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Pulmonary aspiration of gastric contents during elective surgery remains a major cause of airway-related mortality and morbidity. The preoperative fasting times for solids and liquids have been standardized across various anesthesia society guidelines. Enhanced Recovery After Surgery (ERAS) guidelines now advocate liberal clear fluid intake with carbohydrate loading up to 2 h preoperatively. The aim of the study was to assess whether practicing both ASA fasting guidelines and ERAS protocol makes the patients prone to a full stomach. The supine position standard curvilinear ultrasound probe (2–5 MHz) with Sonosite M-Turbo ©system was used to obtain the images. Gastric residual volume (GRV) was derived from the cross-sectional area (CSA) using the Perlas and colleagues model. A total of 102 patients were recruited and analyzed. The mean age and BMI were 50.65 years ± 13.35 years and 22.23 kg/m(2) ± 3.7 kg/m(2), respectively. A total of four patients (3.92%) had gastric volume > 1.5 ml/kg; out of these four patients, three were female and one was male. We did not observe any case of pulmonary aspiration in any of our patients. In conclusion, even though for elective surgeries, the current fasting guidelines are adequate, these findings cannot be extrapolated to patients with risk factors for high gastric residual volume where further studies need to be performed.

Currently, there is a lack of consensus on the provision of preoperative carbohydrate loading in patients with type 2 diabetes mellitus (T2DM) due to theoretical concerns including the possibility of delayed gastric emptying, perioperative hyperglycemia, and poor surgical outcomes. This narrative review summarizes the accumulating evidence on preoperative carbohydrate loading in this population and whether these concerns are supported by preliminary evidence. In general, the available research suggests that carbohydrate loading may be implemented in those with T2DM without increased risk for intra- and postoperative hyperglycemia or surgical complications. However, there is strong justification for future research to definitively study this highly debated and timely topic. Ultimately, the inclusion of preoperative carbohydrate loading for surgical patients with DM should be guided by the surgical team's clinical judgment and individualized based on patient needs and characteristics.

Background Preoperative carbohydrate loading is a component of Enhanced Recovery After Surgery (ERAS) protocols, but there is limited literature in bariatric surgery patients. Objectives The objective of this study was to characterize the impact of preoperative carbohydrate loading on postoperative bariatric surgery outcomes. Setting University Hospital. Methods Patients undergoing a primary minimally invasive Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) between 2018 and 2020 were randomized to standard management or intervention. Standard management patients were nothing by mouth (NPO) after midnight prior to surgery. Intervention patients consumed 2 carbohydrate drinks: 1 the night before and another 3 hours prior to surgery. Primary outcomes analyzed included postoperative nausea and vomiting (PONV), length of stay, and overall complications. Results In total, 134 patients were analyzed: 64 intervention (47.8%) and 70 (52.2%) standard. In the end, 7% and 15% of patients were lost to follow-up at 6-weeks and 3-months, respectively. There was no statistically significant difference in length of stay (2.0 ± 1.2 vs 2.1 ± .9 d; P = .65) or postoperative outcomes between the 2 groups. There were no episodes of aspiration among the intervention group. Among RYGB patients, intervention patients had a shorter duration of nausea compared with standard patients. There was no significant difference in glycemic control among patients with and without diabetes. Conclusions Preoperative carbohydrate drinks can be administered to bariatric surgery patients without significant risks. Carbohydrate loading preoperatively can decrease the duration of PONV in RYGB patients. Carbohydrate drinks can be safely included in bariatric ERAS protocols for patients with and without diabetes, although the benefits remain unknown.

Background Preoperative malnourishment has been consistently associated with poor outcomes after radical cystectomy and other major abdominal surgeries. Most enhanced recovery after surgery (ERAS) studies have examined preoperative nutrition and its relationship to outcomes after gastrointestinal surgery. Although numerous studies have demonstrated the benefits of using an ERAS protocol, this study in unique in comparing 2 ERAS protocols, with and without a nutrition component. Methods A formalized preoperative nutrition protocol (PNP) recommending use of preoperative immunonutrition and carbohydrate drink was introduced in June 2018. A total of 78 consecutive patients who drank both beverages were compared with 92 historical controls. Multivariable logistic regression analyses were sequentially performed to determine if preoperative nutrition was associated with binary outcome variables (30-day complication, infectious complication, and readmission within 30 days). Results The preoperative nutrition group and control group were statistically similar in distribution of age, sex, American Society of Anesthesiologists physical status classification, clinical stage, and body mass index. Return of bowel function was found to occur earlier in the preoperative nutrition group than in the control group (3.12 vs 3.74 days; relative risk, 0.82; CI, 0.73-0.93; P = .0029). Complications within 30 days were similar in both groups (63.6% vs 55.4%; P = 0.36). Infectious complications (42.9% vs 37%; P = .53) and readmission within 30 days (22.1% vs 15.2%; P = .34) were also similar in both groups. Conclusions Use of a PNP including immunonutrition and carbohydrate drink may be associated with earlier return of bowel function after radical cystectomy.

BACKGROUND During competition season, races and games can be scheduled multiple times a week or even within 24 hours. This may interfere with macronutrient periodization, carbohydrate loading regimen, hydration status and nutrition. Most of the studies investigating the influence of diet on performance do not take into consideration that an athlete may need to perform closely spaced, repeated events. The study tested whether the fat-adaptation diet would improve performance on the consecutive day of interval exercise. METHODS Nine healthy, male amateur athletes were randomly assigned to two diets in a single-blinded, crossover study. The fat-adaptation diet consisted of the first five days high-fat diet (2.62 g/kg/d carbohydrates, 2.23 g/kg/d fat). The day six and seven of the fat-adaptation diet consisted of 5.42 g/kg/d carbohydrates. The balanced carbohydrate diet consisted of a seven-day protocol involving consumption of 5.33 g/kg/d. On day seven of each diet protocol, subjects performed an interval treadmill test dependent on exhaustion. Blood glucose and lactate were measured before and immediately after exercise. The identical treadmill test was performed once again after 24 hours on the day eight of each diet. RESULTS There was a significant decrease in the total distance to exhaustion after the fat-adaptation diet (11.2 ±0.6 km vs 10.9 ±0.8 km), p < 0.05 with lactate being lower after exercise on the second day (6.2 ±0.8 mM) compared to the first day (7.4 ±0.9 mM). Glucose was elevated after exercise except on the second test day on the fat-adaptation diet (5.3 ±0.3 mmol/L). CONCLUSIONS Athletes perform better on the balanced carbohydrate diet than short fat-adaptation diet on the consecutive day of interval test.

Background We aimed to determine the effects of preoperative carbohydrate-loading (CHO) as part of an enhanced recovery after surgery (ERAS) pathway on patients with/without type II diabetes (DMII). Methods Retrospective review of ERAS patients with CHO, including 80 with DMII, 275 without DMII in addition to 89 patients with DMII from the previous (non-ERAS) year. Outcomes included glucose-levels, insulin requirements, and complications. Logistic regression was used to determine the association of any complication with perioperative glucose control variables. Results Among ERAS versus non-ERAS patients with DMII, there were significant differences in median preoperative (142 mg/dL versus 129.5 mg/dL, p = 0.017) and postoperative day-1 glucose levels (152 mg/dL, versus 137.5 mg/dL, p = 0.004). There were no differences in insulin requirements, hypoglycemic episodes, or complications. Complications were not associated with Hgb-A1C%, home DMII-medications, or preoperative glucose measurement on logistic regression. Conclusions Patients with DMII tolerated CHO without increasing insulin requirements or substantially affecting glucose levels or complications.

