Reducing preoperative fasting time: A trend based on evidence

Routine Nil Per Os Before All Cardiac Catheterisations: Time to Reconsider?

Nil per os (NPO) is a common instruction before cardiac catheterisation. NPO was originally adopted from general surgery to minimise gastric contents during procedures and reduce the risk of pulmonary aspiration in case of vomiting. However, NPO has since been associated with adverse effects on patient well-being, fasting-related complications, and increased health care costs. These burdens are multiplied by the large number of cardiac catheterisations performed. Advances in anaesthesia and contrast agents may have rendered preprocedural fasting obsolete. Here, we examine the evidence for and against routine NPO practices and consider the possible value of a more targeted approach. Current evidence strongly suggests that not fasting before cardiac catheterisation does not significantly increase the risk of pulmonary aspiration or other complications. Therefore, while further large-scale trials are on-going to confirm the safety of nonfasting, hospitals should begin to reduce fasting periods whenever possible. New guidelines should stratify patients by their risk of aspiration, reserving NPO only for those at high risk.

Preoperative Oral Carbohydrate for Lower Extremity Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

The purpose of this study was to evaluate the effects of preoperative oral carbohydrate (CHO) loading on postoperative insulin resistance, hospital stay, and pain in patients undergoing elective arthroplasty.

METHODS

Clinical randomized controlled trials on the effects of preoperative oral CHO loading in patients undergoing elective hip and knee arthroplasty were searched on PubMed, Web of Science, Cochrane Library, Embase, Chinese Biomedical Literature Database, and China National Knowledge Infrastructure (CNKI) from inception to February 2024. The Cochrane Risk of Bias Assessment Tool was used to evaluate the quality of the enrolled randomized controlled trials.

RESULTS

There were 16 papers included. Meta-analysis unveiled that compared with the control group, the test group had notably reduced postoperative anxiety scores [standardized mean difference = -0.06, 95% CI (confidence interval) (-0.42 to 0.30)] and complication rates [OR (odds ratio) = 0.64, 95% CI (0.41 to 0.99)] and enhanced postoperative active GLP-1 levels after preoperative oral CHO loading [standardized mean difference = 0.46, 95% CI (0.06 to 0.86)]. There was no marked difference in postoperative blood glucose levels, hospitalization time, insulin levels, and pain score.

CONCLUSIONS

Available evidence suggests that preoperative oral CHO loading in patients undergoing arthroplasty may reduce related complications, improve postoperative active GLP-1 levels, and alleviate postoperative anxiety.

Development of Predictive Model of Surgical Case Durations Using Machine Learning Approach

Optimizing operating room (OR) utilization is critical for enhancing hospital management and operational efficiency. Accurate surgical case duration predictions are essential for achieving this optimization. Our study aimed to refine the accuracy of these predictions beyond traditional estimation methods by developing Random Forest models tailored to specific surgical departments. Utilizing a comprehensive dataset, we applied several machine learning algorithms, including RandomForest, XGBoost, Linear Regression, LightGBM, and CatBoost, and assessed their performance using Mean Absolute Error (MAE), Root Mean Squared Error (RMSE), and R-Squared (R2) metrics. Our findings highlighted that Random Forest models excelled in department-specific applications, achieving an MAE of 16.32, an RMSE of 31.19, and an R2 of 0.92, significantly outperforming general models and conventional estimates. This improvement emphasizes the advantage of customizing models to fit the distinct characteristics and data patterns of each department. Additionally, our SHAP-based feature importance analysis identified morning operation timing, ICU ward assignments, operation codes, and surgeon IDs as key factors influencing surgical duration. This suggests that a detailed and nuanced approach to model development can substantially increase prediction accuracy. By providing a more accurate, reliable tool for predicting surgical case durations, our department-specific Random Forest models promise to enhance surgical scheduling, leading to more effective OR management. This approach underscores the importance of leveraging tailored, data-driven models to improve healthcare outcomes and operational efficiency.

Interventions to optimise preoperative fasting in paediatrics: a scoping review

BACKGROUND

Preoperative fasting is the standard of care for patients undergoing a procedure under general anaesthesia. Despite the increased leniency of fasting guideline recommendations, prolonged preoperative fasting periods continue to disproportionally affect paediatric patients. This review maps existing interventions optimising paediatric fasting practices, to explore strategies that can be best applied in clinical practice.

METHODS

A search strategy applied to PubMed, CINAHL, Embase, Scopus, and the Cochrane Database involved four key concepts: (1) fasting, (2) preoperative, (3) paediatric, and (4) quality improvement intervention. The Preferred Reporting Items of Systematic Reviews and Meta-analyses extension for Scoping Reviews was utilised in this review.

RESULTS

Thirteen heterogeneous studies, involving approximately 31 000 children across five continents, were included. Each intervention studied fell into at least one of the following six themes: (1) change in facility protocol, (2) technology-based intervention, (3) individualised fasting programs, (4) processes to improve communication between clinicians, (5) processes to improve communication to parents and families, and (6) staff education.

CONCLUSIONS

A variety of interventions have been studied to optimise paediatric preoperative fasting duration. These interventions show potential in reducing preoperative fasting duration.

Nurses' Recognition and Care of Thirst in Perioperative Patients in Japan

PURPOSE

Postoperative thirst is common and distressing to patients, as is pain and nausea. The causes of postoperative thirst are complex and include factors like preoperative fasting, perioperative fluid loss, and certain anesthesia medications. Effective care for postoperative thirst has been shown in post-anesthesia care units (PACUs), but many Japanese hospitals lack PACUs or do not address thirst in their PACUs. Therefore, cooperation between the operating room and ward nurses is crucial for providing proper care for postoperative thirst. The purpose of this study was to clarify the actual situation of ward nurses' and operating room nurses' recognition and care of thirst in postoperative patients.

METHODS

The study was a cross-sectional survey conducted using a self-administered questionnaire based on previous research. Study participants were nurses working in surgical wards and operating rooms of two university-affiliated hospitals. The survey items included (1) participants' characteristics, (2) recognition of thirst in perioperative patients, and (3) actual care provided to perioperative patients for thirst. Data were collected between September and October 2022 and subjected to descriptive and bivariate analysis.

FINDINGS

A total of 298 ward nurses and 43 operating room nurses were included in the study. Among the observation items, thirst was observed least frequently. Both ward nurses and operating room nurses recognized patient thirst based on complaints rather than physical observations. Sharing of information about patient thirst differed between ward nurses and operating room nurses. None of the participants used scales or scores to evaluate thirst. The most common postoperative care in the ward was "They were asked to do a mouthwash with water," while in the operating room, it was "Placed a moistened gauze against the mouth." The reasons for selecting a particular type of care were primarily based on "Because of the patient's wishes" and "I think it is effective," while the reasons for not providing care included "Because there is an instruction not to drink water," "Due to the possibility of aspiration," "I don't have the knowledge and don't know how," and "I'm busy with other work."

CONCLUSIONS

Regarding the recognition of thirst, both ward nurses and operating room nurses recognized patient thirst most often when the patient directly reported feeling thirsty. They relied more on patients' verbal complaints than physical observations to recognize thirst. Both surgical ward nurses and operating room nurses provided care based on their experience.

Preoperative free access to water compared to fasting for planned cesarean under spinal anesthesia: a randomized controlled trial

BACKGROUND

Contemporary guidance for preoperative feeding allows solids up to 6 hours and clear fluids up to 2 hours before anesthesia. Clinical trial evidence to support this approach for cesarean delivery is lacking. Many medical practitioners continue to follow conservative policies of no intake from midnight to the time of surgery, especially in pregnant women.

OBJECTIVE

This study aimed to evaluate the pragmatic approach of permitting free access to water up to the call to dispatch to the operating theater vs fasting from midnight in preoperative oral intake restriction for planned cesarean delivery under spinal anesthesia on perioperative vomiting and maternal satisfaction.

