Adopting preoperative fasting guidelines

Impacto do estado nutricional e do tempo de jejum nas complicações gastrointestinais e no tempo de hospitalização em pacientes cirúrgicos

Introdução: O estado nutricional e o tempo de jejum pré e pós-cirúrgico impactam na morbimortalidade de pacientes submetidos a cirurgias eletivas. No Brasil, o tempo de jejum prolongado e a elevada prevalência de desnutrição são comuns nos hospitais terciários. Objetivo: Realizar levantamento do tempo de jejum médio praticado em hospital terciário e avaliar o impacto do jejum pré e pós-cirúrgico e do estado nutricional nas complicações gastrointestinais imediatas e no tempo de hospitalização em pacientes cirúrgicos. Material e métodos: Estudo prospectivo, realizado no Hospital Universitário Walter Cantídio, em Fortaleza. Foram avaliados 173 indivíduos submetidos a cirurgias eletivas de médio e grande porte entre agosto de 2016 a janeiro de 2017. Foram coletadas medidas antropométricas, hemograma e informações como tempo de jejum pré e pós-cirúrgico, permanência hospitalar e complicações gastrointestinais. As análises de correlação e associação foram realizadas no Software SPSS®, com nível de significância fixado em p< 0,05. Resultados: A maioria dos pacientes (71,1%) foi submetida à cirurgia de porte II (grande porte). Houve correlação negativa entre tempo de permanência hospitalar e índice de massa corporal [r= -0,223; p= 0,003], circunferência braquial [r= -0,335; p< 0,001], dobra cutânea tricipital [r= -0,320; p< 0,001], área muscular do braço corrigida [r= -0,253; p= 0,001], contagem total de linfócitos [r= -0,223; p= 0,008], hemoglobina [r= -0,243; p= 0,004] e relação linfócito/monócito [r= -0,308; p< 0,001]. Adicionalmente, houve correlação positiva entre tempo de permanência hospitalar com o tempo de jejum pós-cirúrgico [r= 0,456; p< 0,001]. Ausência de complicações gastrointestinais foi associada a valores de triagem (Nutritional Risk Screenin-2002) < 3 (p= 0,034) e entre menor tempo de jejum pós-cirúrgico (p= 0,033). Conclusão: Pacientes desnutridos, com maior risco nutricional e os que se submeteram a um tempo de jejum pós-cirúrgico elevado apresentaram maior tempo de permanência hospitalar e maior incidência de complicações gastrointestinais.

Preoperative fasting durations for adult elective surgical patients: Convenient for the professional, but detrimental to the patient? A narrative review

Preoperative fasting is necessary in reducing the risk of aspiration of stomach contents when undergoing a procedure that requires anaesthesia. There are numerous guidelines based upon evidence-based practice that outline the safe duration of a fast prior to the induction of anaesthesia. Common practice however is to give advice that unnecessarily starves the patient leading to perioperative complications. There is a breadth of literature analysing the fasting durations of various institutions, with a consensus of fasting from midnight being the norm, and side effects of nausea and dehydration being unfortunate by-products of fasting. A review of the literature examines the continued poor compliance of evidenced-based practice.

Preoperative Fasting among Adult Patients for Elective Surgery in a Kenyan Referral Hospital

Background. Preoperative fasting (POF) is physiologically and precautionary important during anesthesia and surgery. POF from midnight has been practiced despite the recommended shorter practice. Objective. Assessing preoperative fasting among adult patients scheduled for elective surgery at Kenyatta National Hospital (KNH). Methods. A descriptive cross-sectional study involving 65 surgical patients. A questionnaire of mixed questions on demographics, reasons, source of instructions, opinion on instructions, time, premedication practices, outcome, and complains on NPO was used. Analysis was quantitatively done with SPSS v. 22. Ethical approval was obtained from KNH-UoN ERC. Results. Of the respondents 93.8% lacked knowledge on the correct reasons for POF and felt that the instructions were unclear and less important <50%. POF instructions were administered by nurses 80%, anesthetists 15%, and surgeons 5%. Most of respondents (73.8%) fasted > 15 hours. The POF outcomes were rated moderately challenging as follows: prolonged wait for surgery 44.6%, thirst 43.1%, hunger 36.9%, and anxiety 29.2%. Conclusion. Nurses are critical in providing POF instructions and care, and patient knowledge level is a mirror reflection of the quality of interventions. This underscores the need to build capacity for nurses and strengthen the health system to offer individualized preoperative interventions as well as monitoring and clinical auditing of fasting practices.

