What is the role of cyclic dextrin in the Enhanced Recovery After Surgery (ERAS) protocol?

The Role of Cyclic Dextrin in Enhanced Recovery After Surgery (ERAS) Protocols

Preoperative carbohydrate loading with complex carbohydrates such as cyclic dextrin is recommended as part of ERAS protocols to reduce postoperative insulin resistance, improve patient outcomes, and shorten hospital stays.

Background and Rationale

Enhanced Recovery After Surgery (ERAS) protocols aim to minimize surgical stress and optimize recovery through evidence-based interventions. A key component of these protocols is preoperative carbohydrate loading, which helps patients enter surgery in a metabolically fed state rather than a fasted state.

Physiological Benefits of Carbohydrate Loading

• Reduces insulin resistance: Postoperative insulin resistance is a significant marker of surgical stress and is associated with increased morbidity and longer hospital stays 1
• Maintains metabolic homeostasis: Helps maintain lean body mass and muscle strength 1
• Improves patient comfort: Reduces preoperative thirst, hunger, and anxiety 1

Cyclic Dextrin in ERAS Protocols

Cyclic dextrin (maltodextrin) is a complex carbohydrate preferred in ERAS protocols because:

1. It provides a relatively high concentration of complex carbohydrates that are gradually absorbed
2. It has a lower osmolality than simple sugars, reducing the risk of gastric discomfort
3. It helps maintain a metabolically fed state during surgery

Administration Guidelines

• Timing: 800 ml the evening before surgery and 400 ml 2-3 hours before anesthesia induction 1
• Concentration: Typically a 12.5% carbohydrate drink (primarily maltodextrins) 1
• Safety: Clear fluids including carbohydrate drinks are safe up to 2 hours before anesthesia in patients without delayed gastric emptying 1

Clinical Outcomes

Implementation of preoperative carbohydrate loading as part of ERAS protocols has demonstrated:

• Reduced length of hospital stay: Meta-analyses show a shortened hospital stay by approximately 0.3 days overall, with greater reductions (1.66 days) in major abdominal surgery 1, 2
• Faster return of bowel function: Shortened time to passage of flatus 1, 2
• Decreased postoperative complications: ERAS protocols including carbohydrate loading have shown lower overall complication rates (RR: 0.85,95% CI: 0.74-0.97) 1
• Improved metabolic response: Reduced nitrogen and protein losses, better-maintained lean body mass 1

Special Considerations

Diabetic Patients

• Carbohydrate treatment can be given to patients with well-controlled type 2 diabetes along with their regular diabetic medication 1, 3
• Studies have shown that gastric emptying is normal in patients with uncomplicated type 2 diabetes 1
• Preoperative carbohydrate loading may facilitate better control of preoperative blood glucose in diabetic patients 3

Implementation Challenges

Despite strong evidence supporting preoperative carbohydrate loading:

• Implementation and compliance rates remain suboptimal 4, 5
• Nutrition care elements of ERAS protocols are often underreported in the literature 5

Practical Recommendations

1. Patient selection: Appropriate for most surgical patients without contraindications (e.g., emergency surgery, documented delayed gastric emptying)
2. Product selection: Use a commercially available complex carbohydrate drink (maltodextrin-based) with approximately 12.5% concentration
3. Administration schedule:
   • 800 ml the evening before surgery
   • 400 ml 2-3 hours before anesthesia induction
4. Integration: Incorporate as part of a comprehensive ERAS protocol that includes other elements such as early mobilization, optimal pain management, and early postoperative feeding

Common Pitfalls and Caveats

• Avoid simple sugars: These may cause rapid blood glucose fluctuations and rebound hypoglycemia
• Respect timing guidelines: Administration should occur no less than 2 hours before anesthesia to ensure gastric emptying
• Consider contraindications: Not recommended in patients with gastroparesis, gastrointestinal motility disorders, or those undergoing emergency surgery 1
• Don't confuse with mechanical bowel preparation: Carbohydrate loading is distinct from bowel preparation; mechanical bowel preparation is generally not recommended in ERAS protocols except in specific circumstances 6

By implementing preoperative carbohydrate loading with cyclic dextrin as part of ERAS protocols, healthcare providers can help reduce postoperative insulin resistance, improve patient comfort, and potentially shorten hospital stays while reducing complications.