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Lestari MI, Sari D, Chandra S, Purwoko P, Isngadi I, Umar TP. Enhanced recovery after cesarean (ERAC) versus conventional care: An expanded systematic review and meta-analysis of 18,368 subjects. J Anaesthesiol Clin Pharmacol 2025; 41:48-61. [PMID: 40026726 PMCID: PMC11867361 DOI: 10.4103/joacp.joacp_339_23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 11/07/2023] [Accepted: 11/08/2023] [Indexed: 03/05/2025] Open
Abstract
Background and Aims Enhanced recovery after cesarean (ERAC) is an interdisciplinary approach to improve patient outcomes following cesarean section. ERAC's execution must be constantly evaluated. Thus, we aimed to analyze parameters associated with ERAC adoption for clinical care in this expanded systematic review. Material and Methods A systematic literature search using Epistemonikos, Google Scholar, PubMed, and Scopus was done until February 2023. The appropriate observational and experimental research comparing the effects of ERAC protocols with conventional care on postoperative adverse events, operation-related characteristics, time to first (oral intake, mobilization, bowel movement, and urinary catheter removal), and opioid use. Meta-analyses were conducted using the RevMan 5.4.1. and Comprehensive Meta-Analysis version 3.3 software. Results In total, 23 studies were included in this systematic review. ERAC implementation was found to be associated with improvement in terms of shorter postoperative hospital stays and faster time to first liquid intake, first solid diet, urinary catheter removal, and mobilization. Furthermore, the rate of opioid-free treatment, total in-hospital morphine milligram equivalent (MME), daily in-hospital MME, and total prescribed opioid pills at discharge (all parameters, P < 0.01) were significantly better in the ERAC group than in the conventional care group. However, no significant difference was observed regarding postoperative adverse events, blood loss, operation duration, and total prescribed MME at discharge parameters between the two observed groups. Conclusion ERAC implementation is associated with better healthcare delivery, as determined by shorter time to first, lower opioid consumption, and shorter postoperative length of stay compared with conventional care. However, it is not associated with a lower dosage of opioid prescription at discharge.
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Affiliation(s)
- Mayang Indah Lestari
- Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Universitas Sriwijaya/Dr. Mohammad Hoesin General Hospital-Siti Fatimah Hospital, Palembang, South Sumatera, Indonesia
| | - Djayanti Sari
- Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/RSUP Dr. Sardjito, Yogyakarta, Indonesia
| | - Susilo Chandra
- Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Universitas Indonesia, Central Jakarta, Jakarta, Indonesia
| | - Purwoko Purwoko
- Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Universitas Negeri Sebelas Maret/RSUD Dr. Moewardi, Surakarta, Central Java, Indonesia
| | - Isngadi Isngadi
- Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Universitas Brawijaya/RS Dr. Saiful Anwar, Malang, East Java, Indonesia
| | - Tungki Pratama Umar
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Medical Profession Program, Faculty of Medicine, Universitas Sriwijaya, Palembang, South Sumatera, Indonesia
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Hu XL, Wang YP, Wu LP, Shi XF, Yu LH, Zhang AH, Zhu XX, Weng XF. Impact of varied feeding protocols on gastrointestinal function recovery in the early postoperative period following repeat cesarean section: a randomized controlled trial. BMC Pregnancy Childbirth 2024; 24:768. [PMID: 39567916 PMCID: PMC11577904 DOI: 10.1186/s12884-024-06983-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 11/12/2024] [Indexed: 11/22/2024] Open
Abstract
