Preoperative Fasting Practices Across Three Anesthesia Societies: Survey of Practitioners

Influence of Shortened Fasting Time on Perioperative Outcomes in Pediatric Patients: A Systematic Review

BACKGROUND

Prolonged preoperative fasting can cause hypoglycemia, dehydration, hypotension, and irritability, especially in children. Multimodal protocols such as the Enhanced Recovery After Operation (ERAS) and the Accelerated Full Postoperative Recovery (ACERTO, Aceleração da Recuperação Total Pós-Operatória) recommend a shortened fasting period. The aim of this study is to evaluate the association between shortened preoperative fasting and perioperative outcomes in pediatric patients.

METHODS

This study is a systematic review of the literature. The inclusion criteria were original studies published between January 2017-November 2022 that used shortened preoperative fasting protocols validated in patients aged 0-17 years and that evaluated the association of this practice with perioperative outcomes. The studies were obtained from the Latin American and Caribbean Literature on Health Sciences (LILACS), National Library of Medicine and National Institutes of Health (PubMed) and Science Direct databases.

RESULTS

A total of 6064 articles were obtained, of which eight were considered eligible. The results showed that shortened preoperative fast is safe in children and adolescents. The main benefits of this practice were higher preoperative blood glucose, no episodes of preoperative hypoglycemia, lower incidence of nausea, and minor complaints of crying.

CONCLUSIONS

Shortening the fasting time with high-carbohydrate drinks between one and 2 h before operation is safe in children and adolescents, being associated with better metabolic and emotional responses in the perioperative period.

LEVELS OF EVIDENCE

Level II.

Preoperative fasting and the risk of pulmonary aspiration-a narrative review of historical concepts, physiological effects, and new perspectives

In the early days of anaesthesia, the fasting period for liquids was kept short. By the mid-20th century 'nil by mouth after midnight' had become routine as the principles of the management of 'full stomach' emergencies were extended to include elective healthy patients. Back then, no distinction was made between the withholding of liquids and solids. Towards the end of the last century, recommendations of professional anaesthesiology bodies began to reduce the fasting time of clear liquids to 2 h. This reduction in fasting time was based on the understanding that gastric emptying of clear liquids is rapid, exponential, and proportional to the current filling state of the stomach. Furthermore, there was no evidence of a link between drinking clear liquids and the risk of aspiration. Indeed, most instances of aspiration are caused by failure to identify aspiration risk factors and adjust the anaesthetic technique accordingly. In contrast, long periods of liquid withdrawal cause discomfort and may also lead to serious postoperative complications. Despite this, more than two decades after the introduction of the 2 h limit, patients still fast for a median of up to 12 h before anaesthesia, mainly because of organisational issues. Therefore, some hospitals have decided to allow patients to drink clear liquids within 2 h of induction of anaesthesia. Well-designed clinical trials should investigate whether these concepts are safe in patients scheduled for anaesthesia or procedural sedation, focusing on both aspiration risk and complications of prolonged fasting.

Perioperative Nutritional Management in Enhanced Recovery after Bariatric Surgery

Obesity is a crucial health problem because it leads to several chronic diseases with an increased risk of mortality and it is very hard to reverse with conventional treatment including changes in lifestyle and pharmacotherapy. Bariatric surgery (BS), comprising a range of various surgical procedures that modify the digestive tract favouring weight loss, is considered the most effective medical intervention to counteract severe obesity, especially in the presence of metabolic comorbidities. The Enhanced Recovery After Bariatric Surgery (ERABS) protocols include a set of recommendations that can be applied before and after BS. The primary aim of ERABS protocols is to facilitate and expedite the recovery process while enhancing the overall effectiveness of bariatric procedures. ERABS protocols include indications about preoperative fasting as well as on how to feed the patient on the day of the intervention, and how to nourish and hydrate in the days after BS. This narrative review examines the application, the feasibility and the efficacy of ERABS protocols applied to the field of nutrition. We found that ERABS protocols, in particular not fasting the patient before the surgery, are often not correctly applied for reasons that are not evidence-based. Furthermore, we identified some gaps in the research about some practises that could be implemented in the presence of additional evidence.

Management of hospital admission, patient information and education, and immediate preoperative care

An increasing proportion of surgical procedures involves elderly and frail patients in high-income countries, leading to an increased risk of postoperative complications. Complications significantly impact patient outcomes and costs, due to prolonged hospitalization and loss of autonomy. Consequently, it is crucial to evaluate preoperative functional status in older patients, to tailor the perioperative plan, and evaluate risks. The hospital environment often exacerbates cognitive impairments in elderly and frail patients, also increasing the risk of infection, falls, and malnutrition. Thus, it is essential to work on dedicated pathways to reduce hospital readmissions and favor discharges to a familiar environment. In this context, the use of wearable devices and telehealth has been promising. Telemedicine can be used for preoperative evaluations and to allow earlier discharges with continuous monitoring. Wearable devices can track patient vitals both preoperatively and postoperatively. Preoperative education of patient and caregivers can improve postoperative outcomes and is favored by technology-based approach that increases flexibility and reduce the need for in-person clinical visits and associated travel; moreover, such approaches empower patients with a greater understanding of possible risks, moving toward shared decision-making principles. Finally, caregivers play an integral role in patient improvement, for example, in the prevention of delirium. Hence, their inclusion in the care process is not only advantageous but essential to improve perioperative outcomes in this population.

