From Stony Brook Medical Center, Stony Brook, NY (Dr. Blum), and NYU Winthrop Medical Center, Mineola, NY (Meredith Akerman, Melissa Callari, Ellen Jordan, and Dr. Capozzi).
Abstract
- Background: Enhanced Recovery After Surgery (ERAS) is a multimodal, standardized approach to the surgical patient that incorporates evidenced-based interventions designed to achieve rapid recovery after surgery by minimizing the patient’s stress response. One aspect of ERAS, carbohydrate loading, has been shown in multiple randomized controlled trials to result in postoperative benefits in patients undergoing colorectal surgery, but there appears to be insufficient data to make definitive recommendations for or against carbohydrate loading in joint replacement patients.
- Objective: To evaluate postoperative nausea and length of stay (LOS) after a preoperative carbohydrate loading protocol was initiated for patients undergoing total joint replacement.
- Design: Retrospective chart review.
- Setting and participants: 100 patients who underwent either total knee or hip arthroplasty at Winthrop University Hospital, Mineola, NY, in the past 4 years and either had (n = 50) or had not received preoperative carbohydrate supplements (n = 50).
- Methods: Using the total joint database, the medical record was reviewed for the patient’s demographics, LOS, documentation of postoperative nausea, and number of doses of antiemetic medication given to the patient.
- Results: The mean LOS for the carbohydrate-loading group and non-carbohydrate group was 1.9 days and 2.6 days. respectively, a difference of 0.70 days (P < 0.0001). The carbohydrate-loaded group received a total of 13 doses of antiemetic medications and the non-carbohydrate group received 21 doses. The average number of antiemetic doses given to a patient postoperatively was 0.26 for the carbohydrate-loaded group and 0.42 for the non-carbohydrate-loaded group. The difference was 0.16 doses (P < 0.7815).
- Conclusion: The implementation of carbohydrate loading decreased LOS for joint replacement patients by approximately 1 day. Additionally, there was a trend towards decreased antiemetic use and fewer documented cases of postoperative nausea after carbohydrate loading.
Keywords: carbohydrate loading, ERAS, joint arthroplasty, length of stay, nausea.
Enhanced Recovery After Surgery (ERAS) is a multimodal, standardized approach to the surgical patient that incorporates evidenced-based interventions designed to achieve rapid recovery after surgery by minimizing the patient’s stress response.1-4 The ERAS protocols have been shown to reduce complications, decrease length of stay (LOS), and improve patient outcomes.3-7 The program was originally designed to facilitate recovery after colorectal operative procedures by maintaining preoperative organ function and reducing the postoperative stress response. This was done through a coordinated program of preoperative counseling, optimizing nutritional status, standardizing analgesic regimens, and early mobilization.3
The principles of an ERAS program with standardized pre- and postoperative protocols appear ideally suited for the total joint arthroplasty patient.1,3-5 Prior studies have demonstrated ERAS to be effective in facilitating decreased LOS, with no apparent increase in readmission rates or complications for both colorectal and joint arthroplasty patients.1-7 The protocols have also been shown to be cost-effective, with decreased incidence of postoperative complications, including thromboembolic disease and infections.3,4,6Since 2014, we have adopted many aspects of the ERAS protocol at our institution’s joint arthroplasty program. All patients attend a preoperative educational program and undergo medical and dental optimization prior to surgery.8 We have adopted guidelines regarding hemoglobin A1c levels (< 8.0), body mass index (< 35), and cessation of smoking (≤ 6 weeks). There are standardized pre- and postoperative pain regimens, including the use of regional anesthesia and postoperative nerve blocks whenever possible.9 All patients are mobilized in the post-anesthesia care unit (PACU) once the regional anesthesia has dissipated and vital signs are stable.10
An important tenet of ERAS protocols is optimizing the nutritional status of the patient prior to surgery.6 This includes avoidance of preoperative fasting in conjunction with carbohydrate loading. ERAS protocols instruct the patient to ingest a carbohydrate-rich beverage 2 hours prior to surgery. The concept of allowing a patient to eat prior to surgery is based on the preference for the patient to present for surgery in an anabolic rather than a catabolic state.2,3,11 Patients in an anabolic state undergo less postoperative protein and nitrogen losses, which appears to facilitate wound healing.2,6,11
There have been multiple randomized controlled trials demonstrating the postoperative benefits of carbohydrate loading prior to colorectal surgery.2,6However, the data regarding the benefits of carbohydrate loading in joint replacement patients have been inconclusive.3,12 One recent study of carbohydrate loading in joint arthroplasty patients has shown promising results, with decreased LOS and decreased C-reactive protein levels in patients who had ingested a carbohydrate drink prior to surgery.13 Although there appears to be insufficient data to make definitive recommendations for or against carbohydrate loading in joint replacement patients,3 the data from the colorectal literature provides a strong basis of support to avoid fasting and preoperatively feed patients in order to enhance recovery after total joint arthroplasty.