Boost Breeze

[turnupthevapor]

You jedis think a jury of our peers would think boost breeze would fit the criteria of a clear?? my facility wants to bail on ensure clearest and move to this product which is clear but has protein whey isolates in it? I wasn’t thrilled the source of sugar is not malodextran (used in all the studies done in this field) but instead high fructose cornsyrup. Also typically we would want Low in osmolality to support gastric emptying before surgery???

But beyond those to points we have to remember that I have a department full of anesthesiologists who would like to follow NPO guidelines and I am not so sure they will accept a liquid with protein counting as a clear liquid (studies are currently underway but not completed.

Fast-track- recovery surgery with a whey-protein-infused carbohydrate-loading drink pre-operatively and early oral feeding post-operatively among surgical gynaecological cancer patients: study protocol of an open-labelled, randomised controlled trial

ClinicalTrials.gov, ID: NCT03667755. Retrospectively registered on 12 September 2018; Protocol version: version 3 dated 27 September 2017.

pubmed.ncbi.nlm.nih.gov

Truthfully I doubt the protein content is going to slow down gastric emptying or have any clinically significant impact but that is just a hunch. When we roll out a protocol we have to be sure we are following the guidelines and the the description of clears in our guideline do not include protein as part of their definition.

When gastric emptying studies were performed, it was demonstrated that clear liquids were cleared more completely at 90 minutes post-ingestion than liquids with protein or fat content.

If by chance we have a fatal aspiration in a patient who received our prescribed carbohydrate load, this may have occurred in that patient irrespective of their carbohydrate load. However if it does occur we have to wonder will a jury of our peers feel that a protein clear is equivalent to the clears described in the npo guidelines.

So I was going to suggest we ask the company to reply in writing if it can be considered a clear for surgically fasted patients. As an alternative if we could find if other large centers (I only found that UCSF is using it) are using this product as their carbohydrate load. I don’t think we should be trailblazers here or wing it.

What Cha All think??

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[deleted126335]

You jedis think a jury of our peers would think boost breeze would fit the criteria of a clear?? my facility wants to bail on ensure clearest and move to this product which is clear but has protein whey isolates in it? I wasn’t thrilled the source of sugar is not malodextran (used in all the studies done in this field) but instead high fructose cornsyrup. Also typically we would want Low in osmolality to support gastric emptying before surgery???

But beyond those to points we have to remember that I have a department full of anesthesiologists who would like to follow NPO guidelines and I am not so sure they will accept a liquid with protein counting as a clear liquid (studies are currently underway but not completed.

Fast-track- recovery surgery with a whey-protein-infused carbohydrate-loading drink pre-operatively and early oral feeding post-operatively among surgical gynaecological cancer patients: study protocol of an open-labelled, randomised controlled trial

ClinicalTrials.gov, ID: NCT03667755. Retrospectively registered on 12 September 2018; Protocol version: version 3 dated 27 September 2017.

pubmed.ncbi.nlm.nih.gov

Truthfully I doubt the protein content is going to slow down gastric emptying or have any clinically significant impact but that is just a hunch. When we roll out a protocol we have to be sure we are following the guidelines and the the description of clears in our guideline do not include protein as part of their definition.

When gastric emptying studies were performed, it was demonstrated that clear liquids were cleared more completely at 90 minutes post-ingestion than liquids with protein or fat content.

If by chance we have a fatal aspiration in a patient who received our prescribed carbohydrate load, this may have occurred in that patient irrespective of their carbohydrate load. However if it does occur we have to wonder will a jury of our peers feel that a protein clear is equivalent to the clears described in the npo guidelines.

So I was going to suggest we ask the company to reply in writing if it can be considered a clear for surgically fasted patients. As an alternative if we could find if other large centers (I only found that UCSF is using it) are using this product as their carbohydrate load. I don’t think we should be trailblazers here or wing it.

What Cha All think??

Waiting for ASA to address in their practice guidelines for perioperative fasting. Almost everything else is crap.

