Brexit: Implications for anaesthesia and healthcare

81 Pages·2016·7.28 MB·English

Issue 99 | September 2016
Bulletin
Second NELA Patient Report
A view from the high-level isolation unit
The role of the nurse within
perioperative medicine
The magazine for members of the Royal College of Anaesthetists
Brexit:
Implications for
anaesthesia
and healthcare
www.rcoa.ac.uk
@RCoANews
Bulletin | Issue 99 | September 2016 2
President
Liam Brennan
Vice-Presidents
Jeremy Langton
Richard Marks
Editorial Board
Monty Mythen
Editor
Richard Marks
Vice-President
Simon Fletcher
Council Member
From the Editor Jaideep Pandit
Council Member
So much can happen in a few short weeks. Britain votes to leave the European Ewen Forrest
Union, appoints a new Prime Minister, and the Royal College of Anaesthetists Lead Regional Adviser
re-brands. I hope you enjoy the new look Bulletin: it is the culmination of many
David Booth
months of other folks’ hard work, and the Bulletin benefits by default. Purple is the Lead College Tutor
new Blue.
Kate Tatham
As always, there is something for everyone in this edition of the Bulletin, from novel Trainee Committee
ways of supporting our trainees with peer coaching and mentoring in the West
Carol Pellowe
Country, to a primary exam network in Wessex. We have updates from the Faculty
Lay Committee
of Pain Medicine on professional standards, and from the Faculty of Intensive Care
Medicine on e-learning opportunities and on the new FICM website. From the Gavin Dallas
NIAA, there is news of a new strategy and a cluster of other reports, giving details Communications Manager
of the Clinical Trials Network launch, Quality initiatives and the first Research
Mandie Kelly
Awards event. The HSRC presents the latest results from the National Emergency
Website and Publications Officer
Laparotomy Audit (NELA); and there are accounts from individual anaesthetists of
what it was like to be an Allied doctor in Belsen in 1945 where typhus was out of Anamika Trivedi
Website and Publications Officer
control, and an intensivist in London in 2015 when Ebola was out of control in west
Africa and the first patients had made it back to the UK. Articles for submission, together with
any declaration of interest, should be
You can read the latest updates on perioperative medicine, including the
sent to the Editor via email to
introduction to Bulletin readers of our recently appointed perioperative medicine
[email protected].
National Clinical Leads (Mike Swart and Chris Snowden), and a view from the US.
All contributions will receive an
Rob Thompson, Chair of the Lay Committee, tells it straight in his article entitled:
acknowledgement and the Editor
“Well, what do you patients want?”, and concludes that the College’s Perioperative
reserves the right to edit articles for
Medicine programme“... addresses so many of the issues raised in... studies of what
reasons of space or clarity.
patients want.” Those of you who are still concerned about how perioperative
medicine will be delivered may be relieved to read the conclusions of Emma The views and opinions expressed in
the Bulletin are solely those of the
McCone, Lead Sister, Pre-Assessment Services, Newcastle, that: “..we mustn’t forget
individual authors. Adverts imply no
that the people who will actually make it work are without doubt the nurses. It can’t
form of endorsement and neither
be done without them and collaborative working must begin now.”
represent the view of the Royal College
of Anaesthetists.
Monty Mythen
© 2016 Bulletin of the Royal College of Anaesthetists
All Rights Reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any other means,
electronic, mechanical, photocopying, recording, or otherwise, without prior permission, in writing, of the Royal College of Anaesthetists.
