Effect of Early Versus Delayed Postoperative Feeding in Lower Limb Fracture Surgery

Lower Limb Fracture Clinical Trial

Official title:

Effect of Early Versus Delayed Postoperative Feeding in Lower Limb Fracture Surgery: a Randomized Controlled Trial

Clinical Trial Details — Status: Not yet recruiting

Administrative data

• NCT number: NCT05823649
• Other study ID #: Postoperative feeding
• Status: Not yet recruiting
• Phase: N/A
• Start date: April 20, 2023
• Est. completion date: February 1, 2024

Study information

• Verified date: April 2023
• Source: Armed Police Force Hospital, Nepal
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

The treatment of lower limb fracture accounting one third of total fracture is a complex problem for the surgical and rehabilitation team. Patients are kept in long term fasting after surgery to prevent from postoperative complications, but it leads to the surgical catabolism resulting delaying the desired improvement in patients. To our knowledge, it has not been widely implemented in clinical settings. Therefore, the aim of the study is to evaluate the effect of early versus delayed postoperative oral feeding in lower limb fracture surgery under regional block anesthesia.

This study utilize single-center, hospital based, open-label, parallel group randomized controlled trial to assess the effect of early postoperative oral feeding in two hours after the surgery over the conventionally delayed feeding. A representative sample size of 275 patients (control group=138 and study group =137) aged 18 years and above having lower limb fracture operated under regional block will be selected for research. The pre-operative nutritional status will be identified with Simplified Nutritional Appetite Questionnaire (SNAQ) and the post-operative outcomes will be measured by Numerical Rating Scale (NRS) system. Preoperative as well as postoperative hand grip strength and Neutrophil Lymphocyte Ratio (NLR) will be assessed. Statistical analysis will be performed using chi square test, Student two sample t-test to compare between the outcome of study and control groups. The outcome of the study may provide an empirical evidence to the anesthesiologists and surgeons towards the emerging concept of postoperative early oral feeding practice in lower limb fracture surgery in clinical settings.

Description:

Orthopedic conditions are the physical injuries related to the musculoskeletal system of an individual. The overall incidence of musculoskeletal injury in low- and lower-middle income countries (LMICs) range from 779 to 1574 per 100,000 person-years. Fracture is one of the main cause of injury showing 1,229 per 100,000 individuals. The most common injury due to the road traffic accident was the 69 % fracture with fractures of tibia/fibula accounted as 30.3%. The road traffic injury (RTI) in Nepal for the period 2001-2013 also revealed that the most common fractures are lower extremities and upper extremities. About one third of the total fracture accounted for lower limb fracture and its complications lead to reason for hospital stay. Surgical management for the lower extremities fracture allows quick stabilization of fractures and early mobilization, hence accelerates the return to usual daily life activities. In fact, lower extremities fracture is a complex problem for the surgical and rehabilitation team. Pain as postoperative outcome is associated with many factors like age, duration of surgery, type of surgery, site of surgery, use of anesthesia, ethnicity, and others. Nutritional status is a strong predictor of postoperative outcomes in orthopedics for the preservation of muscle mass, strength and functionality of movement, and therefore it is recognized as an important component of surgical recovery programs. Nutritional assessment includes subjective as well as objective parameters. There are many tools for examining malnutrition and nutritional assessment as subjective parameters. Similarly, different laboratory markers such as albumin, pre-albumin, total lymphocytes, total cholesterol, C-reactive protein, transferrin are considered the objective parameter for the nutritional status evaluation. Higher the pre- and postoperative Neutrophil Lymphocyte Ratio (NLR) is associated with a higher long-term mortality risk in hip fracture surgery in elder people. Nutritional intervention is crucial for enhanced recovery after surgery. Preoperative carbohydrate loading as nutritional intervention is one component of Enhanced Recovery after Surgery (ERAS) which reduces insulin resistivity and postoperative infection. Another study found that preoperative carbohydrate loading in femur fracture has facilitated the ambulatory function, reduced the postoperative pain and hence reduced the length of hospital stay.

Patients are kept in long term fasting after surgery to prevent from postoperative complications. In fact, postoperative fasting leads to surgical catabolism and has increased the ICU stay among cancer patients undergoing elective cancer surgery. Early feeding after surgery challenges the concept of increased incidence of nausea and vomiting, and so late re-feeding has no advantages. Immediate postoperative re-feeding in orthopedic surgery is safe. Earlier post-operative feeding reduce the infection complications, improve healing, and decrease length of stay, so oral feeding should be resumed as soon as possible after surgery, with the goal of returning to solid foods within 24 hours. Previous study found that around 25 gram of essential amino acid can be fed orally within 30 minutes after surgery to facilitate the injury recovery and rehabilitation among athletes. A randomized controlled trial shows that early postoperative feeding at 4 hours is safe, and the traditional policy of starting feeding after 8 hours is outmoded under general anesthesia in orthopedics. The recommendation 5 of European Society for Clinical Nutrition and Metabolism (ESPEN) which states that enteral feeding can be initiated immediately after surgery. However, postoperative patients are mostly re-fed only after 4-6 hours of the surgery followed by the regional anesthesia (spinal, epidural or nerve block). Therefore, the study is intended to evaluate the effect of early postoperative oral feeding in the lower limb fracture surgery under regional block anesthesia.

