1
|
Rüggeberg A, Meybohm P, Nickel EA. Preoperative fasting and the risk of pulmonary aspiration-a narrative review of historical concepts, physiological effects, and new perspectives. BJA OPEN 2024; 10:100282. [PMID: 38741693 PMCID: PMC11089317 DOI: 10.1016/j.bjao.2024.100282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 03/27/2024] [Indexed: 05/16/2024]
Abstract
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.
Collapse
Affiliation(s)
- Anne Rüggeberg
- Department of Anaesthesiology and Pain Therapy, Helios Klinikum Emil von Behring, Berlin, Germany
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Eike A. Nickel
- Department of Anaesthesiology and Pain Therapy, Helios Klinikum Emil von Behring, Berlin, Germany
| |
Collapse
|
2
|
Alsharkh WS, Aljuaid M, Huda AU, Bawazir A, Alharbi A, Alharbi N. Effect of total fasting hours on the overall quality of recovery after surgery: An observational study. Saudi J Anaesth 2023; 17:373-377. [PMID: 37601496 PMCID: PMC10435811 DOI: 10.4103/sja.sja_71_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 02/21/2023] [Accepted: 02/26/2023] [Indexed: 08/22/2023] Open
Abstract
Context Preoperative fasting is one of the pre-requisite for patients undergoing a surgery. Despite clear instructions, patients frequently fast for extended periods before elective surgeries. Longer periods of fasting may cause discomfort, thirst, hunger, and other physiological problems. Aims To assess the quality of postoperative recovery among adult patients having different preoperative fasting hours by using the postoperative Quality of Recovery40 (QoR40) score. Settings and Design This was an observational study that was conducted for adult patients undergoing elective surgery during four weeks between 19th September and 13th October 2022 at Security Forces Hospital Riyadh, Kingdom of Saudi Arabia. Methods and Material We excluded pediatric patients, patients undergoing spine or neurosurgery, emergency cases, or local anesthesia cases. Non-probability convenient sampling technique was used in this study. The postoperative quality of recovery-40 (QoR-40) questionnaire was distributed among 200 patients. Statistical Analysis Used All analyses were performed with Statistical Package for the Social Sciences software (SPSS) v25. Descriptive statistics (frequency, percentage, median, and IQR) were used for the questionnaire's variables. The difference between the variables was analyzed using Kruskal-Wallis, and a P value <0.05 was considered statistically significant. Results Out of 200 patients, 172 patients responded but 16 responses were excluded. A total of 156 adult patients' responses were included in this study. The majority were female (53%), 31% were older than 45 years. More than 50% of patients reported fasting for more than 6 hours for drinking and more than 8 hours for eating. On the positive scale, the comfort score was significantly affected by the fasting hours for drinking (P value = 0.045). On the negative scale of the questionnaire, the emotions were significantly affected by fasting hours for both drinking (P value = 0.027) and eating (P value = 0.043). Conclusions The study results showed better comfort for patients with lesser fasting hours for drinking. Moreover, the results strongly suggest the need of following the fasting guidelines without prolonging the fasting duration. However, further studies with larger sample sizes are recommended.
