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Preoperative Oral Carbohydrate Load Versus Placebo in Major Elective Abdominal Surgery (PROCY): A Randomized, Placebo-controlled, Multicenter, Phase III Trial.
Gianotti, L, Biffi, R, Sandini, M, Marrelli, D, Vignali, A, Caccialanza, R, Viganò, J, Sabbatini, A, Di Mare, G, Alessiani, M, et al
Annals of surgery. 2018;(4):623-630
Abstract
OBJECTIVE To explore whether preoperative oral carbohydrate (CHO) loading could achieve a reduction in the occurrence of postoperative infections. BACKGROUND Hyperglycemia may increase the risk of infection. Preoperative CHO loading can achieve postoperative glycemic control. METHODS This was a randomized, controlled, multicenter, open-label trial. Nondiabetic adult patients who were candidates for elective major abdominal operation were randomized (1:1) to a CHO (preoperative oral intake of 800 mL of water containing 100 g of CHO) or placebo group (intake of 800 mL of water). The blood glucose level was measured every 4 hours for 4 days. Insulin was administered when the blood glucose level was >180 mg/dL. The primary endpoint was the occurrence of postoperative infection. The secondary endpoint was the number of patients needing insulin. RESULTS From January 2011 through December 2015, 880 patients were randomly allocated to the CHO (n = 438) or placebo (n = 442) group. From each group, 331 patients were available for the analysis. Postoperative infection occurred in 16.3% (54/331) of CHO group patients and 16.0% (53/331) of placebo group patients (relative risk 1.019, 95% confidence interval 0.720-1.442, P = 1.00). Insulin was needed in 8 (2.4%) CHO group patients and 53 (16.0%) placebo group patients (relative risk 0.15, 95% confidence interval 0.07-0.31, P < 0.001). CONCLUSIONS Oral preoperative CHO load is effective for avoiding a blood glucose level >180 mg/dL, but without affecting the risk of postoperative infectious complication.
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Preoperative gastric residual volumes in fasted patients measured by bedside ultrasound: a prospective observational study.
Ohashi, Y, Walker, JC, Zhang, F, Prindiville, FE, Hanrahan, JP, Mendelson, R, Corcoran, T
Anaesthesia and intensive care. 2018;(6):608-613
Abstract
The purpose of this prospective observational study was to measure gastric volumes in fasted patients using bedside gastric ultrasound. Patients presenting for non-emergency surgery underwent a gastric antrum assessment, using the two-diameter and free-trace methods to determine antral cross-sectional area (CSA). Gastric residual volume (GRV) was calculated using a validated formula. Univariate and multivariable analyses were performed to examine any potential relationships between 'at risk' GRVs (>100 ml) and patient factors. Two hundred and twenty-two successful scans were performed; of these 110 patients (49.5%) had an empty stomach, nine patients (4.1%) had a GRV >100 ml, and a further six patients (2.7%) had a GRV >1.5 ml/kg. There was no significant relationship between at risk GRV and obesity, diabetes mellitus, gastro-oesophageal reflux disease or opioid use, although our study had insufficient power to exclude an influence of one or more of these factors. Our results indicate that despite compliance with fasting guidelines, a small percentage of patients still have GRVs that pose a pulmonary aspiration risk. Anaesthetists should consider this background incidence when choosing anaesthesia techniques for their patients. While future observational studies are required to determine the role of preoperative bedside gastric ultrasound, it is possible that this technique may assist anaesthetists in identifying patients with 'at risk' GRVs.
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Preoperative fasting in children: review of existing guidelines and recent developments.
