Features  |   March 2020
Enhanced Recovery After Surgery: Too Many Recommendations … What Should I Do?
Article Information
Pain Medicine / Quality Improvement / Features / Opioid
Features   |   March 2020
Enhanced Recovery After Surgery: Too Many Recommendations … What Should I Do?
ASA Monitor 3 2020, Vol.84, 14-17.
ASA Monitor 3 2020, Vol.84, 14-17.
Enhanced recovery after surgery (ERAS) programs are increasingly being embraced worldwide because they have been shown to reduce postoperative complications and hospital length of stay without increasing post-discharge readmission rates.1,2  Although ERAS programs should become standard of care, implementation has been slow and has low compliance with various components.2,3  The reasons for the lack of implementation or patchy implementation are several; however, conflicting recommendations may be a major factor.
So, why is there so much variation in recommendations, even though the same published evidence is used to develop them?
Most recommendations are developed systematically using well-recognized approaches for identifying and analyzing the available evidence. Systematic reviews/meta-analyses are considered the highest level of evidence. Developing a systematic review involves performing exhaustive literature searches, appropriate selection of studies based on eligibility criteria, grading the included studies and presenting the recommendations in a clinically applicable manner.4 
2 Comments
March 15, 2020
Michael Meddows
Atlantic Anesthesia
Preop carbohydrate loading
Dr Joshi states that preoperative carbohydrate intake is questionable. He supplies two references for this which are both prior narrative reviews of ERAS that he himself wrote. Are there any trial data to support the inclusion of the carbohydrate loading? I suspect high carbohydrate intake may have significant downsides, including poor perioperative glucose control, infection risk, and risk of hypoglycemia with insulin in naive patients.
March 17, 2020
Girish Joshi
University of Texas Southwestern Medical Center, Dallas, Texas
Preoperative Carbohydrate Loading
Dear Dr. Meddows
Thank you for your question. I am sorry, all the references could not be included due to space restrictions. In fact, the evidence for lack of benefits of preoperative carbohydrate loading is substantial. A network meta-analysis of 43 trials found that preoperative carbohydrate loading offered no benefit over good preoperative hydration, although a small reduction in length of stay was noted.1 Also, the most recent guidelines for the perioperative care of patients undergoing colorectal surgery conclude that the qualitative evidence for preoperative carbohydrate drinks is downgraded from low to very low.2 However, interestingly, the authors upgraded the recommendations for preoperative carbohydrate drinks from “weak” to “strong,” without much explanation. This does not make sense, and is indicative of limitations of the methodology of the group.

Also, the assumption that carbohydrate loading has no risks, is completely incorrect. To quote Rushakoff et al.3 – “At this time, there are no data to support the use of preoperative carbohydrate loading in patients with underlying insulin resistance or with diabetes. In these patients, the drink will not reduce insulin resistance, but rather induce hyperglycemia and this could possibly be associated with adverse events. We suggest that patients with diabetes undergoing a procedure on an ERAS pathway should not be administered a carbohydrate drink before surgery.”

Given the questionable benefits and the concerns of risks, at least in the diabetic population, we should be cautious with liberal use of preoperative carbohydrate loading. Also, we have to be concerned about unnecessary cost to our patients and the health care system. It is time that we emphasize preoperative hydration and limit preoperative fasting. I believe that there is room for improvement, as we have still not adequately addressed this issue, and do not specifically advise our patients to drink plenty of water during the fasting period. In addition, we must encourage patients to drink water in the preoperative area while they are waiting for surgery. I doubt that there is much effort placed in educating preoperative nurses to ask patients if they are thirsty during the hours they wait in the preoperative area. In fact, the nurses are afraid that if they let the patients have even a sip of water, the surgery would be cancelled and they would be blamed. It is time we start adopting the 6-4-0 rule rather than the 6-4-2 rule. There is much work to be done!

References:
1. Amer MA, Smith MD, Herbison GP, Plank LD, McCall JL. Network meta-analysis of the effect of preoperative carbo- hydrate loading on recovery after elective surgery. Br J Surg. 2017;104:187–197.
2. Gustafsson UO, Scott MJ, Hubner M, et al. Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations: 2018. World J Surg 2019; 43: 659–695.
3. Rushakoff RJ, Wick EC, McDonnell ME. Enhanced recovery in patients with diabetes. Is it time for a moratorium on use of preoperative carbohydrate beverages? Ann Surg 2019; 269: 411–412.

Girish P. Joshi, MBBS, MD, FFARCSI
Professor of Anesthesiology and Pain Management
University of Texas Southwestern Medical Center
Dallas, Texas
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