BACKGROUND With the adjustment of China's birth policy, the repeat cesarean sections raises concerns about potential gastrointestinal mechanical injuries and disturbances in gastrointestinal neurohormonal regulation, affecting the postoperative recovery of gastrointestinal function. These affect maternal nutritional status, prolong recovery, extend hospitalization, increase medical costs, and lead to neonatal care challenges.This study is to examine the effects of different postoperative feeding protocols on the restoration of gastrointestinal function in women undergoing repeat cesarean section. METHODS A total of 103 women were randomly assigned to three groups: experimental group A (n = 35), experimental group B (n = 34), and a control group (n = 34). In group A, women without choking symptoms received a clear fluid diet postoperatively, followed by a pureed diet after 6 h, and a regular soft diet after passing flatus. In group B, women chewed gum postoperatively, followed by a clear fluid diet after 2 h, a pureed diet after 6 h, and a regular soft diet after passing flatus. The control group received a clear fluid diet, a pureed diet after passing flatus, and a regular soft diet after defecation. Outcomes measured included recovery of gastrointestinal function, blood biochemical markers, comfort level, exclusive breastfeeding rate, and newborn weight loss. RESULTS The baseline maternal data across the three groups demonstrated no significant differences (P > 0.05). Both experimental groups A and B showed earlier recovery of postoperative gastrointestinal function compared to the control group, though there was no significant difference between the two experimental groups (P > 0.05). Additionally, postoperative comfort levels were significantly higher in both experimental groups than in the control group (P < 0.05). CONCLUSIONS Early feeding is safe and effective for women who underwent repeat cesarean sections.It has been shown to accelerate gastrointestinal recovery, significantly improve maternal comfort and satisfaction.In cases where immediate postoperative oral intake is not feasible, chewing gum demonstrates a comparable promotive effect, providing a viable substitute in facilitating recovery. TRIAL REGISTRATION This trial has been prospectively registered at Chinese Clinical Trial Registry (ChiCTR2200065825) and the first registration date was 11/16/2022.
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Affiliation(s)
- Xiao-Li Hu
- Department of Obstetrics, Women's Hospital, School of Medicine, Zhejiang University, No.1 XueShi Road, Hangzhou, 310006, China.
| | - Yu-Peng Wang
- Department of Obstetrics, Women's Hospital, School of Medicine, Zhejiang University, No.1 XueShi Road, Hangzhou, 310006, China
| | - Lu-Ping Wu
- Department of Obstetrics, Women's Hospital, School of Medicine, Zhejiang University, No.1 XueShi Road, Hangzhou, 310006, China
| | - Xiao-Feng Shi
- Department of Obstetrics, Women's Hospital, School of Medicine, Zhejiang University, No.1 XueShi Road, Hangzhou, 310006, China
| | - Li-Hua Yu
- Department of Obstetrics, Women's Hospital, School of Medicine, Zhejiang University, No.1 XueShi Road, Hangzhou, 310006, China
| | - Ai-Hua Zhang
- Department of Obstetrics, Women's Hospital, School of Medicine, Zhejiang University, No.1 XueShi Road, Hangzhou, 310006, China
| | - Xiao-Xiao Zhu
- Department of Obstetrics, Women's Hospital, School of Medicine, Zhejiang University, No.1 XueShi Road, Hangzhou, 310006, China
| | - Xiao-Feng Weng
- Department of Obstetrics, Women's Hospital, School of Medicine, Zhejiang University, No.1 XueShi Road, Hangzhou, 310006, China
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Chen D, Lang B, Wu L, Zhou S, Chen S. Early oral feeding within two hours for parturients compared with delayed oral feeding after cesarean section: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2024; 24:623. [PMID: 39354421 PMCID: PMC11443750 DOI: 10.1186/s12884-024-06838-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2024] [Accepted: 09/17/2024] [Indexed: 10/03/2024] Open
Abstract