Food deprivation is a common condition for visceral surgeons and especially laparoscopic approaches require high levels of concentration. The current literature does not provide adequate answers whether intraoperative breaks, especially food intake, might influence the quality of the surgical skills. Thus, the primary aim of this trial was to analyze the influence of food deprivation on the laparoscopic performance.37 laparoscopic novices participated from 10/2017 to 04/2018 in this single center, prospective-randomized trial and were trained during laparoscopic training sessions until they reached a predefined level of proficiency. Subsequently, participants were randomized into 3 different groups: food deprivation of 8 hours, 4 hours, or carbohydrate loading directly prior to the laparoscopic exam. The exam comprised PEG-transfer, precise cutting, gallbladder resection and surgical knot.Completion time for PEG-transfer, precise cutting, gallbladder resection and surgical knot was 63s, 139s, 192s and 272s respectively. Participants starving for 8 hours performed 3 of 4 tasks more slowly whilst participants starving for 4 hours performed 3 of 4 tasks faster than the average. Analyzing self-reported level of appetite revealed: Students with an intermediate level were significantly faster (p0.05) during complex procedures compared to participants that reported hunger prior to performing these tasks (192s vs. 307s). Additionally, hungry students had been more inaccurate during the surgical knot (p0.05) whilst students with intermediate appetite level tend to be most accurate (p - value 0.012).The subjective level of appetite rather than the absolute number of fasting hours influences the laparoscopic performance most. Thus, any extreme level of appetite may be avoided and surgeons may achieve the best performance when they have an intermediate level of appetite. In consequence, heavy meals may be omitted immediately prior to demanding laparoscopic procedures and surgeons may have access to mini-breaks and refreshers during major procedures.

Authors et al. have continued diabetic practice and research for long, and started Low Carbohydrate Diet (LCD) first in Japan. We developed social LCD movement by Japanese LCD Promotion Association (JLCDPA), and proposed petite-, standard-, super LCDs with carbohydrate 40%, 26%, 12%, respectively. Methods included 9 healthy medical staffs and two exams of 75g Oral Glucose Tolerance Test (OGTT) and Meal Tolerance Test (MTT). MTT means super-LCD breakfast with carbohydrate 6g. Results showed that blood glucose / immunoreactive insulin (IRI) at 0-30 min on average changed 88.0-130.6 mg/dL/5.1-46.5 μU/mL for GTT, and 90.1-86.3 mg/dL/4.8-12.5 μU/mL for MTT. IRI responses in GTT and MTT were calculated by 3 methods, which are i) increment (delta), ii) Area Under the Curves (AUC), iii) Multiple (times) of basal value. Both data from GTT and MTT showed significant correlation in i) and ii) (p

The ergogenic effect of caffeine is well established, although no investigations providing a high carbohydrate feeding strategy (pre-exercise meal=2 g/kg BM) co-ingested with caffeine exist for soccer. This investigation examines the effect of caffeine in addition to a pre-exercise carbohydrate meal and drink mid-way through a soccer simulation. Eight recreational soccer players completed an 85-minute soccer simulation followed by an exercise capacity test (Yo-yo Intermittent Endurance test level 2) on two occasions. Prior to exercise participants consumed a high carbohydrate meal, with placebo or 5 mg/kg BM-1 caffeine. No significant performance effect was identified (p=0.099) despite a 12.8% (109 m) improvement in exercise capacity following caffeine. Rates of carbohydrate and fat oxidation did not differ between conditions and nor were differences apparent for plasma glucose, fatty acids, glycerol, β-hydroxybutyrate (p>0.05). However, an increase in lactate was observed for caffeine (p=0.039). A significant condition effect on rating of perceived exertion was identified (p

BACKGROUND Intraoperative hypothermia is a common complication after neuraxial block in cesarean delivery. At least 1 animal study has found that carbohydrate loading can maintain the body temperature of rats during general anesthesia, but it is unclear whether carbohydrate loading is beneficial for body temperature maintenance in parturient women during combined spinal-epidural anesthesia (CSEA) for elective cesarean delivery. METHODS Women undergoing elective cesarean delivery were randomized into a control group (group C), an oral carbohydrate group (group OC), or an oral placebo group (group OP), with 40 women in each group. Core body temperature (Tc) and body surface temperature (Ts) before and after cesarean delivery, changes in Tc (ΔTc) and Ts (ΔTs), and the incidence of side effects (eg, intraoperative shivering) were compared among the groups. RESULTS The postoperative Tc (core body temperature after cesarean delivery [Tc2]) of group OC (36.48 [0.48]°C) was higher than those of group C (35.95 [0.55]°C; P < .001), and group OP (36.03 [0.49]°C; P = .001). The ΔTc (0.30 [0.39]°C) in group OC was significantly smaller than those in group C (0.73 [0.40]°C; P = .001) and group OP (0.63 [0.46]°C; P = .0048). CONCLUSIONS Oral carbohydrate loading 2 hours before surgery facilitated body temperature maintenance during CSEA for elective cesarean delivery.

Purpose The purpose of this project was to implement carbohydrate loading in patients undergoing thoracic surgery in an effort to decrease postoperative pain, nausea, and length of stay as a part of an enhanced recovery after surgery protocol. Design This quality-improvement project used a preintervention and postintervention design. Methods Carbohydrate loading was given to 50 patients before undergoing thoracic surgery. Chart review was performed for 47 patients who received standard preoperative instructions in the preintervention group as historical control. Findings Patients who received carbohydrate loading had a decreased use of opioids in the first 4 hours after surgery (P = .028) and decreased use of antiemetic medication in the first 24 hours after surgery compared with the preintervention group (P = .066). Patients who were instructed to consume carbohydrate loading complied 87% of the time. Conclusions Carbohydrate loading can decrease postoperative nausea and pain in patients undergoing thoracic surgery.

Background Ventilator dependency constitutes a major problem in the intensive care setting. Malnutrition is considered a major determinant of extubation failure, however, attention has been attracted to modulating carbon dioxide production through decreasing carbohydrate loading and increasing the percent of fat in enteral feeds. The detected interrelation between substrate oxidation and ventilation outcome became the base of several research to determine the appropriate composition of the nonprotein calories of diet in ventilated patients. Purpose We aimed to assess the effect of high-fat dietary modification and nutritional status on ventilatory and final outcomes of pediatric intensive care. Methods Fifty-one ventilated children (1 month to 12 years of age) with pulmonary disease who could be enterally fed, in the Cairo University Pediatric intensive care unit, were divided into 2 groups: group A included 25 patients who received isocaloric high-fat, low-carbohydrate diet; group B included 26 patients who received standard isocaloric diet. Comprehensive nutritional assessment was done for all patients. Results Group A had a significant reduction in carbon dioxide tension, but no similar reduction in the duration or level of ventilatory support. Assisted minute ventilation was predicted by weight-for-age and caloric intake rather than the type of diet. Poor nutritional status was associated with higher mortality and lower extubation rates. Mild hypertriglyceridemia and some gastrointestinal intolerance were significant in group A, with no impact on the adequacy of energy or protein delivery. Conclusion The high-fat enteral feeding protocol may contribute to reducing carbon dioxide tension, with mild hypertriglyceridemia and negligible gastrointestinal intolerance as potential adverse effects. Optimization of nutritional status rather than dietary modification may improve ventilatory and survival outcomes in critically ill-ventilated children.

