Impact of Low Dose Maltodextrin/Citrulline Loading on the Severity and Duration of Stress Induced Hyperglycemia in Cardiac Surgery

INTRODUCTION: Postoperative stress induced insulin resistance, and the resulting glycemic variability, is clearly associated with complication rates in cardiac surgery. Despite this, there is a paucity of data regarding the duration of stress induced hyperglycemia in cardiac surgery as well as the impact of specific strategies for carbohydrate loading in cardiac surgery patients. Prior work in colorectal and bariatric surgery has shown a significant reduction in glycemic events with the use of a low dose maltodextrin and citrulline loading strategy, but there is no data that the commonly recommended 50 gram supplements provides any impact on stress induced postoperative hyperglycemia. The aim of this study was to compare standard of care (SOC group) versus a three dose, 25 gram dose carbohydrate loading strategy (CL group) on the duration and severity of postoperative glycemic variability in both diabetic and non-diabetic cardiac surgery patients. METHODS: We compared CABG/AVR/MVR retrospective patients who received standard of care (SOC) to a prospective set of patients who were carbohydrate loaded (CL) with 3 preoperative doses of 25g maltodextrin/3g citrulline (G.E.D. TM , SOF Health, LLC). RESULTS: 152 patients total were included (SOC n=80, CL n= 72). 66 patients were diabetic. In both non-diabetic and diabetic patient populations, there was a statistically significant reduction in glycemic variability in G.E.D. groups for non- diabetics (27% reduction) and diabetics (40% reduction). The glycemic variability on POD 2 was not statistically different between treatment groups in non-diabetics (G.E.D. 25.2% vs SOC 24.7%) but approached significance in diabetics (G.E.D. 24.7% vs SOC 32.9%e). CONCLUSION: These are the first data demonstrating the reduction in post operative stress induced glycemic variability in cardiac surgery using a low dose carbohydrate loading regimen which includes the amino acid citrulline. The impact of surgical stress on glycemic variability appears to resolve by POD#2 in non-diabetics but may persist longer in diabetic patients. These data represent the first information regarding the benefits of a specific strategy for carbohydrate loading to reduces the stress induced component of post operative hyperglycemia in cardiac surgery.