ISSN (print): 2040-8846 ISSN (online): 2040-8854
Bulletin | Issue 99 | September 2016 3
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CONTENTS
Page 4 Page 23 Page 43
The President’s View Perioperative Quality Improvement Peer coaching and mentoring for
Brexit: Implications for anaesthesia and Programme trainees at Royal Cornwall Hospitals
healthcare Working together to improve patient Trust
outcome
Page 6 Page 46
Guest Editorial Page 24
POET(ry) at Duke University Medical
Controversies in preoperative National Institute of Academic
Anaesthesia Centre, USA
carbohydrate loading
Future strategy Page 50
Page 12
Page 26 The cardiac catheterisation laboratory:
Revalidation for anaesthetists
National Institute of Academic anaesthetic trainees’ experiences
‘Top tips’ for the CPD systems
Anaesthesia (NIAA)
Page 53
Page 13 NIAA Research Award 2016
Patient Perspective An anaesthetist at Belsen
Page 28
Well, what do you patients want?
Health Services Research Centre Page 56
Page 16 NIAA Perioperative Medicine Clinical The Wessex primary exam support
Anaesthesia Clinical Services Trials Network network
Accreditation
National recognition for ACSA Page 30 Page 58
standards and regional engagement Health Services Research Centre College Tutors Meeting:
The RCoA/HSRC Quality Faculty poster competition winners
Page 18
“This is just what we do…”
The Faculty of Pain Medicine Page 61
Update from Professional Standards Page 32 Senior Fellows Club Meeting
Committee RCoA Perioperative Medicine National
Page 62
Clinical Leads
Page 19 As we were
The Faculty of Intensive Care Medicine Page 34
Page 63
Recruitment, e-Learning and the A view from the high-level isolation
Report from Council
website unit
Page 66
Page 20 Page 37
Health Services Research Centre Notices and advertisements
FOAMed* – the future of
What you need to know from the
postgraduate medical education? Page 67
Second NELA Patient Repor
Consultations
Page 40
The role of the nurse within Page 68
perioperative medicine Programme of Events

Royal College of Anaesthetists is grateful for the contribution to the production of the Bulletin by
Bulletin | Issue 99 | September 2016 4
The President’s View
Brexit: Implications for anaesthesia
and healthcare
'Fog in channel – Continent cut off'
The Times, October 1957
Liam Brennan
President
The vote to leave the European Union (EU) is perhaps the
most momentous decision that the UK electorate has taken
since the end of the Second World War and the creation
of the NHS. At the time of writing (in July), following what
promised to be a protracted and unprecedented situation
of simultaneous leadership contests in two of the UK’s
major political parties, Theresa May has been appointed
as Britain's Prime Minister. She faces a series of challenges
at a critical time following the Brexit vote, and at this period of such uncertainty,
I have decided to use my Bulletin article this month to reflect upon some of
the potential implications of the referendum result for our specialty, the wider
profession, and healthcare generally in the UK.
Workforce pivotal contribution of EEA colleagues. clearly going to be a major issue that will
The UK is currently heavily dependent The House of Commons Public need to be unravelled in the weeks and
on the invaluable contribution EU Accounts Committee estimate that the months to come, if and when Article 50,
migrants make to staffing the NHS and NHS is short of at least 50,000 staff, and signalling the UK's desire to leave the EU,
social care sectors. 130,000 people the College's recent workforce census4 is triggered.
from the EU work for the NHS or in estimates a current 7% shortfall in
In addition to freedom of movement,
social care, including 10% of doctors, anaesthetic workforce provision. Unless
existing European legislation affecting
5% of nurses and 5% of the social care we do something soon this number is
the healthcare workforce is also going to
workforce. The recent RCoA members' set to grow. Quite simply, we are not
be prominent in the debate surrounding
survey reveals that 6.5% of our members training and recruiting enough health
the UK's exit from the EU. The European
originate from the European Economic and social care personnel, including
Working Time Directive (EWTD) has
Area (EEA).1 anaesthetists.
been a controversial issue in healthcare,
As we have emphasised recently in the Any situation that causes uncertainty and and for the medical profession in
national media2 and in a joint statement fails to value the current or potential EEA particular, for many years. On one hand
with our associated Faculties and the migrant workforce risks exacerbating the EWTD has been welcomed for the
AAGBI3, we could not deliver a safe and current acute NHS staffing problems. protection it brings for doctors and their
sustainable anaesthetic, pain medicine Freedom of workforce movement, patients from working excessively long
and intensive care service without the a cornerstone of EU membership, is hours, whilst others express concerns
Bulletin | Issue 99 | September 2016 5
that doctors in training are denied the diaspora currently dispersed across the across the EU, ensuring consistency
opportunity to gain valuable clinical EU. and transparency in reporting research
experience and to maintain continuity of outcomes.