This study aimed to evaluate the effect of preoperative carbohydrate oral (CHO) loading on the postoperative metabolic and inflammatory response, perioperative discomfort and surgical clinical outcomes in open colorectal surgery compared with a conventional fasting protocol. Fifty patients were randomly allocated to either the intervention group (CHO), to receive preoperative oral carbohydrate supplementation, or the control group (FAST), to undergo preoperative fasting. Insulin resistance, insulin sensitivity, the Glasgow Prognostic Score (GPS) and IL-6 levels were analysed at 06 h on the day of surgery (T1), 6 h after surgery (T2) and at 06 h on postoperative day 1 (T3) and postoperative day 2 (T4). Thirst, hunger, dry mouth, weakness, anxiety and pain were assessed using the visual analogue scale (VAS) prior to anaesthesia induction and at 0–4, 4–8, 8–12 and 12–24 h after surgery. Surgical clinical outcomes included the return of gastrointestinal function, time to independent ambulation and postoperative discharge day. Postoperative insulin resistance was 30% lower (p

BackgroundThe effect of a combination of a goal-directed fluid protocol and preoperative carbohydrate loading on postoperative complications in elderly patients still remains unknown. Therefore, we designed this trial to evaluate the relative impact of preoperative carbohydrate loading and intraoperative goal-directed fluid therapy versus conventional fluid therapy (CFT) on clinical outcomes in elderly patients following gastrointestinal surgery.MethodsThis prospective randomized controlled trial with 120 patients over 65 years undergoing gastrointestinal surgery were randomized into a CFT group (n = 60) with traditional methods of fasting and water-deprivation, and a GDFT group (n = 60) with carbohydrate (200 ml) loading 2 h before surgery. The CFT group underwent routine monitoring during surgery, however, the GDFT group was conducted by a Vigileo/FloTrac monitor with cardiac index (CI), stroke volume variation (SVV), and mean arterial pressure (MAP). For all patients, demographic data, intraoperative parameters and postoperative outcomes were recorded.ResultsPatients in the GDFT group received significantly less crystalloids fluid (1111 ± 442.9 ml vs 1411 ± 412.6 ml;p p p = 0.002) and oral intake (72 ± 16.9 h vs 85 ± 26.8 h;p = 0.011), as well as a reduction in the rate of postoperative complications (15 (25.0%) vs 29 (48.3%) patients;p = 0.013). However, postoperative hospitalization or hospitalization expenses were similar between groups (p > 0.05).ConclusionsFocused on elderly patients undergoing open gastrointestinal surgery, we found perioperative fluid optimisation may be associated with improvement of bowel function and a lower incidence of postoperative complications.Trial registrationChiCTR,ChiCTR1800018227. Registered 6 September 2018 - Retrospectively registered.

Background Hip fractures represent a major clinical burden for patients. Studies on the effect of preoperative carbohydrate loading before different surgical interventions have shown promising results but have not been tested in patients with hip fracture. Aim This study aimed to investigate the effects of preoperative oral carbohydrate drinks on the postoperative energy intake and incidence of complications after hip fracture surgery. Method This was a pilot study using a quasi-experimental design with a control group and an intervention group. Result The number of patients affected by more than one complication was higher in the control group than in the intervention group. According to the logistic regression analysis, the risk of any postoperative complication was reduced by approximately 50% OR (95% CI) 0.508 (0.23–1.10) in patients in the IG compared to those in the CG (p = 0.085). Conclusion The result of this pilot study indicated that using preoperative carbohydrate drinks can decrease the number of postoperative complications in patients with a hip fracture. Furthermore, the number of patients who meet their energy needs during the first three days postoperatively might increase. More research is needed to confirm the effect of preoperative carbohydrate drinks.

We read, with interest, the publication in Nutrients on the effects of preoperative carbohydrate loading on outcomes after cardiac surgery [...]

We appreciate the thoughts and questions posed by Drs Dileep N Lobo and Girish P Joshi [...]

BackgroundPreoperative carbohydrate loading is used to improve patients’ comfort and recovery, but evidence remains limited in diabetic patients. We tested the feasibility of a preoperative carbohydrate drink with supplemental insulin in diabetic patients for gastrointestinal surgery.MethodsAdult patients with type 2 diabetes mellitus who were scheduled for major gastrointestinal surgery were randomized to carbohydrate group (carbohydrate drink with supplement insulin selectively) or control group (clinical routine management). The primary outcome was the time to first flatus after surgery. Among secondary outcomes, subjective feelings of thirsty, hunger and fatigue were assessed with the Visual Analogue Scale (scores range from 0 to 100, where 0 indicate no discomfort and 100 the most severe discomfort) before and after surgery.ResultsA total of 63 patients were randomized. Time to first flatus did not differ between groups (median [95% CI], 40 hours [30, 50] in control group vs. 43 hours [37, 48] in carbohydrate group, hazard ratio [95% CI], 1.24 [0.74, 2.07], P = 0.411). Both pre- and postoperative subjective feelings of discomfort were all significantly lower in carbohydrate group than in control group (median difference from − 50 to 0; all P

Women undergoing elective caesarean deliveries are fasted for long periods prior to surgery and can become catabolic. The use of pre-operative carbohydrate drinks to optimise patients ahead of major surgery is now well established. However, evidence to support this in women undergoing elective caesarean delivery is limited.We conducted a single-blind randomised control trial to study the effect of carbohydrate preloading on the presence of urinary ketones in mothers undergoing elective caesarean deliveries compared with standard care, fasting from midnight the night before surgery with free clear fluids until two hours prior to surgery.Two-hundred-and-nine patients were allocated to either standard care (n=104) or pre-operative carbohydrate drinks (n=105) prior to elective caesarean section. Twenty-five were excluded from the analysis, leaving 184 (n=90; n=94). The incidence of urinary ketones immediately prior to surgery was lower in the carbohydrate group, 18.1% compared with 61.1% in the standard care group (P0.001). Relative risk (95% CI) 3.33 (2.12 to 5.26), with a number needed-to-treat of three to prevent urinary ketosis in one woman. There were no major adverse events.The results of this study support the introduction of carbohydrate drinks ahead of caesarean delivery to offset the effects of pre-operative fasting. However, the results may not be generalisable to all maternity units due to differences in fasting protocols.