BACKGROUND It is recommended that postpartum women undergo early oral feeding (EOF) after cesarean section (CS). However, the optimal early time for oral feeding after CS is unclear. We performed a meta-analysis to assess whether EOF within two hours is superior to delayed oral feeding (DOF) after CS. METHODS The PubMed, Embase, Cochrane Library, and Google Scholar databases were searched from inception to February 2024 for randomized controlled trials comparing EOF versus DOF after CS. Primary outcomes included the time to normal bowel function. The secondary outcomes included postoperative complications, the time to ambulation after surgery, the time to removal of the catheter, the time to start of a regular diet, the length of hospital stay and patient satisfaction. RESULTS Data from 8 studies involving a total of 2572 women were obtained. EOF within two hours was significantly associated with shorter durations of return bowel movement (WMD, - 2.41, 95% CI, - 3.80-- 1.02; p < 0.001; I2 = 96%), passage flatus after surgery (WMD, - 3.55, 95% CI, - 6.36-- 0.75; p = 0.01; I2 = 98%), ambulation after surgery (WMD, - 0.96, 95% CI, - 1.80-- 0.13; p = 0.02; I2 = 53%), removal of catheters (WMD, - 15.18, 95% CI, - 25.61-- 4.74; p = 0.004; I2 = 100%) and starting a regular diet (WMD, - 7.03, 95% CI, - 13.13-- 0.92; p = 0.02; I2 = 99%) compared with DOF. EOF was not related to increased vomiting (RR, 1.08; 95% CI, 0.74-1.57; p = 0.69; I2 = 0%), nausea (RR, 1.21; 95% CI, 0.83-1.77; p = 0.33; I2 = 37%), abdominal distension (RR, 0.76; 95% CI, 0.31-1.89; p = 0.55; I2 = 54%) or ileus (RR, 0.91; 95% CI, 0.40-2.06; p = 0.81; I2 = 12%). CONCLUSIONS This meta-analysis provides evidence that EOF within two hours after CS has comparable safety with DOF, and can accelerate the recovery time for normal bowel function. TRIAL REGISTRATION INPLASY202320055.
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Affiliation(s)
- Dongxu Chen
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan Province, 610041, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan Province, China
| | - Bingchen Lang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan Province, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan Province, China
| | - Lan Wu
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan Province, 610041, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan Province, China
| | - Shengping Zhou
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan Province, 610041, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan Province, China
| | - Shouming Chen
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan Province, 610041, China.
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan Province, China.
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He LB, Liu MY, He Y, Guo AL. Nutritional status efficacy of early nutritional support in gastrointestinal care: A systematic review and meta-analysis. World J Gastrointest Surg 2023; 15:953-964. [PMID: 37342843 PMCID: PMC10277940 DOI: 10.4240/wjgs.v15.i5.953] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 02/20/2023] [Accepted: 03/31/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Gastrointestinal surgery is a complicated process used to treat many gastrointestinal diseases, and it is associated with a large trauma: Most patients often have different degrees of malnutrition and immune dysfunction before surgery and are prone to various infectious complications during postoperative recovery, thus affecting the efficacy of surgical treatment. Therefore, early postoperative nutritional support can provide essential nutritional supply, restore the intestinal barrier and reduce complication occurrence. However, different studies have shown different conclusions.
AIM To assess whether early postoperative nutritional support can improve the nutritional status of patients based on literature search and meta-analysis.
METHODS Articles comparing the effect of early nutritional support and delayed nutritional support were retrieved from PubMed, EMBASE, Springer Link, Ovid, China National Knowledge Infrastructure, China Biology Medicine databases. Notably, only randomized controlled trial articles were retrieved from the databases (from establishment date to October 2022). The risk of bias of the included articles was determined using Cochrane Risk of Bias V2.0. The outcome indicators, such as albumin, prealbumin, and total protein, after statistical intervention were combined.