STUDY DESIGN

A randomized controlled trial was conducted in the obstetrical unit of the University of Malaya Medical Centre from October 2020 to May 2022. A total of 504 participants scheduled for planned cesarean delivery were randomized: 252 undergoing preoperative free access to water up to the call to dispatch to the operating theater (intervention group) and 252 undergoing fasting from midnight (fasting arm). The primary outcomes were perioperative vomiting and maternal satisfaction. Analyses were performed using t test, Mann-Whitney U test, and chi-square test, as appropriate.

RESULTS

Of note, 9 of 252 patients (3.6%) in the intervention group and 24 of 252 patients (9.5%) in the control group had vomiting at up to 6 hours after completion of cesarean delivery (relative risk, 0.38; 95% confidence interval, 0.18-0.79; P=.007), and the maternal satisfaction scores (0-10 visual numerical rating scale) were 9 (interquartile range, 8-10) in the intervention group and 5 (interquartile range, 3-7) in the control group (P<.001). Assessed before dispatch to the operating theater, feeling of thirst was reported by 69 of 252 patients (27.4%) in the intervention group and 134 of 252 patients (53.2%) in the control group (relative risk, 0.52; 95% confidence interval, 0.41-0.65; P<.001), capillary glucose levels were 4.8±0.7 mmol/L in the intervention group and 4.9±0.8 mmol/L in the control group (P=.048), and preoperative intravenous fluid hydration was commenced in 49 of 252 patients (19.4%) in the intervention group and 76 of 252 patients (30.2%) in the control group (relative risk, 0.65; 95% confidence interval, 0.47-0.88; P=.005). In the operating theater, ketone was detected in the catheterized urine in 38 of 252 patients (15.1%) in the intervention group and 78 of 252 patients (31.0%) in the control group (relative risk, 0.49; 95% confidence interval, 0.25-0.59; P<.001), and the numbers of doses of vasopressors needed to correct hypotension were 2.3±1.7 in the intervention group and 2.7±2.2 in the control (P=.009). The recommendation rates for preoperative oral intake regimen to a friend were 95.2% (240/252) in the intervention group and 39.7% (100/252) in the control group (relative risk, 2.40; 95% confidence interval, 2.06-2.80; P<.001), in favor of free access to water. Other assessed maternal and neonatal outcomes were not different.

CONCLUSION

Compared with fasting, free access to water in planned cesarean delivery reduced perioperative vomiting and was strongly favored by women. In addition, several pre- and intraoperative secondary outcomes were improved. However, postcesarean delivery recovery and neonatal outcomes were not different.

The Effect of Menthol Ice on Laparoscopic Cholecystectomy Patients' Thirst, Dry Mouth, Mouth Taste, and Bad Mouth Odor: A Randomized Controlled Trial

PURPOSE

This study aimed to determine the effect of menthol ice application on thirst, dry mouth, mouth taste, and bad mouth odor in patients who underwent laparoscopic cholecystectomy in the postoperative period.

DESIGN

The study was conducted as a randomized controlled trial with an experimental design.

METHODS

The study sample consisted of 90 patients who underwent laparoscopic cholecystectomy and met the inclusion criteria. Patients were divided into three groups by randomization program. Patients in the menthol ice and ice popsicle (ice prepared with drinking water only) group were administered menthol ice/ice popsicle (10 mL) twice at 20 minutes intervals. Patients in the control group did not receive any intervention. Routine practices of the clinic were performed by the nurses of the general surgery clinic. Postoperative thirst intensity, severity of dry mouth, bad taste, and bad odor in the mouth were evaluated at 0, 20, and 40 minutes.

FINDINGS

No statistically significant difference was found between the sociodemographic and clinical characteristics of the patients in the control group, menthol ice group, and ice popsicle group (P > .05). A statistically significant difference was found between the 3 groups in terms of thirst intensity and severity of dry mouth at times at the 20th and 40th minutes after the application (P < .01). We found a statistically significant difference between the bad taste and bad odor sensation scores of the patients in the control and intervention groups at the 20th and 40th minutes after the application (P < .05).

CONCLUSIONS

The study concluded that menthol ice and ice popsicle application are effective strategies to reduce the intensity of thirst, severity of dry mouth, bad taste, and bad odor in postoperative patients.

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.

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.

Association Between Nil Per Os Status and Intubated Patients Undergoing Surgery

INTRODUCTION

Patient outcomes heavily rely on nutritional support. However, holding enteric feeds prior to surgical operations in critically ill patients is still a common practice in intensive critical units. Our objective is to describe the relationship between duration of nil per os (NPO) and respiratory outcomes in intubated, critically ill patients requiring operative intervention.

METHODS

We conducted a retrospective analysis on intubated, critically ill patients who underwent operative intervention between January 1, 2016, and December 31, 2018, to investigate how the duration of NPO status may affect respiratory outcomes. We compared adverse respiratory events among patients who maintain NPO ≥6 h (NPO group) versus those who were NPO <6 h (non-NPO group) prior to surgery.

RESULTS

Two hundred patients met inclusion criteria: 104 for NPO and 96 for non-NPO. Aspiration event was found in 5.8% of NPO patients and 7.3% in non-NPO patients, P = 0.66. Desaturation event was found in 16.3% for NPO and 14.6% in non-NPO, P = 0.73. Pneumonia was found in 18.3% of NPO patients and 19.8% in non-NPO patients, P = 0.78. Reintubated rates were 13.5% for NPO and 16.7% for non-NPO, P = 0.57. Median (range) hours of NPO for non-NPO was 1.0 h (0-3.0) and 13.0 h (6.0-20.0) for NPO, P < 0.05.

CONCLUSIONS

For intubated, critically ill patients requiring operative intervention, there was no difference observed in adverse respiratory events between those kept NPO for 6 h or greater compared to those kept NPO for less than 6 h. Patients were commonly without enteric nutrition for periods of time much greater than the American Society of Anesthesia's recommended 6-h period.

Registered nurses' knowledge and practice of preoperative fasting and medication administration

Background

Knowledge of fasting or Nil Per Os (NPO) guidelines is an essential component of nursing care in the preoperative period.

Aim

To describe registered nurses' (RNs) knowledge and management of the preoperative NPO period.

Setting

Selected surgical wards in a tertiary hospital in the Western Cape, South Africa.

Methods

Quantitative descriptive, cross-sectional study utilising a structured questionnaire. The population consisted of RNs working in selected surgical wards. Convenience sampling was used and adequate knowledge was determined as ≥ 90%.

Results

The response rate was 100%. Of the 68 participants, 48 (70.6%) held a diploma and 20 (29.4%) held a degree as the highest academic qualification achieved. Sixty-one (89.7%) participants knew the correct reason for keeping patients NPO. Sixty-five (95.6%) knew the correct answer for the NPO time for solids while only 27 (39.7%) knew the correct answer for clear fluids. Only 30 (44.1%), 26 (38.2%) and 33 (48.5%) participants, respectively, answered the questions about oral analgesia, oral antibiotics and chronic medication administration during the NPO period correctly. Significantly more degree participants knew the correct answer for the fasting time for non-human milk (p = 0.005) and more diploma participants would administer chronic medication during the NPO period (p = 0.037).

Conclusion

Inadequate knowledge of NPO times for various fluids and unsatisfactory practice of medication administration for oral and chronic medication require attention.

Contribution

This study highlights the importance that ongoing education is needed to ensure that patients receive the most up-to-date evidence-based care during the NPO period.

RESIDUAL GASTRIC VOLUME IN MORBIDLY OBESE DIABETICS AFTER AN OVERNIGHT FASTING OR 3 HOURS OF A CARBOHYDRATE-ENRICHED SUPPLEMENT: A RANDOMIZED CROSSOVER PILOT STUDY

BACKGROUND

To reduce the risk of regurgitation during anesthesia for elective procedures, residual gastric volumes (RGV) have traditionally been minimized by overnight fasting. Prolonged preoperative fasting presents some adverse consequences and has been abandoned for most surgical procedures, except for obese and/or diabetic patients.

