Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures

Enhanced recovery after surgery-Preoperative fasting and glucose loading-A review

In this review, we explore the rationale and history behind the practice of preoperative fasting in elective surgery including the gradual move toward longer fasting and the more recent change in direction of practice. Gastric emptying physiology and the metabolic effects of prolonged fasting and carbohydrate loading are examined. Most recent guidelines related to these topics are discussed and practical recommendations for implementing these guidelines are suggested.

Laparoscopy during pregnancy: Case report and key points to improve laparoscopic management

CASE REPORT

A 34-year-old woman in her 19th week of gestation was admitted to the Emergency Department of our hospital for acute abdominal pain. The patient was diagnosed with haemoperitoneum. Laparoscopy was performed and revealed acute bleeding from a crumbly superficial uterine vascular network. Haemostasis was achieved and both mother and foetus recovered well after surgery. A caesarean section was performed at 38 weeks, delivering a healthy newborn and revealing that the pregnancy had developed in a rudimentary hemiuterus. Laparoscopy during pregnancy is safe and feasible and can be performed in any trimestre of pregnancy with no differences in perinatal outcomes but, as intervention complexity increases with gestational age, laparoscopy during pregnancy should be performed by experienced surgeons To minimise surgical risk several recommendations should be taken into account: gravid patients should be positioned in a left-tilted supine position, trocar placement should be adjusted to uterine size and gas insuflattion of 10-15mmHg can be used.

Variability in Perioperative Fasting Practices Negatively Impacts Nutritional Support of Critically Ill Intubated Patients

The aim of the study was to quantify nutritional losses related to pre- and postoperative fasts in critically ill intubated patients and to explore whether shorter fasts are safe and appropriate in this population. A retrospective review of mechanically ventilated adults undergoing surgery more than 24 hours after admission to a Level I trauma center over 15 months was done, which yielded 132 procedures and 81 unique patients. Ninety per cent of preoperative periods and 43 per cent of postoperative periods were affected by nonmedical barriers to feeding. Eighty-two per cent of gastrically fed nonemergent cases were fasted for longer than the 6-hour American Society of Anesthesiologists guideline, whereas 91 per cent of emergent cases had shorter fasts. There were no anesthetic complications, placing an upper limit of 6 per cent on the rate of aspiration for fasts shorter than six hours (95% confidence). Forty-three per cent of cases did not resume tube feeds within 90 minutes postoperatively, and only 37 per cent had a documented justification for delay. Intubated patients were frequently fasted preoperatively for longer than recommended and postoperatively for longer than medically indicated. No complications were observed with shorter-than-guideline fasts. This strengthens the evidence that “standard” preoperative fasting is unnecessary and deleterious in many critically ill intubated patients. New protocols and national guidelines are needed to ensure adequate nutrition.

Enhanced recovery after surgery for hip and knee arthroplasty: a systematic review and meta-analysis

Objectives

To collect data of randomised controlled trials (RCTs) and clinical controlled trials (CCTs) for evaluating the effects of enhanced recovery after surgery on postoperative recovery of patients who received total hip arthroplasty (THA) or total knee arthroplasty (TKA).

Methods

Relevant, published studies were identified using the following key words: arthroplasty, joint replacement, enhanced recovery after surgery, fast track surgery, multi-mode analgesia, diet management, or steroid hormones. The following databases were used to identify the literature consisting of RCTs or CCTs with a date of search of 31 December 2016: PubMed, Cochrane, Web of knowledge, Ovid SpringerLink and EMBASE. All relevant data were collected from studies meeting the inclusion criteria. The outcome variables were postoperative length of stay (LOS), 30-day readmission rate, and total incidence of complications. RevMan5.2. software was adopted for the meta-analysis.

Results

A total of 10 published studies (9936 cases) met the inclusion criteria. The cumulative data included 4205 cases receiving enhanced recovery after surgery (ERAS), and 5731 cases receiving traditional recovery after surgery (non-ERAS). The meta-analysis showed that LOS was significantly lower in the ERAS group than in the control group (non-ERAS group) (p<0.01), and there were fewer incidences of complications in the ERAS group than in the control group (p=0.03). However, no significant difference was found in the 30-day readmission rate (p=0.18).

Conclusions

ERAS significantly reduces LOS and incidence of complications in patients who have had THA or TKA. However, ERAS does not appear to significantly impact 30-day readmission rates.