Frykholm, P, Schindler, E, Sümpelmann, R, Walker, R, Weiss, M
British journal of anaesthesia. 2018;(3):469-474
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Abstract
The current guidelines for preoperative fasting recommend intervals of 6, 4, and 2 h (6-4-2) of fasting for solids, breast milk, and clear fluids, respectively. The objective is to minimize the risk of pulmonary aspiration of gastric contents, but also to prevent unnecessarily long fasting intervals. Pulmonary aspiration is rare and associated with nearly no mortality in paediatric anaesthesia. The incidence may have decreased during the last decades, judging from several audits published recently. However, several reports of very long fasting intervals have also been published, in spite of the implementation of the 6-4-2 fasting regimens. In this review, we examine the physiological basis for various fasting recommendations, the temporal relationship between fluid intake and residual gastric content, and the pathophysiological effects of preoperative fasting, and review recent publications of various attempts to reduce the incidence of prolonged fasting in children. The pros and cons of the current guidelines will be addressed, and possible strategies for a future revision will be suggested.
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Supportive interventions to improve physiological and psychological health outcomes among patients undergoing cystectomy: a systematic review.
Quirk, H, Rosario, DJ, Bourke, L
BMC urology. 2018;(1):71
Abstract
BACKGROUND Our understanding of effective perioperative supportive interventions for patients undergoing cystectomy procedures and how these may affect short and long-term health outcomes is limited. METHODS Randomised controlled trials involving any non-surgical, perioperative interventions designed to support or improve the patient experience for patients undergoing cystectomy procedures were reviewed. Comparison groups included those exposed to usual clinical care or standard procedure. Studies were excluded if they involved surgical procedure only, involved bowel preparation only or involved an alternative therapy such as aromatherapy. Any short and long-term outcomes reflecting the patient experience or related urological health outcomes were considered. RESULTS Nineteen articles (representing 15 individual studies) were included for review. Heterogeneity in interventions and outcomes across studies meant meta-analyses were not possible. Participants were all patients with bladder cancer and interventions were delivered over different stages of the perioperative period. The overall quality of evidence and reporting was low and outcomes were predominantly measured in the short-term. However, the findings show potential for exercise therapy, pharmaceuticals, ERAS protocols, psychological/educational programmes, chewing gum and nutrition to benefit a broad range of physiological and psychological health outcomes. CONCLUSIONS Supportive interventions to date have taken many different forms with a range of potentially meaningful physiological and psychological health outcomes for cystectomy patients. Questions remain as to what magnitude of short-term health improvements would lead to clinically relevant changes in the overall patient experience of surgery and long-term recovery.
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PRE-OPERATIVE FASTING: WHY ABBREVIATE?
Campos, SBG, Barros-Neto, JA, Guedes, GDS, Moura, FA
Arquivos brasileiros de cirurgia digestiva : ABCD = Brazilian archives of digestive surgery. 2018;(2):e1377
Abstract
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.
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Preoperative Evaluation in Bariatric Surgery.
Schlottmann, F, Nayyar, A, Herbella, FAM, Patti, MG
Journal of laparoendoscopic & advanced surgical techniques. Part A. 2018;(8):925-929
Abstract
An adequate preoperative workup is critical for the success of bariatric surgery. A key component of the preoperative evaluation involves a comprehensive patient education about surgical outcomes and the postoperative behavioral regimen required. A complete medical evaluation should include the study of the cardiovascular, pulmonary, and gastrointestinal systems as well as a metabolic status assessment. The nutrition professional should be in charge of the nutritional assessment, preoperative weight loss efforts, and diet education regarding postoperative eating behaviors. A psychological evaluation is also needed because psychosocial factors have a significant impact on the long-term outcomes of bariatric surgery, including adherence to recommended postoperative lifestyle regimen, emotional adjustment, and weight loss outcomes. We recommend preoperative abdominal ultrasound to assess for biliary tract pathology, steatosis, fibrosis, and presence of nonalcoholic steatohepatitis. A routine preoperative esophagogastroduodenoscopy is also recommended to evaluate common gastrointestinal disorders associated with obesity. Preoperative weight loss should be strongly encouraged.
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Multimodal Prehabilitation Programs as a Bundle of Care in Gastrointestinal Cancer Surgery: A Systematic Review.