There are approximately 2 million UK
patient care. Let's hope that this issue is
citizens currently living, working and
not used too much as a political football, Public health matters
travelling in the EU, with 380,000
and that the needs of patients and our
There are over 80,000 pages of EU
living in Spain alone. Currently, EU
profession are the overriding concerns in
regulations related to public health
membership entitles our citizens to
deciding the way forward on this issue in
related matters. These range from use
access to the host country's public
the post-Brexit era.
of tobacco products to food regulation,
healthcare system on the same basis as
from water and air quality to coordinated
the indigenous population. Post Brexit,
Financial pressures responses to pandemics. With legislative
it remains to be seen what the impact
The financial challenge for the NHS time in Westminster at a premium, if and
on the NHS would be of large numbers
received considerable attention during when Article 50 is enacted, it will be a
of ex-pats returning to the UK to access
the referendum campaign, with the now considerable challenge to ensure that
healthcare, particularly as many will be
infamous claim that a vote for Brexit such a vast number of EU regulations are
older people with more complex needs.
would release £350 million per week scrutinised to decide which should and
of additional healthcare funding. With which should not be adopted into UK law.
Medical and scientific
doubts being expressed by independent
commentators, this sound bite has research Final thoughts
already been downgraded, with some of The prospect of Brexit is causing The vote to leave the EU has resulted
the Conservative leadership candidates considerable anxiety amongst the in an uncertain future for the whole
pledging £100 million per week and medical and wider scientific research UK, with considerable challenges and
some not being drawn at all. communities for several reasons. With unanswered questions for all of us
23% of research scientists and 5% who work in healthcare. The College
Post referendum, there has been the
of undergraduates in our universities reiterates its gratitude to and its support
predicted volatility in the money markets
from the EU, constraints on freedom of for all its members and the wider NHS
and foreign exchange rates, with some
movement would potentially limit the workforce who contribute so much to
economic experts predicting a ‘high
opportunities to travel, collaborate and healthcare in the UK. As we said in
disruption scenario' of a 6% fall in GDP
share ideas. Financially, the UK receives our statement in the aftermath of the
by 2020. Simon Stevens, the NHS
16% of all its research funding from the referendum result, “we want to stress how
England CEO, has said that the financial
EU – £8 billion between 2006-2015. much we value the contribution of every
stability of the NHS depends on a
Projects funded by the EU or those anaesthetist, pain medicine specialist and
flourishing and growing economy, and
planned under the umbrella of EU intensivist, whether from the UK or from
that any extra investment should go into
regulation may be jeopardised. Finally the 30% of our membership from the EU
social care. However, more concerning
the European Medicines Agency (EMA), and around the world.”3
is overall public spending, including
which is at the heart of pharmaceutical
that for health and social care, which
research and innovation, is currently In the months ahead, Council and I will
would inevitably come under pressure
based in London and employs over 800 do all that we can to represent the needs
if the UK economy went into recession
people. The UK is the leading player in of patients and the views of anaesthetists
jeopardising the already challenging
European pharma development, with and our research colleagues in the post-
NHS funding situation.