Recruitment information / eligibility

• Status: Not yet recruiting
• Enrollment: 275
• Est. completion date: February 1, 2024
• Est. primary completion date: December 1, 2023
• Accepts healthy volunteers: Accepts Healthy Volunteers
• Gender: All
• Age group: 18 Years to 60 Years

Eligibility

Inclusion Criteria:

• Patients aged 18 to 60 years undergoing the lower limb fracture surgery under regional anesthesia

• Intermediate to major categories of surgeries

• American Society of Anesthesiologists (ASA) I and II

Exclusion Criteria:

• Cognitive dysfunction

• Pathological fracture

• Fracture more than one site

• Redo/follow-up surgery

• Unanticipated intraoperative complications

• Use of intraoperative drugs that causes the postoperative nausea and vomiting

• Gastrointestinal disorder such as peptic ulcer, hiatus hernia, peptic ulcer, irritable bowel syndrome or esophagitis

• History of gastrointestinal surgery

Related Conditions & MeSH terms

• Fractures, Bone
• Lower Limb Fracture

Intervention

Dietary Supplement:
• Early feeding/intervention group
The patients will be given orally 5 to 10 ml of warm water as first feeding. If there will be no problem of swallowing and other clinical complication, they will be further provided 20 ml of water after 10 minutes. If further patients do not suffer from nausea, vomiting and other discomfort, 100 ml clear fluid or less than it will be provided as based on the protocol followed by the study. We will use oral rehydration solution (ORS) as clear fluid.

Locations

Country	Name	City	State
n/a

Sponsors (2)

Lead Sponsor	Collaborator
Armed Police Force Hospital, Nepal	Nepal Orthopedic Hospital, Kathmandu, Nepal

References & Publications (21)

Belete Y, Belay GJ, Dugo T, Gashaw M. Assessment of Functional Limitation and Associated Factors in Adults with Following Lower Limb Fractures, Gondar, Ethiopia in 2020: Prospective Cross-Sectional Study. Orthop Res Rev. 2021 Mar 9;13:35-45. doi: 10.2147/ — View Citation

Bergh C, Wennergren D, Moller M, Brisby H. Fracture incidence in adults in relation to age and gender: A study of 27,169 fractures in the Swedish Fracture Register in a well-defined catchment area. PLoS One. 2020 Dec 21;15(12):e0244291. doi: 10.1371/journ — View Citation

Bharadwaj S, Ginoya S, Tandon P, Gohel TD, Guirguis J, Vallabh H, Jevenn A, Hanouneh I. Malnutrition: laboratory markers vs nutritional assessment. Gastroenterol Rep (Oxf). 2016 Nov;4(4):272-280. doi: 10.1093/gastro/gow013. Epub 2016 May 11. — View Citation

Chaudhary NK, Sunuwar DR, Sharma R, Karki M, Timilsena MN, Gurung A, Badgami S, Singh DR, Karki P, Bhandari KK, Pradhan PMS. The effect of pre-operative carbohydrate loading in femur fracture: a randomized controlled trial. BMC Musculoskelet Disord. 2022 — View Citation

Chen YH, Chou CH, Su HH, Tsai YT, Chiang MH, Kuo YJ, Chen YP. Correlation between neutrophil-to-lymphocyte ratio and postoperative mortality in elderly patients with hip fracture: a meta-analysis. J Orthop Surg Res. 2021 Nov 18;16(1):681. doi: 10.1186/s13 — View Citation

Cordero DM, Miclau TA, Paul AV, Morshed S, Miclau T 3rd, Martin C, Shearer DW. The global burden of musculoskeletal injury in low and lower-middle income countries: A systematic literature review. OTA Int. 2020 Apr 23;3(2):e062. doi: 10.1097/OI9.000000000 — View Citation

Fachini C, Alan CZ, Viana LV. Postoperative fasting is associated with longer ICU stay in oncologic patients undergoing elective surgery. Perioper Med (Lond). 2022 Aug 2;11(1):29. doi: 10.1186/s13741-022-00261-4. — View Citation