AIMS

The aim of this study was to assess the RGV in morbidly obese diabetic patients after traditional or abbreviated fasting.

METHODS

This study was approved by the Ethics Committee for Research with Human Beings from the Federal University of Mato Grosso, under number 179.017/2012. This is a prospective, randomized, and crossover design study in eight morbidly obese type II diabetic patients. RGV was measured endoscopically after either traditional overnight fasting of at least 8 hours, or after abbreviated fasting of 6 hours for solids and 3 hours for a drink containing water plus 25 g (12.5%) of maltodextrin. Data were expressed as mean and range and differences were compared with paired t-tests at p<0.05.

RESULTS

The study population had a mean age of 41.5 years (28-53), weight of 135 kg (113-196), body mass index of 48.2 kg/m2 (40-62.4), and type II diabetes for 4.5 years (1-10). The RGV after abbreviated fasting was 21.5 ml (5-40) vs 26.3 ml (7-65) after traditional fasting. This difference was not significant (p=0.82).

CONCLUSIONS

Gastric emptying in morbidly obese diabetic patients is similar after either traditional or abbreviated fasting with a carbohydrate drink.

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.

Perioperative nutrition for gastrointestinal surgery: On the cutting edge

Evidence on perioperative nutrition interventions in gastrointestinal surgery is rapidly evolving. We conducted a narrative review of various aspects of nutrition support, including formula choice and route of administration, as well as duration and timing of nutrition support therapy. Studies have demonstrated that nutrition support is associated with improved clinical outcomes in malnourished patients and those at nutrition risk, emphasizing the importance of nutrition assessment, for which several validated nutrition risk assessment tools exist. The assessment of serum albumin levels has fallen out of favor, as it is an unreliable marker of nutrition status, whereas imaging evidence of sarcopenia has prognostic value and may emerge as a standard component of nutrition assessment. Preoperatively, evidence supports limiting fasting to reduce insulin resistance and improve oral tolerance. Benefits to preoperative carbohydrate loading remain unclear, whereas literature suggests preoperative parenteral nutrition (PN) may reduce postoperative complications in high-risk patients with malnutrition or sarcopenia. Postoperatively, early oral feeding is safe with benefits in time to return of bowel function and reduced hospital stay. There is a signal for potential benefit to early postoperative PN in critically ill patients, though evidence is sparse. There has also been a recent emergence in randomized studies evaluating the use of ω-3 fatty acids, amino acids, and immunonutrition. Meta-analyses have reported favorable outcomes for these supplements, though individual studies are small and with significant methodological limitations and risk of bias, emphasizing the need for high-quality randomized studies to guide clinical practice.

Effect of menthol lozenges after extubation on thirst, nausea, physiological parameters, and comfort in cardiovascular surgery patients: A randomized controlled trial

OBJECTIVES

To determine the effect of post-extubation oral menthol lozenges on thirst, nausea, physiological parameters, and comfort level in patients undergoing cardiovascular surgery.

RESEARCH METHODOLOGY/DESIGN

The study was a single-centre, randomized controlled trial.

SETTING

This study included 119 patients undergoing coronary artery bypass graft surgery in a training and research hospital. Patients in the intervention group (n = 59) received menthol lozenges at 30, 60, and 90 min after extubation. Patients in the control group (n = 60) received standard care and treatment.

MAIN OUTCOME MEASURES

The primary outcome of the study was the change in post-extubation thirst assessed by Visual Analogue Scale after using menthol lozenges compared to baseline. Secondary outcomes were changes in post-extubation physiological parameters and nausea severity assessed by Visual Analogue Scale compared to baseline, and comfort level assessed with Shortened General Comfort Questionnaire.

RESULTS

Between-group comparisons showed that the intervention group had significantly lower thirst scores at all time points and nausea at the first assessment (p < 0.05) and significantly higher comfort scores (p < 0.05) than the control group. There were no significant differences between the groups in physiological parameters at baseline or any of the postoperative assessments (p > 0.05).

CONCLUSION

In patients undergoing coronary artery bypass graft surgery, the use of menthol lozenges effectively increased comfort level by reducing post-extubation thirst and nausea, but had no effect on physiological parameters.

IMPLICATIONS FOR CLINICAL PRACTICE

Nurses should be vigilant for complaints such as thirst, nausea, and discomfort in patients after extubation. Nurses' administration of menthol lozenges to patients may help reduce post-extubation thirst, nausea, and discomfort.

Does the preoperative fasting period affect the liver in a distant organ model of renal ischaemia reperfusion?

OBJECTIVES

To experimentally evaluate the effects of preoperative fasting duration on distant organ liver in renal ischaemia-reperfusion (IR) injury.

METHODS

This is an experimental study. In the study, 3 groups were formed. In Group A, abdominal laparotomy was carried out after 12 hours of preoperative fasting without any IR damage. In Group B, IR injury was carried out after 12 hours of preoperative fasting, and abdominal laparotomy was carried out, in Group C after 2 hours of fasting after IR injury. Apoptosis, congestion, balloon degeneration, nuclear pleomorphism, and leukocyte infiltration were examined histopathologically and tumor necrosis factor-alpha (TNF-α), interleukin (IL) -1 beta, IL-6, and IL-10 were evaluated biochemically.

RESULTS

A statistically significant difference was determined between the groups in respect of postoperative IL-10 levels (p=0.020) with significantly lower levels determined in Group C than in Groups A and B (p=0.021). Similar rates of mild nuclear polymorphism were seen with no statistically significant difference determined between the groups (p>0.167). A statistically significant difference was determined between the groups in respect of the congestion scores (p<0.001), with a lower score in Group C than in Groups A and B, where the scores were similar (p<0.001, p=0.017).

CONCLUSION

With this result, it would be correct to say that the short preoperative fasting period has protective effects on the liver tissue.

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.

Adherence to pre-operative fasting guidelines and associated factors among pediatric surgical patients in selected public referral hospitals, Addis Ababa, Ethiopia: Cross sectional study

Background

Fasting before anesthesia is mandatory in children to reduce the complications of regurgitation, vomiting, and aspiration during anesthesia and surgery. Prolonged fasting times have several negative implications in children, because high fluid turnover quickly leads to dehydration, hypotension, metabolic disturbances, and hypoglycemia, resulting in poor anesthetic outcomes.

Aims

This study aimed to assess adherence to preoperative fasting guidelines and associated factors among pediatric patients undergoing elective surgery in Addis Ababa public hospitals in Ethiopia in 2020.

Methods

A cross-sectional survey was conducted in Addis Ababa, which selected public hospitals in Ethiopia, in 2020. A total of 279 pediatric patients aged <17 years scheduled for elective surgery were included in the study. Data analysis was performed using SPSS V.21, and the values of the variables and factors were checked for associations using logistic regression. Statistical significance was determined at P -value of <0.05. The results are presented in text, tables, charts, and graphs.

Results

A total of 279 pediatric patients responded to the analysis, with a 98.6% response rate. The majority of the participants (n = 251, 89.96%) did not follow the guidelines for preoperative fasting. The mean fasting time for clear liquids was 10 ± 4.03 (2-18 h) for breast milk 7.18 ± 2.26 (3.5-12 h), and for solid foods 13.5 ± 2.76 (8-19 h). The reasons for which the preoperative fasting delay was due to incorrect order were 35.1%, prior case procedures took longer times 34.1%, and changing sequence of schedule was 20.8%.

Conclusion

Most children had prolonged fasting. The staff's instructions and schedules were challenged to follow international fasting guidelines.

