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

Effects of menthol on thirst during surgery patients fasting: A systematic review and meta-analysis of randomized controlled studies

AIMS

We aim to analyse the effect of menthol on thirst intensity and thirst comfort in surgical patients.

BACKGROUND

Menthol has achieved good results in quenching thirst in patients in intensive care units, but its safety and reliability in perioperative fasting patients are unknown.

DESIGN

A systematic review with meta-analysis of intervention studies was performed.

DATA SOURCES

We used Chinese and English databases from their dates of inception to May 2022. Literature was retrieved from PubMed, Web of Science, Cochrane Library, Embase, CINHAL, SinoMed, CNKI, Wanfang and VIP database.

REVIEW METHODS

Two reviewers independently examined the records according to the eligibility criteria and extracted the data of each included study.

RESULTS

A total of seven studies were identified in this review, which included 537 surgical patients. Overall, menthol reduced thirst intensity in surgical patients and decreased thirst discomfort. Further subgroup analysis revealed that the menthol intervention significantly improved thirst intensity in surgical patients during preoperative and postoperative fasting periods. The Egger's tests showed no significant bias (p = 0.113 and 0.553, thirst intensity and thirst discomfort, respectively).

CONCLUSION

Menthol intervention effectively improved thirst intensity and thirst discomfort during fasting in surgical patients, but more large-scale, multicentre randomized controlled trials are required to confirm these findings further.

Short-term fasting of mice elevates circulating fibroblast growth factor 23 (FGF23)

AIMS

Phosphate and vitamin D homeostasis are controlled by fibroblast growth factor 23 (FGF23) from bone suppressing renal phosphate transport and enhancing 24-hydroxylase (Cyp24a1), thereby inactivating 1,25(OH)2 D3 . Serum FGF23 is correlated with outcomes in several diseases. Fasting stimulates the production of ketone bodies. We hypothesized that fasting can induce FGF23 synthesis through the production of ketone bodies.

METHODS

UMR106 cells and isolated neonatal rat ventricular myocytes (NRVM) were treated with ketone body β-hydroxybutyrate. Mice were fasted overnight, fed ad libitum, or treated with β-hydroxybutyrate. Proteins and further blood parameters were determined by enzyme-linked immunoassay (ELISA), western blotting, immunohistochemistry, fluorometric or colorimetric methods, and gene expression by quantitative real-time polymerase chain reaction (qRT-PCR).

RESULTS

β-Hydroxybutyrate stimulated FGF23 production in UMR106 cells in a nuclear factor kappa-light-chain enhancer of activated B-cells (NFκB)-dependent manner, and in NRVMs. Compared to fed animals, fasted mice exhibited higher β-hydroxybutyrate and FGF23 serum levels (based on assays either detecting C-terminal or intact, biologically active FGF23 only), cardiac, pancreatic, and thymic Fgf23 and renal Cyp24a1 expression, and lower 1,25(OH)2 D3 serum concentration as well as renal Slc34a1 and αKlotho (Kl) expression. In contrast, Fgf23 expression in bone and serum phosphate, calcium, plasma parathyroid hormone (PTH) concentration, and renal Cyp27b1 expression were not significantly affected by fasting.

CONCLUSION

Short-term fasting increased FGF23 production, as did administration of β-hydroxybutyrate, effects possibly of clinical relevance in view of the increasing use of FGF23 as a surrogate parameter in clinical monitoring of diseases. The fasting state of patients might therefore affect FGF23 tests.

A Quality Improvement Project to Assess if Preoperative Trauma Patients Are Receiving Their Prescribed Medications Preoperatively

Introduction All preoperative trauma patients should receive their preoperative medications regardless of being nil per os (NPO). Anticoagulants, angiotensin-converting enzyme inhibitors (ACE-I), and angiotensin II receptor blockers (ARBs) should be omitted. This is according to both local and national guidelines. We noticed that some preoperative patients have not been receiving their morning medications prior to having their operations. This has led to pre and perioperative complications. The aim of this study, therefore, was to conduct a quality improvement project to assess if preoperative trauma patients are receiving their prescribed medications preoperatively when placed NPO. We then aimed to determine the adverse outcome associated with omission and to furthermore devise a robust system to prevent recurrence. Methods Data were collected from the relevant patients' drug charts on the day of the operation. These cases were available on the daily trauma list. We evaluated if there was any clear reason documented for not providing the medications. Following the first round, we implemented our action plan for posters to be taped to drug trolleys on the orthopedic wards and informed the nursing staff of the need to give preoperative medications. We deemed the following to be important medication classes: calcium channel blockers, neuromodulators, beta-blockers, anti-epileptics, digoxin, bronchodilators, anti-anginals, anti-epileptics, and benzodiazepines. This was re-audited after one month to assess compliance and monitor for improvement. Results Forty patients were included in the first round and 41 in the re-audit. In the first round, 16/41 (39%) patients received their medications correctly. In patients who did not receive their medications (n=25), 22 had important medication classes omitted. Post implementation of the posters, 25/41 (61%) patients received their medications correctly. In patients who did not receive their medications (n=16), 10 had important medication classes omitted. The main reason why medications were incorrectly not given was that patients were NPO. Conclusion This quality improvement audit shows that our interventions between audit cycles have made a significant improvement in patients receiving their medications and therefore this has a direct positive impact on patient safety and outcomes. We should continue to have a close rapport with the nursing staff to maintain standards of correct practice, and these audit findings should be escalated to the emergency theatre thereafter.

