[Preoperative fasting of 8 hours or 2 hours: what does evidence reveal?]

Preoperative Nil Per Os Duration Predicts Mortality and Ambulation Following Below-Knee Amputation

BACKGROUND

Routine use of nil per os (NPO) prior to procedures has been associated with dehydration and malnutrition leading to patient discomfort. We aim to examine how duration of NPO status affects postoperative outcomes in patients undergoing elective below-knee amputation (BKA).

METHODS

We performed a retrospective chart review of 92 patients who underwent elective BKA between 2014-2022 for noninfectious indications. We performed statistical analysis using Chi-square tests, t-tests, and linear/logistic regression with odds ratio using P < .05 as our significance level.

RESULTS

The mean age was 48.0 ± 16.7 years, and there were 64 (70%) male patients and 41 (45%) Black patients. Mean NPO duration was 12.9 ± 4.7 hours. Patients with longer NPO duration were associated with increased rates of postoperative stroke (P = .03). Patients with shorter NPO duration had significantly lower mean BUN on postoperative day (POD) 1 (14.5, P < .001) and POD 3 (14.1, P < .001) compared to preoperative mean BUN (16.8), however this normalized by POD 7 (19.2, P = .26). There were no changes in postoperative renal function based on baseline kidney disease status or associated with longer NPO duration. Shorter NPO duration was a predictor of increased likelihood of 1-year follow-up (OR: 2.9 [1.24-6.79], P = .01), independent ambulation (OR: 2.7 [1.03-7.34], P = .04), and decreased mortality (OR: .11 [.013-.91], P = .04).

CONCLUSION

While NPO duration does not appear to result in postoperative renal dysfunction, prolonged NPO duration predicts worse rates of follow-up, ambulation, and survival and is associated with increased stroke rates.

SHORTEN PREOPERATIVE FASTING AND INTRODUCING EARLY EATING ASSISTANCE IN RECOVERY AFTER GASTROJEJUNAL BYPASS?

Rational:

The metabolic response to surgical trauma is enhanced by prolonged preoperative fasting, contributing to increased insulin resistance. This manifestation is more intense on the 1^st and 2^nd postoperative days and is directly proportional to the size of the operation.

Aim:

To compare whether preoperative fasting abbreviation and early postoperative refeeding associated with intraoperative and postoperative fluid restriction interfere in the evolution of patients undergoing gastrojejunal bypass.

Methods:

Eighty patients indicated for Roux-en-Y gastrojejunal bypass were selected. They were randomly divided into two groups: Ringer Lactate (RL) group, who underwent a 6 hours solids fasting, with the administration of 50 g of maltodextrin in 100 ml of mineral water 2 hours before the beginning of anesthesia; and Physiologic Solution (PS) group, who underwent a 12 hours solids and liquids fasting. Anesthesia was standardized for both groups. During the surgical procedure, 1500 ml of ringer lactate solution was administered in the RL and 2500 ml of physiological solution (0.9% sodium chloride) in the PS. In both groups, the occurrence of bronchoaspiration was analyzed during intubation, and the residual gastric volume was measured after opening the abdominal cavity. In the postoperative period in Group RL, patients started a liquid diet 24 hours after the end of the operative procedure; whilst for PS group, fasting was maintained for the first 24 hours, it was prescripted 2000 ml of physiological solution and a restricted liquid diet after 36 hours. Each patient underwent CPK, insulin, sodium, potassium, urea, creatinine, PaCO2, pH and bicarbonate dosage in the immediate postoperative period, and 48 hours later, the exams were repeated.

Results:

There were no episodes of bronchoaspiration and gastrojejunal fistulas in either group. In the analysis of the residual gastric volume of the PS and RL groups, the mean volumes were respectively 16.5 and 8.8, which shows statistical significance between the groups. In laboratory tests, there was no difference between groups in sodium; PS group showed a higher level of serum potassium (p=0.029); whilst RL group showed a higher urea and creatinine values; CPK values were even for both; PS group demonstrated a higher insulin level; pH was higher in PS group; sodium bicarbonate showed a significant difference at all times; PaCO2 values in RL group was higher than in PS. In the analysis of the incidence of nausea and flatus, no statistical significance was observed between the groups.