Bolshinsky, V, Li, MH, Ismail, H, Burbury, K, Riedel, B, Heriot, A
Diseases of the colon and rectum. 2018;(1):124-138
Abstract
BACKGROUND Prehabilitation reflects a proactive process of preoperative optimization undertaken between cancer diagnosis and definitive surgical treatment, with the intent of improving physiological capacity to withstand the major insult of surgery. Prehabilitation before GI cancer surgery is currently not widely adopted, and most research has focused on unimodal interventions such as exercise therapy, nutritional supplementation, and hematinic optimization. A review of the existing literature was undertaken to investigate the impact of multimodal prehabilitation programs as a "bundle of care." DATA SOURCE A systematic literature search was performed utilizing Medline, PubMed, Embase, Cinahl, Cochrane, and Google Scholar databases. STUDY SELECTION The quality of studies was assessed by using the Cochrane tool for assessing risk of bias (randomized trials) and the Newcastle-Ottawa Quality Assessment scale (cohort studies). INTERVENTION Studies were chosen that involved pre-operative optimization of patients before GI cancer surgery. MAIN OUTCOMES The primary outcome measured was the impact of prehabilitation programs on preoperative fitness and postoperative outcomes. RESULTS Of the 544 studies identified, 20 were included in the qualitative analysis. Two trials investigated the impact of multimodal prehabilitation (exercise, nutritional supplementation, anxiety management). Trials exploring prehabilitation with unimodal interventions included impact of exercise therapy (7 trials), impact of preoperative iron replacement (5 trials), nutritional optimization (5 trials), and impact of preoperative smoking cessation (2 trials). Compliance within the identified studies was variable (range: 16%-100%). LIMITATIONS There is a lack of adequately powered trials that utilize objective risk stratification and uniform end points. As such, a meta-analysis was not performed because of the heterogeneity in study design. CONCLUSION Although small studies are supportive of multimodal interventions, there are insufficient data to make a conclusion about the integration of prehabilitation in GI cancer surgery as a bundle of care. Larger, prospective trials, utilizing uniform objective risk stratification and structured interventions, with predefined clinical and health economic end points, are required before definitive value can be assigned to prehabilitation programs.
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Clear Liquid Versus Low-fibre Diet in Bowel Cleansing for Colonoscopy in Children: A Randomized Trial.
Mytyk, A, Lazowska-Przeorek, I, Karolewska-Bochenek, K, Kakol, D, Banasiuk, M, Walkowiak, J, Albrecht, P, Banaszkiewicz, A
Journal of pediatric gastroenterology and nutrition. 2018;(5):720-724
Abstract
OBJECTIVES In light of a paucity of data on the role of diet in colonoscopy preparation in paediatric population, the present study was designed to compare the effectiveness of clear liquid and low-fibre diets for breakfast and lunch on the day preceding colonoscopy in children. METHODS This prospective, randomised trial was conducted at the Department of Paediatric Gastroenterology and Nutrition in Warsaw, Poland. Eligible patients, referred for colonoscopies, were 6 to 18 years old. Patients were randomly divided into 2 groups: the first received a clear liquid diet and the second a low-fibre diet on the day before colonoscopy. In the afternoon, all participants were asked to drink polyethylene glycol with electrolytes at a dose of 66 mL/kg to a maximum of 4 L. The effectiveness of bowel cleansing was measured using the Boston Bowel Preparation Scale (BBPS). The preparation tolerance was assessed by parents and children using a visual analogue scale. Adverse effects were reported. RESULTS In total, 184 patients were enrolled. Of those, 96 received the clear liquid diet and 88-the low-fibre diet. The mean age of both groups was 15 years. There were no differences between the 2 study groups in age, weight, and sex, as well as in total BBPS score (BBPS ≥ 5 96.6% vs 95.1%, P = 0.5). The frequency of adverse effects was similar in both groups; nausea was the most common (P = 0.8). CONCLUSIONS Clear liquid and low-fibre diets administered to children the day before colonoscopy demonstrated similar bowel cleansing effectiveness.