Determination of Knowledge and Attitudes of Cardiac Surgery Nurses Regarding the Enhanced Recovery After Surgery Protocol

PURPOSE

This study aimed to examine the knowledge and attitudes of cardiac surgery nurses regarding the enhanced recovery after surgery protocol.

DESIGN

This was a descriptive, cross-sectional study.

METHODS

The sample consisted of 50 nurses working in the cardiovascular surgery clinic of a university hospital in the province of Izmir, Turkey. A questionnaire consisting of three sections was prepared by the researchers to collect data. The first section of the form captured sociodemographic and descriptive characteristics; the second section examined the level of knowledge about the enhanced recovery protocol for cardiac surgery; the third section captured the nurses' attitudes regarding the enhanced recovery protocol. The questionnaire was distributed to the nurses and the research data were collected after a certain amount of time. Descriptive statistics, Mann-Whitney U test, Kruskal-Wallis test, and correlation analysis were used in the analysis of the data.

FINDINGS

The mean age of the nurses was 31.26 ± 6.74 (min = 23, max = 47); 78% were female; 76% had a bachelor's degree; 48% were employed in the intensive care unit. The mean score of the nurses regarding their level of knowledge on the enhanced recovery protocol for cardiac surgery was 18.70 ± 5.29 (min = 0.00, max = 28.00); the mean score regarding attitude toward the enhanced recovery protocol after surgery was 30.00 ± 3.86 (min = 12.00, max = 33.00). There was a positive, moderate, statistically significant correlation (r = 0.396, P = .005) between the mean knowledge level score and the mean attitude level score.

CONCLUSIONS

Results showed that nurses' knowledge was at a moderately positive level. Increasing the level of knowledge increased positive attitudes. Recommendations include disseminating protocol information and providing necessary training to increase positive attitudes in an effort to ensure protocol adherance.

Association of a Liberal Fasting Policy of Clear Fluids Before Surgery With Fasting Duration and Patient Well-being and Safety

Importance

Current fasting guidelines for procedures under anesthesia are poorly implemented, leading to negative metabolic sequelae. Recent studies in children showed support of liberal clear fluid intake; adult physiology can support clear fluid intake, but implementation studies are lacking.

Objective

To evaluate the successfulness of implementation of a liberal clear fluid policy with regard to fasting duration, well-being, and safety in adults scheduled for anesthesia.

Design, Setting, and Participants

This was a quality improvement study conducted from January 2016 to July 2021 at a tertiary referral hospital in the Netherlands. Adults scheduled for nonemergency procedures under anesthesia were included in the study. Patients undergoing obstetrics procedures or those who were intubated preoperatively were excluded.

Interventions

Stepwise introduction of a liberal fluid fasting policy, allowing for ingestion of clear fluids until arrival at the operating room.

Main Outcomes and Measures

The primary outcome was change in fasting duration. Secondary outcomes were patient well-being, measured as preoperative thirst, amount of fluid ingested, postoperative nausea and vomiting (PONV), and administration of antiemetics. Safety was measured as incidence of regurgitation and aspiration (pneumonia).

Results

Of the 76 451 patients (mean [SD] age, 56 [17] years; 39 530 male individuals [52%] 36 921) included in the study, 59 036 (78%) followed the standard policy, and 16 815 (22%) followed the liberal policy. Time series analysis showed an estimated fasting duration decrease of 3:07 hours (IQR, 1:36-7:22; P < .001) after implementation of the liberal policy. Postimplementation median (IQR) fasting duration was 1:20 (0:48-2:24) hours. The incidence of regurgitation changed from 18 (95% CI, 14-21) to 24 (95% CI, 17-32) in 10 000 patients, and the incidence of aspiration changed from 1.7 (95% CI, 0.6-2.7) to 2.4 (95% CI, 0.5-4.7) in 10 000 patients. In the liberal policy, thirst feelings decreased (37% [4982 of 8615] vs 46% [3373 of 7362]; P < .001). PONV incidence decreased from 10.6% (6339 of 59 636) to 9.4% (1587 of 16 815; P < .001) and antiemetic administration decreased from 11.0% (6538 of 59 636) to 9.5% (1592 of 16 815; P < .001).

Conclusions and Relevance

Results of this quality improvement study suggest that a liberal fasting policy was associated with a clinically relevant reduction in fasting duration and improved patient well-being with regard to preoperative thirst and PONV. Although a slightly higher incidence of regurgitation could not be ruled out, wider implementation of such a policy may be advocated as results are still within the clinically accepted risks margins. Results suggest that surgical procedures in patients who drink clear fluids within 2 hours before anticipated anesthesia should not be postponed or canceled.

Effect of multidisciplinary interventions in perioperative management center on duration of preoperative fasting: A single-center before-and-after study

OBJECTIVES

Our aims were to clarify the actual situation regarding preoperative fasting and determine whether multidisciplinary interventions in a perioperative management center shorten the duration of preoperative fasting.

