The Feasibility and Benefits of Preoperative Whey Protein-Infused Carbohydrate Loading in Elderly with Hip Fractures Undergoing Surgery: A Pilot Study

ABSTRACT

Introduction: Preoperative carbohydrate loading in Enhanced Recovery After Surgery (ERAS) is an independent predictor of postoperative outcomes. By reducing the impact of surgical stress response, fasting-induced insulin resistance is modulated. As a clear fluid, consuming whey protein-infused carbohydrate is safe up to 2 hours preoperatively. Widely practiced in abdominal surgeries, its implementation in hip fracture surgeries is yet to be recognized. Methods: We aim to identify the feasibility of preoperative carbohydrate loading in hip fracture surgery and assess its clinical effects. A randomized controlled, open labelled trial in patients ≥ 65 years old without diabetes mellitus, has hip fracture was conducted in University Malaya Medical Centre between November 2020 and May 2021. Intervention Carbohydrate loading (Resource-Nestle®) with 100g on the day before surgery and 50g up to 2 hours preoperatively versus standard preoperative fasting. Results: Thirty ASA 1-3 patients (carbohydrate loading and control, n = 15 each), mean age 79 years (SD±8.5), mean body mass index 23.8 (SD±3.5kg/m2) were recruited. Analysis for feasibility of carbohydrate loading (n = 15) demonstrated attrition rate of 20%, n = 3 (one participant completed the drinks but operation was postponed and two patients were not served the third drink by ward staff). Otherwise, patients were 100% compliant with no adverse events reported. 26 randomized participants were analyzed for secondary outcomes (intervention n = 12, control n = 14). There was no significant difference among groups in the postoperative nausea and vomiting, pain score, fatigue level and muscle strength assessed at 24-48 hours postoperatively. Conclusion: COVID-19 pandemic had interrupted recruitment resulting in a small number of participants. Nevertheless, this study demonstrated that implementation of preoperative carbohydrate loading is feasible for hip fracture surgeries without complications but requires careful coordination among surgical, anaesthetic and nursing teams. An adequately powered randomized controlled study is needed to examine the full benefits of preoperative carbohydrate loading in this group of patients.