Hemmann P, Friederich M, Korner D, Klopfer T, Bahrs C. Changing epidemiology of lower extremity fractures in adults over a 15-year period - a National Hospital Discharge Registry study. BMC Musculoskelet Disord. 2021 May 19;22(1):456. doi: 10.1186/s12891- — View Citation

Hirsch KR, Wolfe RR, Ferrando AA. Pre- and Post-Surgical Nutrition for Preservation of Muscle Mass, Strength, and Functionality Following Orthopedic Surgery. Nutrients. 2021 May 15;13(5):1675. doi: 10.3390/nu13051675. — View Citation

Karkee R, Lee AH. Epidemiology of road traffic injuries in Nepal, 2001-2013: systematic review and secondary data analysis. BMJ Open. 2016 Apr 15;6(4):e010757. doi: 10.1136/bmjopen-2015-010757. — View Citation

Kim JW, Park YG, Kim JH, Jang EC, Ha YC. The Optimal Time of Postoperative Feeding After Total Hip Arthroplasty: A Prospective, Randomized, Controlled Trial. Clin Nurs Res. 2020 Jan;29(1):31-36. doi: 10.1177/1054773818791078. Epub 2018 Jul 24. — View Citation

Lai L, Zeng L, Yang Z, Zheng Y, Zhu Q. Current practice of postoperative fasting: results from a multicentre survey in China. BMJ Open. 2022 Jul 8;12(7):e060716. doi: 10.1136/bmjopen-2021-060716. — View Citation

Mu J, Wu Y, Jiang C, Cai L, Li D, Cao J. Progress in Applicability of Scoring Systems Based on Nutritional and Inflammatory Parameters for Ovarian Cancer. Front Nutr. 2022 Apr 8;9:809091. doi: 10.3389/fnut.2022.809091. eCollection 2022. — View Citation

Nogueira PLB, Dock-Nascimento DB, de Aguilar-Nascimento JE. Extending the benefit of nutrition intervention beyond the operative setting. Curr Opin Clin Nutr Metab Care. 2022 Nov 1;25(6):388-392. doi: 10.1097/MCO.0000000000000868. Epub 2022 Aug 24. — View Citation

Reber E, Gomes F, Vasiloglou MF, Schuetz P, Stanga Z. Nutritional Risk Screening and Assessment. J Clin Med. 2019 Jul 20;8(7):1065. doi: 10.3390/jcm8071065. — View Citation

Rimmele T, Combourieu E, Wey PF, Boselli E, Allaouchiche B, Chassard D, Escarment J. Immediate postoperative refeeding in orthopedic surgery is safe. J Anesth. 2005;19(4):323-4. doi: 10.1007/s00540-005-0337-x. — View Citation

Smith-Ryan AE, Hirsch KR, Saylor HE, Gould LM, Blue MNM. Nutritional Considerations and Strategies to Facilitate Injury Recovery and Rehabilitation. J Athl Train. 2020 Sep 1;55(9):918-930. doi: 10.4085/1062-6050-550-19. — View Citation

Sugi MT, Davidovitch R, Montero N, Nobel T, Egol KA. Treatment of lower-extremity long-bone fractures in active, nonambulatory, wheelchair-bound patients. Orthopedics. 2012 Sep;35(9):e1376-82. doi: 10.3928/01477447-20120822-25. — View Citation

Toms AS, Rai E. Operative fasting guidelines and postoperative feeding in paediatric anaesthesia-current concepts. Indian J Anaesth. 2019 Sep;63(9):707-712. doi: 10.4103/ija.IJA_484_19. — View Citation

Tong E, Chen Y, Ren Y, Zhou Y, Di C, Zhou Y, Shao S, Qiu S, Hong Y, Yang L, Tan X. Effects of preoperative carbohydrate loading on recovery after elective surgery: A systematic review and Bayesian network meta-analysis of randomized controlled trials. Fro — View Citation

Weimann A, Braga M, Carli F, Higashiguchi T, Hubner M, Klek S, Laviano A, Ljungqvist O, Lobo DN, Martindale R, Waitzberg DL, Bischoff SC, Singer P. ESPEN guideline: Clinical nutrition in surgery. Clin Nutr. 2017 Jun;36(3):623-650. doi: 10.1016/j.clnu.2017 — View Citation

* Note: There are 21 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Incidence of Nausea and vomiting	The primary outcome will be the comparison of incidence of nausea and vomiting in early versus delayed postoperative feeding.	Two weeks
Secondary	Change in postoperative pain	Measure the change of postoperative pain between intervention and control groups using Visual Analogue Scale (VAS).	Two weeks
Secondary	Improved hand grip strength	Measure the hand grip strength using the hand grip dynamometer of the patients between intervention and control groups	Two weeks
Secondary	Length of hospital stay	Assess the length of hospital stay between intervention and control groups	Two weeks