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Randomised controlled trial comparing preoperative carbohydrate loading with standard fasting in paediatric anaesthesia.
Tudor-Drobjewski, BA, Marhofer, P, Kimberger, O, Huber, WD, Roth, G, Triffterer, L
British journal of anaesthesia. 2018;(3):656-661
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Abstract
BACKGROUND Preoperative fasting is a major cause of perioperative discomfort in paediatric anaesthesia and leads to postoperative insulin resistance, thus potentially enhancing the inflammatory response to surgery. Addressing these problems by preoperative carbohydrate intake has not been a well-defined approach in children. METHODS We randomised 120 children scheduled for gastroscopy under general anaesthesia to either a control group of standard preoperative fasting or a study group receiving a carbohydrate beverage (PreOp™; Nutricia, Erlangen, Germany). Their stomach contents were aspirated endoscopically, and the volume and pH measured. Perioperative discomfort was evaluated using, among other parameters, an observational pain scale in ≤4-yr-olds and a VAS in >4-yr-olds. The investigators doing the endoscopies and outcome evaluations were blinded to the study group allocation. RESULTS Compared with fasting, carbohydrate loading was associated with significantly less gastric content (P=0.01), fewer patients experiencing postoperative nausea (P=0.028), with no significant difference in postoperative vomiting. High preoperative VAS scores (>5) were recorded for only one child in the carbohydrate group vs five children in the fasting group. Bowel cleansing for simultaneous colonoscopies (n=61) made no difference to any of the intergroup findings. CONCLUSIONS Preoperative carbohydrates can reduce nausea and gastric content, the latter being a surrogate parameter for the risk and severity of gastric aspiration into the lungs during anaesthesia. Our study adds knowledge for preoperative fasting guidelines in paediatric anaesthesia. CLINICAL TRIAL REGISTRATION DRKS00005020.
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Preoperative Use of Oral Beta-Adrenergic Blocking Agents and the Incidence of New-Onset Atrial Fibrillation After Cardiac Surgery. A Systematic Review and Meta-Analysis.
Thein, PM, White, K, Banker, K, Lunny, C, Mirzaee, S, Nasis, A
Heart, lung & circulation. 2018;(3):310-321
Abstract
BACKGROUND Current epidemiological data suggests that postoperative atrial fibrillation or atrial flutter (POAF) causes significant morbidity and mortality after cardiac surgery. The literature for prophylactic management of POAF is limited, resulting in the lack of clear guidelines on management recommendations. AIM: To examine the efficacy of prophylactic rate control agents in reducing the incidence of new-onset POAF in patients undergoing elective cardiac surgery. METHODS Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and Medline were systematically searched for blinded randomised controlled studies (RCT) evaluating adults with no history of atrial fibrillation randomised to a pharmacological agent (either beta blocker, calcium channel blocker or digoxin), compared to placebo. Utilising Cochrane guidance, three reviewers screened, extracted and the quality of the evidence was assessed. We used a random effects meta-analysis to compare a rate-control agent with placebo. RESULTS Five RCTs (688 subjects, mean age 61±8.9, 69% male) were included. Beta blocker administration prior to elective cardiac surgery significantly reduced the incidence of POAF (OR 0.43, 95%Cl [0.30-0.61], I2=0%) without significant impact on ischaemic stroke (OR 0.49, 95%Cl [0.10-2.44], I2=0%), non-fatal myocardial infarction (OR 0.76, 95%Cl [0.08-7.44], I2=0%), overall mortality (OR 0.83, 95%Cl [0.19-3.66], I2=0%), or length of stay (mean -0.96days 95%Cl [-1.49 to -0.42], I2=0%). An increased rate of bradycardic episodes was observed (OR 3.53, 95%Cl [1.22-10.23], I2=0%). CONCLUSIONS This review suggests that selective administration of prophylactic oral beta blockers prior to elective cardiac surgery is safe and may reduce the incidence of POAF.