Introduction There has been growing evidence on the favourable outcomes of fast-track-recovery (FTR) surgery; to expedite recovery, minimise complications, and reduce the length of hospital stay for surgical patients. However, there is lack of evidence on the effectiveness of FTR in surgical gynaecological cancer (GC) patients. Most of the previous studies did not focus on feeding composition in the FTR surgery protocol. This study aims to determine the effectiveness of FTR feeding with a whey-protein-infused carbohydrate-loading drink pre-operatively and early oral feeding post-operatively on post-operative outcomes among surgical GC patients. Methods/design This open-labelled, randomised controlled trial (RCT) will randomly allocate patients into intervention and control groups. Ambulated Malaysian aged over 18 years and scheduled for elective surgery for (suspected) GC, will be included in this study. The intervention group will be given whey-protein-infused carbohydrate-loading drinks on the evening before their operation and 3 h before their operation as well as started on early oral feeding 4 h post-operatively. The control group will be fasted overnight pre-operation and only allowed plain water, and return to a normal diet is allowed when bowel sounds return post-operatively. The primary outcomes of study are length of post-operative hospital stay, length of clear-fluid tolerance, solid-food tolerance and bowel function. Additional outcome measures are changes in nutritional status, biochemical profile and functional status. Data will be analysed on an intention-to-treat basis. Trial registration ClinicalTrials.gov, ID: NCT03667755. Retrospectively registered on 12 September 2018; Protocol version: version 3 dated 27 September 2017.

Purpose of review The aim of this review is to give an overview of recently published articles covering preoperative carbohydrate loading in surgical patients. Recent findings Between January 1, 2017, and December 31, 2019, 26 publications addressing the effect of carbohydrate load were retrieved through a systematic search. Seventeen were randomized clinical trials, three prospective observational studies and six retrospective series with case-control comparison. Most of the studies were underpowered, addressed surrogate endpoints, and variability among dose and timing of carbohydrate (CHO) treatment was high. The most recent literature endorses preoperative carbohydrate loading up to 2 h before operations as a safe treatment. The new evidence confirm that this strategy is effective in reducing perioperative insulin resistance and the proportion of hyperglycemia episodes, and improving patient well-being and comfort but without affecting surgery-related morbidity. Summary Further properly designed randomized clinical trials, addressing more clinically relevant endpoints such as length of hospitalization and morbidity rate, are warrant.

Earlier studies suggest that carbohydrate loading is effective in reducing preoperative nausea. This study was conducted to investigate the effect of preoperative oral versus parenteral carbohydrate loading on the postoperative pain, nausea, and quality of recovery (QoR).Three-arm randomized, single-blind clinical trial.In this study, 95 adult patients scheduled for elective laparoscopic cholecystectomy were randomly assigned into three groups of preoperative intravenous dextrose 10% infusion, oral carbohydrate (OCH)-rich drink, and control. The pain and nausea severity scores were measured during recovery, 6 hours, and 24 hours thereafter. The 40-item QoR score was evaluated the day after surgery.In recovery, nausea severity was comparable among three groups, whereas pain score in the OCH group was significantly less than the controls (P = .009). Pain score in patients who received intravenous dextrose was mediocre and not statistically different from two other groups. Six and 24 hours after surgery, nausea and pain scores in OCH and dextrose infusion groups were significantly lower than the control group (P.05). The 40-item QoR score was significantly higher in intervention groups than control participants (P.05). Blood glucose levels were comparable in three groups before and after surgery.Preoperative carbohydrate loading significantly improves the QoR after laparoscopic cholecystectomy without significant effect on blood glucose levels. Oral route more effectively controls nausea and pain than parenteral dextrose administration.

The effect of an enhanced recovery protocol including preoperative carbohydrate loading on patients with diabetes is unclear. This study investigated the effect of both on perioperative glucose management and postoperative outcomes in patients with diabetes undergoing colorectal surgery.A retrospective study was conducted on patients undergoing elective colorectal surgery before and after implementation of an enhanced recovery protocol. Ninety-nine patients with type 2 diabetes (DM, 41 control versus 58 enhanced recovery) and 366 patients without diabetes (NDM, 158 control versus 158 enhanced recovery) were included. Multivariate analyses were run to compare mean peak perioperative serum glucose and postoperative outcomes in enhanced recovery and control cohorts with (DM) and without diabetes (NDM).Mean peak preoperative glucose was elevated in DM enhanced recovery compared with DM control patients (192.2 [72.2] versus 139.8 [41.4]; P 0.001). Mean peak intraoperative (162.3 [43.1] versus 163.8 [39.6]; P = 0.869) and postoperative glucose (207.7 [75.8] versus 217.8 [78.5]; P = 0.523) were similar in DM enhanced recovery compared with DM control group. Enhanced recovery led to decreased LOS in DM (P = 0.001) and NDM enhanced recovery patients (P 0.000) compared with their control groups.An enhanced recovery protocol may lead to increased peak preoperative glucose levels and 30-d readmissions in patients with type 2 diabetes undergoing colorectal surgery. However, the ultimate clinical significance of transiently elevated preoperative glucose in DM patients is uncertain. Our results suggest that an enhanced recovery protocol and preoperative carbohydrate loading does not lead to poorer postoperative glycemic control overall in patients with diabetes undergoing colorectal surgery.

Recently, low carbohydrate diets have become very popular due to their numerous health benefits. Unfortunately, little is known about their chronic effects on the blood lipid profile and other cardiovascular disease risk factors in athletic populations. We compared the results of a four week, well-planned low carbohydrate diet (LCD) followed by seven days of carbohydrate loading (Carbo-L) on fasting lipids - triacylglycerol’s (TAG), LDL-C, HDL-C, total cholesterol (TCh), glucose, insulin and HOMA-IR levels in 11 competitive basketball players. During the experiment, we also measured body mass (BM) and body composition changes: body fat (BF), % of body fat (PBF), and fat free mass (FFM). Both diet procedures significantly changed the fasting serum concentration of TAG (p < 0.05) and body fat content (kg and %) (p < 0.05), without negative changes in FFM. The Carbo-L procedure increased (p < 0.05) fasting glucose levels significantly. A LCD may be suggested for athletes who want to reduce body mass and fat content without compromising muscle mass. Several weeks on a LCD does not change the lipoprotein - LDL-C and HDL-C level significantly, while a seven-day Carb-L procedure may increase body fat content and fasting glucose concentration. Such dietary procedures are recommended for team sport athletes to reduce fat mass, lipid profile disorders and insulin resistance.

Acute pancreatitis (AP), a human disease in which the pancreas digests itself, has substantial mortality with no specific therapy. The major causes of AP are alcohol abuse and gallstone complications, but it also occurs as an important side effect of the standard asparaginase-based therapy for childhood acute lymphoblastic leukemia. Previous investigations into the mechanisms underlying pancreatic acinar cell death induced by alcohol metabolites, bile acids, or asparaginase indicated that loss of intracellular ATP generation is an important factor. We now report that, in isolated mouse pancreatic acinar cells or cell clusters, removal of extracellular glucose had little effect on this ATP loss, suggesting that glucose metabolism was severely inhibited under these conditions. Surprisingly, we show that replacing glucose with galactose prevented or markedly reduced the loss of ATP and any subsequent necrosis. Addition of pyruvate had a similar protective effect. We also studied the effect of galactose in vivo in mouse models of AP induced either by a combination of fatty acids and ethanol or asparaginase. In both cases, galactose markedly reduced acinar necrosis and inflammation. Based on these data, we suggest that galactose feeding may be used to protect against AP.