Effect of Carbohydrate-Enriched Drink Compared to Fasting on Hemodynamics in Healthy Volunteers. A Randomized Trial

Fasting prior to surgery can cause dehydration and alter hemodynamics. This study aimed to determine the impact of a carbohydrate-enriched drink (NutriciaTM Pre-op®) on selected hemodynamical parameters, measured in a non-invasive manner. We enrolled 100 healthy volunteers and measured their weight, height, systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), thoracic fluid content (TFC), thoracic fluid index (TFCI), stroke volume (SV), stroke volume variation (SVV), stroke index (SI), cardiac output (CO), cardiac index (CI), heather index (HI), systolic time ration (STR), systemic time ratio index (STRI), systemic vascular resistance (SVR), and systemic vascular resistance index (SVRI) by a Niccomo™ device, implementing the impedance cardiography (ICG) method. Measurements were performed at the beginning of the study, and after 10 h and 12 h. We randomly allocated participants to the control group and the pre-op group. The pre-op group received 400 mL of Nutricia™ preOp®, as suggested in the ERAS guidelines, within 10 h of the study. Student's t-test or the Mann-Whitney U test were used to compare the two groups, and p < 0.05 was considered significant. We did not observe any changes in hemodynamical parameters, blood pressure, and heart rate between the groups. We have proven that carbohydrate-enriched drink administration did not have a significant impact on the hemodynamical parameters of healthy volunteers.

The Effect of the Preoperative Fasting Regimen on the Incidence of Gastro-Oesophageal Reflux in 90 Dogs

Simple Summary

Gastro-oesophageal reflux (GOR), a potential risk during anaesthesia, happens when the stomach contents move up into the oesophagus. The refluxed contents can damage the lining of the oesophagus or the respiratory tract. For many years it was believed that an increase in the stomach contents’ volume increases the risk of GOR. However, more recent studies have demonstrated this to be incorrect. The objective of this study was to compare the effects of three different pre-anaesthetic fasting regimens on the frequency of GOR in dogs under anaesthesia. Ninety dogs undergoing non-abdominal and non-thoracic elective surgery were included in the study and equally allocated to three groups. The results of this study suggest that the administration of a meal 3 h before anaesthesia does not have any beneficial effect in the reduction of GOR incidence in dogs compared to the administration of a meal 12 h before anaesthesia.

Abstract

This study aimed to investigate the effect of three different preoperative fasting regimens on the incidence of gastro-oesophageal reflux (GOR) in dogs under general anaesthesia. Ninety dogs undergoing non-abdominal and non-thoracic elective surgery were included in the study and equally allocated to three groups. Dogs received canned food providing half the daily resting energy requirements (RER) 3 h prior to premedication (group 3H), a quarter of the daily RER 3 h before premedication (group 3Q), and half the daily RER 12 h before premedication (group 12H). The animals were premedicated with acepromazine and pethidine, anaesthesia was induced with propofol and maintained with isoflurane vaporised in oxygen. Oesophageal pH was monitored throughout anaesthesia. Demographic and surgery-related parameters were not different among groups. The incidence of GOR was 11/30 in group 3H (36.7%), 9/30 in group 3Q (30.0%) and 5/30 in group 12H (16.7%), which was not statistically different (p = 0.262). Reduction of the amount of the preoperative meal from half to a quarter of the daily RER did not reduce the incidence of GOR but resulted in a lower oesophageal pH (p = 0.003). The results of this study suggest that the administration of a meal 3 h before anaesthesia does not have any beneficial effect in the reduction of GOR incidence in dogs compared to the administration of a meal 12 h before anaesthesia.

The effect of shortening the preoperative fasting period on patient comfort and gastrointestinal function after elective laparoscopic surgery

OBJECTIVE

To explore the influence of shortening preoperative fasting on the comfort and gastrointestinal function of patients undergoing elective laparoscopic surgery.

METHODS

a total of 179 patients undergoing elective laparoscopic cholecystectomies (LC) in our hospital from March, 2019 to August, 2020 were recruited as the study cohort and placed into the research group (n=97) or the control group (n=82) according to different fasting periods assigned to each patient. In the control group, the patients were subjected to 12-h fasting and 6-h water deprivation before their surgeries, and the patients in the research group were subjected to 6-h fasting and 2-h water deprivation. The preoperative hunger and thirst, comfort, anxiety, and intraoperative aspiration, as well as the postoperative hospital stay durations, the blood glucose levels, the nausea and vomiting, the pain levels, and the times to the recovery of gastrointestinal function were compared between the two groups.

RESULTS

The research group had shorter hospital stay durations and decreased blood glucose levels. No intraoperative aspiration occurred in either group, and the incidence of postoperative nausea and vomiting in the research group was lower than it was in control group. The patients in the research group were less hungry and thirsty and were more comfortable in the preoperative period, and their preoperative self-rating anxiety scale (SAS) and postoperative visual analog scale (VAS) scores were lower than the corresponding scores in the control group. The times to first oral feeding, ambulation, anal flatus, defecation, and bowel sounds in the research group were earlier than they were in the control group.

CONCLUSION

Shortening preoperative fasting improves the comfort levels of patients undergoing elective LC, alleviates thirst and hunger, promotes the recovery of gastrointestinal function, and relieves preoperative anxiety, postoperative pain, and adverse reactions.

Effect of different preoperative fasting time on safety and postoperative complications of painless gastrointestinal endoscopy for polyps in patients

OBJECTIVE

To determine the effect of different preoperative fasting time on safety and postoperative complications of painless gastrointestinal endoscopy for polyps in patients.

METHODS

Enrolled patients were assigned to an observation group and a control group by the random number table method (each n=68). Before operation, each patient in the observation group was fasted from solids for 6 h and from liquids for 2 h, while each one in the control group was fasted from solids for 8-12 h and from liquids for 4 h according to the conventional method. The levels of blood glucose, insulin, potassium and sodium in patients before and after operation were determined, and their hunger and thirst were recorded before anesthesia. Additionally, the incidences and degrees of vomiting and nausea among the patients after anesthesia and operation were recorded.

RESULTS

Before operation, the observation group showed higher levels of blood glucose, insulin, serum potassium and serum sodium than the control group (all P<0.001), while after operation, the observation group showed lower levels of blood glucose and insulin and higher levels of serum potassium and serum sodium than the control group (all P<0.001). In addition, the degrees and incidences of hunger and thirst in patients of the observation group were significantly lower than those in the control group before operation (P<0.01), and the degrees and incidences of nausea and vomiting in the observation group were also notably lower than those in the control group before and after operation (both P<0.05).

CONCLUSION

For patients undergoing painless gastrointestinal endoscopy for polyps, shortening their fasting time from solids and liquids before operation can stabilize their blood glucose, insulin and electrolyte levels before and after operation, relieve their thirst and hunger before operation, and reduce the incidences of postoperative nausea and vomiting.

Preoperative Fasting Time and Its Association with Hypoglycemia during Anesthesia in Pediatric Patients Undergoing Elective Procedures at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia

BACKGROUND

Preoperative fasting is important to reduce the risk of pulmonary aspiration during anesthesia. The influence of prolonged fasting time on glucose levels during anesthesia in children remains uncertain. Therefore, this study is aimed at assessing preoperative fasting time and its association with hypoglycemia during anesthesia in pediatric patients undergoing elective procedures at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. The research hypothesis of the study is as follows: there is a prolonged preoperative fasting time, and it influences the glucose levels during anesthesia among pediatric patients undergoing elective procedures at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia.

METHODS

Institutional based cross-sectional study was conducted among 258 pediatric patients who had undergone elective procedures in a tertiary care center. A systematic sampling method was used to select study participants. The data were collected through face-to-face interviews and medical record reviews. Binary logistic regression was used to identify associated factors of hypoglycemia during anesthesia among pediatric patients undergoing elective procedures. All explanatory variables with a p value of ≤0.25 from the bivariable logistic regression model were fitted into the multivariable logistic regression model to control the possible effect of confounders, and finally, the variables which had an independent association with hypoglycemia were identified based on adjusted odds ratio with 95% confidence interval, and a p value less than 0.05 was significant.

