Effects of Preoperative Carbohydrate Rich Drinks on Immediate Postoperative Outcome in Total Knee Arthroplasty

Postoperative nausea and vomiting (PONV) continues to pose serious challenge to orthopaedic
adult reconstructive surgeons, even after recent advances in anesthesia and improvements in
perioperative care. Preoperative carbohydrate loading has been well studied in
non-arthroplasty surgical fields. It has been shown to benefits which include decreased
postoperative catabolism and insulin resistance, dampened metabolic stress response, thus
decreased postoperative pain, anxiety, nausea, and vomiting. To the investigators knowledge,
there is currently no literature describing the effects of preoperative carbohydrate rich
drinks (CHO) in the setting of elective total joint arthroplasty. Using a prospective,
randomized, double blind, placebo controlled model, the investigators aim to determine the
effect of CHO on PONV in total knee arthroplasty.

The investigators plan to include a total of 150 patients in this study. All the arthroplasty
surgeons at HF Main Campus expect to participate. Estimating approximately 20 patients
enrolled per month, enrollment would likely occur over time span of 8 months.

Patients who are scheduled for elective, primary total knee arthroplasty will be recruited
and consented in preoperative clinic visit according to the inclusion and exclusion criteria
as outlined. Screening and consenting will be performed by the orthopaedic surgeon, resident,
physician assistant, or nurse practitioner in clinic, who will be trained for this study.
Patients who elect to participate will be randomized to CHO drink (Group A), placebo drink
(Group B), or traditional fasting/no drink (Group C). Randomization will occur prior to
enrollment in batches of twenty. Patients and treatment team will be blinded to the
assignment. Enrolled subjects will be given a kit which will include study information,
instructions for participation, data collection questionnaire (included with this
submission), multiple-alarm timer, and two beverage bottles (labeled Drink 1 and Drink 2) for
those in Group A or B. Group C will receive the kit, but without beverage. A research
assistant who is not involved in any of the subjects' care will be responsible for
preparation of the kits.

Beverage in Group A will consist of a clear, non-carbonated lemon-flavored, iso-osmolar
carbohydrate drink (Nutricia preOp; 12.5% carbohydrates, 50kcal/100mL, 260mOsm/kg, pH 5.0).
This drink has been previously used in studies supporting Enhanced Recovery After Surgery
(ERAS) Society Consensus Guidelines. Beverage in Group B will consist of the same quantity of
clear, lemon flavored water (Nestle Splash Lemon; 0kcal/100mL). All beverages will be bottled
in clear PET plastic IPEC tamper evident bottles. Bottles will be labeled Drink 1 (800 mL) or
Drink 2 (400 mL). Neither subjects nor treatment team will be able to identify type of
beverage, however each drink label will include a special code, available only to research
assistant to be able to identify contents of bottle (treatment vs placebo).

During the evening before surgery (8:00-10:00 PM), subjects in Group A and B will consume
Drink 1 (800 mL) of their respective drink. After midnight, nothing will be allowed by mouth,
except for except for single morning dose of appropriate drink (Drink 2, 400 mL) in Group A
and Group B. Subjects will be instructed to consume morning drink 3 hours prior to scheduled
time of surgery, and be completely consumed at least 2 hours prior to surgery.

Remainder of perioperative care will be standardized and occur according to routine care for
Henry Ford Joints Protocol. Henry Ford Main Campus Perioperative Primary Total Joints
Protocol is included with this submission for reference. All patients will receive epidural
for anesthesia. All patients will receive dexamethasone 10mg IV x 1 dose preoperatively. All
patients will have ondansetron 4mg IV Q6 hours as needed available postoperatively.
Multimodal perioperative pain management regimen will be standardize according to protocol.

Postoperatively, data points will be recorded by nurse in electronic medical record: events
of nausea and vomiting, medication consumption, and pain VAS scores. These data points will
be collected and separated by postop 0-4 hours, 4-12 hours, and 12-24 hours. Additionally,
subjects will be reminded to fill out their questionnaire in preop, 4 hours postop, 12 hours
postop, and 24 hours postop (questionnaire is included in this submission). Primary goal is
to compare incidence and timing of postoperative nausea and vomiting between groups.

The drink/placebo will be supplied to the patient by the treating surgeon, physician
assistant, or orthopaedic resident in clinic at the time of the last preoperative clinic
visit prior to surgery. The appropriate drink will be included in a "kit" that will be given
to the patient at that time. The kit will include study information, instructions for
participation, the data collection questionnaire (included with this submission), a
multiple-alarm timer, and two beverage bottles (labeled Drink 1 and Drink 2) for those in
Group A or B. Group C will receive the same kit with all the same contents, but without a
beverage.

The drinks will be mixed and bottled by the research assistant, and will be "ready to drink"
upon receipt by the participant. This will be performed in batches of 20 to prevent any
shelf-life errors. The carbohydrate rich drink (Nutricia preOp) is purchased in powder form
with included instructions on mixing. Each patient package comes with 6 powder packs. The
powder will be mixed in appropriate plastic beverage container with purified drinking water.
Purified water will be room temperature at time of mixing, per Nutricia instructions. Drinks
will be mixed in their respective beverage container according to manufacturer instruction:
Drink 1 is 800 cc (4 powder packs), and drink 2 is 400 cc (2 powder packs). This drink will
therefore appear clear and similar to the placebo group. For the placebo group, the
appropriate amount of Nestle Splash Lemon flavored water will be poured into the appropriate
bottles. Bottles will be capped with tamper evident caps. "Ready to drink" beverages will
then be included in the appropriate kits by the research assistant. The kits will then be
stored in a cool place, locked, away from light, in one of the K12 clinic offices. All mixing
and bottling will be performed with use of standard sanitary precautions by one person, the
research assistant. The research assistant will also be responsible for labelling and coding
the drinks to allow for identification of the drinks.

The questionnaire will be included in the kit, which is given to the patient at their last
preoperative visit prior to surgery. The kit will also include a handheld multiple-alarm
timing device, which will be used to ensure patients complete the appropriate sections of
their questionnaire at the requested time points. In the preoperative holding area, the
patients will simply be reminded by the staff, resident, or surgeon, to complete the "preop"
portion of the questionnaire. Post-operatively, the multiple-alarm timer will be utilized to
standardize timing of responses. The timer will be programmed appropriately before surgery,
and will be "started" by the orthopaedic resident postoperatively once the patient is dropped
off in the recovery unit following surgery. The handheld timer will be pre-programmed to
sound an alarm at time points 4 hours, 12 hours, and 24 hours post surgery.

Patients themselves will be mostly responsible for ensuring they comply with the requested
time points in completing the questionnaire. However, the orthopaedic floor nurses will also
be educated on this study and will encourage/assist in administration of the questionnaire
when needed. The nurse will collect the questionnaire once it is complete, prior to patient
discharge. The nursing station will have a specific folder where each questionnaire will be
placed following completion. The research assistant will check folder daily, and items will
be collected.

Inclusion Criteria:

- Adult patients (>18 years of age) scheduled for elective, unilateral, primary total
knee arthroplasty

- Able to give valid consent

Exclusion Criteria:

- Impaired gastrointestinal motility

- On pro-motility medication

- Pregnancy

- HbA1c > 7.5

- Fasting glucose >200

- Acquired immunodeficiency

- Renal failure (creatinine > 2 mg/dL)

- Cirrhosis

- Severe malnutrition.