 

[Mman]

if it contains protein it almost assuredly will slow gastric emptying. Water + carbs + electrolytes goes through the fastest. Protein or fat will slow it down.

 

[GassYous]

Obviously not a clear

 

[pjl]

Waiting for ASA to address in their practice guidelines for perioperative fasting. Almost everything else is crap.

I’m sure this will be out within the next 20 years, and equally as “helpful” as the rest of their guidelines.

 

[BLADEMDA]

You jedis think a jury of our peers would think boost breeze would fit the criteria of a clear?? my facility wants to bail on ensure clearest and move to this product which is clear but has protein whey isolates in it? I wasn’t thrilled the source of sugar is not malodextran (used in all the studies done in this field) but instead high fructose cornsyrup. Also typically we would want Low in osmolality to support gastric emptying before surgery???

But beyond those to points we have to remember that I have a department full of anesthesiologists who would like to follow NPO guidelines and I am not so sure they will accept a liquid with protein counting as a clear liquid (studies are currently underway but not completed.

Fast-track- recovery surgery with a whey-protein-infused carbohydrate-loading drink pre-operatively and early oral feeding post-operatively among surgical gynaecological cancer patients: study protocol of an open-labelled, randomised controlled trial

ClinicalTrials.gov, ID: NCT03667755. Retrospectively registered on 12 September 2018; Protocol version: version 3 dated 27 September 2017.

pubmed.ncbi.nlm.nih.gov

Truthfully I doubt the protein content is going to slow down gastric emptying or have any clinically significant impact but that is just a hunch. When we roll out a protocol we have to be sure we are following the guidelines and the the description of clears in our guideline do not include protein as part of their definition.

When gastric emptying studies were performed, it was demonstrated that clear liquids were cleared more completely at 90 minutes post-ingestion than liquids with protein or fat content.

If by chance we have a fatal aspiration in a patient who received our prescribed carbohydrate load, this may have occurred in that patient irrespective of their carbohydrate load. However if it does occur we have to wonder will a jury of our peers feel that a protein clear is equivalent to the clears described in the npo guidelines.

So I was going to suggest we ask the company to reply in writing if it can be considered a clear for surgically fasted patients. As an alternative if we could find if other large centers (I only found that UCSF is using it) are using this product as their carbohydrate load. I don’t think we should be trailblazers here or wing it.

What Cha All think??

I would want 4 hours of NPO status after consuming this product. I do not consider it a "clear liquid" by my usual definition. That said, I also don't think I need to wait 6 hours and treat it as a light meal. Of course, there are providers in my group who will disagree with me and require 6 hours while others only wait 2 hours.

Impact of Enhanced Recovery after Surgery with Preoperative Whey Protein-Infused Carbohydrate Loading and Postoperative Early Oral Feeding among Surgical Gynecologic Cancer Patients: An Open-Labelled Randomized Controlled Trial - PubMed

Enhanced Recovery after Surgery (ERAS) with sole carbohydrate (CHO) loading and postoperative early oral feeding (POEOF) <b>s</b>hortened the length of postoperative (PO) hospital stays (LPOHS) without increasing complications. This study aimed to examine the impact of ERAS with preoperative...

pubmed.ncbi.nlm.nih.gov

 

[BLADEMDA]

In this study the authors waited 3 hours after consuming the protein infused drink before proceeding with anesthesia/surgery.

Impact of Enhanced Recovery after Surgery with ... - MDPI​

https://www.mdpi.com › pdf

PDF

by HC Yi · 2020 · Cited by 5 — loading in the form of whey protein infused with CHO drinks prior to ... Guidelines for preoperative CHO loading and postoperative early oral ...