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.

In this narrative review, we describe the physiological basis for nutritional prehabilitation and evaluate the clinical evidence for its current roles in the perioperative period. Surgical stress and fasting induce insulin resistance as a result of altered mitochondrial function. Insulin resistance in the perioperative period leads to increased morbidity in a dose-dependent fashion, while preoperative carbohydrate loading attenuates insulin resistance, minimises protein loss and improves postoperative muscle function. Carbohydrate loading is an established practice in many countries and a key component of enhanced recovery after surgery (ERAS) programs, yet its independent effects on clinical outcomes remain unclear. Amino acid supplements may confer additional positive effects on a number of markers of clinical outcomes in the perioperative period, but their current role is also poorly defined. Clinical studies evaluating nutritional interventions have been marred by conflicting data, which may be due to small sample sizes, as well as heterogeneity of patients and surgical procedures. At present, it is known that carbohydrate loading is safe and improves patients’ wellbeing, but does not appear to influence length of hospital stay or rate of postoperative complications. This should be appreciated before its routine inclusion in ERAS programs.

Objective To examine the effect of a lifestyle behavior intervention (SystemCHANGE) on physical activity and diet quality among sedentary people living with HIV (PLHIV). All participants expressed a desire to improve lifestyle health behaviors. Methods One hundred and seven HIV+ adults were randomized to either the intervention (6, in-person, standardized group sessions focusing on improving lifestyle behaviors) or a control condition (general advice on AHA diet and exercise guidelines). All participants wore an ActiGraph accelerometer and completed 24-hour dietary recalls at baseline, 3, and 6 months. Generalized estimating equations were used to examine intervention effects. The primary activity outcome was time spent in moderate-to-vigorous physical activity, and the primary dietary outcome was Healthy Eating Index. Results Mean age was 53 years, 65% were male, and 86% African American. Approximately 90% attended at least half of the sessions and 60% attended 5 or more sessions. The intervention did not significantly improve our primary lifestyle behavior endpoints (P ≥ 0.05); however, intervention participants consumed fewer carbohydrates-primarily sugar-sweetened beverages-per day and lost 0.732 kg body weight compared with a 0.153 weight gain in the control group (P = 0.03). Conclusions Among sedentary PLHIV at high risk of cardiovascular disease, the SystemCHANGE intervention reduced daily carbohydrate intake and body weight, but did not increase physical activity or improve overall diet quality. Future work should identify fundamental personal, interpersonal, and contextual factors that will increase physical activity and improve overall diet quality among this population, and integrate these factors into tailored, lifestyle interventions for aging PLHIV.

The aim of this study was to determine whether perioperative stress hyperglycemia is correlated with surgical site infection (SSI) rates in non-diabetes mellitus (DM) patients undergoing elective colorectal resections within an SSI bundle. American College of Surgeons National Surgical Quality Improvement Program data of patients treated at a single institution in 2006–2012 were supplemented by institutional review board-approved chart review. A multifactorial SSI bundle was implemented in 2009 without changing the preoperative 8-h nil per os, and in the absence of either a carbohydrate loading strategy or hyperglycemic management protocol. Hyperglycemia was defined as blood glucose level > 140 mg/dL. The primary endpoint was SSI defined by the Centers for Disease Control National Nosocomial Infections Surveillance. Of 690 patients included, 112 (16.2%) had pre-existing DM. Overall SSI rates were significantly higher in DM patients as compared to non-DM patients (28.7 vs. 22.3%, p = 0.042). Postoperative hyperglycemia was more frequently seen in non-DM patients (46 vs. 42.9%). The SSI bundle reduced SSI rates (17 vs. 29.3%, p

[Purpose] The purpose of our study was to determine the effectiveness of carbohydrate loading by additional carbohydrate supplements for 7 days after prolonged interval exercise on exercise performance and energy metabolism during submaximal exercise in team-sports athletes. [Methods] Twenty male team-sports athletes (14 soccer and 6 rugby players) volunteered to participate in the study and were equally divided into the experimental group (EXP, n=10) performing additional carbohydrate supplementation for 7 days after prolonged interval exercise until blood glucose level reaches 50 mg/dL or less and the control group (CON, n=10). Then, maximal oxygen consumption (VO2max) and minute ventilation (VE), oxygen consumption (VO2), carbon dioxide excretion (VCO2), respiratory exchange ratio (RER), blood glucose level, and blood lactate level were measured in all team-sports players during submaximal exercise corresponding to 70% VO2max before and after intervention. [Results] There was no significant interaction in all parameters, but team-sports players in the EXP presented more improved VO2max (CON vs EXP = vs 5.3% vs 6.3%), VE (CON vs EXP = vs 3.8% vs 6.6%), VO2 (CON vs EXP = vs 8.5% vs 9.9%), VCO2 (CON vs EXP = vs 2.8% vs 4.0%), blood glucose level (CON vs EXP = vs -12.9% vs -7.6%), and blood lactate level (CON vs EXP = -18.2% vs -25%) compared to those in the CON. [Conclusion] These findings showed that additional carbohydrate supplementation conducted in our study is not effective in exercise performance and energy metabolism during submaximal exercise.

Objectives: Hypoglycemia is a recognized danger in pediatric patients. Extended period of preoperative fasting in this subset of patients is not well tolerated with metabolic derangements. The oral carbohydrate loading preoperatively can ameliorate many adverse effects. The aim of this study was to compare the glycemic profile in pediatric cardiac surgical patients kept fasting preoperatively with those fed oral clear solutions of carbohydrate half hour prior to induction of anaesthesia. Also we tried to establish a correlation with other factors contributing to preoperative hypoglycemia. Methodology: We planned a randomized controlled study. Group A included patients who were kept fasting according to the ASA guidelines preoperatively and Group B included patients who received 2 ml per kg of body weight of 10% Dextrose water as oral feeds half hour before the expected time of start of anaesthesia. Results: The mean (SD) preoperative BG concentrations were higher in group B (102.5 ±16.97) as compared to group A (64.08 ± 25.37) (p value -0.86 and -0.67) (pvalue Conclusion: Preoperative oral carbohydrate preloading can develop as the easiest and cheapest path to better perioperative blood glucose concentration management in congenital cardiac disease children.