Conclusions:

The abbreviation of preoperative fasting and early postoperative refeeding of Roux-en-Y gastrojejunal bypass with the application of ERAS or ACERTO Project accelerated the patient’s recovery, reducing residual gastric volume and insulin level, and do not predispose to complications.

Risk factors for intraoperative pressure injuries in patients undergoing digestive surgery: A retrospective study

AIM AND OBJECTIVE

To investigate the incidence of intraoperative blanchable erythema and pressure injuries in patients undergoing digestive surgery and to explore potential risk factors.

BACKGROUND

Pressure injuries pose significant economic and healthcare burden to patients and are used as one of the key indicators of nursing in the operation room with high incidence.

DESIGN

A retrospective observational study.

METHODS

Basic information and the results of 3S intraoperative risk assessment scale of pressure injury were obtained from the information system. And the patients with intraoperative blanchable erythema or pressure injuries were followed up for 72 hr by the information system. The clinical data were collected to analyse risk factors for intraoperative blanchable erythema and pressure injuries by univariate analysis and logistic regression analysis. STROBE checklist for cohort studies was applied in the preparation of the paper.

RESULTS

Of 5,136 surgical cases, 134 (2.61%) had blanchable erythema, 37 (0.72%) had intraoperative pressure injuries, and 8 (0.16%) had pressure injuries at 72-hr follow-up. Preoperative skin under compression, preoperative physical activity, surgical position and extra intraoperative pressure were considered independent risk factors for intraoperative pressure injuries.

CONCLUSION

The incidence of pressure injuries in our study was lower than those reported in the previous studies. Accessing preoperative skin under compression, preoperative physical activity, surgical position and extra intraoperative pressure was considered to be significant for preventing pressure injuries.

RELEVANCE TO CLINICAL PRACTICE

The findings suggest that preoperative skin under compression, preoperative physical activity, surgical position and extra intraoperative pressure are associated with intraoperative pressure injuries in patients undergoing digestive surgery.

Sleeve Gastrectomy With or Without a Multimodal Perioperative Care. A Randomized Pilot Study

BACKGROUND

Multimodal protocols may enhance postoperative recovery. The aim of this study was to evaluate the influence of a multimodal protocol in the clinical results, insulin resistance, and inflammatory response to trauma in morbidly obese patients undergoing sleeve gastrectomy.

METHODS

The population of the study consisted of morbidly obese patients, who were operated using sleeve gastrectomy, from Cuiaba, MT, Brazil, between April and October 2012. Twenty patients were divided into two groups whom received either traditional preoperative care or treatment following the Acerto (accelerating the total recovery of patients in the postoperative period) protocol. The study examined inflammatory response and insulin resistance by measuring levels of glucose, insulin, Homa-IR, reactive C protein, albumin, prealbumin, alpha 1 acid glycoprotein, interleukin 6, and glycosylated hemoglobin. In addition, the study investigated hydration levels, nausea and vomiting, hypertension, and length of hospital stay.

RESULTS

Patients who followed the Acerto protocol showed no postoperative hypertensive crises (p = 0.03), and 30 % less vomiting (p = 0.35), and showed significant reductions in length of hospital stay, on average of 3 days versus 2 days (p = 0.02). There were not significant statistical differences between the two groups with respect to inflammatory response and insulin resistance (p > 0.05).

CONCLUSION

This pilot study suggests that the prescription of the Acerto multimodal protocol for morbidly obese patients undergoing sleeve gastrectomy was safe, reduced the rate hypertensive complications, and the length of both ICU and hospital postoperative stay. However, there was no improvement in postoperative insulin resistance or inflammatory acute phase response.

FASTING IN ELECTIVE SURGICAL PATIENTS: COMPARISON AMONG THE TIME PRESCRIBED, PERFORMED AND RECOMMENDED ON PERIOPERATIVE CARE PROTOCOLS

BACKGROUND

Prolonged preoperative fasting may impair nutritional status of the patient and their recovery. In contrast, some studies show that fasting abbreviation can improve the response to trauma and decrease the length of hospital stay.

AIM

Investigate whether the prescribed perioperative fasting time and practiced by patients is in compliance with current multimodal protocols and identify the main factors associated.

METHODS

Cross-sectional study with 65 patients undergoing elective surgery of the digestive tract or abdominal wall. We investigated the fasting time in the perioperative period, hunger and thirst reports, physical status, diabetes diagnosis, type of surgery and anesthesia.