Collapse
Affiliation(s)
- Wejdan S. Alsharkh
- Department of Anesthesia, Security Forces Hospital, Riyadh, Saudi Arabia
| | - Mohammad Aljuaid
- Department of Health Administration, College of Business Administration, King Saud University, Riyadh, Saudi Arabia
| | - Anwar U. Huda
- Department of Anesthesia, Security Forces Hospital, Riyadh, Saudi Arabia
| | - Atheer Bawazir
- Department of Anesthesia, Security Forces Hospital, Riyadh, Saudi Arabia
| | - Abdullah Alharbi
- Department of Anesthesia, Security Forces Hospital, Riyadh, Saudi Arabia
| | - Nouf Alharbi
- Department of Health Administration, College of Business Administration, King Saud University, Riyadh, Saudi Arabia
| |
Collapse
|
3
|
Hommel E, Sissoho FB, Chang K, Suthar K. Reducing the use of nil per os past midnight for inpatient diagnostic and therapeutic procedures: A quality improvement initiative. J Hosp Med 2023; 18:375-381. [PMID: 36806907 PMCID: PMC10186274 DOI: 10.1002/jhm.13066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 01/07/2023] [Accepted: 02/02/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND Pre-procedural fasting (nil per os [NPO]) is a commonly implemented protocol to prevent aspiration during certain diagnostic and therapeutic procedures. However, evidence suggests aspiration risk is quite low. Current guidelines support a reduced fasting duration before procedures necessitating anesthesia or sedation, but many health systems persist in the use of NPO past midnight. OBJECTIVE We aimed to reduce the use of NPO p MN before inpatient diagnostic and therapeutic procedures necessitating anesthesia or sedation by 50% within 6 months. DESIGN, SETTING AND PARTICIPANTS We performed a quality improvement initiative at a single academic health system in Southeast Texas. We include the experience of patients of all ages across 4 affiliated hospitals (one main academic hospital and three community satellite hospitals). INTERVENTION An interprofessional team was convened to review best practices and oversee this quality improvement initiative. Diagnostic imaging protocols previously requiring NPO were amended to reflect evidence-based fasting requirements. A pre-procedure clear liquid diet was also implemented. MAIN OUTCOME AND MEASURES We describe the steps to implementation, feasibility of implementation as described through key process measures, and the safety of implementation (balancing measures). RESULTS NPO requirements were removed from 70% of existing diagnostic imaging and therapeutic orders. After these amended protocols and the implementation of a pre-procedure clear liquid diet, we displayed an immediate 50% reduction in NPO past midnight usage. Further stakeholder engagement/education and targeted interventions reduced NPO past midnight usage to only 33% of pre-procedural diet orders. Surgery remains the most common indication for continued use of NPO. Aspiration events and procedural delays were rare.
Collapse
Affiliation(s)
- Erin Hommel
- The University of Texas Medical Branch, Department of
Medicine, Division of Geriatrics and Palliative Care, Galveston, TX
| | - Fatoumatta B. Sissoho
- The University of Texas Medical Branch, Department of
Medicine, Division of Geriatrics and Palliative Care, Galveston, TX
| | - Karen Chang
- The University of Texas Medical Branch, School of
Medicine, Galveston, TX
| | - Krishna Suthar
- Baylor Scott & White, Department of Internal Medicine,
Division of Hematology & Medical Oncology, Temple, TX
| |
Collapse
|
4
|
Arab S, Yaghmaei M, Mokhtari M. The Effect of Various Pre-Cesarean Fasting Times on Maternal and Neonatal Outcomes. Adv Biomed Res 2022; 11:104. [PMID: 36660761 PMCID: PMC9843591 DOI: 10.4103/abr.abr_118_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 06/07/2022] [Accepted: 06/08/2022] [Indexed: 01/21/2023] Open
Abstract
Background Although it is currently recommended that patients avoid solid food for 6-8 h and liquid for 2 h before cesarean section, longer restrictions still apply in many centers. Since studies on the duration of fasting before cesarean section is scarce, we aimed to investigate the effect of different fasting times before cesarean section on maternal and neonatal complications. Materials and methods This descriptive study was performed on 405 candidates for cesarean section. These women were divided into five groups due to the length of time they did not consume clear liquid and solid food. Then, maternal and neonatal outcomes were compared using Kruskal-Wallis and Chi-square tests. Results The rate of nausea during surgery was lower in the groups who ate solid food between 2 and 8 h and clear liquid <2 h before surgery (P = 0.04). Also, abdominal distension in the first 6 h after surgery in the group that did not eat solid food for <6-8 h and clear liquid for <2 h was more than in the other groups (P < 0.05). The prevalence of hypoglycemia was significantly lower in women who ate solid food for <6 h and drank clear liquid for <2 h (P < 0.05). Conclusion Prolonged fasting time before cesarean section not only reduce complications but also may have undesirable consequences. The results of this study showed that it is better to use less strict measures in patients who are candidates for cesarean section and in patients with labor pains who are likely to have a cesarean section.