15% of the EMA budget invested in referendum debate. As always, please
UK-led projects. Leaving the EU risks let me know your views and, in particular,
Clinical pressures downgrading the UK's pre-eminent the impact the referendum result has had
The clinical pressures on the NHS position as, although the UK may still in your workplace.
are huge, and much has been made be able to access funding, it would not
of the potential additional burden have the same influence on research References
that growing immigration to the UK policy that it currently enjoys. It also 1 RCoA members' survey 2016.
brings to a system under considerable remains to be seen if a post-Brexit UK 2 Non-UK staff - Letter to The Times, July 1st
strain. Whilst a revised approach to would sign up to the EU Clinical Trials 2016 (www.rcoa.ac.uk/node/23576).
immigration controls may arguably ease regulations which are due to come into 3 Joint RCoA/FICM/FPM/AAGBI EU
referendum statement, June 28 2016
some of these pressures, what has not force in 2017-18. These are important,
(www.rcoa.ac.uk/node/23569).
been so prominent in the debate are as they will harmonise procedures for
4 RCoA workforce census 2015
the healthcare requirements of the UK the conduct of multi-centre clinical trials (www.rcoa.ac.uk/census2015).
Bulletin | Issue 99 | September 2016 6
Guest Editorial
Controversies in preoperative
carbohydrate loading
William Fawcett
Consultant in Anaesthesia, Royal Surrey County Hospital
Nicholas Levy
Consultant in Anaesthesia, Bury St Edmunds
The optimisation of a patient’s physical status prior to major elective surgery
to prepare them to withstand the subsequent physiological changes is at the
heart of perioperative medicine. Many of these areas have been common
in preoperative anaesthetic practice for many years, for example optimal
management of hypertension, heart failure, asthma, diabetes mellitus, etc.
More recently, the concept of prehabilitation has been popularised, to boost
functional physiological reserve to prepare patients for the inevitable decline
that occurs in the postoperative period. 1 Preoperative carbohydrate loading is
now an integral component of the strategies used to attenuate the metabolic
stress response of surgery.
The metabolic changes that occur adverse effects, not only hyperglycaemia Some of the benefits of oral
as a result of surgery have been well (from reduced serum glucose clearance carbohydrates loading (along with
characterised,2 and there is now greater and increased hepatic gluconeogenesis) associated fluid) are self-evident.
understanding of the relevance of with its attendant complications, but in The historical scenario of a patient
these changes and how they can be addition reduced glucose uptake into arriving in a theatre-suite for major
manipulated. The characteristic ‘stress’ muscle with poor muscle glycogen surgery after prolonged starvation and
response, in which neuroendocrine storage followed by muscle catabolism. rendered dehydrated, insulin resistant
activation (pituitary and sympathetic and catabolic even before the first
nervous system) leads to a predictable Optimisation of muscle function is a key
incision, has given way to patients now
series of metabolic changes, including area for postoperative recovery, with arriving in a relatively metabolically fed
catabolism and hyperglycaemia. In numerous recent studies demonstrating and euvolaemic state, with resultant
addition, there is an inflammatory that poor muscle function is predictive improvements in patient comfort and
response (e.g. interleukin release). for postoperative complications.4,5 This wellbeing.9,10 In addition, a number
The neuroendocrine activation can has sparked interest in several areas such of studies over the last 30 years have
be quantified in several ways such as
as prehabilitation. In addition, given shown that carbohydrate loading
raised serum glucose, cortisol, growth
the importance of muscle function and (initially intravenous) reduced many of
hormone, catecholamines, etc; but at
delaying fatigue for endurance athletes, the undesirable effects of starvation and
the very heart of these changes is insulin
there is a parallel between preparation surgery.11,12 The benefits include less
resistance, which increases with the
for competitive sport and major surgery.6 insulin resistance and hyperglycaemia,
magnitude of surgery.3
One such parallel is carbohydrate with the preservation of muscle
Why should we be concerned about loading which has been shown for about function13 and muscle mass,14 reduced
insulin resistance in the immediate 50 years to improve muscle function and nitrogen loss,11 and an improvement
postoperative period? It has a number of muscle glycogen.7,8 in overall insulin sensitivity.10,12 At a
Bulletin | Issue 99 | September 2016 7
cellular level, carbohydrate loading What is the optimal In 2008, Gustaffson and colleagues
improves intracellular signalling and composition of the published a study titled “Pre-operative
anabolic pathways in muscle.10 There carbohydrate loading may be used in
carbohydrate preload?
