Is CF(Preop)® Safe For Patients with Diabetes?

One of the most asked questions when it comes to CF(Preop)® is whether or not patients with diabetes may consume it before surgery. Today, we break down the research surrounding preoperative carbohydrate loading for patients with diabetes. We also discuss CF Nutrition’s protocol for carbohydrate loading in patients with diabetes.

 Why is preoperative carb loading necessary?

Before ERAS® protocols were discovered, the traditional approach to surgery was to fast after midnight prior to surgery to decrease the risk for aspiration. In the 1990’s, evidence-based research suggested that this was not necessary. There are detrimental effects caused by this period of prolonged fasting. Prolonged fasting worsens the catabolic state, increases metabolic stress, hyperglycemia and insulin resistance. Furthermore, when the body is fasted for a prolonged time, glycogen stores are depleted which can lead to protein and muscle breakdown. Postoperative insulin resistance (PIR), a result of the stress response from surgery and further exaggerated with prolonged fasting, is directly related to delayed wound healing, increased morbidity/mortality and LOS . To enhance recovery after surgery, it is important to decrease PIR. Preoperative carbohydrate loading maximizes glycogen stores in the body as an energy source in order to minimize degeneration of body tissues and reduce insulin resistance. By changing the metabolic state, and shortening preoperative fasting (aka providing a complex carbohydrate 2-3 hours prior to surgery), PIR will be decreased, protein loss will be reduced, and muscle function will improve.

What has CF Nutrition done to research the use of CF(Preop)® for patients with diabetes?

The founder of CF Nutrition, Dr. Lou Marsh, researched CF(Preop)® and blood glucose levels extensively. She found that after ingestion of 50 grams of carbohydrate, the blood glucose levels will spike in any individual. What becomes important is the time the patient drinks CF(Preop)® and the time the blood glucose levels are checked. This will help to see where each specific patient’s blood glucose levels are at two hours after consuming CF(Preop)® and eliminate any excess intervention which leads to hypoglycemia intra-operatively. If blood sugars are checked prior to the two hour mark, excess insulin may be prescribed which leads to hypoglycemia intra-operatively. CF Nutrition provides a questionnaire to help create a standardization of care for checking blood glucose before, during and after surgery. 

What research studies support preoperative carb loading in patients with diabetes?

Administering a carbohydrate drink prior to surgery leaves some surgeons skeptical on the effects it may have on blood glucose levels. Unfortunately, several studies exclude diabetic patients. However, there are some studies that have been done to evaluate the safety of administering dextrose to diabetic patients undergoing surgery. Gustafsson et al conducted a study to evaluate the safety of preoperative carbohydrate loading on patients with diabetes. Twenty-five patients were included with type 2 diabetes (mean HbAlc 6.2± 0.2%) and 10 healthy control subjects. A carbohydrate drink (400mL, 12.5%) was given with the determination of gastric emptying. 

As expected, peak glucose was significantly higher in the diabetic patients compared to the control (p<0.01) and occurred later after intake of the carbohydrate drink (p<0.01). Glucose returned to baseline in 180 minutes in diabetic patients and 120 minutes in the control group (p<0.01). In terms of gastric emptying, at 120 minutes, 10.9 ± 0.7% and 13.3 ± 1.2% of paracetamol remained in the stomach in diabetic and healthy subjects respectively. Gastric half-emptying time occurred at 49.8 ± 2.2 minutes in diabetics and 58.6± 3.7 minute in healthy subjects (p<0.05). These results illustrate that there are no signs of delayed gastric emptying. Therefore, a carbohydrate drink can safely be administered 180 minutes before anesthesia without risk of hyperglycemia or aspiration risk preoperatively according to the results from this study.

​Furthermore, Li Na Ge et al conducted a systematic review to examine the effectiveness and safety of oral carbohydrates in those with diabetes. The review included 5 randomized control trials. Because there are no widely accepted indicators of the effects of preoperative carbohydrate in surgical patients with diabetes, this systematic review intended to offer a basis for the progress of ERAS® pathways for diabetic patients. This systematic review concludes that preoperative oral carbohydrate is effective, safe, and feasible for patients with diabetes. When a diabetic patient is fasted, the lack of glycogen reserve can lead to an insufficient energy supply, strong fluctuation of blood glucose, increased risk of hypoglycemia, nerve and kidney damage, and injury of tissues and organs. Additionally, prolonged fasting increases stress. This increased stress joint with surgical trauma can lead to increased glucocorticoids and glucagon, reduced insulin sensitivity, and reduced utilization of glucose in peripheral tissues. As a result, patients are at risk for postoperative hyperglycemia and increased insulin resistance. Postoperative insulin resistance can increase risk for developing infection and increasing length of stay. By consuming an oral carbohydrate 2-3 hours before surgery, the energy supply is enhanced consequently reducing perioperative hypoglycemia and insulin resistance. 

Providing a carbohydrate drink prior to surgery may help to reduce the stress response of surgery and put the body into a FED state entering surgery. Putting the body into a more normal physiological state entering surgery may be advantageous in overall recovery. 

What are CF Nutrition’s recommendations for CF(Preop)® and patients with diabetes?

With all this being said, here are important things to consider when providing CF(Preop)® to a diabetic patient:

1. Do they have a known risk for delayed gastric emptying? If so, consider adjusting the window for consuming CF(Preop)® per MD recommendations

2. A pt’s blood glucose will spike after the consumption CF(Preop)® however, it should return to baseline

3. Blood glucose should be checked regularly 

CF Nutrition  Recommendations:

Type 1 Diabetic 

With appropriate insulin administration, yields euglycemia. 

• 1st Bottle: Drink the night before surgery once in the fasting window 

• 2nd Bottle: Complete 2 hours before surgery Patients simply “match their short-acting insulin injections” to their blood glucose level and to the carb load that is listed on the drink label.

Type 2 Diabetic 

With preservation of their oral antihyperglycemic agent schedule at bedtime. 

• 1st Bottle: Drink the night before surgery once in the fasting window

• 2nd Bottle: Complete 2 hours before surgery Morning dose of oral agent may be held based on the actual surgical time, e.g., as when surgery is scheduled as one of the first cases of the morning.

Now that you know CF(Preop)® may be used in patients with diabetes, visit our website to purchase today!

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