RESULTS Fourteen literatures with 2145 adult patients undergoing gastrointestinal surgery (1138 patients (53.1%) receiving early postoperative nutritional support and 1007 patients (46.9%) receiving traditional nutritional support or delayed nutritional support) were included in this study. Seven of the 14 studies assessed early enteral nutrition while the other seven studies assessed early oral feeding. Furthermore, six literatures had "some risk of bias," and eight literatures had "low risk". The overall quality of the included studies was good. Meta-analysis showed that patients receiving early nutritional support had slightly higher serum albumin levels, than patients receiving delayed nutritional support [MD (mean difference) = 3.51, 95%CI: -0.05 to 7.07, Z = 1.93, P = 0.05]. Also, patients receiving early nutritional support had shorter hospital stay (MD = -2.29, 95%CI: -2.89 to -1.69), Z = -7.46, P < 0.0001) shorter first defecation time (MD = -1.00, 95%CI: -1.37 to -0.64), Z = -5.42, P < 0.0001), and fewer complications (Odd ratio = 0.61, 95%CI: 0.50 to 0.76, Z = -4.52, P < 0.0001) than patients receiving delayed nutritional support.
CONCLUSION Early enteral nutritional support can slightly shorten the defecation time and overall hospital stay, reduce complication incidence, and accelerate the rehabilitation process of patients undergoing gastrointestinal surgery.
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Affiliation(s)
- Li-Bin He
- Department of Anesthesia and Surgery, Xiang'an Hospital Affiliated to Xiamen University, Xiamen 361100, Fujian Province, China
| | - Ming-Yuan Liu
- Department of Endocrine, Xiang'an Hospital, Xiamen University, Xiamen 361100, Fujian Province, China
| | - Yue He
- Department of Rheumatology and Immunology, Run Run Shaw Hospital, Medical College of Zhejiang University, Hangzhou 310000, Zhejiang Province, China
| | - Ai-Lin Guo
- Department of Cardiac Surgery, Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen 361100, Fujian Province, China
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Abstract
OBJECTIVE A gap between clinical practice and evidence is common. The present multicentre study was designed to explore the actual postoperative fasting practice, including the instructed fasting time from the ward staff and the actual postoperative fasting time. DESIGN Multicentre survey. SETTING Four tertiary hospitals in Shenzhen City, China. PARTICIPANTS A total of 988 patients completed a survey on instructed and actual postoperative fasting. OUTCOMES All patients received postoperative instructed fasting time from the ward staff. The median instructed fasting time for fluids from ward staff was 6 hours (IQR, 4-6 hours), and the median instructed fasting time for solid food was also 6 hours (IQR 5-6 hours) after surgery. The actual postoperative fasting time, including fluid and solid food intake, was significantly longer than the time recommended by the ward staff (both p<0.001). RESULTS The median time to postoperative first flatus (FFL) was 16.5 hours (IQR 8-25.5 hours), and the median time to postoperative first faeces (FFE) was 41 hours (IQR 25-57 hours). The fasting time was significantly shorter than the time to FFL and the time to FFE, regardless of surgery type or anaesthesia type (all p<0.001). Postoperative nausea and vomiting (PONV) occurred in 23.6% of patients. After surgery, 58.70% of patients reported thirst, and 47.47% reported hunger. No ileus occurred. CONCLUSION Approximately half of the patients reported thirst and hunger postoperatively. Patients initiated oral intake earlier than the time to FFL or FFE without increasing serious complications. This study may support the rationale for interventions targeting postoperative oral intake time in future studies.