is also a reduction in length of stay with type 2 diabetes patients”, which has
Currently most sachets, when diluted
carbohydrate-loaded patients.15,16 been cited nearly 60 times to promote
to 400 mls, will result in a drink of
carbohydrate loading for the surgical
So, what are the concerns? approximately 12.5% carbohydrate with
patient with diabetes.21 Close inspection
135 mOsm kg-1, and approximately 200
of the methodology of the study reveals
Is there an increased risk of calories. Is this the best formula or would
that the message of the title may be
pulmonary aspiration? another carbohydrate composition be
an oversimplification. The study was
superior? This is addressed in more detail
Carbohydrate loading consists of mainly performed on only 25 patients with
below.
maltodextrin (a polysaccharide), which is type 2 diabetes mellitus (T2DM), all
emptied from the stomach reliably after with excellent glycaemic control and no
Are the benefits of
two hours. The most popular regimen evidence of either obesity or autonomic
is the administration of 800 mls on the preoperative carbohydrate neuropathy. The control group consisted
night prior to surgery and 400 mls two restricted to major elective of ten healthy subjects. All the subjects
to three hours prior to surgery. Fears surgery? had their usual medication the night
of incomplete gastric emptying appear A trial is underway to evaluate whether before the study, and were then starved,
groundless. Various methods of assessing patients who have suffered a hip receiving an oral carbohydrate-rich drink
gastric emptying using scintigraphy, fracture would benefit from preoperative with 1.5g of paracetamol at 8.00am,
paracetamol co-administration (i.e. carbohydrate loading.20 Perhaps, and then the administration of all their
measuring the rate of rise in the carbohydrate loading may be beneficial normal medication. The results showed
paracetamol absorbed from the small to medical patients too. that glucose concentrations were
intestine) and assessment of gastric antral back to baseline within 180 minutes
cross-sectional area using ultrasound for the subjects with diabetes and
Is it safe to administer the
have all confirmed that gastric emptying 120 minutes for the healthy controls.
preoperative carbohydrate
still reliably occurs.17-19 Thus the risk of Gastric emptying time (estimated by
load to the surgical patient
pulmonary aspiration of gastric contents measuring serum paracetamol levels)
should be low. The outcomes for an with diabetes? was not prolonged in the subjects with
estimated 5 million patients who have This is the most difficult and controversial diabetes. The authors did acknowledge
received the carbohydrate loading within question, as the combination of pre- that peak glucose level was higher in
Enhanced Recovery Programmes would existing hyperglycaemia and delayed the diabetic subjects than in the non-
support this. Clearly, those patients gastric emptying (due to either diabetic controls (13.4 ±0.5 vs 7.6 ± 0.5
with delayed gastric emptying (for autonomic neuropathy or medication) mmol litre-1; P<0.01). On the basis of
example those with major gastrointestinal may coexist. There is very little strong these findings, the authors concluded
emergency or mechanical gastric outlet evidence in this area.6 that preoperative carbohydrate loading
obstruction) are not suitable. may be used in the surgical patient
with T2DM, as it caused neither
prolonged hyperglycaemia or delayed
gastric emptying. The findings and
conclusions are to be expected. All the
subjects of the study had superbly well
controlled diabetes, had had all their
normal medication, had no pre-existing
autonomic neuropathy, and had had no
surgery! However, since the majority of
patients with T2DM do not have perfect
glycaemic control and are obese, the
results of this study are not representative.
In addition, it does need to be
emphasised that the diabetic patients did
develop hyperglycaemia, and were not
even subjected to the stress of surgery.