 

[BLADEMDA]

Shrinking preoperative fast time with maltodextrin and protein hydrolysate in gastrointestinal resections due to cancer

Prolonged preoperative fasting increases postoperative hospital length of stay and current evidence recommends patients drink a carbohydrate-based liq…

www.sciencedirect.com

 

[BLADEMDA]

UCSF seems to allow "Boost Breeze" to be consumed up to 2 hours prior to surgery. YMMV, but I would be a bit more conservative with protein infused drinks at this time at my community shop.

https://anesthesia.ucsf.edu/sites/anesthesia.ucsf.edu/files/wysiwyg/PrepforEnhanced%20RecafterOpenSurgeryEng.pdf

Looks like another academic place allows "Boost Breeze Clear' to be consumed up to 2 hours prior to surgery.

https://healthonline.washington.edu/sites/default/files/record_pdfs/Carbohydrate-Loading-Before-Surgery.pdf

 

[BLADEMDA]

You jedis think a jury of our peers would think boost breeze would fit the criteria of a clear?? my facility wants to bail on ensure clearest and move to this product which is clear but has protein whey isolates in it? I wasn’t thrilled the source of sugar is not malodextran (used in all the studies done in this field) but instead high fructose cornsyrup. Also typically we would want Low in osmolality to support gastric emptying before surgery???

But beyond those to points we have to remember that I have a department full of anesthesiologists who would like to follow NPO guidelines and I am not so sure they will accept a liquid with protein counting as a clear liquid (studies are currently underway but not completed.

Fast-track- recovery surgery with a whey-protein-infused carbohydrate-loading drink pre-operatively and early oral feeding post-operatively among surgical gynaecological cancer patients: study protocol of an open-labelled, randomised controlled trial

ClinicalTrials.gov, ID: NCT03667755. Retrospectively registered on 12 September 2018; Protocol version: version 3 dated 27 September 2017.

pubmed.ncbi.nlm.nih.gov

Truthfully I doubt the protein content is going to slow down gastric emptying or have any clinically significant impact but that is just a hunch. When we roll out a protocol we have to be sure we are following the guidelines and the the description of clears in our guideline do not include protein as part of their definition.

When gastric emptying studies were performed, it was demonstrated that clear liquids were cleared more completely at 90 minutes post-ingestion than liquids with protein or fat content.

If by chance we have a fatal aspiration in a patient who received our prescribed carbohydrate load, this may have occurred in that patient irrespective of their carbohydrate load. However if it does occur we have to wonder will a jury of our peers feel that a protein clear is equivalent to the clears described in the npo guidelines.

So I was going to suggest we ask the company to reply in writing if it can be considered a clear for surgically fasted patients. As an alternative if we could find if other large centers (I only found that UCSF is using it) are using this product as their carbohydrate load. I don’t think we should be trailblazers here or wing it.

What Cha All think??

Here you go:

Ensure Pre-Surgery ( up to 2 hours prior to surgery)

Boost Breeze would be 3 hours prior to surgery based on the current studies/data.

 

[Planktonmd]

So, it seems this craziness is getting worse!
A patient having surgery should be OK to fast a few hours... and all these stupid arguments about how much better they are if they have a soda on the way to OR are just silly BS.
People in anesthesia should just stop doing studies and writing articles about silly stuff and try to find something worth arguing about.

 

[okayplayer]

Thank you, plankton. Yes!

 

[dabears505]

I just don't understand why this stuff is necessary at all. Most of my patients could easily survive a few months of fasting with no harm. Why do we need to cram 50 g more carbs into them because they didn't eat overnight? What's absurd is the surgeons order this stuff for diabetes as well and they are like my sugar is never in the 200s, I dont know why it's so high this morning. Well that carb load which somehow is going to enhance your recovery is to blame. There are things that just don't make any sense yet faulty evidence will make it come to be.

 

[DrZzZz]

I just don't understand why this stuff is necessary at all. Most of my patients could easily survive a few months of fasting with no harm. Why do we need to cram 50 g more carbs into them because they didn't eat overnight? What's absurd is the surgeons order this stuff for diabetes as well and they are like my sugar is never in the 200s, I dont know why it's so high this morning. Well that carb load which somehow is going to enhance your recovery is to blame. There are things that just don't make any sense yet faulty evidence will make it come to be.