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Affiliation(s)
- Lifei Lai
- Department of Anesthesiology, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
| | - Lianghua Zeng
- Department of Anesthesiology, Shenzhen Qianhai Shekou Free Trade Zone Hospital, Shenzhen, China
| | - Zhijing Yang
- Department of Anesthesiology, Shenzhen University General Hospital, Shenzhen, China
| | - Yingling Zheng
- Department of Anesthesiology, Integrated Traditional Chinese and Western Medicine Hospital, Shenzhen, China
| | - Qianqian Zhu
- Department of Anesthesiology, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
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Dongare PA, Bhaskar SB, Harsoor SS, Garg R, Kannan S, Goneppanavar U, Ali Z, Gopinath R, Sood J, Mani K, Bhatia P, Rohatgi P, Das R, Ghosh S, Mahankali SS, Singh Bajwa SJ, Gupta S, Pandya ST, Keshavan VH, Joshi M, Malhotra N. Perioperative fasting and feeding in adults, obstetric, paediatric and bariatric population: Practice Guidelines from the Indian Society of Anaesthesiologists. Indian J Anaesth 2020; 64:556-584. [PMID: 32792733 PMCID: PMC7413358 DOI: 10.4103/ija.ija_735_20] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 06/20/2020] [Accepted: 06/22/2020] [Indexed: 02/07/2023] Open
Affiliation(s)
- Pradeep A Dongare
- Assistant Professor, Department of Anaesthesiology, ESIPGIMSR, Bengaluru, India
| | - S Bala Bhaskar
- Department of Anaesthesiology, Vijayanagar Institute of Medical Sciences, Ballari, India
| | - S S Harsoor
- Professor, Department of Anaesthesiology, Dr BR Ambedkar Medical College and Hospital, Bengaluru, India
| | - Rakesh Garg
- Additional Professor, Department of Onco-Anaesthesia, Pain and Palliative Medicine, DR BRAIRCH, AIIMS, New Delhi, India
| | - Sudheesh Kannan
- Professor, Department of Anaesthesiology, BMCRI, Bengaluru, India
| | - Umesh Goneppanavar
- Professor, Department of Anaesthesiology, Dharwad Institute of Mental Health and Neurosciences, Dharwad, India
| | - Zulfiqar Ali
- Associate Professor, Department of Anesthesiology and Critical Care, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Ramachandran Gopinath
- Professor and Head,Department of Anaesthesiology and Intensive Care, ESIC Medical College and Hospital, Hyderabad, India
| | - Jayashree Sood
- Honorary. Joint Secretary, Board of Management, Chairperson, Institute of Anaesthesiology, Pain and Perioperative Medicine, Sir Ganga Ram Hospital, New Delhi, India
| | - Kalaivani Mani
- Scientist IV, Department of Biostatistics, AIIMS, New Delhi, India
| | - Pradeep Bhatia
- Professor and Head, Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, India
| | | | - Rekha Das
- Professor and Head, Department Anaesthesiology, Critical care and Pain, Acharya Harihar Post Graduate Institute of Cancer, Cuttack, India
| | - Santu Ghosh
- Assistant Professor, Department of Biostatistics, St John's Medical College, Bengaluru, India
| | | | - Sukhminder Jit Singh Bajwa
- Professor and Head, Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Punjab, India
| | - Sunanda Gupta
- Professor and Head, Department of Anaesthesiology, Geetanjali Medical College and Hospital, Udaipur, India
| | - Sunil T Pandya
- Chief of Anaesthesia and Surgical ICU, AIG Hospitals, Hyderabad, India
| | - Venkatesh H Keshavan
- Senior Consultant and Chief, Department of Neuroanaesthesia and Critical Care, Apollo Hospitals, Bengaluru, India
| | - Muralidhar Joshi
- Head, Department of Anaesthesia and Pain Medicine, Virinchi Hospitals, Hyderabad, India
| | - Naveen Malhotra
- Professor, Department of Anaesthesiology and In Charge Pain Management Centre, Pt BDS PGIMS, Haryana, India
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Abstract
PURPOSE OF REVIEW Preoperative nutrition support has been extensively studied; however, data on the timing of postoperative nutrition initiation are scarce. The current review focuses on the importance of early nutritional support in surgical patients and their impact on outcomes. RECENT FINDINGS Early nutrition support during the postoperative course may be the most important step that can be taken toward preventing subsequent malnutrition-related complications. European Society for Parenteral and Enteral Nutrition guidelines recommends early nutrition to improve outcomes after surgery and accelerates the recovery. Moreover, nutritional support should be personalized, and disease process-based. SUMMARY Existing studies appear to focus mostly on abdominal and gastrointestinal surgery. Further prospective observational and randomized clinical trials across different surgical populations will aid surgeons to better understand how early feeds in either form can reduce morbidity, quality of life, and increase recovery rates.
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