Background: Preoperative carbohydrate loading enhances postoperative recovery and reduces patient discomfort. However, gastric emptying of liquids can be delayed in elderly populations. Therefore, this study aimed to evaluate the gastric emptying of 400 mL of a carbohydrate drink ingested 2 hours before surgery in elderly patients. Methods: In this prospective, randomized controlled study, patients aged >65 years were allocated to either fast from midnight (nil per os [NPO] group, n = 29) or drink 400 mL of a carbohydrate drink 2 hours before surgery (carbohydrate group, n = 29). The gastric antrum was assessed using ultrasonography in the supine position, followed by the right lateral decubitus (RLD) position. The gastric antrum was graded as grade 0 (fluid not seen in both positions), grade 1 (fluid only seen in the RLD position), and grade 2 (fluid seen in both positions). The gastric antral cross-sectional area (CSA) and aspirated residual gastric volume were measured. Results: In 58 patients, the incidence of grade 2 stomach was 13.8% in NPO group and 17.2% in carbohydrate group (P = .790). The gastric antral CSA in the supine position was larger in carbohydrate group than in NPO group (4.42 [3.72–5.18] cm2 vs 5.31 [4.35–6.92] cm2, P = .018). The gastric antral CSA in the RLD position was not different in NPO and carbohydrate groups (P = .120). There was no difference in gastric volume (2 [0–7.5] vs 3 [0–13.4], P = .331) in NPO group versus carbohydrate group. Conclusion: The incidence of grade 2 stomach was not different between NPO group and carbohydrate group in elderly patients.

Enhanced recovery pathways (ERP) are focused on improving perioperative patient care to reduce postoperative complications and improve outcomes. ERP includes elements of preoperative preparation, fluid management, anesthesia and analgesia, and perioperative nutrition and mobilization. Significant evidence suggests that traditional non-evidence-based perioperative nutritional and fluid management dogmas that prolong fasting and promote fluid overload should be abandoned. Carbohydrate loading has been shown to be safe in non-diabetic patients while also reducing postoperative insulin resistance. Evidence suggest that perioperative fluid overload and restriction should be avoided, and near-zero homeostasis should be the goal of perioperative fluid management. Goal-directed fluid therapy (GDFT) has shown to be safe in most patients and could be beneficial in high-risk patients.

In this review, we explore the rationale and history behind the practice of preoperative fasting in elective surgery including the gradual move toward longer fasting and the more recent change in direction of practice. Gastric emptying physiology and the metabolic effects of prolonged fasting and carbohydrate loading are examined. Most recent guidelines related to these topics are discussed and practical recommendations for implementing these guidelines are suggested.

Contemporary sports nutrition guidelines recommend that each athlete develop a personalised, periodised and practical approach to eating that allows him or her to train hard, recover and adapt optimally, stay free of illness and injury and compete at their best at peak races. Competitive triathletes undertake a heavy training programme to prepare for three different sports while undertaking races varying in duration from 20 min to 10 h. The everyday diet should be adequate in energy availability, provide CHO in varying amounts and timing around workouts according to the benefits of training with low or high CHO availability and spread high-quality protein over the day to maximise the adaptive response to each session. Race nutrition requires a targeted and well-practised plan that maintains fuel and hydration goals over the duration of the specific event, according to the opportunities provided by the race and other challenges, such as a hot environment. Supplements and sports foods can make a small contribution to a sports nutrition plan, when medical supplements are used under supervision to prevent/treat nutrient deficiencies (e.g. iron or vitamin D) or when sports foods provide a convenient source of nutrients when it is impractical to eat whole foods. Finally, a few evidence-based performance supplements may contribute to optimal race performance when used according to best practice protocols to suit the triathlete’s goals and individual responsiveness.

Endurance events are becoming popular globally and at the same time demands higher energy levels to sustain the performance in the form of carbohydrates. Different carbohydrate loading at various stages like pre-competition, and during the exercise has been prescribed for athletes depending upon the nutritional demands of that particular sport. Honey is a natural source of energy rich in carbohydrates and other minerals and vitamins. Carbohydrates like fructose and glucose present in honey and low glycemic index makes it eligible for consumption for endurance athletes. There are limited studies that show the honey improves the physical performance among endurance athletes and it seems promising to be ingested as an alternate health drink for such athletes.

Enhanced Recovery after Surgery (ERAS) with sole carbohydrate (CHO) loading and postoperative early oral feeding (POEOF) shortened the length of postoperative (PO) hospital stays (LPOHS) without increasing complications. This study aimed to examine the impact of ERAS with preoperative whey protein-infused CHO loading and POEOF among surgical gynecologic cancer (GC) patients. There were 62 subjects in the intervention group (CHO-P), which received preoperative whey protein-infused CHO loading and POEOF, and 56 subjects formed the control group (CO), which was given usual care. The mean age was 49.5 &plusmn, 12.2 years (CHO-P) and 51.2 &plusmn, 11.9 years (CO). The trial found significant positive results which included shorter LPOHS (78.13 &plusmn, 33.05 vs. 99.49 &plusmn, 22.54 h), a lower readmission rate within one month PO (6% vs. 16%), lower weight loss (&minus, 0.3 &plusmn, 2.3 kg vs. &minus, 2.1 &plusmn, 2.3 kg), a lower C-reactive protein&ndash, albumin ratio (0.3 &plusmn, 1.2 vs. 1.1 &plusmn, 2.6), preserved muscle mass (0.4 &plusmn, 1.7 kg vs. &minus, 0.7 &plusmn, 2.6 kg), and better handgrip strength (0.6 &plusmn, 4.3 kg vs. &minus, 1.9 &plusmn, 4.7 kg) among CHO-P as compared with CO. However, there was no significant difference in mid-upper arm circumference and serum albumin level upon discharge. ERAS with preoperative whey protein-infused CHO loading and POEOF assured better PO outcomes.

There is increasing evidence that exercise training may facilitate weight management via improvements in homeostatic appetite control, but little is known about how exercise training affects food reward and susceptibility to overeating.This study examined changes in food reward and eating behavior traits after a supervised 12-wk exercise intervention (10.5 MJ·wk) in inactive individuals with overweight/obesity (exercisers; n = 46, 16 men/30 women; mean (SD) body mass index, 30.6 (3.8) kg·m; and mean (SD) age, 43.2 (7.5) yr) compared with nonexercising controls (n = 15; 6 men/9 women; mean (SD) body mass index, 31.4 (3.7) kg·m; and mean (SD) age, 41.4 (10.7) yr). Liking and wanting scores for high-fat relative to low-fat foods were assessed with the Leeds Food Preference Questionnaire before and after consumption of an isoenergetic high-fat or high-carbohydrate lunch. Eating behavior traits were assessed using the Three-Factor Eating Questionnaire and Binge Eating Scale.A week-group interaction indicated that wanting scores decreased from baseline to postintervention in exercisers only (M[INCREMENT]Pre-Post = -4.1, P = 0.03, ηp = 0.09, 95% confidence interval [CI], -7.8 to -0.4), but there was no exercise effect on liking. There was also a week-group interaction for binge eating, which decreased in exercisers only (M[INCREMENT]Pre-Post = -1.5, P = 0.01, ηp = 0.11; 95% CI, -2.7 to -0.4). A small reduction in disinhibition was also apparent in exercisers (M[INCREMENT]Pre-Post = -0.7, P = 0.02, ηp = 0.10; 95% CI, -1.3 to -0.1).This study showed that 12 wk of exercise training reduced wanting scores for high-fat foods and trait markers of overeating in individuals with overweight/obesity compared with nonexercising controls. Further research is needed to elucidate the mechanisms behind these exercise-induced changes in food reward.

