Effective Reduction in Stress Induced Postoperative Hyperglycemia in Bariatric Surgery by Better Carb Loading
Patrick Knight, MD, Stuart Verseman, MD, Alain Elian, MD
Although carbohydrate loading is a recommended component of enhanced recovery protocols (ERP's), there is limited understanding regarding the desired outcome measures tied to the process: a reduction in the rate of stress induced hyperglycemia and the subsequent need for rescue insulin therapy. This has resulted in a lack of standardization in the chemical composition of these preoperative drinks. There is no published data in bariatric surgery patients on the impact of specific drinks on post-operative stress induced hyperglycemia.
A pragmatic bariatric surgery quality improvement project was performed assessing the rate of glycemic variability (incidence of serum glucose >140mg/dl) and the number of patients requiring insulin treatment postoperatively in a non-diabetic group of patients. A historical control group (Grape), who received three doses of grape juice, was compared to a consecutive group who received 3 doses of a perioperative drink (25 grams maltodextrin/3 grams citrulline- GED). No other changes were made in the ERP.
The study population included 70 patients (Grape - 54; GED - 16). There was no significant difference in gender, age or mix of sleeve gastrectomy/bypass between the groups. The rate of glycemic variability was significantly higher for the Grape group on postoperative day 0 (113/162, 70% vs 17/48, 35%; p<0.05). In addition, a significantly greater number of Grape patients required postoperative insulin treatment (63% vs 25%; p<0.05).
The results demonstrate that preoperative loading with a low complex carb/citrulline drink results in both a significantly lower rate of glycemic variation and the need for postoperative insulin management in a non-diabetic bariatric surgery patient population compared to grape juice. These data represent the first direct evidence that a specific preoperative drink composition and treatment process is necessary to reduce the rate and severity of postoperative stress induced hyperglycemia.