From clinical guidelines to practice: The nutrition elements for enhancing recovery after colorectal surgery

The Enhanced Recovery After Surgery (ERAS) Care System improves patient outcomes. The ERAS Protocol describes multimodal, evidence-based processes that are bundled into >20 care elements, and the ERAS Implementation Program provides strategies to guide the successful adoption of the care elements. Although formal training is essential to implement ERAS correctly, with this article we aim to bridge the gap between the nutritionally relevant care elements of the protocol and their implementation for colorectal surgery. This article also describes how dietitians can support optimal patient outcomes by playing an active role in implementing, monitoring, and evaluating ERAS practices.

Development and validation of a new nursing diagnosis: Perioperative thirst

PURPOSE

To develop and validate the content of the nursing diagnosis proposal for perioperative thirst.

METHODS

A content analysis by 34 judges. An online Delphi panel was used in one round, evaluating criteria of relevance, clarity and precision. Wilcoxon's one-tailed test was used and the content validity index to maintain the item was set to 0.80.

FINDINGS

The content validity index in relation to the evaluated items reached levels between 0.87-1.00. The final components of the diagnosis proposal included the following items as defining characteristics: dry mouth, dry throat, dry lips, thick saliva, thick tongue, constant swallowing of saliva, desire to drink water, bad taste in the mouth, and caregiver's report. Related factors are as follows: pre- and postoperative fasting, oral breathing, dehydration, hypovolemia, insensitive loss of hydration by breathing, dry mouth, habit of drinking water, high room temperature. Associated conditions: intubation, use of muscarinic and nicotinic anticholinergics and water restriction.

CONCLUSIONS

All components of the nursing diagnosis were validated in relation to relevance, clarity, and accuracy, demonstrating high levels of agreement between experts. Qualitative observations were found to be fundamental for both combining and excluding some items.

IMPLICATIONS FOR NURSING PRACTICE

Improvement of refinement and clarity levels of this nursing diagnosis proposal aiding its inclusion in the NANDA International taxonomy and thus enabling greater understanding of the phenomenon of thirst in surgical patients. This study helps to explain and facilitate the identification of defining characteristics, related factors, and associated conditions for nurses, nursing students, and researchers on this subject.

Preoperative Fasting Practices Across Three Anesthesia Societies: Survey of Practitioners

Background

Pulmonary aspiration of gastric contents is recognized as a complication of anesthesia. To minimize that risk, anesthesiologists advised fasting for solid foods and liquids for an often prolonged period of time. However, 30 years ago, evidence was promulgated that fasting for clear liquids was unnecessary to ensure an empty stomach. Despite a strong evidence base and the knowledge that fasting may be physiologically harmful and unpleasant for patients, the adoption of society guidelines recommending short fasting periods for clear fluids into clinical practice is uncertain.

Objective

This study aimed to determine the current practices of anesthetists with respect to fasting guidelines.

Methods

An electronic internet survey was distributed to anesthetists in Canada (CAN), Australia and New Zealand (ANZ), and Europe (EUR) during April 2014 to February 2015. The anesthetists were asked about fasting guidelines, their recommendations to patients for the consumption of clear fluids and solid foods, and the reasons and consequences if these guidelines were not followed.

Results

A total of 971 anesthetists completed the survey (CAN, n=679; ANZ, n=185; and EUR, n=107). Although 85.0% (818/962) of these participants claimed that their advice to patients followed current society guidelines, approximately 50.4% (476/945) enforced strict fasting and did not allow clear fluids after midnight. The primary reasons given were with regard to problems with a variable operating room schedule (255/476, 53.6%) and safety issues surrounding the implementation of clear fluid drinking guidelines (182/476, 38.2%).

Conclusions

Many anesthetists continue to follow outdated practices. The current interest in further liberalizing preoperative fluid intake will require more change in anesthesia culture.

Influence of different preoperative fasting times on women and neonates in cesarean section: a retrospective analysis

Background

This study was to evaluate the impact of different preoperative fasting conditions on women and neonates through a retrospective analysis.

Methods

A total of 1599 women were divided into 5 groups according to different preoperative fasting times: group A: solid food ≥8 h; clear fluids ≥6 h; B: solid food ≥8 h; clear fluids ≥2 h < 6 h; C: solid food ≥6 h < 8 h; clear fluids < 2 h; D: solid food ≥2 h < 6 h; clear fluids < 2 h; E: solid food < 2 h; clear fluids < 2 h.

Results

Incidence rate of vomiting of women was lower in group C (solid food ≥6 h < 8 h and clear fluids < 2 h) than other groups (P <  0.05). Compared with the fasting for a long time (groups A and B: solid food > 8 h and clear fluids > 2 h at least), the incidence rate of hypoglycemia and acidosis of neonates in group C displayed a certain decrease (P <  0.05). Although shorter fasting times (solid food < 6 h at least) reduced the incidence of hypoglycemia and acidosis in neonates, it increased the risk of vomiting of women.

Conclusion

The preoperative fasting of solid food ≥6 h < 8 h and clear fluids < 2 h reduces the incidence of vomiting in women’s anesthesia and the risk of hypoglycemia and acidosis in neonates.

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.