RESULTS

The mean (standard deviation) fasting hours from breast milk, solid foods, and clear fluids were 7.75 (2.89), 13.25 (3.14), and 12.31 (3.22), respectively. The majority (89.9%, 57.9%, and 100%) of participants had fasted from solid, breast milk, and clear fluids for more than 8, 6, and 4 hours, respectively. More than one-fourth (26.2%) of participants were hypoglycemic immediately after induction. Residence, order of nothing per mouth, source of patient, and duration of fasting from solid foods had a significant association with hypoglycemia during anesthesia in children.

CONCLUSION

Children undergoing elective procedures were exposed to unnecessarily long fasting times which were associated with hypoglycemia during anesthesia.

The Effect of Preoperative Oral Intake of Liquid Carbohydrate on Postoperative Stress Parameters in Patients Undergoing Laparoscopic Cholecystectomy: An Experimental Study

PURPOSE

The aim of this study is to investigate the effects of preoperative oral intake of liquid carbohydrate on postoperative stress parameters (blood glucose, insulin resistance, cortisol, noradrenaline, and adrenaline levels) in patients who underwent laparoscopic cholecystectomy.

DESIGN

This is an experimental study with intervention and control groups.

METHODS

The sample consisted of 68 patients who underwent laparoscopic cholecystectomy (control group = 33; intervention group = 35). Twelve-hour preoperative fasting was applied to the patients in the control group in accordance with the clinical routine. Clear oral liquid carbohydrate (400 mL; 12.5 g/100 mL maltodextrin, 50 kcal/100 mL, pH 5.0) was administered to the patients in the intervention group at the preoperative second hour. Blood samples were taken from the patients at the preoperative 2nd and postoperative 2nd and 24th hours, and their blood glucose, insulin resistance, cortisol, noradrenaline, and adrenaline levels were measured.

RESULTS

Preoperative oral intake of carbohydrate had no effect on blood glucose (P > .05) but decreased insulin resistance at the postoperative 24th hour (P = .044; intervention and control group: 3.62 ± 3.44 to 8.16 ± 12.57 respectively) and cortisol level at the postoperative 2nd hour (P = .005; intervention and control group: 15.16 ± 6.53 mg/dl to 20.14 ± 7.49 mg/dl, respectively). In all of the three measurements, we found that the noradrenaline level of the patients in the intervention group was higher than the value of those in the control group (319.80 ± 301.49 pg/mL to 211.65 ± 141.11 pg/mL [P = .450]; 361.40 ± 213.50 pg/mL to 216.13 ± 114.53 [P = .001]; 268.40 ± 164.04 pg/mL to 196.00 ± 83.33 pg/mL [P = .026], respectively). Preoperative oral intake of liquid carbohydrate had no effect on postoperative adrenaline level (P > .05).

CONCLUSIONS

Oral intake of liquid carbohydrate given at the preoperative 2nd hour decreased postoperative stress response through insulin resistance and cortisol.

ACERTO Project - 15 years changing perioperative care in Brazil

The ACERTO project is a multimodal perioperative care protocol. Implemented in 2005, the project in the last 15 years has disseminated the idea of a modern perioperative care protocol, based on evidence and with interdisciplinary team work. Dozens of published studies, using the protocol, have shown benefits such as reduced hospital stay, postoperative complications and hospital costs. Disseminated in Brazil, the project is supported by the Brazilian College of Surgeons and the Brazilian Society of Parenteral and Enteral Nutrition, among others. This article compiles publications by the authors who belong to the CNPq research group "Acerto em Nutrição e Cirurgia", refers to the experience of other national authors in various surgical specialties, and finally outlines the evolution of the ACERTO project in the timeline.

The Effect of Preoperative Oral Versus Parenteral Dextrose Supplementation on Pain, Nausea, and Quality of Recovery After Laparoscopic Cholecystectomy

PURPOSE

Earlier studies suggest that carbohydrate loading is effective in reducing preoperative nausea. This study was conducted to investigate the effect of preoperative oral versus parenteral carbohydrate loading on the postoperative pain, nausea, and quality of recovery (QoR).

DESIGN

Three-arm randomized, single-blind clinical trial.

METHODS

In this study, 95 adult patients scheduled for elective laparoscopic cholecystectomy were randomly assigned into three groups of preoperative intravenous dextrose 10% infusion, oral carbohydrate (OCH)-rich drink, and control. The pain and nausea severity scores were measured during recovery, 6 hours, and 24 hours thereafter. The 40-item QoR score was evaluated the day after surgery.

FINDINGS

In recovery, nausea severity was comparable among three groups, whereas pain score in the OCH group was significantly less than the controls (P = .009). Pain score in patients who received intravenous dextrose was mediocre and not statistically different from two other groups. Six and 24 hours after surgery, nausea and pain scores in OCH and dextrose infusion groups were significantly lower than the control group (P < .05). The 40-item QoR score was significantly higher in intervention groups than control participants (P < .05). Blood glucose levels were comparable in three groups before and after surgery.

CONCLUSIONS

Preoperative carbohydrate loading significantly improves the QoR after laparoscopic cholecystectomy without significant effect on blood glucose levels. Oral route more effectively controls nausea and pain than parenteral dextrose administration.

Reduced fasting time in patients who underwent totally laparoscopic distal gastrectomy

Purpose

The aim of this study was to analyze the effects of reduced fasting time on postoperative recovery in patients who underwent totally laparoscopic distal gastrectomy (TLDG).

Methods

This retrospective study included 347 patients who underwent TLDG. Patients were divided into 2 groups: reduced fasting time group (n = 139) and conventional feeding group (n = 208). We compared the total hospital cost and recovery parameters, such as postoperative complications, mean hospital stay, day of first flatus, initiation of soft diet, and serum CRP levels, between the 2 groups.

Results

The reduced fasting time group had a lower total hospital cost (P < 0.001) than the conventional feeding group. Regarding postoperative complications, there was no significant difference between the 2 groups (P = 0.085). Patients in the reduced fasting time group had a significantly shorter duration of mean hospital stay (P < 0.001), an earlier first flatus (P = 0.002), an earlier initiation of soft diet (P < 0.001), and lower level of serum CRP concentration (day of surgery, P = 0.036; postoperative days 2, 5, and 7, P = 0.01, 0.009, and 0.012, respectively) than patients in the conventional feeding group.

Conclusion

Reduced fasting time can enhance postoperative recovery in patients who undergo TLDG and may reduce medical costs.

Interventions Aimed at Reducing Fasting Times in Acute Hospital Patients: A Systematic Literature Review

Despite current guidelines recommending fasting from solids for ≤6 hours and clear fluids for ≤2 hours prior to surgery, outdated practices endure; patients fast for unnecessarily prolonged periods because of beliefs regarding aspiration risk upon anaesthesia induction. This literature review aimed to identify and evaluate current interventions aiming to reduce preoperative fasting times for acutely ill hospital patients, summarizing effective interventional strategies and associated outcomes. EMBASE, MEDLINE, PreMEDLINE, and CINAHL were systematically searched. Quality of evidence was assessed using Cochrane risk-of-bias tools. Studies, of any type, reporting fasting times as a primary or secondary outcome were included. A total of 1918 potential studies were identified; of these, 16 studies were included. Seven studies investigated the effect of changing fasting protocol on gastric fluid volume/residual gastric volume (GFV/RGV) and gastric pH as surrogate measures for aspiration risk. No significant differences in GFV/RGV and gastric pH due to reduced preoperative fasting were reported, thus no change in aspiration risk. Eight studies documented improvements in patient-reported outcomes with shorter fasting times. However, this review identified a paucity of studies that trialled interventions to reduce fasting times as the primary aim. These interventions were multimodal and multidisciplinary in nature, incorporating principles of implementation science to successfully achieve significant reductions in fasting times. This review highlights that reducing the preoperative fasting period is safe while improving patient's physical and psychological well-being. Further high-quality studies that investigate multimodal interventions, and that utilize implementation science principles, are required in this area.