Bulletin | Issue 99 | September 2016 8
Is perioperative hyperglycaemia in patients not known The use of carbohydrate loading is
hyperglycaemia innocuous? to have diabetes, is a greater risk probably safe and efficacious in the
factor for harm than hyperglycaemia in surgical patient with diabetes, provided
For many years, the primary aim of
patients known to have diabetes.26 They that the CBG will be regularly monitored
perioperative glycaemic control in the
retrospectively examined the case notes and insulin is titrated to ensure that the
surgical patient with diabetes has been
of over 40,000 patients undergoing CBG remains <10mmol litre-1.
to prevent the catastrophic effects
surgery in the state of Washington during
of neuroglycopaenia and diabetic
the period from 2010 to 2012. In their What are the recent
ketoacidosis. However, various
study, 19% of the patients had pre-
studies have now demonstrated that developments in the
existing diabetes! But, more relevantly,
perioperative hyperglycaemia in constituents of the
they discovered that in the surgical
the surgical patient with diabetes is carbohydrate drink?
patient without known diabetes there is
associated with significantly increased
Newer preparations of complex
a dose-response relationship between
mortality and morbidity. Thus, it is now
carbohydrate drinks are now being
the level of CBG and composite adverse
accepted that hyperglycaemia in the
commercially produced with the
events. Furthermore, the non-diabetic
surgical patient with diabetes needs
explicit aim of reducing the glycaemic
patient who developed hyperglycaemia
to be prevented. This association
surge associated with the traditional
was less likely to receive insulin.
between hyperglycaemia in the surgical
carbohydrate drink. The manufacturers
patient with diabetes and increased
Thus, it can be concluded that of one such drink, Glycaemic
risk of complications and death has
hyperglycaemia needs to be prevented Endothelial Drink (GED), claim that their
been widely demonstrated, and has
in all surgical patients. Moreover, it product is superior as it contains less
been discussed in recent reviews.22,23
needs to be recognised that apart from maltodextrin, and this reduced dose
However, it is now beginning to be
patients with pre-existing diabetes, there provides the benefit without the harm
appreciated that it is the patient who
are three further populations who are at of excessive carbohydrate loading.28
either has undiagnosed diabetes or
risk of perioperative hyperglycaemia: Furthermore, GED contains citrulline,
who develops stress hyperglycaemia
patients with undiagnosed diabetes, the pharmacologically active precursor
that is at the highest risk of harm from
patients with pre-diabetes/borderline of arginine, which is claimed to reduce
perioperative hyperglycaemia. In a
diabetes, and thirdly those patients gluconeogenesis and maintain a normal
retrospective study by Frisch et al,
who exhibit stress hyperglycaemia. The ratio of systemic arginine to asymmetric
published in 2010, the case notes of over
incidence of undiagnosed diabetes/pre- dimethylarginine (ADMA). There is
3,000 surgical patients were reviewed,
diabetes is by definition unknown, but evidence to suggest that an abnormal
and the authors demonstrated that
some studies suggest that it may be as systemic arginine to ADMA ratio is
hyperglycaemia was associated with a
high as 35% in some populations.27 associated with poorer patient outcomes.
worse outcome, and that patients with
pre-existing diabetes faired better that Before the widespread adoption of this
Can preoperative
those without pre-existing diabetes.24 novel type of carbohydrate drink, further
carbohydrate loading cause
These findings were repeated in the studies are warranted to assess the safety
hyperglycaemia?
retrospective study by Kwon et al, and efficacy of these drinks, especially
which was published in 2013. In this Whilst it is appreciated that the aim of considering the potential for patient
study, the case notes of over 11,000 carbohydrate loading is to attenuate harm due to the increased prevalence of
surgical patients were reviewed.25 insulin resistance in the surgical patient, diabetes.