Background Preoperative acetaminophen and carbohydrate loading has been shown to improve the functional recovery of surgical patients. Objective To determine the effects of preoperative acetaminophen and carbohydrates on functional outcomes and the use of pain medications after surgery in patients undergoing Mohs Micrographic Surgery (MMS) for nonmelanoma skin cancer (NMSC). Materials and methods One hundred patients treated with MMS for NMSC at an academic center were randomized into a control group receiving standard preoperative care or an intervention group receiving acetaminophen and carbohydrate drinks immediately before surgery. Patients rated levels of pain, thirst, hunger, anxiety, and fatigue on the day of surgery on a scale of 0 to 100, and reported through a phone interview the use of pain medications within 48 hours of surgery. Results There was no significant difference between intervention and control groups in maximum pain score on the day of surgery; maximum pain score 48 hours after surgery; use of nonopioid pain medications; and use of opioids. However, the intervention group had lower anxiety levels during and at the end of surgery. Conclusion Patients undergoing MMS for NMSC reported very low levels of pain during and after surgery. Preoperative acetaminophen and carbohydrate loading had no impact on pain levels or the use of pain medications but did reduce levels of anxiety.

Background Conflicting results have been reported on the influence of carbohydrates in breast cancer. Objective To determine the influence of pre-operative per-oral carbohydrate load on proliferation in breast tumors. Design Randomized controlled trial. Setting University hospital with primary and secondary care functions in South-West Norway. Patients Sixty-one patients with operable breast cancer from a population-based cohort. Intervention Per-oral carbohydrate load (preOp™) 18 and 2–4 h before surgery (n = 26) or standard pre-operative fasting with free consumption of tap water (n = 35). Measurements The primary outcome was post-operative tumor proliferation measured by the mitotic activity index (MAI). The secondary outcomes were changes in the levels of serum insulin, insulin-c-peptide, glucose, IGF-1, and IGFBP3; patients’ well-being, and clinical outcome over a median follow-up of 88 months (range 33–97 months). Results In the estrogen receptor (ER) positive subgroup (n = 50), high proliferation (MAI ≥ 10) occurred more often in the carbohydrate group (CH) than in the fasting group (p = 0.038). The CH group was more frequently progesterone receptor (PR) negative (p = 0.014). The CH group had a significant increase in insulin (+ 24.31 mIE/L, 95% CI 15.34 mIE/L to 33.27 mIE/L) and insulin c-peptide (+ 1.39 nM, 95% CI 1.03 nM to 1.77 nM), but reduced IGFBP3 levels (− 0.26 nM; 95% CI − 0.46 nM to − 0.051 nM) compared to the fasting group. CH-intervention ER-positive patients had poorer relapse-free survival (73%) than the fasting group (100%; p = 0.012; HR = 9.3, 95% CI, 1.1 to 77.7). In the ER-positive patients, only tumor size (p = 0.021; HR = 6.07, 95% CI 1.31 to 28.03) and the CH/fasting subgrouping (p = 0.040; HR = 9.30, 95% CI 1.11 to 77.82) had independent prognostic value. The adverse clinical outcome of carbohydrate loading occurred only in T2 patients with relapse-free survival of 100% in the fasting group vs. 33% in the CH group (p = 0.015; HR = inf). The CH group reported less pain on days 5 and 6 than the control group (p Limitation Only applicable to T2 tumors in patients with ER-positive breast cancer. Conclusions Pre-operative carbohydrate load increases proliferation and PR-negativity in ER-positive patients and worsens clinical outcome in ER-positive T2 patients. Trial registration CliniTrials.gov; NCT03886389. Retrospectively registered March 22, 2019.

Preoperative carbohydrate loading is a contemporary element of the enhanced recovery after surgery (ERAS) paradigm. In addition to intraoperative surgical and anesthetic modifications and postoperative care practices, preoperative optimization is essential to good postsurgical outcomes. What was long held as dogma, a period of prolonged fasting prior to the administration of anesthesia, was later re-examined and challenged. Along with the proposed physiologic effects of decreasing the surgical stress response and insulin resistance, preoperative carbohydrate loading was also demonstrated to improve patient satisfaction and well-being, without an increase in perioperative complications. The benefits are most strongly observed in abdominal and cardiac surgery patients, but there has also been data which support its use in other specialties and surgeries. Barriers to the adoption of perioperative carbohydrate loading are few, but importantly include overcoming the inertia to modify older and more restrictive fasting guidelines and achieving the multidisciplinary consensus necessary to implement such changes. Despite these challenges, and with an existing body of evidence supporting its benefits, preoperative carbohydrate loading presents a significant contribution to the ERAS programs.

IntroductionPreoperative carbohydrate loading is an effective method to control postoperative insulin resistance. However, data are limited concerning the effects of carbohydrate loading on preoperative hyperglycemia and possible impacts on complication rates.MethodsA prospective cohort study was performed of patients enrolled in an enhanced recovery after surgery pathway at a single institution. All patients underwent laparotomy for known or suspected gynecologic malignancies. Patients who had been diagnosed with diabetes preoperatively and those prescribed total parenteral nutrition by their providers were excluded. Data regarding preoperative carbohydrate loading with a commercial maltodextrin beverage, preoperative glucose testing, postoperative day 1 glucose, insulin administration, and complications (all complications, infectious complications, and hyperglycemia-related complications) were collected. The primary endpoint of the study was the incidence of postoperative infectious complications, defined as superficial or deep wound infection, organ/space infection, urinary tract infection, pneumonia, sepsis, or septic shock.ResultsOf 415 patients, 76.9% had a preoperative glucose recorded. The mean age was 60.5±12.4 years (range 18–93). Of those with recorded glucose values, 30 patients (9.4%) had glucose ≥180 mg/dL, none of whom were actually given insulin preoperatively. Median preoperative glucose value was significantly increased after carbohydrate loading (122.0 mg/dL with carbohydrate loading vs 101.0 mg/dL without, U=3143, p=0.001); however, there was no relationship between carbohydrate loading and complications. There was a significantly increased risk of hyperglycemia-related complications with postoperative day 1 morning glucose values ≥140 mg/dL (OR 1.85, 95% CI 1.07 to 3.23; p=0.03). Otherwise, preoperative and postoperative hyperglycemia with glucose thresholds of ≥140 mg/dL or ≥180 mg/dL were not associated with increased risk of other types of complications.DiscussionCarbohydrate loading is associated with increased preoperative glucose values; however, this is not likely to be clinically significant as it does not have an impact on complication rates. Preoperative hyperglycemia is not a risk factor for postoperative complications in a carbohydrate-loaded population when known diabetic patients are excluded.PrecisWhile glucose increased with carbohydrate loading in non-diabetic patients, this was not associated with complications.

Background and aims The fasting protocol of enhanced recovery after surgery (ERAS) recommends a carbohydrate loading 2 hours prior to surgery to prevent insulin resistance. In this study, both coconut and sugarcane juices were used as alternative carbohydrate drinks in a setting wherein the standard solution is not available. Methods After approval from the Research Ethics and Review Committee (RERC), 45 healthy adult volunteers were enlisted to ingest coconut water, sugarcane juice, and plain water (control) for 3 separate days. Before and after ingestion of each drink, both the gastric emptying time and blood glucose levels were measured. Results The majority of the gastric contents of the participants were emptied within 60 minutes in coconut water group (64.44%), 90 minutes in sugarcane juice group (44.44%), and 30 minutes in the control group (55.56%). Overall, the gastric contents in these 3 groups returned to baseline levels ( Conclusions Both coconut water and sugarcane juice conform to the safety standard of presenting a half-life of no more than 120 minutes from consumption, therefore, they may be safely given preoperatively affording protection against insulin resistance with minimal risk for bronchoaspiration during anesthesia.