Metabolic and Inflammatory Benefits of Reducing Preoperative Fasting Time in Pediatric Surgery

OBJECTIVE

To investigate the metabolic/inflammatory impact of reducing the preoperative fasting time in preschool children.

METHODS

Forty children were randomly assigned to a fasting group (absolute fasting after 00:00) and a carbohydrate (CHO) group (allowed to ingest, two hours before surgery, a carbohydrate-rich beverage). Blood samples were collected right before and after surgery to quantify the levels of albumin, interleukin-6, glucose, insulin, C-reactive protein and to calculate insulin resistance by the HOMA-IR index.

RESULTS

Preoperative fasting time in the CHO group were shorter than in the fasting group (2.49h vs. 11.24h, p <0.001). Pre- and post-surgical CRP levels were significantly lower in the CHO group (p = 0.05 and p = 0.02, respectively). The preoperative CRP/albumin ratios in the CHO group were lower than in the fasting group (p = 0.03). Four patients (21%) in the fasting group but none in the CHO group were hyperglycemic before surgery (p = 0.04). The two groups had similar levels of albumin, interleukin-6, insulin and HOMA index. There were no adverse events.

CONCLUSION

Reducing the preoperative fasting time with carbohydrate-rich beverages improves the perioperative metabolic and inflammatory responses of preschool children undergoing inguinal hernia surgery.

Perioperative aspiration events in children: A report from the Wake Up Safe Collaborative

BACKGROUND

Perioperative aspiration, while rare, is a serious complication of anesthetic care. Consequences of aspiration may include physical obstruction, wheezing, and pneumonia, resulting in mild to severe hypoxemia and even death.

AIM

We used a multi-institutional registry of pediatric patients to identify factors that influence the rate and resulting harm of perioperative pulmonary aspiration.

METHODS

The Wake Up Safe registry was queried for all severe adverse events reported from 29 institutions from 2010 to 2017. Aspiration events were identified through the "respiratory adverse event" data entry form or through free text search. Multivariable regression was used to predict aspiration events, and contributory factors were identified by reviewing free text case comments.

RESULTS

Analysis included 2 440 810 anesthetics administered involving patients ≤18 years of age. There were 135 pulmonary aspiration events, for an incidence of 0.006%. Within these 135 cases, 110 cases (82%) resulted in escalation of care and 51 (38%) resulted in patient harm, including 2 deaths (1.5%). In multivariable analysis, patients undergoing emergency surgery (OR 2.0 [1.2-3.5]) or with higher ASA status were more likely to experience aspiration (ASA 3 (OR 5.0 [2.6-9.1]); ASA ≥ 4 (OR 5.5 [3.8-16.8])). Noted causes of aspiration included gastrointestinal comorbid conditions (19%), postcoughing event or laryngospasm (14%), nil per os (NPO) violation (11%), blood or secretions in the airway following or during the procedure (6%), and oral premedication reaction (3%).

CONCLUSION

Although infrequent, death was reported as a consequence of perioperative aspiration in two patients. The frequency with which NPO violations were identified as a potential cause of aspiration highlights the struggles institutions face with adherence to NPO regulations, as these cases may be preventable. Furthermore, preventive measures may be needed to address other common causes of aspiration, such as gastrointestinal comorbid conditions.

An exploration of pre-operative fasting practices in adult patients having elective surgery

Background:

Patients fast routinely before elective surgery in order to reduce gastric volume and acidity. The standard fasting time is ‘nil by mouth’ from midnight before surgery. In recent years, new guidelines have recommended that patients remain nil by mouth from clear fluids for 2 hours and from solids for 6 hours. This literature review explored preoperative fasting practices in adult patients from an international perspective.

Methods:

A literature search was undertaken of databases, including CINAHL Plus, PubMed, Medline, the Cochrane Central Register of Controlled Trials, Science Direct, Sage Journals and Embase.

Results:

Anaesthetists were found to possess greater knowledge of reduced preoperative fasting than other health professionals including nurses.

Conclusion:

Actual fasting time was found to be relatively longer than prescribed fasting times.

Ultrasound to guide the individual medical decision by evaluating the gastric contents and risk of aspiration: A literature review

Pulmonary aspiration of gastric contents is one of the most terrible complications following general anesthesia. It is important for patients to prevent this complication by obeying the preoperative fasting protocol strictly. At present, it has been reported by many studies that bedside ultrasound, as a non-invasive and convenient method, could be used to evaluate gastric contents qualitatively and quantitatively. With the advantages of reliability, accuracy and repeatability, it can greatly reduce the risk of aspiration and ensure patients' life security. But most of the data were acquired from the healthy volunteers. For the gastrointestinal disorder, the pregnant women, obesity, children, the elderly and diabetes patients, the accuracy and reliability of ultrasound to predict the risk of aspiration remains to be identified by more further studies. For these patients with increasing risk of aspiration, I-AIM (Indication, Acquisition, Interpretation, Medical decision-making) framework plays an important role in ensuring the safety of patients. It is crucial to make appropriate clinical decisions by evaluating the gastric contents with ultrasound.

Nutritional management of patients undergoing laparoscopic surgery for gastric cancer based on the concept of rapid rehabilitation

As a common malignant tumor, patients with gastric cancer (GC) are prone to malnutrition during the development and treatment of the disease. Fast track surgery (FTS), as a perioperative medical concept based on evidence-based medicine, plays an important role in nutrition management, including preoperative malnutrition screening and treatment, preoperative nutritional management, postoperative early oral feeding, accelerated promotion of gastrointestinal function recovery, and nutritional support. Based on a series of small sample studies, the safety and importance of FTS in laparoscopic nutrition management of GC are gradually emerging, but clinical implementation is difficult. This article will review the research progress of FTS in the field of laparoscopic nutrition management of GC in the past decade.

Cardiac and lung point-of-care ultrasound in pediatric anesthesia and critical care medicine: Uses, pitfalls, and future directions to optimize pediatric care

Point-of-care ultrasound (POCUS) has found many relevant applications in pediatric anesthesia and critical care medicine. Specifically, the cardiac and pulmonary POCUS examinations provide a wealth of information from physical examination assistance to diagnostic evaluation and assessment of treatment response. However, as with any adjunct, potentially dangerous pitfalls exist when POCUS is performed, interpreted, and applied by the novice sonographer. Using case illustrations, we highlight the clinical application of POCUS in addition to potential dangers. Additionally, suggestions for learning POCUS, assessing competency and credentialing are reviewed.

Potential of mid-infrared spectroscopy as a non-invasive diagnostic test in urine for endometrial or ovarian cancer

The current lack of an accurate, cost-effective and non-invasive test that would allow for screening and diagnosis of gynaecological carcinomas, such as endometrial and ovarian cancer, signals the necessity for alternative approaches. The potential of spectroscopic techniques in disease investigation and diagnosis has been previously demonstrated. Here, we used attenuated total reflection Fourier-transform infrared (ATR-FTIR) spectroscopy to analyse urine samples from women with endometrial (n = 10) and ovarian cancer (n = 10), as well as from healthy individuals (n = 10). After applying multivariate analysis and classification algorithms, biomarkers of disease were pointed out and high levels of accuracy were achieved for both endometrial (95% sensitivity, 100% specificity; accuracy: 95%) and ovarian cancer (100% sensitivity, 96.3% specificity; accuracy 100%). The efficacy of this approach, in combination with the non-invasive method for urine collection, suggest a potential diagnostic tool for endometrial and ovarian cancers.

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.

Multimodal Enhanced Recovery After Surgery (ERAS) Program is the Optimal Perioperative Care in Patients Undergoing Totally Laparoscopic Distal Gastrectomy for Gastric Cancer: A Prospective, Randomized, Clinical Trial

BACKGROUND

The application of ERAS protocol has widely gained acceptance after gastrointestinal surgery. Well-designed, randomized, control trials are needed to evaluate fully its safety and efficacy in the field of gastric cancer. This study aims to compare the enhanced recovery after surgery (ERAS) protocol and the conventional perioperative care program after totally laparoscopic distal gastrectomy (TLDG) in gastric cancer.

