Enhanced Recovery After Surgery (ERAS) Pre-Operative Carbohydrate Loading is Safe in Type II Diabetics
*Stephanie D Talutis1, *Su Yeon Lee1, *Daniel Cheng2, *Pamela Rosenkranz1, *Sara M Alexanian1, David McAneny1
1Boston University, Boston, MA;2University of North Carolina, Chapel Hill, NC
Objective: Determine safety of pre-operative carbohydrate beverage (CHO) consumption in an Enhanced Recovery After Surgery (ERAS) protocol among patients with Type II diabetes (DMII).
Design: Retrospective chart review.
Setting: 496-bed academic hospital.
Patients: Eligible patients drank CHO as part of ERAS protocol during 10/1/15−9/30/16. Patients with diet-controlled DMII were excluded. 355 patients met inclusion criteria, including 80 DMII and 275 non-diabetics. 89 historical DMII patients from the previous year were reviewed for comparison.
Interventions: N/A
Main Outcome Measures: Insulin requirements, inpatient endocrine consultations, hypoglycemic episodes, and post-operative complications
Results: ERAS patients, with and without DMII, were similar to historical DMII patients(Table). No significant differences were observed in hemoglobin A1C or number of pre-operative DMII medications between ERAS and historical DMII groups. A significant difference was observed in median glucose measurements on POD 1 for DMII patients (ERAS 152 vs Historical 137.5, p=0.004). Otherwise, there were no differences in perioperative glucose measurements (after CHO consumption), perioperative insulin dosing, intraoperative insulin infusion usage, episodes of hypoglycemia, or inpatient endocrine consultations.
There were no significant differences in complications between patients with and without DMII. A trend of increased risk of any complication with increasing number of DMII medications was observed, although this was not significant(OR 1.316, CI(0.489, 3.537)). Additionally, risk of complications was not influenced by hemoglobin A1C(0.642(0.372, 1.109)), pre-operative glucose(1.008(0.993, 1.204)), or home insulin dosage(0.983(0.958, 1.009)).
Conclusions: Patients with DMII safely tolerated CHO in an ERAS protocol without requiring more insulin. Complications were not increased among DMII patients on the ERAS protocol.
| ERAS | ERAS | Historical | ||
| Non-Diabetics | DM II | DM II | P | |
| (n = 275) | (n = 80) | (n = 89) | ||
| Age (years, median, range) | 43 (21-89) | 48 (20-86) | 51 (25-93) | 1.000 |
| % Female | 74.9% | 78.8% | 74.2% | 0.743 |
| BMI (median) | 39.5 (16.7 - 81.4) | 38.6 (19.8-69.5) | 40.5 (20.7-59.3) | 0.367 |
| Hemoglobin A1C (median, range) | N/A | 7 (5 - 12.5) | 7.4 (5.5 - 12.6) | 0.432 |
| Home Diabetes Medications | 1.000 | |||
| Oral Agent | N/A | 90% (72/80) | 92.1% (82/89) | |
| Insulin | 28.8% (23/80) | 23.6% (21/89) | ||
| Number of Agents | 0.698 | |||
| 1 | 57.8% (47/80) | 66.3% (59/89) | ||
| 2 | 25% (20/80) | 22.5% (20/89) | ||
| 3 | 7.5% (6/80) | 9.0% (8/89) | ||
| 4 | 3.8% (3/80) | 2.2% (2/89) | ||
| Home Insulin Dosing (U, median, range) | N/A | 36 (6-178) | 39 (6-200) | 0.760 |
| Operating Room Time (hours) | 3.02 (1.50-11.10) | 3.18 (1.67-10.80) | 2.7 (1.70-11.60) | 0.085 |
| Subspecialty | 0.200 | |||
| Bariatric | 62.9% | 71.3% | 67.4% | |
| Colorectal | 25.8% | 13.8% | 23.6% | |
| Surgical Oncology | 11.3% | 15.0% | 9.0% | |
| % Laparoscopic Surgery | 83.6% | 90.0% | 93.3% | 0.078 |
| ASA | 1.000 | |||
| 1 | 0.4% | 0.0% | 0.0% | |
| 2 | 51.6% | 22.5% | 38.2% | |
| 3 | 47.6% | 67.3% | 60.7% | |
| 4 | 0.4% | 1.3% | 1.1% | |
| Clavien Dindo Classification | 0.651 | |||
| No Complication | 78.9% | 80.0% | 73.0% | |
| Grade I | 7.6% | 12.5% | 14.6% | |
| Grade II | 8.7% | 5.0% | 7.9% | |
| Grade IIIa | 2.5% | 2.5% | 2.2% | |
| Grade IIIb | 2.5% | 0.0% | 2.2% | |
| Antiemetic Doses (median, range) | 0 (0-9) | 0 (0-5) | 1 (0-13) | 1.000 |
| Length of Stay (days, median) | 2 (0-37) | 2 (2-33) | 2 (1-14) | 0.383 |
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