Collapse
Affiliation(s)
- Sogol Arab
- Resident of Obstetrics and Gynecology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Minoo Yaghmaei
- Preventative Gynecology Research Center (PGRC), Department of Obstetrics and Gynecology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mojgan Mokhtari
- Shahid Akbarabadi Clinical Research Development Unit (ShACRDU), Department of Obstetrics and Gynecology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran,Address for correspondence: Dr. Mojgan Mokhtari, Akbarabadi Hospital, Molavi Street, Bagh-e-Ferdous, Tehran, Iran. E-mail:
| |
Collapse
|
5
|
Mehdiratta L, Bajwa SJS, Kurdi MS. A tripartite challenge of orphaned manuscripts, heedless writing and reluctant reviewing...... revamping the editing process! Indian J Anaesth 2022; 65:777-781. [PMID: 35001948 PMCID: PMC8680421 DOI: 10.4103/ija.ija_979_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 11/08/2021] [Accepted: 11/08/2021] [Indexed: 01/09/2023] Open
Affiliation(s)
- Lalit Mehdiratta
- Department of Anaesthesiology, Critical Care and Emergency Medicine, Narmada Trauma Centre, Bhopal, Madhya Pradesh, India
| | - Sukhminder Jit Singh Bajwa
- Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Banur, Patiala, Punjab, India
| | - Madhuri S Kurdi
- Department of Anaesthesiology, Karnataka Institute of Medical Sciences (KIMS), Hubli, Karnataka, India
| |
Collapse
|
6
|
Paul PA, Joselyn AS, Pande PV, Gowri M. A cross sectional, observational study to evaluate the surgeons' knowledge and perspective on preoperative fasting guidelines in a tertiary care teaching hospital in Southern India. J Anaesthesiol Clin Pharmacol 2022; 38:434-439. [PMID: 36505197 PMCID: PMC9728431 DOI: 10.4103/joacp.joacp_413_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 11/30/2020] [Accepted: 03/07/2021] [Indexed: 12/15/2022] Open
Abstract
Background and Aims The preoperative fasting orders given by the Anesthesiologists as per ASA and Enhanced Recovery After Surgery protocol, are often modified by the surgeons, for practical convenience, which can end up with patients being starved for prolonged periods of time. Hence, this study was conducted among various specialty surgical colleagues, to evaluate the knowledge and their perspective regarding patients' preoperative fasting guidelines. Material and Methods A validated questionnaire was distributed to 68 surgeons belonging to various surgical specialties, which included consultants and postgraduate residents. The surgeons were grouped as surgeons operating only on children, only on adults, and on adults and children (mixed). Data were summarized using the mean (SD)/median for continuous variables and categorical data were expressed as frequency and percentage. The difference in knowledge score, among the surgeons of three groups, was analyzed using ANOVA, with Bonferroni as post hoc. Results This study shows an overall decrease in knowledge (score of 6.13 ± 1.74) about preoperative fasting guidelines among surgeons. We found that the level of knowledge about preoperative fasting guidelines and complications was higher among surgeons who operate only on children (score of 7.05) as compared to surgeons operating only on adults (score 5.5) and adults and children (mixed) (score 6.1), which was statistically significant (P = 0.013). We found no difference in knowledge level based on designation and gender. All the surgeons uniformly had the perspective that patients have to be kept fasting preoperatively. Conclusion Preoperative fasting orders for all surgical patients, especially for vulnerable patients such as children and geriatrics, should be administered by the anesthesiologist or surgeon who is familiar with fasting guidelines. We intend to raise the awareness of fasting guidelines of surgical colleagues by putting up placards and posters in the wards.
