glucose was 17.2 mmol/litre. She underwent a laparoscopic high anterior resection and was in hospital for 5 days and encountered no complications.

Female, aged 74. Diabetes controlled with tablets, on metformin 500 mg twice daily. Her preoperative blood glucose was 12.6 mmol/litre. She underwent a laparoscopic right hemicolectomy and was in hospital for 6 days and encountered no complications.

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42(7):613-24. doi: 10.1007/s00595-012-0188-7 Ljungqvist O (2010) Insulin resistance and outcomes in surgery. J Clin

Endocrinol Metab 95(9):4217-9. doi: 10.1210/jc.2010-1525 Lui D, Murphy M, McHugh G et al (2010) Prospective randomised

controlled study: pre operative carbohydrate loading in hip and femoral fracture patients reduces post operative hyperglycaemia. Journal of Bone and Joint Surgery (British volume) 92-B(suppl I): 44

Luttikhold J, Oosting A, van den Braak CC et al (2013) Preservation of the gut by preoperative carbohydrate loading improves postoperative food intake. Clin Nutr 32(4): 556-61. doi: 10.1016/j.clnu.2012.11.004. Epub 2012

Nelson G, Altman AD, Nick A et al (2016) Guidelines for pre- and intra- operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations—Part I. Gynecol Oncol 140(2): 313-22. doi: 10.1016/j.ygyno.2015.11.015. Epub 2015

Noblett SE, Watson DS, Huong H, Davison B, Hainsworth PJ, Horgan AF (2006) Pre-operative oral carbohydrate loading in colorectal surgery: a randomized controlled trial. Colorectal Dis 8(7): 563-9

Nursing and Midwifery Council (2015) The Code: Professional standards of practice and behaviour for nurses and midwives. NMC, London.

Nygren J, Thorell A, Jacobsson H et al (1995) Preoperative gastric emptying: the effects of anxiety and oral carbohydrate administration. Ann Surg 222(6):728-34

Nygren J, Soop M, Thorell A, Efendic S, Nair KS, Ljungqvist O (1998) Preoperative oral carbohydrate administration reduces postoperative insulin resistance. Clin Nutr 17(2):65-71

Park MI, Camilleri M (2006) Gastroparesis: clinical update. Am J Gastroenterol 101(5):1129-39

Polle SW, Wind J, Fuhring JW, Hofland J, Gouma DJ, Bemelman WA (2007)

Implementation of a fast-track perioperative care program: what are the difficulties? Dig Surg 24(6): 441-9

Sammour T, Zargar-Shoshtari K, Bhat A, Kahokehr A, Hill AG (2010) A programme of Enhanced Recovery After Surgery (ERAS) is a cost-effective intervention in elective colonic surgery. N Z Med J 123(1319):61-70.

Shanley S (2009) Preoperative carbohydrate loading: a review of the current evidence. Journal of Human Nutrition and Dietetics 22(3): 261-2. doi: 10.1111/j.1365-277X.2009.00952_8.x

Sjetne IS, Krogstad U, Ødegård S, Engh ME (2009) Improving quality by introducing enhanced recovery after surgery in a gynaecological department: consequences for ward nursing practice. Qual Saf Health Care 18(3):236-40. doi: 10.1136/qshc.2007.023382

Svanfeldt M, Thorell A, Hausal J et al (2007) Randomized clinical trial of the effect of preoperative oral carbohydrate treatment on postoperative whole-body protein and glucose kinetics. Br J Surg 94(11): 1342-5

Taylor C, Burch J (2011) Feedback on an enhanced recovery programme for colorectal surgery. Br J Nurs 20(5): 286-90. doi: 10.12968/ bjon.2011.20.5.286

Thorell A, Nygren J, Ljungqvist O (1999) Insulin resistance: a marker of surgical stress. Curr Opin Clin Nutr Metab Care 2(1):69-78.

Yagmurdur H, Gunal S, Yildiz H, Gulec H and Topkaya C (2011) The effects of carbohydrate-rich drink on perioperative discomfort, insulin response and arterial pressure in spinal aesthesia. J Res Med Sci 16(11):1483-9

Yuill KA, Richardson RA, Davidson HI, Garden OJ, Parks RW (2005) The administration of an oral carbohydrate-containing fluid prior to major elective upper-gastrointestinal surgery preserves skeletal muscle mass postoperatively – a randomised clinical trial. Clin Nutr 24(1):32–7.

Edited by Carol Cox, Martin Steggall and Alison Coutts

A practical and comprehensive clinical guide for all health professionals who work with patients with gastrointestinal conditions. Relevant to healthcare students and seasoned practitioners alike, this book presents core knowledge — it offers clear descriptions of the epidemiology, pathophysiology, assessment and diagnosis of gastrointestinal disorders and it also supports the development of clinical skills that are required when caring for patients.

Information is presented in a user-friendly format, with clear headings, tables and  gures throughout. All major topics are covered, including: Anatomy and physiology of the gastrointestinal system; Nutrition; Upper and lower gastrointestinal complaints; Tumours of the gastrointestinal tract; Malabsorption syndromes; Intestinal complications of in€ ammatory bowel disease; Gastrointestinal imaging studies; Other diseases.

ISBN-13: 978-1-85642-426-4; 210 x 148 mm; paperback; 220 pages; publication 2012; £19.99

Fundamental Aspects of Gastrointestinal Nursing

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About the book Fundamental Aspects of Gastrointestinal Nursing is a practical and comprehensive clinical guide for all health professionals who work with patients with gastrointestinal conditions. Relevant to healthcare students and seasoned practitioners alike, this book presents core knowledge — it offers clear descriptions of the epidemiology, pathophysiology, assessment and diagnosis of gastrointestinal disorders and it also supports the development of clinical skills that are required when caring for patients.

Information is presented in a user-friendly format, with clear headings, tables and figures throughout. All major topics are covered, including: • Anatomy and physiology of the gastrointestinal system • Nutrition • Upper and lower gastrointestinal complaints • Tumours of the gastrointestinal tract • Malabsorption syndromes • Intestinal complications of inflammatory bowel disease • Gastrointestinal imaging studies • Other diseases

A new addition to the successful Fundamental Aspects of Nursing series, this useful handbook is the perfect tool to support gastrointestinal nursing practice. About the editors Professor Carol Cox, is Professor of Nursing, Advanced Clinical Practice and Associate Dean for Research and Enterprise in the School of Health Sciences at City University, London. Professor Cox is the Academic Lead for the Advanced Practice Colorectal Nursing Research Unit at the Homerton University Hospital NHS Foundation Trust in London and she has researched and published extensively in advanced practice and gastrointestinal nursingMartin Steggall, is the Associate Dean, Director of Undergraduate Studies in the School of Health Sciences at City University, London. Dr. Steggall practices as a Clinical Nurse Specialist in Erectile Dysfunction/Premature Ejaculation at Barts and The London NHS Trust in London and has published within the fields of urological and gastrointestinal nursing

Mrs Alison Coutts, is a Senior Lecturer and Programme Director for the Master of Science in Nursing Programme at City University, London. She is widely published in the fields of nutrition and gastrointestinal nursing

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