Preoperative oral carbohydrate treatment to prevent perioperative complications in adults : a systematic review of the evidence

Kriel, Janine (2017-03)

Thesis (MNutr)--Stellenbosch University, 2017.

Thesis

ENGLISH SUMMARY : Background: Preoperative standard fasting is associated with deleterious effects with consequent negative clinical outcomes. Preoperative oral carbohydrate loading (POCL) is considered a safe alternative to fasting, and recommended by numerous anaesthesia societies worldwide. The evidence supporting this intervention is increasing and pooling of data is required to promote clinical relevance. Objectives: To systematically review the effect of POCL on perioperative complications and well-being in adult patients undergoing elective surgery. Search strategy: Electronic databases, article reference lists and personal files were searched from inception up to May 2015. Selection criteria: Randomised controlled trials (RCTs) of POCL compared with other preoperative regimens in adult patients undergoing elective surgery. The experimental group had to receive at least 45 g of carbohydrates with an osmolality of less than 300 mOsm/kg within three hours before surgery. Data collection and analysis: Details of the eligible studies were extracted by the principal investigator and independent reviewer. Authors were contacted to obtain missing information. Methodological quality was assessed according to methodology described by The Cochrane Collaboration. Results: Twenty four RCTs involving 1 903 participants were identified for inclusion. The majority of the trials were conducted in developed and emerging countries and were based on otherwise healthy adult participants who were not considered to be at increased risk of regurgitation or aspiration. The quality of the evidence was moderate to low, hence the high risk of bias. Due to the heterogeneity of trials and the small number of included trials per comparison, limited data could be pooled for inclusion in a meta-analysis. Twenty-three trials including 1 841 participants reported on the primary outcomes. The immune status (in terms of C-reactive protein levels) of patients receiving POCL was better preserved compared to those in the standard fasting group (p = 0.006). No significant evidence of effect for POCL was demonstrated for any other clinical outcomes. Adverse events in terms of regurgitation, aspiration, morbidity and mortality were either not reported to occur or were not investigated in the included trials. As reported by 16 trials involving 1449 participants, the well-being of patients receiving POCL was improved or at least maintained in most of the trials. Conclusion: POCL is a safe alternative to standard fasting with no associated adverse events. There is not enough evidence to draw conclusions with absolute certainty on the clinical outcomes. However, there is a trend that POCL improves the well-being of surgical patients. Therefore, the potential benefits of POCL need to be balanced against the cost as well as patient preference. Emphasis should be on the type of surgery performed as well as the effect of minor versus major surgery on outcomes. Keep in mind that POCL is time (up to two hours before surgery), dose (at least 45 g carbohydrates) and patient (otherwise healthy elective surgery patients) specific. POCL should be perceived as a single element of enhanced recovery and the combination of different elements might produce more beneficial results than a single element by itself.

AFRIKAANSE OPSOMMING : Agtergrond: Standaard vasperiodes voor chirurgie word gekenmerk deur nadelige effekte wat ’n negatiewe kliniese uitkoms veroorsaak. Preoperatiewe orale koolhidraat inname (POCL) is ’n veilige alternatief vir vas, en dit word wêreldwyd aanbeveel deur verskeie narkoseverenigings. Die literatuur wat hierdie intervensie ondersteun, is besig om toe te neem en die groepering van data is nodig om kliniese toepaslikheid te bevorder. Doelwitte: Om sistematies die effek van POCL op perioperatiewe komplikasies en welstand in volwasse pasiënte wat elektiewe chirurgie ondergaan, te ondersoek. Soekstrategie: Elektroniese databasisse, artikels se verwysingslyste en persoonlike dokumente tot en met Mei 2015 is bestudeer. Seleksiekriteria: Ewekansig gekontrolleerde proewe van POCL in vergelyking met ander preoperatiewe praktyke in volwasse pasiënte wat elektiewe chirurgie ondergaan. Die eksperimentele groep moes ’n koolhidraatlading van minstens 45 g koolhidrate ontvang met ’n osmolaliteit van minder as 300 mOsm/kg binne drie ure voor die aanvang van chirurgie. Dataversameling en –analise: Inligting van relevante studies is deur die hoof navorser en onafhanklike hersiener onttrek. Outeurs van artikels is gekontak om alle relevante inligting te bekom. Die metodologiese kwaliteit van studies is geassesseer soos voorgestel deur The Cochrane Collaboration. Resultate: Vier-en-twintig ewekansig-gekontrolleerde proewe waarby 1 903 deelnemers betrokke was, is ingesluit. Die meeste proewe is uitgevoer in ontwikkelde lande en lande wat besig is om te ontwikkel, en is gebaseer op andersins gesonde volwasse deelnemers wat nie ’n verhoogde risiko vir regurgitasie en aspirasie getoon het nie. Die kwaliteit van die inligting was middelmatig tot laag, daarom die hoë risiko vir sydigheid. Weens die heterogene inligting in die proewe en die klein getal proewe per vergelyking wat ingesluit kon word, is daar beperkte inligting wat gegroepeer kon word vir insluiting in ’n meta-analise. Drie-en-twintig proewe met 1 841 deelnemers het verslag gedoen oor die primêre uitkomstes van hierdie oorsig. Die immuunstatus (in terme van CRP-vlakke) in pasiënte wat POCL ontvang het, was beter in vergelyking met die standaard vasgroep (p = 0.006). Geen beduidenheid is gevind vir die effek van POCL op enige ander kliniese uitkomste nie. Nadelige effekte in terme van regurgitasie, aspirasie, morbiditeit en mortaliteit is of nie aangedui of nie ondersoek by enige van die proewe nie. Soos aangedui deur 16 proewe, waarby 1 449 deelnemers betrokke was, was die welstand van die pasiënte wat POCL ontvang het, verbeter of ten minste onderhou in meeste van die proewe. Gevolgtrekking: POCL is ’n veilige alternatief vir standaard vasperiodes deurdat dit geen addisionele nadelige effekte inhou nie. Daar is egter nie genoeg bewyse in hierdie oorsig om gevolgtrekkings met sekerheid te maak oor die kliniese uitkomstes nie. Ongeag daarvan is daar ’n neiging dat POCL die welstand van chirurgie-pasiënte verbeter. Dus moet die potensiële voordele van POCL gemeet word teen die koste van die intervensie sowel as die pasiënt se voorkeur. Daar moet aandag geplaas word op die tipe chirurgie wat uitgevoer word sowel as die effek van klein teenoor groot chirurgie op die uitkomstes. Hou in gedagte dat die effek van POCL is tyd- (tot twee ure voor chirurgie), dosis- (tenminste 45 g CHO) en pasiënt- (andersins gesonde, elektiewe chirurgie-pasiënte) spesifiek. POCL is ’n enkele element van spoedige herstel, en die kombinasie van verskillende elemente mag meer voordelige resultate lewer as ’n enkele element.

Please refer to this item in SUNScholar by using the following persistent URL: http://hdl.handle.net/10019.1/101474
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