The authors concluded that patients the effects of carbohydrate loading
who had hyperglycaemia, as defined in surgical patients susceptible to
Can modern diabetes
by a capillary blood glucose (CBG) hyperglycaemia appears at the very
medication reduce gastric
level of >180mg dl-1 (10mmol litre-1), least to cause transient hyperglycaemia.
had a significantly increased risk of As the incidence of diabetes and emptying?
infection, re-operative interventions, and undiagnosed T2DM is increasing, and As the market for diabetes drugs expands
death. More importantly, those with the United Kingdom is now teetering on due to the increasing prevalence
hyperglycaemia on the day of surgery the edge of a pandemic of diabetes, we of diabetes, the pharmaceutical
who received insulin had no significant argue that preoperative carbohydrate companies are developing innovative
increased risk of infections, re-operative loading can no longer routinely be drugs to achieve glycaemic control.
interventions, or death. More recently, recommended without the regular These include the development of the
in a study published in 2015, Kotagal monitoring of CBGs and treatment with dipeptidyl peptidase inhibitors, e.g.
et al have replicated the findings that insulin for any resultant hyperglycaemia. sitagliptin and glucagon-like peptide
Bulletin | Issue 99 | September 2016 9
(GLP-1) analogues such as exenatide.29 4 Ida S et al. Sarcopenia is a predictor of 20 Moppett IK et al. Pre-Operative nutrition In
postoperative respiratory complications in Neck of femur Trial (POINT)-carbohydrate
These drugs exert part of their glycaemic
patients with esophageal cancer. Annals of loading in patients with fragility hip fracture:
control by reducing gastric emptying
Surgical Oncology 2015; 22: 4432-4437. study protocol for a randomised controlled
and promoting satiety. The safety of the 5 Otsuji H et al. Preoperative sarcopenia trial. Trials. 2014; 15 : 1.
use of these drugs combined with the negatively impacts postoperative outcomes 21 Gustafsson UO et al. Pre‐operative
following major hepatectomy with carbohydrate loading may be used in type
administration of carbohydrate drinks
extrahepatic bile duct resection. World Journal 2 diabetes patients. Acta Anaesthesiologica
just prior to anaesthesia has not been
of Surgery 2015;39:1494-1500. Scandinavica. 2008; 52: 946-951.
assessed, and warrants safety trials. This 6 Scott MJ, Fawcett WJ. Oral carbohydrate 22 Sebranek JJ, Lugli AK, Coursin DB. Glycaemic
is especially important for the GLP-1 preload drink for major surgery – the first control in the perioperative period. BJA 2013
steps from famine to feast. Anaesthesia 2014; Dec;111 Suppl 1:i18-34.
analogues, some of which are now
69: 308-313. 23 Dhatariya K, Levy N, Hall GM. The impact of
available as a once-a-week preparation.
7 Bergström J et al. Diet, muscle glycogen and glycaemic variability on the surgical patient.
physical performance. Acta Physiologica Current Opinion in Anesthesiology. 2016 Jun
Conclusion Scandinavica 1967; 71: 140–150. 1;29(3):430-437.
8 Pizza FX et al. A carbohydrate loading 24 Frisch A et al. Prevalence and clinical
In summary, carbohydrate loading
regimen improves high intensity, short outcome of hyperglycemia in the
provides a useful adjunct to preoperative duration exercise performance. International perioperative period in noncardiac surgery.
preparation; the potential for improving Journal of Sport Nutrition 1995; 5: 110-116. Diabetes Care. 2010; 33:1783-1788.
outcome is well recognised, with the 9 Hausel J et al. A carbohydrate-rich drink 25 Kwon S, et al. Importance of perioperative
reduces preoperative discomfort in elective glycemic control in general surgery: a report
reduction of insulin resistance and
surgery patients. Anesthesia and Analgesia from the Surgical Care and Outcomes
improved glycaemic control in the general 2001; 93: 1344-1350. Assessment Program. Annals of Surgery 2013;
population. However, a major concern 10 Wang ZG et al. Randomized clinical trial to 257 :8.
is its potential deleterious effects on compare the effects of preoperative oral 26 Kotagal M et al. Perioperative hyperglycemia
carbohydrate versus placebo on insulin and risk of adverse events among patients
glycaemic control for those susceptible
resistance after colorectal surgery. British with and without diabetes. Annals of Surgery.
to hyperglycaemia. In all patients, the Journal of Surgery 2010 ; 97:317-327. 2015;261(1):97-103.
