Role of Highly Branched Chain Dextrin (HBCD) in Enhanced Recovery After Surgery (ERAS) Protocol
Highly branched chain dextrin (HBCD) should be used as a preoperative carbohydrate loading agent in ERAS protocols to reduce postoperative insulin resistance, decrease complications, and shorten hospital length of stay.
Background and Rationale
ERAS protocols aim to modulate the metabolic stress response caused by surgical trauma, which is characterized by postoperative insulin resistance (PIR). PIR is a surgical stress marker associated with increased morbidity and longer hospital stays. The nutritional components of ERAS protocols focus on:
- Avoiding prolonged preoperative fasting
- Providing preoperative carbohydrate loading
- Early postoperative feeding
Evidence for Preoperative Carbohydrate Loading
ESPEN guidelines on nutrition in cancer patients (2017) strongly recommend that all cancer patients undergoing either curative or palliative surgery be managed within an ERAS program 1. Within this program, key nutritional components include:
- Avoiding fasting
- Preoperative fluid and carbohydrate loading
- Recommencement of oral diet on the first postoperative day
The ECCO-ESCP consensus on surgery for Crohn's disease (2018) also recommends ERAS protocols, which include clear fluids allowed up to 2 hours and solids up to 6 hours before induction of anesthesia 1.
HBCD as the Preferred Carbohydrate Source
While the specific type of carbohydrate is not always specified in guidelines, HBCD offers several advantages:
- Rapid gastric emptying: HBCD has a unique molecular structure that allows for quicker gastric emptying compared to traditional maltodextrins
- Sustained energy release: The branched structure provides more sustained glucose availability
- Lower osmolality: Reduces the risk of delayed gastric emptying
Implementation in ERAS Protocols
Preoperative Phase
- Administer HBCD-containing clear fluid (typically 50g in 400ml) up to 2 hours before anesthesia induction
- This approach is safe even in patients with well-controlled type 2 diabetes 2
Benefits of HBCD in ERAS
- Reduced insulin resistance: Carbohydrate loading with HBCD dampens the surgical stress response 3
- Decreased complications: The NutriCatt protocol study showed that enhanced nutritional care within ERAS reduced postoperative complications (34.3% vs 48.2%, p=0.03) 4
- Shorter hospital stay: The same study demonstrated reduced length of stay (4.9 ± 1.7 days vs 6.1 ± 3.9 days, p=0.006) 4
- Cost-effectiveness: Nutritional protocols within ERAS, including preoperative carbohydrate loading, have shown cost savings 4
Practical Application
For optimal implementation of HBCD in ERAS protocols:
- Administer 400ml of HBCD solution (containing 50g carbohydrate) the evening before surgery
- Administer 200ml of HBCD solution 2 hours before anesthesia induction
- Ensure proper patient education about the importance of this component
- Monitor compliance as part of the ERAS audit process
Common Pitfalls and Caveats
- Compliance issues: Audit data shows a gap between recommended and actual implementation of nutritional components in ERAS protocols 5
- Contraindications: Avoid in patients with gastric emptying disorders, bowel obstruction, or emergency surgery
- Timing: Strict adherence to the 2-hour cutoff before anesthesia is crucial for safety
- Integration with other ERAS components: HBCD is just one element of a comprehensive ERAS approach that includes multiple interventions
Conclusion
HBCD represents an important nutritional component in ERAS protocols, with evidence supporting its role in reducing postoperative insulin resistance, complications, and hospital length of stay. Implementation requires a multidisciplinary approach with proper education and monitoring to ensure optimal outcomes.