Collapse
Affiliation(s)
| | - Anita Shirley Joselyn
- Department of Anaesthesia, Christian Medical College and Hospital, Vellore, Tamil Nadu, India,Address for Correspondence: Dr. Anita Shirley Joselyn, Department of Anaesthesia, Christian Medical College & Hospital, Vellore - 632 002, Tamil Nadu, India. E-mail:
| | - Priyanka Vandana Pande
- Department of Pediatric Emergency, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Mahasampath Gowri
- Department of Biostatistics, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| |
Collapse
|
7
|
Puri K, Kundal R, Kundal V, Pawar JG, Kumar A, Choudhury SR. Influence of Parental Awareness Drive on Preoperative Fasting Compliance in Pediatric Day Care Surgery. J Indian Assoc Pediatr Surg 2022; 27:236-240. [PMID: 35937103 PMCID: PMC9350648 DOI: 10.4103/jiaps.jiaps_390_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/16/2021] [Accepted: 04/21/2021] [Indexed: 11/30/2022] Open
Abstract
CONTEXT Optimum preoperative fasting is imperative for the prevention of aspiration in pediatric patients. The current guidelines advocate 2-4-6 rule for the same. However, direct supervision is lacking in large volume centers. AIMS Thus, we aimed to determine the fasting compliance of children preoperatively and to ascertain whether parents understood the significance and purpose of optimum fasting. MATERIALS AND METHODS Design - A prospective questionnaire-based study regarding preoperative fasting was performed in pediatric patients aged 1-10 years scheduled for "day care surgery" or "same day admission surgery" over 12 weeks. Thereafter, parental awareness drive was carried out, and a re-audit was performed with a questionnaire in the next cohort of patients. RESULTS The number of patients in the pre and postcounseling groups were 98 and 99. Thirteen percent of the patients were optimally fasted for solids initially. Re-audit confirmed compliance increased to 46%. Patients fasting adequately (2-3 h) for clear fluids increased from 22.4% to 51.5% postcounseling. The number for optimally breast-fed children increased postaudit (23.1%-39.1%). Consequent to the drive, parental awareness increased and 49.5% parents knew that only plain water was permitted during fasting. Number of parents considering preoperative fasting important increased from 39.8% to 79.7%. Initially, 27.6% of the parents did not know the reason for fasting, which reduced to 3% postaudit. CONCLUSION Parents are misinformed and ignorant about optimum preoperative fasting. Adequate education and awareness to improve their knowledge was associated with increased compliance for optimal fasting.
Collapse
Affiliation(s)
- Kriti Puri
- Department of Anesthesiology, Lady Hardinge Medical College, Kalawati Saran Children's Hospital, New Delhi, India
| | - Raksha Kundal
- Department of Anesthesiology, Lady Hardinge Medical College, Kalawati Saran Children's Hospital, New Delhi, India,Address for correspondence: Dr. Raksha Kundal, Department of Anesthesiology, Lady Hardinge Medical College, Kalawati Saran Children's Hospital, New Delhi, India. E-mail:
| | - Vijay Kundal
- Department of Pediatric Surgery ABVIMS, Dr RML Hospital, New Delhi, India
| | | | - Ajai Kumar
- Department of Anesthesiology, Lady Hardinge Medical College, Kalawati Saran Children's Hospital, New Delhi, India
| | - Subhasis Roy Choudhury
- Department of Pediatric Surgery, Lady Hardinge Medical College, Kalawati Saran Children's Hospital, New Delhi, India
| |
Collapse
|
8
|
Zhu Q, Li Y, Deng Y, Chen J, Zhao S, Bao K, Lai L. Preoperative Fasting Guidelines: Where Are We Now? Findings From Current Practices in a Tertiary Hospital. J Perianesth Nurs 2021; 36:388-392. [PMID: 33678495 DOI: 10.1016/j.jopan.2020.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/31/2020] [Accepted: 09/07/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE New evidence-based fasting guidelines have been published in recent years. However, while water and solid food fasting times before anesthesia are recommended to be 2 and 6 hours, respectively, these times are often longer in clinical practice. This study aimed to investigate the awareness and implementation of the fasting guideline recommendations among nurses and anesthesiologists, as well as evaluate the actual fasting durations in patients in a tertiary hospital. DESIGN A cross-sectional study was used. METHODS Questionnaires were designed to collect the knowledge of fasting time among registered anesthesiologists and nurses. Data on the instructed and actual fasting durations among patients scheduled for elective surgery were evaluated. FINDINGS Approximately half of the nurses indicated that solid food fasting durations were shorter than 6 hours or longer than 8 hours, and two-thirds indicated that clear fluid fasting durations were shorter than 2 hours or longer than 4 hours. However, in clinical practice, nurse-instructed fasting durations were longer than what they knew was optimal. The anesthesiologists also prescribed longer fasting durations than the minimum fasting duration recommended. The actual fasting durations of the patients were significantly longer than the nurse-instructed fasting durations for solid food (13.41 ± 2.64 vs 9.87 ± 2.20 hours, P < .001) and clear fluids (10.27 ± 3.67 vs 8.98 ± 2.90 hours, P < .001). The nurse-instructed durations were significantly longer than the anesthesiologist-instructed durations according to the statements of patients (9.87 ± 2.20 vs 9.00 ± 2.00 hours for solid food, P < .001; 8.98 ± 2.90 vs 6.15 ± 3.25 hours for clear fluids, P < .001). CONCLUSIONS Excessive fasting durations were observed among patients. Anesthesiologists and nurses must work together to ensure that updated fasting instructions are implemented in routine clinical practice.
