Page 64 - Read Online

Page 6 of 15 Gidumal et al. Plast Aesthet Res 2021;8:42 https://dx.doi.org/10.20517/2347-9264.2021.27

many institutions use the cutoff of 8 h of fasting for any solid foods, light or heavy.

Perioperative nutrient loading (glucose, protein)
The physiologic stress of surgery induces a metabolic response that results in insulin resistance and
subsequent hyperglycemia [40,45] . As previously mentioned, hyperglycemia in the intraoperative and
postoperative settings is associated with significant morbidities, such as poor wound healing, atrial
fibrillation, pulmonary complications, and heart failure [41,42] . Preoperative oral carbohydrate loading,
through consumption of a carbohydrate-rich clear liquid up to 2 h before surgery, has been shown to
[46]
increase insulin sensitization in the intraoperative setting . This practice minimizes preoperative
gluconeogenesis and glycogen depletion and reduces insulin resistance by 50%, lowering the risk of
perioperative hyperglycemia and its associated comorbidities [46,47] . Evidence indicates that many patients are
likely to benefit from the practice of oral carbohydrate loading with carbohydrate-rich clear liquids up to 2 h
before surgery.

While solid data on the benefits of preoperative carbohydrate loading has been recognized, newer evidence
suggests that patients who add protein to their preoperative carbohydrate bolus demonstrate even fewer
[48]
postoperative complications than those who take carbohydrates alone . While the mechanism of action is
not yet clear, it is thought that in addition to further reducing insulin resistance, the addition of protein or
amino acids to the preoperative oral carbohydrate load reduces the acute-phase inflammatory response to
surgery. It has been demonstrated through measurements of c-reactive protein, a marker of inflammation,
which appears to be lower in patients taking protein with their preoperative carbohydrate than those taking
carbohydrates alone and those taking just water before surgery [48-50] . Prior studies have demonstrated that
elevated levels of inflammatory markers in the first 24 h after surgery are associated with higher rates of
postoperative complications; thus, through this mechanism, protein supplementation prior to surgery is
thought to reduce postoperative complications . Although a further study will be required to elucidate the
[51]
precise mechanism of action of this intervention, we recommend considering preoperative oral loading with
25 g of carbohydrates and 7 g of protein or amino acids to reduce insulin resistance and inflammation
perioperatively.

Intraoperative interventions
Anesthetic agents
Short-acting anesthetic agents, such as propofol and remifentanil, are preferred for maintaining anesthesia
during head and neck surgery. Long-acting agents are associated with an increased risk of residual
neuromuscular blockade and critical respiratory events, leading to worse patient outcomes [52,53] .
Furthermore, recent data suggest an association between volatile anesthetics, such as desflurane,
sevoflurane, isoflurane, and increased rates of cancer metastasis. The completion of an ongoing randomized
controlled trial, General Anesthetics in Cancer Resection Surgery (GA-CARES Trial - NCT03034096), may
shed more light on whether the choice of general anesthetic impacts long-term cancer morbidity and
mortality. While those data are completed, we currently favor the use of short-acting total intravenous
anesthesia in place of traditional inhaled anesthetic agents.

Vitamin C administration
Recent data support the administration of intravenous vitamin C in the perioperative setting as a
mechanism to reduce postoperative pain and narcotic usage [54,55] . Vitamin C, a water-soluble vitamin found
widely in fruits and vegetables, plays a prominent role in wound healing and hemostasis. It is best
exemplified by the pathologic state that develops in vitamin C deficiency, scurvy, which is characterized by
spontaneous bleeding, anemia, and gingival ulceration. Vitamin C is also known that have antinociceptive