Advances in understanding role of enhanced recovery after surgery and damage control surgery in acute abdominal disease

Enhanced recovery after surgery and damage control surgery have been gradually applied to clinical surgery in recent years, aimed to reduce perioperative stress response in surgical patients. Research on the perioperative period of selective surgery proves that enhanced recovery after surgery and damage control surgery play an important role in reducing perioperative stress reaction, especially in patients with acute abdominal pain. This article briefly summarizes the recent progress in understanding the role of enhanced recovery after surgery and damage control surgery in acute abdominal disease.

Randomized Controlled Trial Assessing the Feasibility of Shortened Fasts in Intubated ICU Patients Undergoing Tracheotomy

Objective

American Society of Anesthesiology guidelines recommend preoperative fasts of 6 hours after light snacks and 8 hours after large meals. These guidelines were designed for healthy patients undergoing elective procedures but are often applied to intubated intensive care unit (ICU) patients. ICU patients undergoing routine procedures may be subjected to unnecessary prolonged fasts. This study tests whether shorter fasts allow for better nutrition delivery and patient outcomes without increasing the risk.

Study Design

Randomized blinded controlled trial.

Setting

Tertiary academic medical center.

Subjects

ICU patients undergoing bedside tracheotomy.

Methods

Intubated ICU patients who were receiving enteral feeding and for whom bedside tracheotomy was indicated were enrolled prospectively and randomly allocated to 2 parallel preoperative fasting regimens: a 6-hour fast (control) and a 45-minute fast (intervention). Patients were assessed for aspiration, caloric delivery, metabolic markers, and infectious and noninfectious complications.

Results

Twenty-four patients were enrolled and randomized. There were no complications related to the procedure. There were no cases of intraoperative aspiration identified. There was a single postoperative pneumonia in the control group. Median (interquartile range) length of fast and caloric delivery were significantly different between the control group and the shortened fast group: 22 hours (18, 34) vs 14 hours (5, 25; P < .001) and 429 kcal (57, 1125) vs 1050 kcal (825, 1410; P = .01), respectively.

Conclusions

Shortening preoperative fasts in intubated ICU patients allowed for better caloric delivery in the preoperative period.

[Preoperative fasting guidelines: an update]

Anesthesiology societies have issued various guidelines on preoperative fasting since 1990, not only to decrease the incidence of lung aspiration and anesthetic morbidity, but also to increase patient comfort prior to anesthesia. Some of these societies have been updating their guidelines, as such that, since 2010, we now have 2 evidence-based preoperative fasting guidelines available. In this article, an attempt is made to review these updated guidelines, as well as the current instructions for more controversial patients such as infants, the obese, and a particular type of ophthalmic surgery.

Regional anaesthesia with sedation protocol to safely debride sacral pressure ulcers

A treatment challenge for patients with sacral pressure ulcers is balancing the need for adequate surgical debridement with appropriate anaesthesia management. We are functioning under the hypothesis that regional anaesthesia has advantages over general anaesthesia. We describe our regional anaesthesia protocol for perioperative and postoperative management.

Technology-based methods of dietary assessment: recent developments and considerations for clinical practice

PURPOSE OF REVIEW

The objective of this review is to provide an overview of recent findings in technology-based methods for the collection and analysis of dietary information, and explore the potential implications of these technologies for dietary assessment in a clinical setting.

RECENT FINDINGS

Numerous technology-based methods for dietary assessment have emerged in recent years. These methodologies have the potential to enhance the dietary assessment process, and overall appear to yield valid results in a wide variety of populations. However, as is the case with the existing technologies they are designed to replace, none is error free and each has its own unique limitations. Therefore, the decision to incorporate one of these methodologies into clinical practice should only be made after a thorough evaluation of the methodology and with specific outcome goals in mind.

SUMMARY

Evidence supporting the emerging role of technology-based methods for dietary assessment is growing. As technological advances move rapidly forward it is important to consider a theoretical foundation to help guide the translation of these innovations into routine use in clinical practice.