RESULTS

The patients were between 19 and 87 years, mostly female (73.8%). The most performed procedure was cholecystectomy (47.69%) and general anesthesia the most used (89.23%). The most common approach was to start fasting from midnight for liquids and solids, and most of the patients received grade II (64.6%) to the physical state. The real fasting average time was 16 h (9.5-41.58) was higher than prescribed (11 h, 6.58 -26.75). The patients submitted to surgery in the afternoon were in more fasting time than those who did in the morning (p<0.001). The intensity of hunger and thirst increased in postoperative fasting period (p=0.010 and 0.027). The average period of postoperative fasting was 18.25 h (3.33-91.83) and only 23.07% restarted feeding on the same day.

CONCLUSION

Patients were fasted for prolonged time, higher even than the prescribed time and intensity of the signs of discomfort such as hunger and thirst increased over time. To better recovery and the patient's well-being, it is necessary to establish a preoperative fasting abbreviation protocol.

Benefits of maltodextrin intake 2 hours before cholecystectomy by laparotomy in respiratory function and functional capacity: a prospective randomized clinical trial

OBJECTIVE

To evaluate the change in respiratory function and functional capacity according to the type of preoperative fasting.

METHODS

Randomized prospective clinical trial, with 92 female patients undergoing cholecystectomy by laparotomy with conventional or 2 hours shortened fasting. The variables measured were the peak expiratory flow, forced expiratory volume in the first second, forced vital capacity, dominant handgrip strength, and non-dominant handgrip strength. Evaluations were performed 2 hours before induction of anesthesia and 24 hours after the operation.

RESULTS

The two groups were similar in preoperative evaluations regarding demographic and clinical characteristics, as well as for all variables. However, postoperatively the group with shortened fasting had higher values than the group with conventional fasting for lung function tests peak expiratory flow (128.7±62.5 versus 115.7±59.9; p=0.040), forced expiratory volume in the first second (1.5±0.6 versus 1.2±0.5; p=0.040), forced vital capacity (2.3±1.1 versus 1.8±0.9; p=0.021), and for muscle function tests dominant handgrip strength (24.9±6.8 versus 18.4±7.7; p=0.001) and non-dominant handgrip strength (22.9±6.3 versus 17.0±7.8; p=0.0002). In the intragroup evaluation, there was a decrease in preoperative compared with postoperative values, except for dominant handgrip strength (25.2±6.7 versus 24.9±6.8; p=0.692), in the shortened fasting group.

CONCLUSION

Abbreviation of preoperative fasting time with ingestion of maltodextrin solution is beneficial to pulmonary function and preserves dominant handgrip strength.

Fasting abbreviation among patients submitted to oncologic surgery: systematic review

INTRODUCTION

The abbreviation of perioperative fasting among candidates to elective surgery have been associated with shorter hospital stay and decreased postoperative complications.

OBJECTIVE

To conduct a systematic review from randomized controlled trials to detect whether the abbreviation of fasting is beneficial to patients undergoing cancer surgery compared to traditional fasting protocols.

METHOD

A literature search was performed in electronic databases: MEDLINE (PubMed), SciELO, EMBASE and Cochrane, without time restriction. Were used the descriptors: "preoperative fasting", "cancer", "diet restriction" and "perioperative period". Randomized trials were included in adults of both sexes, with diagnosis of cancer. Exclusion criteria were: use of parenteral nutrition and publications in duplicate. All analyzes, selections and data extraction were done blinded manner by independent evaluators.

RESULTS

Four studies were included, with a total of 150 patients, 128 with colorectal cancer and 22 gastric cancer. The articles were published from 2006 to 2013. The main outcome measures were heterogeneous, which impaired the unification of the results by means of meta-analysis. Compared to traditional protocols, patients undergoing fasting abbreviation with the administration of fluids containing carbohydrates had improvements in glycemic parameters (fasting glucose and insulin resistance), inflammatory markers (interleukin 6 and 10) and indicators of malnutrition (grip strength hand and CRP/albumin ratio), and shorter hospital stay. The methodological quality of the reviewed articles, however, suggests that the results should be interpreted with caution.

CONCLUSION

The abbreviation of perioperative fasting in patients with neoplasm appears to be beneficial.