Real-World Evidence: How Long Do Our Patients Fast?-Results from a Prospective JAGO-NOGGO-Multicenter Analysis on Perioperative Fasting in 924 Patients with Malignant and Benign Gynecological Diseases

[Myths in Anaesthesia - Liberal Clear Liquid Fasting Regimens]

International guidelines recommend encouraging patients to drink up to two hours before induction of anaesthesia. But why are patients still fasting for up to a median of 12 hours? Are liberal clear liquid fasting regimens harmful to patients or considered "best clinical practice"? Gastric emptying of clear liquids is very fast, exponential and proportional to the current filling of the stomach. There is no evidence of a link between drinking clear liquids and the risk of aspiration. As a result, more and more hospitals are allowing their patients to drink clear liquids until they are called for surgery. Since 2021, "SipTilSend" has become best practice in the UK and the concept of fasting cards has been awarded by patient safety organisations in 2024.

Daytime versus out-of-hours surgery for Chronic Subdural Hematoma

Chronic Subdural Hematoma (CSDH) is one of the most common neurosurgical pathologies. Due to an elderly demographic with increasing co-morbidities, surgery is often deferred out of hours. This may reduce complication risk, but increases length of stay and may compromise patient care due to delayed surgery. We performed a retrospective service evaluation of CSDH patients undergoing primary surgery (September 2021-September 2023) at a tertiary neurosciences centre. Out of hours (OOH) was defined as an operation start time outside 8 am-8 pm. Primary outcome was recurrence requiring repeat surgery. Secondary outcomes included complications, thromboembolic events (DVT/PE), length of stay, and in hospital mortality. Differences were assessed using Chi-Squared tests and Student's t-tests. A total of 263 patients were included (200 (76.0 %) male, mean age 75.0 ± 11.3 yrs). Median time from admission to surgery was 37 h (IQR 14-71.5 h). In total, 49.8 % (131/263) of operations took place OOH. There were no significant differences in baseline characteristics between the two groups. At a median follow-up of 9.2 months (IQR 4.8-13.2 months) there was no difference in recurrence rates between OOH and in hours groups (14.5 % vs. 17.7 %, p = 0.483). There was no difference in complication rates (13.7 % vs 16.2 %, p = 0.585), thromboembolic events (3.8 % vs 3.1 %, p = 0.743), length of stay (mean 15.9 vs 15.2 days, p = 0.787), or in-hospital mortality (2.3 % vs 3.1 %, p = 0.483). OOH surgery for CSDH surgery is safe, does not appear to affect complications, recurrence, or mortality, and should be considered in appropriately selected cases.

Association between preoperative fasting time and clinical outcomes in surgical patients in a private general hospital

PURPOSE

Surgical patients are routinely subjected to long periods of fasting, a practice that can exacerbate the metabolic response to trauma and impair postoperative recovery. The aim of this study was to evaluate the association between preoperative fasting time and clinical outcomes in surgical patients.

METHODS

An observational, prospective study with a non-probabilistic sample that included patients of both sexes, aged over 18, undergoing elective surgeries. Data were extracted from electronic medical records, and a questionnaire was applied in 48 hours after surgery. Variables related to postoperative discomfort were assessed using an 11-point numeric rating scale.

RESULTS

The sample consisted of 372 patients, and the duration of the surgical event ranged from 30-680 minutes. The incidence of nausea (26.34%) was twice that of vomiting (13.17%) and showed an association with the surgical procedure's size (p = 0.018). A statistically significant difference was observed only between pain intensity and preoperative fasting times for liquids (p = 0.007) and postoperative fasting time (p = 0.08). The occurrence of postoperative complications showed no association with preoperative fasting time (p = 0.850).

CONCLUSIONS

Although no association was observed between preoperative fasting time and surgical complications, it is noteworthy that both recommended and actual fasting time exceeded the proposed on clinical guidelines.

Morning or Afternoon Scheduling for Elective Coronary Artery Bypass Surgery: Influence of Longer Fasting Periods from Metabolic and Hemodynamic Perspectives

BACKGROUND

Prolonged preoperative fasting may worsen postoperative outcomes. Cardiac surgery has higher perioperative risk, and longer fasting periods may be not well-tolerated. We analysed the postoperative metabolic and hemodynamic variables in patients undergoing elective coronary artery bypass grafting (CABG) according to their morning or afternoon schedule.

METHODS

Single-centre retrospective study at University teaching hospital (1-year data collection from electronic medical records). Using a mixed-effects linear regression model adjusted for several covariates, we compared metabolic (lactatemia, pH, and base deficit [BD]) and haemodynamic values (patients on vasoactive support, and vasoactive inotropic score [VIS]) at 7 prespecified time-points (admission to intensive care, and 1st, 3rd, 6th, 12th, 18th, and 24th postoperative hours).

RESULTS

339 patients (n = 176 morning, n = 163 afternoon) were included. Arterial lactatemia and BD were similar (overall P = 0.11 and P = 0.84, respectively), while pH was significantly lower in the morning group (overall P < 0.05; mean difference -0.01). Postoperative urine output, fluid balance, mean arterial pressure, and central venous pressure were similar (P = 0.59, P = 0.96, P = 0.58 and P = 0.53, respectively). A subgroup analysis of patients with diabetes (n = 54 morning, n = 45 afternoon) confirmed the same findings. The VIS values and the proportion of patients on vasoactive support was higher in the morning cases at the 18th (P = 0.002 and p=0.04, respectively) and 24th postoperative hours (P = 0.003 and P = 0.04, respectively). Mean intensive care length of stay was 1.94 ± 1.36 days versus 2.48 ± 2.72 days for the afternoon and morning cases, respectively (P = 0.02).

CONCLUSIONS

Patients undergoing elective CABG showed similar or better metabolic and hemodynamic profiles when scheduled for afternoon surgery.

Effects of caloric and nutrient content of oral fluids on gastric emptying in volunteers: a randomised crossover study

BACKGROUND

Previous studies demonstrated conflicting results regarding the determinants of gastric emptying for fluids. Our aim was to compare gastric emptying times of fluids with different caloric and nutrient content.

METHODS

Healthy adult volunteers underwent gastric ultrasound assessment for 4 h after consuming beverages with different caloric and nutrient content using a crossover design (oat drink with 3% fat [310 kcal], mango juice [310 kcal], oat drink with 0.5% fat [185 kcal], and blackcurrant juice [175 kcal]). Gastric emptying time, gastric content volume, and the area under the curve (AUC) of gastric content volume-time profiles were calculated.

RESULTS

Eight females and eight males completed the study protocol. The mean (sd) gastric emptying times were 89 (32) min for blackcurrant juice, 127 (54) min for oat drink with 0.5% fat, 135 (36) min for mango juice, and 152 (40) min for oat drink with 3% fat. Gastric emptying times were slower for oat drink with 3% fat (P=0.007) and mango juice (P=0.025) than for blackcurrant juice. At 1 h after ingestion, gastric content volume was greater for mango juice (P=0.021) and oat drink with 3% fat (P=0.003) than for blackcurrant juice. The AUC was greater for oat drink with 3% fat than mango juice (P=0.029), oat drink with 0.5% fat (P=0.004), and blackcurrant juice (P=0.002), and for mango juice than blackcurrant juice (P=0.019).

CONCLUSIONS

Caloric and nutrient content significantly affected gastric emptying times. A high-calorie fruit juice (mango) exhibited delayed emptying times compared with a low-calorie fruit juice (blackcurrant).

CLINICAL TRIAL REGISTRATION

ISRCTN17147574.