METHODS

Patients with gastric cancer indicated for TLDG were randomly assigned to either the ERAS group or the conventional group. The ERAS protocol included short fasting time, fluid restriction, early oral feeding, immediate mobilization, and use of epidural patient-controlled analgesia. Primary endpoint was recovery time, which was defined with the criteria of tolerable diet, safe ambulation, no requirement of additional analgesics, and afebrile state. Hospital stay, pain score, complications, and readmission rate were secondary endpoints.

RESULTS

A total of 97 patients who underwent TLDG from October 2012 to August 2014 were enrolled (ERAS = 46, conventional = 51). The ERAS group had faster recovery time (111.6 ± 34.3 vs. 126.7 ± 30.7 h; p = 0.026) and significantly less pain through postoperative days 1-4. Possible hospital stay also was faster in the ERAS group (5.0 ± 1.9 vs. 5.7 ± 1.6 days, p = 0.038), but there was no difference in actual hospital stay. No difference was found in complication, and there was no mortality or readmission in both groups.

CONCLUSIONS

ERAS is safe and enhances postoperative recovery after TLDG in gastric cancer.

TRIAL REGISTRATION

The trial was registered in ClinicalTrials.gov (NCT01938313).

Evaluation of the intensity and discomfort of perioperative thirst

Abstract Objective: To evaluate the intensity and discomfort of perioperative thirst and related factors during anesthesia recovery. Method: This is a quantitative, cross-sectional, descriptive study. Results: Of the 203 participants, 182 (89.6%) reported they were thirsty. The mean intensity of thirst was 6.9 measured using a verbal numerical scale of 0 to 10 and discomfort was 7.3 on a scale of 0 to 14. All attributes evaluated by the scale were cited including dry mouth and desire to drink water (87.3%), dry lips (79.1%), thick tongue feeling (43.4%), thick saliva (56.5%), dry throat (75.2%) and bad taste in the mouth (63.1%). There was a positive correlation between the intensity of thirst and discomfort assessed by the scale (Spearman coefficient: 0.474; p-value: <0.05). No correlation was found between age, length of fasting and use of opioids with the intensity of thirst and discomfort. Conclusion and implication in the clinical practice: Discomfort arising from the attributes of thirst is evidenced as the intensity of thirst increases.

Knowledge of Nurses About Preoperative Fasting in a Corporate Hospital

BACKGROUND

Preoperative fasting is a requirement to be made by anesthesiologists, but they generally depend on nurses to ensure it is carried out by patients. Lack of updated knowledge among nurses may cause complications.

METHOD

The objective of this study was to understand the knowledge of nurses about preoperative fasting. The multi-unit study was conducted in the units of our hospitals using an Internet-based survey. The responders were anonymous to the authors.

RESULTS

The survey was sent to approximately 5,000 nurses, with more than 600 responding to the survey. Most of the respondents were aware of the preoperative fasting guidelines. The understanding regarding preoperative fasting appeared to be insufficient among nurses. The nurses appreciated the concern of the anesthesiologists about fasting. The nurses opined that additional training regarding preoperative fasting might benefit them.

CONCLUSION

This survey conveyed to the authors that the nurses of our hospitals were knowledgeable but required further training to update them. J Contin Educ Nurs. 2018;49(3):127-131.

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

Background. Preoperative fasting (POF) is physiologically and precautionary important during anesthesia and surgery. POF from midnight has been practiced despite the recommended shorter practice. Objective. Assessing preoperative fasting among adult patients scheduled for elective surgery at Kenyatta National Hospital (KNH). Methods. A descriptive cross-sectional study involving 65 surgical patients. A questionnaire of mixed questions on demographics, reasons, source of instructions, opinion on instructions, time, premedication practices, outcome, and complains on NPO was used. Analysis was quantitatively done with SPSS v. 22. Ethical approval was obtained from KNH-UoN ERC. Results. Of the respondents 93.8% lacked knowledge on the correct reasons for POF and felt that the instructions were unclear and less important <50%. POF instructions were administered by nurses 80%, anesthetists 15%, and surgeons 5%. Most of respondents (73.8%) fasted > 15 hours. The POF outcomes were rated moderately challenging as follows: prolonged wait for surgery 44.6%, thirst 43.1%, hunger 36.9%, and anxiety 29.2%. Conclusion. Nurses are critical in providing POF instructions and care, and patient knowledge level is a mirror reflection of the quality of interventions. This underscores the need to build capacity for nurses and strengthen the health system to offer individualized preoperative interventions as well as monitoring and clinical auditing of fasting practices.

Duration of Nil Per Os is causal in hospital length of stay following laparoscopic bariatric surgery

INTRODUCTION

A recent bariatric surgical study demonstrated an inverse relationship of intraoperative hydration with the incidence of extended hospital length of stay (ehLOS: >1 postoperative hospital day). In that study, a post hoc analysis of the preoperative duration of Nil Per Os (NPO) past midnight revealed a significant dose-response association on the incidence of ehLOS, with the lowest incidence (10-12 %) predicted within the 2-5-h NPO interval. As NPO is associated with a state of compensatory dehydration, the objectives of this study were to prospectively examine the role of decreasing preoperative NPO intervals on the incidence of ehLOS in a similar bariatric surgical population and to establish causality of this association.

METHODS

Following IRB approval, 168 bariatric surgeries were analyzed following institution of a revised oral water ad libitum policy until 2 h prior to surgery on the incidence of ehLOS. The role of duration of NPO on the incidence of ehLOS was assessed by logistic fit graphs and misclassification rates on the two groups. A statistical process control chart monitored the efficacy of the revised NPO guidelines.

RESULTS

There were statistically significant, but not clinical, differences in the incidences of histories of anemia, gastroesophageal reflux disease, previous percutaneous cardiac intervention/percutaneous transluminal coronary artery angioplasty, or preoperative albumin levels between the two groups. There were no perioperative pulmonary aspirations of gastric contents in either group. Following reduction of the oral hydration interval to ≥2 h, a 13-15 % incidence of ehLOS was observed within the 2-5-h NPO interval with similar misclassification rates observed between the two groups.

CONCLUSIONS

Allowing bariatric patients access to ad libitum water for up to 2 h prior to surgery decreased the incidence of ehLOS. Comparison of the dose-response curves within the 2-5-h NPO intervals before and after introduction of the revised NPO guidelines was similar and confirms causality.

Critical role of microbiota within cecal crypts on the regenerative capacity of the intestinal epithelium following surgical stress

Cecal crypts represent a unique niche that are normally occupied by the commensal microbiota. Due to their density and close proximity to stem cells, microbiota within cecal crypts may modulate epithelial regeneration. Here we demonstrate that surgical stress, a process that invariably involves a short period of starvation, antibiotic exposure, and tissue injury, results in cecal crypt evacuation of their microbiota. Crypts devoid of their microbiota display pathophysiological features characterized by abnormal stem cell activation as judged by leucine-rich repeat-containing G protein-coupled receptor 5 (Lgr5) staining, expansion of the proliferative zone toward the tips of the crypts, and an increase in apoptosis. In addition, crypts devoid of their microbiota display loss of their regenerative capacity as assessed by their ability to form organoids ex vivo. When a four-member human pathogen community isolated from the stool of a critically ill patient is introduced into the cecum of mice with empty crypts, crypts become occupied by the pathogens and further disruption of crypt homeostasis is observed. Fecal microbiota transplantation restores the cecal crypts' microbiota, normalizes homeostasis within crypts, and reestablishes crypt regenerative capacity. Taken together, these findings define an emerging role for the microbiota within cecal crypts to maintain epithelial cell homeostasis in a manner that may enhance recovery in response to the physiological stress imposed by the process of surgery.