METHODS

The cohort of this before-and-after study comprised patients undergoing elective surgery aged 18 years or older who underwent general anesthesia at one of three stages: after starting a short preoperative fasting protocol (Group A), after the anesthesiologist started explaining the protocol (Group B), and after the start of the perioperative management center (Group C). Instructions on drinking clear fluids were given up to 2 h and 4 h before the start of elective surgery to the first patient on the list (on-time) and to the second and subsequent patients (on-call), respectively. Data were collected retrospectively in Groups A and B and prospectively in Group C.

RESULTS

The study cohort comprised 89 patients in Group A (50 on-time, 39 on-call), 108 in Group B (65 on-time, 43 on-call), and 284 in Group C (182 on-time, 102 on-call). The difference between the instructed and last drinking time was significantly shorter in Group C than Group A (30 [10, 140] vs. 30 [10, 60] vs. 20 [0, 50] min, p=0.003). The duration of fasting was significantly shorter in Group C than Group B (243 [150, 395] vs. 213 [151, 323] vs. 180 [146, 280] min, p=0.01).

CONCLUSIONS

Multidisciplinary interventions at the perioperative management center tended to reduce the duration of fasting, suggesting that this approach may contribute to improved compliance.

Optimized perioperative management (fast-track, ERAS) to enhance postoperative recovery in elective colorectal surgery

Aim

This manuscript provides information on the history, principles, and clinical results of Fast-track or ERAS concepts to optimize perioperative management (OPM).

Methods

With the focus on elective colorectal surgery description of the OPM concept and its elements for with special attention to the prevention of infectious complications and clinical results compared to traditional care will be given using recent systematic literature reviews. Additionally, clinical results for other major abdominal procedures are given.

Results

An optimized perioperative management protocol for elective colorectal resections will currently consist of 25 perioperative elements. These elements include the time from before hospital admission (patient education, screening, and treatment of possible risk factors like anemia, malnutrition, cessation of nicotine or alcohol abuse, optimization of concurrent systemic disease, physical prehabilitation, carbohydrate loading, adequate bowel preparation) to the preoperative period (shortened fasting, non-sedative premedication, prophylaxis of PONV and thromboembolic complications), intraoperative measures (systemic antibiotic prophylaxis, standardized anesthesia, normothermia and normovolemia, minimally invasive surgery, avoidance of drains and tubes) as well as postoperative actions (early oral feeding, enforced mobilization, early removal of a urinary catheter, stimulation of intestinal propulsion, control of hyperglycemia). Most of these elements are based on high-level evidence and will also have effects on the incidence of postoperative infectious complications.

Conclusion

Optimized perioperative management should be mandatory for elective surgery today as it enhances postoperative patient recovery, reduces morbidity and infectious complications.

The History of ERAS (Enhanced Recovery After Surgery) Society and its development in Latin America

The shortage of hospital beds and changes in the payment model have promoted an increased attention and financing of programs that focus on perioperative care efficiency in. Latin America. In this paper, Enhanced Recovery After Surgery (ERAS) programs developed by the ERAS® Society will be discussed. The implementation and use of ERAS®Society Guidelines consistently demonstrated a reduction in postoperative complications, hospital stay and costs. In the current paper, the definition of ERAS programs, their core elements, and the results of their implementation and regional developments are presented with special focus on Latin America.

Slated versus actual operating room entry time in a British Columbia health authority

PURPOSE

To determine how frequently the published operating room (OR) schedule of case start times correlated with the actual OR entry time for elective cases in the Fraser Health Authority (FHA) in British Columbia, Canada. Society guidelines recommend periods of fasting of two hours prior to the induction of general anesthesia, but patients frequently end up fasting much longer. This review aimed to determine when patients arrive in the OR-either earlier than their scheduled time or later. The premise of some is that patients often arrive earlier, and advising short fasting times on the basis of the OR slate time is unreliable. I wished to determine whether this fear is justified.

METHODS

The computerized OR management database was queried for slated time of entry and actual time of entry for elective surgical cases in 11 hospitals in the FHA. The difference in slated vs actual entry time of patients (in 30 min blocks) was reviewed to examine the proportion of patients entering the OR earlier than 90 min from their slated time. Additionally, anesthesiologists from the Royal Columbian/Eagle Ridge Hospitals were surveyed for their recall of case delays that were related to inappropriate consumption of fluids.

RESULTS

One hundred and twenty-three thousand eight hundred and sixty-five cases from 11 hospitals over a 32-month period were analyzed. A very small proportion of cases (753 of 123,865 cases, 0.6%) entered the OR earlier than 90 min from their slated time. Relatively few cases were actually cancelled because of inappropriate fluid consumption in the recall of anesthesiologists in two institutions.

CONCLUSION

In the FHA, the OR schedule is a reliable guide to providing instructions on timing of preoperative fluid consumption in appropriately selected elective surgical patients. Quality of care and patient satisfaction will safely be enhanced by limiting the period of fasting for elective surgical patients.