Collapse
Affiliation(s)
- Qianqian Zhu
- Department of Anesthesiology, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen City, People's Republic of China.
| | - Yamei Li
- Department of Urology, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen City, People's Republic of China
| | - Yingqing Deng
- Department of Anesthesiology, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen City, People's Republic of China
| | - Jiaxin Chen
- Department of Anesthesiology, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen City, People's Republic of China
| | - Shuhua Zhao
- Department of Anesthesiology, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen City, People's Republic of China
| | - Kaibei Bao
- Department of Anesthesiology, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen City, People's Republic of China
| | - Lifei Lai
- Department of Anesthesiology, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen City, People's Republic of China
| |
Collapse
|
9
|
Tarboush NA, Alkayed Z, Alzoubi KH, Al-Delaimy WK. The understanding of research ethics at health sciences schools in Jordan: a cross-sectional study. BMC MEDICAL EDUCATION 2020; 20:121. [PMID: 32316962 PMCID: PMC7175529 DOI: 10.1186/s12909-020-02040-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 04/13/2020] [Indexed: 05/10/2023]
Abstract
BACKGROUND Research ethics is required for high-quality research that positively influences society. There is limited understanding of research ethics in Middle Eastern countries including Jordan. Here, we aim to investigate the level of understanding of research ethics principles among health sciences faculty members in Jordan. METHODS This is a cross sectional study where faculty members from the University of Jordan were surveyed for their knowledge and, attitude of research ethics principles. The study was conducted in the period between July 2016 to July 2017 using a customized-design questionnaire involving demographic data and participants' contributions toward research, and assessment of participants' knowledge, belief and attitude towards research ethics. Different question-formats have been used including multiple-choice, yes or no, and a four point Likert-type questions. Obtained responses were tabulated according to gender, academic-rank, and knowledge about research ethics principles. RESULTS The study had a response rate of 51%. Among the 137 participants of this study, most (96%) were involved in human and animal research, yet, only 2/3 had prior training in research ethics. Moreover, 91% believed that investigators should have training in research ethics and 87% believed that there should be a mandatory postgraduate course on that. The average correct scores for correct understanding of researchers towards research ethics was 62%. Yet, there were some misconceptions about the major ethical principles as only 43% identified them correctly. Additionally, the role of research ethics committees was not well understood by most of the respondents. CONCLUSIONS Although there is acceptable knowledge about research ethics, discrepancies in understanding in research ethics principles seems to exist. There is a large support for further training in responsible conduct of research by faculty in health sciences in Jordan. Thus, such training should be required by universities to address this knowledge gap in order to improve research quality and its impact on society.
Collapse
Affiliation(s)
- Nafez Abu Tarboush
- Department of Biochemistry and Physiology, School of Medicine, The University of Jordan, Amman, 11942, Jordan.
| | - Zaid Alkayed
- Internal Medicine Unit, Psychiatry Division, Jordan University Hospital, Amman, Jordan
| | - Karem H Alzoubi
- Department of Clinical Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Wael K Al-Delaimy
- Department of Family Medicine and Public Health, University of California San Diego, San Diego, CA, USA
| |
Collapse
|