NEW & NOTEWORTHY

This study provides novel insight into the process by which surgical injury places the intestinal epithelium at risk for colonization by pathogenic microbes and impairment of its regenerative capacity via loss of its microbiota. We show that fecal transplant restores crypt homeostasis in association with repopulation of the microbiota within cecal crypts.

Surgical fasting guidelines in children: Are we putting them into practice?

BACKGROUND

Patients are traditionally kept fasting (NPO) from midnight prior to surgery, to prevent aspiration during anesthesia. NPO time is continued postoperatively, out of concern for ileus. Prolonged periods of NPO place the pediatric population at risk for under-nutrition. Published guidelines for preoperative NPO times have been shown to be safe. The aim of this study was to investigate current pre- and postoperative feeding practices of children at a pediatric tertiary care hospital.

METHODS

Medical charts were used to extract data prospectively from 53 patients undergoing general, neurosurgical, or urological procedures. Date and time of NPO periods were recorded as well as the physician's postoperative diet orders and diet progression. Surgical procedures were classified as complex or noncomplex by the surgeons. Data were summarized and compared to published recommendations.

RESULTS

Preoperative NPO times were greater than recommended in 70% of patients studied (n=37). Median time spent NPO preoperatively was not significantly different between complex (11.5h) and noncomplex groups (10.8h). Postoperative NPO time was significantly greater for complex procedures than for noncomplex. Most patients received some postoperative NPO time, even when it was not included in the physician diet order.

CONCLUSION

Observed preoperative NPO time exceeded current recommendations in this study.

Fast-Tracking Colostomy Closures

There have been very few studies on applying fast-track principles to colostomy closures. We believe that outcome may be significantly improved with multimodal interventions in the peri-operative care of patients undergoing this procedure. A retrospective study was carried out comparing patients who had undergone colostomy closures by the fast-track and traditional care protocols at our centre. We intended to analyse peri-operative period and recovery in colostomy closures to confirm that fast-track surgery principles improved outcomes. Twenty-six patients in the fast-track arm and 24 patients in the traditional care arm had undergone colostomy closures. Both groups were comparable in terms of their baseline parameters. Patients in the fast-track group were ambulatory and accepted oral feeding earlier. There was a significant reduction in the duration of stay (4.73 ± 1.43 days vs. 7.21 ± 1.38 days, p = 0.0000). We did not observe a rise in complications or 30-day re-admissions. Fast-track surgery can safely be applied to colostomy closures. It shows earlier ambulation and reduction in length of hospital stay.

Preoperative fasting times in elective surgical patients at a referral Hospital in Botswana

Introduction

Adults and children are required to fast before anaesthesia to reduce the risk of regurgitation and aspiration of gastric contents. However, prolonged periods of fasting are unnecessary and may cause complications. This study was conducted to evaluate preoperative fasting period in our centre and compare it with the ASA recommendations and factors that influence fasting periods.

Methods

This is a cross-sectional study of preoperative fasting times among elective surgical patients. A total numbers of 260 patients were interviewed as they arrived at the reception area of operating theatre using questionnaire.

Results

Majority of patients (98.1%) were instructed to fast from midnight. Fifteen patients (5.8%) reported that they were told the importance of preoperative fasting. The mean fasting period were 15.9±2.5 h (range 12.0-25.3 h) for solids and 15.3±2.3 h (range 12.0-22.0 h) for liquids. The mean duration of fasting was significantly longer for patients operated after midday compared to those operated before midday, p<0.001.

Conclusion

The mean fasting periods were 7.65 times longer for clear liquid and 2.5 times for solids than the ASA guidelines. It is imperative that the Hospital should establish Preoperative fasting policies and teach the staff who should ensure compliance with guidelines.

Early combined parenteral and enteral nutrition for pancreaticoduodenectomy - Retrospective cohort analysis

Background

Suggested guidelines for nutritional support after pancreaticoduodenectomy are still controversial. Recent evidence suggests that combining enteral nutrition (EN) with parenteral nutrition (PN) improves outcome. For ten years, patients have been treated with Early Combined Parenteral and Enteral Nutrition (ECPEN) after PD. The aim of this study was to report on rationale, safety, effectiveness and outcome associated with this method.

Methods

Consecutive PD performed between 2003 and 2012 were analyzed retrospectively. Early EN and PN was standardized and started immediately after surgery. EN was increased to 40 ml/h (1 kcal/ml) over 24 h, while PN was supplemented based on a daily energy target of 25 kcal/kg. Standard enteral and parenteral products were used.

Results

Sixty-nine patients were nutritionally supplemented according to ECPEN. The median coverage of kcal per patients related to the total caloric requirements during the entire hospitalization (nutrition balance) was 93.4% (range: 100%–69.3%). The nutritional balance in patients with needle catheter jejunostomy (NCJ) was significantly higher than in the group with nasojejunal tube (97.1% vs. 91.6%; p < 0.0001). Mortality rate was 5.8%, while major complications (Clavien-Dindo 3–5) occurred in 21.7% of patients. Neither the presence of preoperative malnutrition nor the application of preoperative immunonutrition was associated with postoperative clinical outcome.

Conclusion

This is the first European study of ECPEN after PD. ECPEN is safe and, especially in combination with NCJ, provides comprehensive coverage of caloric requirements during the postoperative phase. Clinical controlled trials are needed to investigate potential benefits of complete energy supplementation during the early postoperative phase after PD.

•

ECPEN is one possible nutritional technique after pancreaticoduodenectomy.

•

The coverage of caloric requirements per patient was 93.4%.

•

The coverage was higher in patients with needle catheter jejunostomy.

•

With ECPEN malnutrition or immunonutrition did not affect outcomes.

Perioperative thirst: an analysis from the perspective of the Symptom Management Theory

A theoretical study aimed to analyze the existing knowledge in the literature on the perioperative thirst symptom from the perspective of Symptom Management Theory, and supplemented with the experience of the study group and thirst research. Thirst is described as a very intense symptom occurring in the perioperative period, and for this reason it cannot be ignored. The Symptom Management Theory is adequate for understanding the thirst symptom and is a deductive theory, focused on the domains of the Person, Environment and Health / Illness Status, as well as on the dimensions of Experience, Management Strategies and Symptom Outcomes. Using the theory leads us to consider perioperative thirst in its multifactorial aspects, analyzing the interrelation of its domains and dimensions in order to draw attention to this symptom that has been insufficiently valued, recorded and treated in clinical practice.

Evaluation of effects of a preoperative 2-hour fast with glutamine and carbohydrate rich drink on insulin resistance in maxillofacial surgery

INTRODUCTION

The aim of this prospective, randomized, single-blinded study was to compare the effects of preoperative fast for clear fluids on insulin resistance and hemodynamic stability on patient undergoing maxillofacial surgery.

METHOD

In this study 20 patients undergoing maxillofacial surgery were randomized into four groups i.e. - group I patients with standard 08 h fasting before anesthesia, group-II patients were given 400 ml and 200 ml of water 08 h and 2 h respectively before anesthesia, group III patients were given 400 ml water with 50 gms of glucose and 40 gm of glutamine 08 h before anesthesia and 200 ml water with 25 gms of glucose and 10 gm of glutamine 2 h before anesthesia, group IV patients were given 400 ml water with 50 gms of glucose 08 h before anesthesia and 200 ml water with 25 gms of glucose 2 h before anesthesia. Blood samples were collected pre-operatively and post-operatively.

RESULTS

Overall results suggest that Post-operative insulin resistance was greater in control patients (2.0 [0.3]) compared with the other 3 groups (placebo = 1.8 [0.9]); glutamine = (1.8 [0.6]); carbohydrate = (1.9 [0.6]).

DISCUSSION

This study shows that shortening of pre-operative fasting time for clear fluids until 2- h prior to anesthesia may induce a favorable environment for the post-operative course. In conclusion, Glutamine with carbohydrate drink can be used safely in surgical patients.