All our diabetic patients get G2 instead of Ensure for the ERAS cases and since that switch, we haven't had the issues with preop sugars being through the roof. That being said, I agree the presurgical drink is mostly voodoo anyway.

 

[BLADEMDA]

https://www.gatorade.com/hydration/g2

So, is this the drink some of you prefer for diabetics prior to surgery? And this is the difference in patients going home early? If I was going to prescribe these types of drinks I would be very SPECIFIC to the patient so there would not be any confusion. My patients can't remember which meds to take so adding on a drink with a time limit seems to be asking for more trouble.

 

[okayplayer]

I miss the days of nothing by mouth after midnight. So much harder for people to mess that up.

 

[Urzuz]

I miss the days of nothing by mouth after midnight. So much harder for people to mess that up.

This is rosy retrospection/nostalgia bias. People were idiots back then too and would **** it up constantly. It was like the Denny’s next to the hospital was offering a discount to preop patients on their Grand Slam breakfast.

 

[GassYous]

This is rosy retrospection/nostalgia bias. People were idiots back then too and would **** it up constantly. It was like the Denny’s next to the hospital was offering a discount to preop patients on their Grand Slam breakfast.

The other day I had 12 cases and 4 of them decided to eat or drink something that morning. One said they ate at 4 am when I saw them at noon which was suspicious to say the least.

 

[dchz]

The other day I had 12 cases and 4 of them decided to eat or drink something that morning. One said they ate at 4 am when I saw them at noon which was suspicious to say the least.

If I was having some minor surgery at noon. I'd eat at 4AM if I private practice hasn't taught me to master my hunger.

 

[nimbus]

This is rosy retrospection/nostalgia bias. People were idiots back then too and would **** it up constantly. It was like the Denny’s next to the hospital was offering a discount to preop patients on their Grand Slam breakfast.

I once had a patient show up to a surgery center licking a McDonald’s ice cream cone.

 

[GravelRider]

My guess is that this (dumb) product is less about patient outcomes and more about patient satisfaction survey scores. I don’t think I have ever made it through an entire day without having at least one patient whine about being NPO.

 

[Gas you down]

Lots of these articles use 3hours out, like Blade said, and they’re measuring lots of stuff, except not stomach volumes?One was behind a paywall so I didn’t read that one.

haven’t seen a single study that measured gastric volumes at two hours after a protein drink
Maybe someone can point the way

 

[GassYous]

Lots of these articles use 3hours out, like Blade said, and they’re measuring lots of stuff, except not stomach volumes?One was behind a paywall so I didn’t read that one.

haven’t seen a single study that measured gastric volumes at two hours after a protein drink
Maybe someone can point the way

Is stomach volume relevant? I know about the 2.5 25 but don't know if gastric us has been validated

 

[BobLoblaw78]

Is stomach volume relevant? I know about the 2.5 25 but don't know if gastric us has been validated

I validate it! Now feel free to use it.

I doubt there will ever be a study that measures risk of aspiration comparing empty stomach vs empty/increased small intestine volume. I would support empty gastric volume confirmed with ultrasound as reasonable to proceed albeit never with zero risk (or at least risk stratification for emergent cases). I wouldn't supplant NPO guidelines with ultrasound until it is more widely used and evaluated.

 

[BLADEMDA]

Gastric emptying as percentage of meal retention over 3 h after the consumption of 450-mL test drinks containing either 30 or 70 g whey protein isolate or saline control. Data are means ± SEMs. There was a load × time interaction (analyzed with the use of repeated-measures ANOVA), P < 0.01. Post hoc comparisons (analyzed with the use of Bonferroni’s correction) revealed significant differences between treatments, P < 0.05: *compared with C, §compared with L. C, saline control; H, 70 g pure whey protein isolate; L, 30 g pure whey protein isolate.