CBG must be tightly monitored and 11 Crowe PJ, Dennison A, Royle GT. The 27 Mainous AG et al. Prevalence of prediabetes
any resultant hyperglycaemia must be effect of pre-operative glucose loading on in England from 2003 to 2011: population-
postoperative nitrogen metabolism. British based, cross-sectional study. BMJ Open. 2014
treated with insulin. Additionally, prior
Journal of Surgery 1984; 71: 635-637. May 1;4(6):e005002.
to administration, the potential risk of
12 Ljungqvist O et al. Glucose infusion instead 28 Benefits of G.E.D. versus other Options for
pulmonary aspiration must be considered. of preoperative fasting reduces postoperative “Carb Loading”. SoF Health
insulin resistance. Journal of the American (http://bit.ly/29APtEG) ( accessed July 2016 ).
Conflict of interests College of Surgeons 1994; 178: 329-336. 29 Drucker DJ, Nauck MA, The incretin system:
Dr Fawcett has received travel expenses 13 Henriksen MG et al. Effects of preoperative glucagon-like peptide-1 receptor agonists and
oral carbohydrates and peptides on dipeptidyl peptidase-4 inhibitors in type 2
to attend symposia to discuss the
postoperative endocrine response, diabetes. Lancet 2006;368(9548):1696-1705.
benefits of carbohydrate loading; has mobilization, nutrition and muscle function in
received paid honoraria lecturing/book abdominal surgery. Acta Anaesthesiologica
Scandinavica. 2003; 47: 191-199.
chapters/educational resources from
14 Yuill, K. A. et al. The administration of an
Grunethal, Merck and Baxter; and is a
oral carbohydrate-containing fluid prior
ERAS® Society committee member. to major elective upper-gastrointestinal
surgery preserves skeletal muscle mass
Dr Levy has received travel expenses to postoperatively—a randomised clinical trial.
Clinical Nutrition 2005 ; 24: 32-37.
attend symposia to discuss perioperative
15 Awad S et al. A meta-analysis of randomised
glycaemic control.
controlled trials on preoperative oral
carbohydrate treatment in elective surgery.
References Clinical Nutrition. 2013; 32: 34-44.
1 Gillis C et al. Prehabilitation versus 16 Smith MD et al. Preoperative carbohydrate
Rehabilitation: A Randomized Control Trial treatment for enhancing recovery after
in Patients Undergoing Colorectal Resection elective surgery. Cochrane Library. 2014
for Cancer. Journal of the American Society of 17 Darwiche G et al. Correlation between
Anesthesiologists 2014;121:937-947. simultaneous scintigraphic and
2 Desborough JP. The stress response to trauma ultrasonographic measurement of gastric
and surgery. BJA 2000;85:109-117. emptying in patients with type 1 diabetes
mellitus. J Ultrasound Med 2003; 22: 459-466.
3 Thorell A et al. Development of postoperative
insulin resistance is associated with the 18 Hillyard S et al. Does adding milk to tea delay
magnitude of operation. European Journal of gastric emptying?. BJA 2014; 112: 66-71.
Surgery 1992;159:593-599. 19 Van de Putte P, Perlas A. Ultrasound
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BJA 2014; 113: 12-22.
Bulletin | Issue 99 | September 2016 10
YEARS
ANAESTHESIA RESEARCH INNOVATION EDUCATION SCIENTIFIC
2017
DATES TO BE
ANNOUNCED
Anaesthesia Research Innovation
Education and Scientific (ARIES) Talks
Free, short, informative and entertaining talks from high profile speakers on areas of
relevance to anaesthesia, critical care and pain medicine.
29 September 2016: Patient and public involvement, military anaesthesia and more
26 October 2016: Paediatric anaesthesia, anaesthesia in 25 years and more
For full details and to book a place, please visit www.rcoa.ac.uk/rcoa25
Twitter #RCoA25 | Web www.rcoa.ac.uk/rcoa25 | Email [email protected] | Tel [phone]