The enhanced recovery after surgery (ERAS) protocol is a perioperative care pathway adopted in health systems across the nation as part of quality improvement efforts. A bundle of 20 elements demonstrated improved clinical and financial outcomes. A key element promotes carbohydrate loading a few hours before surgery using beverages such as Boost or ClearFast. There is limited data on pre-DM and DM patients and no clear guidelines on use in these populations. Scripps Health, a large health system in Southern California, adopted the ERAS protocol as a systemwide approach for care improvement in the perioperative process in 2018. Pre-DM and DM patients were represented more commonly in the bariatric surgery group thus providing an opportunity to compare outcomes in these patients receiving a carbohydrate loaded beverage pre and post implementation of the standardized ERAS protocol. We compared N=97 bariatric pre-DM and DM patients who did not receive Clearfast from Jan-Sept 2017 to N=64 bariatric pre-DM and DM patients who received Clearfast from Jan-Sept 2018. See Table 1. Interestingly, in patients with pre-DM and DM, there was a substantial increase in pre-op hyperglycemia but a post-op decrease was noted when a carb-loaded beverage-Clearfast was given to patients prior to bariatric surgery when compared to the previous year when ERAS and carb loading were not part of the perioperative preparation process. Disclosure K.L. Barthelmess: None. L. Talavera: None. A. Philis-Tsimikas: Advisory Panel; Self; AstraZeneca, Lilly Diabetes, Novo Nordisk A/S, Sanofi. Employee; Spouse/Partner; Ionis Pharmaceuticals, Inc. Research Support; Self; Dexcom, Inc., Glooko, Inc., National Institute of Diabetes and Digestive and Kidney Diseases. Stock/Shareholder; Spouse/Partner; Ionis Pharmaceuticals, Inc., Novo Nordisk Inc.

Background Pre-operative carbohydrate loading has been shown to reduce pre-operative discomfort and postoperative nausea and vomiting in general surgical patients. Few studies have considered day-case surgery. Objective The aim of this prospective randomised study was to determine whether pre-operative carbohydrate loading enhanced recovery after day-case cholecystectomy. Design A randomised controlled trial. Setting Secondary care in a district general and a university hospital in Finland between 2013 and 2016. Patients A total of 113 patients American Society of Anesthesiologists physical status I or II aged 18 to 70 undergoing day-case cholecystectomy were included in the study. Exclusion criteria were bleeding or coagulation disorders, BMI more than 40 kg m, dementia, insulin-treated diabetes, migraine, Meniere's disease or a history of alcohol or drug abuse. Intervention The carbohydrate-rich drink group received oral carbohydrate (200 ml) 2 to 3 h before surgery, and the control (fasting) group fasted from midnight according to standard protocol. Main outcome measures Visual analogue scales (VAS) were used to score six forms of discomfort: the need for analgesia and antiemetics, the time to drinking, eating and first mobilisation after surgery and the time to discharge. Any hospital re-admission was also recorded. Results The highest VAS scores were seen for mouth dryness and tiredness 2 h after surgery in the fasting group. There were no significant differences in any VAS scores between the study groups. No differences in time to mobilisation, need for pain or antiemetic medication or time to discharge were seen between the groups. Conclusion Compared with overnight fasting, pre-operative carbohydrate loading did not significantly enhance peri-operative well being or recovery in patients undergoing day-case cholecystectomy. Trial registration Clinicaltrials.gov Identifier: NCT03757208.

With the acceleration of an aging population, postoperative cognitive dysfunction (POCD) has become a large problem. Preoperative carbohydrate (CHO) loading has been reported to attenuate surgery stress response and insulin resistance. The present study aimed to investigate whether preoperative vitamin-rich CHO loading has an effect on POCD, endoplasmic reticulum (ER) stress, and apoptosis. Eighty male Sprague-Dawley rats (20-month old) were randomly assigned to four groups (20 per group): control group (no anesthesia and surgery), fasting group (fasting 14 h before surgery), water group (oral water 3 h before surgery), and CHO group (oral vitamin-rich CHO 3 h before surgery). The POCD rat model was established by splenectomy under intraperitoneal injection of pentobarbital sodium. Cognitive function was assessed using the Morris water maze (MWM) after surgery. The levels of endoplasmic reticulum (ER) stress markers and apoptosis related proteins in the hippocampus were examined by western blot analysis. The vitamin-rich CHO treated animals performed better in the MWM tests than the animals in the fasting and water groups. Furthermore, preoperative CHO loading reduced ER stress and neuronal apoptosis in the hippocampus of aged rats, as indicated by the protein biomarkers of GRP78, eIF2a, Beclin1, Bax, and Bcl-2. In conclusion, preoperative vitamin-rich CHO loading could improve POCD by attenuating ER stress and neural apoptosis, providing a basis as a potential treatment against POCD.

Researchers and practitioners in sports nutrition would greatly benefit from a rapid, portable, and non-invasive technique to measure muscle glycogen, both in the laboratory and field. This explains the interest in MuscleSound®, the first commercial system to use high-frequency ultrasound technology and image analysis from patented cloud-based software to estimate muscle glycogen content from the echogenicity of the ultrasound image. This technique is based largely on muscle water content, which is presumed to act as a proxy for glycogen. Despite the promise of early validation studies, newer studies from independent groups reported discrepant results, with MuscleSound® scores failing to correlate with the glycogen content of biopsy-derived mixed muscle samples or to show the expected changes in muscle glycogen associated with various diet and exercise strategies. The explanation of issues related to the site of assessment do not account for these discrepancies, and there are substantial problems with the premise that the ratio of glycogen to water in the muscle is constant. Although further studies investigating this technique are warranted, current evidence that MuscleSound® technology can provide valid and actionable information around muscle glycogen stores is at best equivocal.

Highlights • Gastroparesis may present with post-operative nausea/vomiting in diabetics. • Pre-operative carbohydrate loading should be used with caution in diabetics. • In enhanced recovery pathways, the role of carbohydrate loading should be clarified in diabetics., Gastroparesis is a syndrome of delayed gastric emptying associated with nausea, vomiting, and postprandial fullness. Despite multiple etiologies, diabetes is one of the principal causes of gastroparesis. This case report examines a 57 year-old woman with poorly controlled diabetes type II (HbA1c 8.3%) complicated by diabetic nephropathy who was readmitted for gastroparesis after two days following uncomplicated robotic surgical staging for endometrial cancer. Prior to the procedure, the patient had received carbohydrate loading in accordance with our center’s enhanced recovery pathway; this resulted in severe acute hyperglycemia, a recognized cause of gastroparesis in women with diabetes. During her readmission, she improved with bowel rest and optimization of glycemic control. This case suggests that routine pre-operative carbohydrate loading should be used with caution in poorly controlled diabetic patients.