Acute load-dependent effects of oral whey protein on gastric emptying, gut hormone release, glycemia, appetite, and energy intake in healthy men

ABSTRACT. Background: In healthy individuals, intraduodenal whey protein load-dependently modulates gastrointestinal motor and hormonal functions and suppresses

academic.oup.com

 

[BLADEMDA]

Mean ± SEM percentage of gastric retention in older men (n = 7; closed circles) and women (n = 8; open circles) after intakes of drinks containing flavored water (control; dotted line) and whey-protein loads of 30 g (dashed line) or 70 g (solid line). Main sex and protein-load effects and interaction effects were determined with the use of a repeated-measures ANOVA. *P < 0.001: main effect of protein load for 50% gastric-emptying time (main effect of sex: P = 0.41; interaction effect of sex by protein load: P = 0.77). #P < 0.001: main effect of protein load AUC from 0 to 180 min, from 0 to 60 min (early phase), and from 60 to 180 min (late phase) (main effect of sex AUC from 0 to 180 min: P = 0.22, AUC from 0 to 60 min: P = 0.27, AUC from 60 to 180 min: P = 0.24; interaction effect of sex by protein load AUC from 0 to 180 min: P = 0.58, AUC from 0 to 60 min: P = 0.43, AUC from 60 to 180 min: P = 0.46).

Effects of randomized whey-protein loads on energy intake, appetite, gastric emptying, and plasma gut-hormone concentrations in older men and women

ABSTRACT. Background: Protein- and energy-rich supplements are used widely for the management of malnutrition in the elderly. Information about the effects of p

academic.oup.com

 

[BLADEMDA]

Lots of these articles use 3hours out, like Blade said, and they’re measuring lots of stuff, except not stomach volumes?One was behind a paywall so I didn’t read that one.

haven’t seen a single study that measured gastric volumes at two hours after a protein drink
Maybe someone can point the way

I posted the studies. Again, based on the data these protein drinks should be in the 3-4 hour range prior to surgery especially in older patients.

 

[BLADEMDA]

In the present study, gastric emptying of water and both protein drinks was slower in older men than young controls, consistent with results of previous studies (16, 24, 28). The water drink emptied slower in older men than young controls, which implies an “intragastric” etiology. There was a dose-dependent slowing of gastric emptying by protein to a similar degree in both age groups, with 50% gastric emptying time more than doubling from the control to the 30 g protein drink day, and from the 30 g to the 70 g protein drink day. The older subjects had a slower gastric emptying of the protein drinks than the young subjects (0.8 kcal compared with 1.0 kcal/min on average over 180 min), especially during the initial phase of emptying. Therefore, the older men had greater intragastric volumes at all time points between protein ingestion and the buffet meal than the young men,

Lesser suppression of energy intake by orally ingested whey protein in healthy older men compared with young controls - PMC

Protein-rich supplements are used widely for the management of malnutrition in young and older people. Protein is the most satiating of the macronutrients in young. It is not known how the effects of oral protein ingestion on energy intake, ...

www.ncbi.nlm.nih.gov

 

[BLADEMDA]

(PDF) Residual gastric volume evaluation with ultrasonography after ingestion of carbohydrate- or carbohydrate plus glutamine-enriched beverages: A randomized, crossover clinical trial with healthy volunteers

PDF | BACKGROUND - Abbreviation of preoperative fasting to 2 hours with maltodextrin (CHO)-enriched beverage is a safe procedure and may enhance... | Find, read and cite all the research you need on ResearchGate

www.researchgate.net

 

[caveat87]

One important consideration with these drinks is diabetic patients. We have had some diabetic patients do the ensure pre-surgery clear drinks and come in with blood sugars in the 250-350 range, causing our total joint surgeons to delay or cancel cases due to infection risk. My counter argument is what happens when the patient goes home and eats their Big Mac or drink soda (ie: infection risk probably remains elevated in the post-operative period in patients that have poor glycemic control, hence many orthopedists used A1C cutoffs when deciding to operate).

Also, I’m curious if you all deem certain patients ineligible for these pre-procedure drinks based on medical comorbidities such as known gastroparesis, esophageal dysmotility, etc.