preoperative fasting anesthesiaPosted on December 6th, 2020
Modern preoperative fasting practices date to observations published by Dr. Curtis Mendelson in 1946. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. For caloric liquids and solids, emptying follows zero-order kinetics, which is linear but biphasic in pattern. Gastric physiology is under a complex set of control factors that combine to ensure a steady release of nutrients to the small bowel and beyond. We wish to provide further education about preoperative fasting in our nursing conferences and reassess at a later date. Impat of preoperative fasting times on blood glucose concentration, ketone bodies and acid-base balance in children younger than 36 months. Lack of updated knowledge among nurses may cause complications. Descriptive analysis was performed based on survey questions, and subgroup analysis was done to describe the salient points. Additional fasting time ( e.g., 8 or more hours) may be needed in cases of patient intake of fried foods, fatty foods, or meat. (2007). Preoperative fasting is a routine that aims to secure an empty stomach by the time of induction of anesthesia in order to reduce the risk of regurgitation of acid gastric content that may flow into the lungs and cause dangerous chemical pneumonia. However, gastric motility differs between the fed and fasting states. Scintigraphy using radiolabelled meals represents the gold standard for the measurement of gastric emptying either directly or via breath tests; however, differing protocols between centres hamper its interpretation. (2015). The participation in the survey was voluntary and no incentives were offered to respondents. However, he noted that those patients that aspirated fluid were critically ill, with an acute ‘asthma-like’ attack, and mottling on chest X-ray, which cleared in 7–10 days. Brady MC, Kinn S, Ness V, O’Rourke K, Randhawa N, Stuart P. Preoperative fasting for preventing perioperative complications in children. Dennhardt, N, Beck, C, Huber, D, et al 2016 Optimized preoperative fasting times decrease ketone body concentration and stabilize mean arterial blood pressure during induction of anesthesia in children younger than 36 months: a prospective observational cohort study Paediatric Anaesthesia 26 … Preoperative medication given before anesthesia Anesthesiologists may prescribe or administer a premedication prior to administration of a general anesthetic. • Fried foods, fatty foods, or meat- Additional fasting time (e.g., 8 or more hours) * These recommendations apply to healthy patients who are undergoing elective procedure requiring general anesthesia, regional anesthesia, or procedural sedation and analgesia. Institutional review board approval was obtained prior to deployment. Knowledge About Allowed Water to Consume Regular Medicines in Adults, Knowledge About Allowed Water to Consume Regular Medicines in Pediatrics, Correct Duration of Fasting for Various Types of Fluids and Solids. They ought to mention the number of hours of fasting prior to any surgery or procedure and the complications resulting from inadequate fasting. The duration of fasting of children before anesthesia has traditionally followed the 6-4-2 rule: 6 h for light food and milk, 4 h for breast and formula milk, and 2 h for clear fluids. Dr. Mohan is Consultant Anesthesiologist, Dr. Chakravarthy is Chief Consultant, Department of Anesthesia, Critical Care and Pain Relief, Dr. George is Consultant Anesthesiologist, Dr. Devanahalli is Consultant Anesthesiologist, and Mr. Kumar is Resident in Anesthesia, Fortis Hospitals, Bangalore, India. As with clear fluids, an increase in acidity, osmolality, and fatty acid concentration will slow emptying.9,10. The RCRI consists of fiv… Pre-operative fasting, which is defined as the restriction of food and fluid intake for few hours before general anaesthesia or sedation, is one of the cornerstones of perioperative patient safety. It has been revealed that adequate preoperative instructions alleviate anxiety, increase patient participation in their own care and patient satisfaction and minimize the development of perioperative complications (Lee & Lee, 2000). This is why it requires a 6 h fast in common with other solids. preoperative fasting was associated with increased gastric acidity and an increased occurrence of reflux. Minimum preoperative fasting time of 6 h recommended for food (solids and milk) D Breast milk may be given up to 4 h before induction; formula or cows' milk up to 6 h before induction B Chewing gum should not be permitted on the day of surgery D Sweets (including lollipops) are solid food. The importance of a preoperative fast was acknowledged early in the evolution of anesthesia as a discipline of medicine. Two guidelines recommend using the Revised Cardiac Risk Index (RCRI) to assess the risk of cardiac complications after noncardiac surgery 4,7 (Table 210). For non-caloric liquids, such as water, gastric emptying begins immediately and exponentially, following first-order kinetics, proportional to the volume present in the stomach and thus the gastro-duodenal pressure gradient. The respondents could not edit the questions; however, they could alter their responses until submission. The survey was created using SurveyMonkey™ and was e-mailed to all the nursing staff of all the units of Fortis hospitals of India after testing its viability via a pilot study. The guideline development group recommends that up to 30 mL of clear fluid could be taken at any time preoperatively to help adult patients take their medications and up to 0.5 mL/kg of water orally in children (Royal College of Nursing, 2005). The healed wound left a permanent gastric fistula through which Beaumont made direct observations of gastric emptying times, noting that for easily digested food, such as meat, potatoes, and bread, these varied from 1.5 h to 5 h, whereas most fluids passed from the stomach almost immediately. Anesthetic premedication may consist of a drug or combination of drugs that improve the effects of the anesthetic drugs or … Motility across the entire gastrointestinal tract peaks at approximately 30 min and continues for about 4 h during which liquids and particles with a size of 1–2 mm are emptied from the stomach. The nurses in our survey appear to be varied in their knowledge about this. Therefore, nurses need to be knowledgeable about nil per os (NPO) guidelines so that they would be able to implement them appropriately and educate patients (Liddle, 2014). 1 Yet, in the intervening years, fasting times have increased in the belief that this may reduce the risk of pulmonary aspiration of gastric contents. The nurses appreciated the concern of the anesthesiologists about fasting. Address correspondence to Murali Chakravarthy, MD, DA, DNB, FIACTA, Chief Consultant, Department of Anesthesia, Critical Care and Pain Relief, Fortis Hospitals, 154/9, Opposite IIM Bangalore, Bannerghatta Road, Bangalore, Karnataka 560076, India; e-mail: In this survey, the responding nurses were aware of issues concerning preoperative fasting, and the adverse effects of nonadherence, but only a minority knew the guidelines accurately. The anesthesiologists may teach their nursing colleagues because this issue actually concerns their patient safety, quality, and reputation. The objective of this study was to understand the knowledge of nurses about preoperative fasting. Do you instruct patients about nil by mouth (NBM) or wait for the orders by doctor? All rights reserved. Most of the nurses understood the insistence of the anesthesiologists about preoperative fasting by patients. Incomplete responses were not a reason for exclusion. RATIONALE FOR PREOPERATIVE FASTING. If the patients are excessively fasted preoperatively, they may experience: Agency for Healthcare Research and Quality. Preoperative fasting: Instructions to patients and length of fasting—A prospective, descriptive survey. Approximately 80% incorrectly responded that clear fluids could be allowed for up to 6 hours, and 13.6% thought fasting for 4 hours prior to surgery was adequate; only 6% correctly knew that clear fluids could be allowed up to 2 hours prior to surgery. 2 Pediatric hospitals have recently enacted more liberal preoperative clear fluid fasting guidelines. With emerging evidence of the safety of liberalizing clear fluid ingestion to either 1 h or up to the time of anaesthesia, fasting times can be reduced even further. Shivegowda Mohan, DA, DNB; Murali Chakravarthy, MD, DA, DNB, FIACTA; Antony George, MD, DM; Ashokanand Devanahalli, DA, DNB; Jeevan Kumar, MBBS. Intended for general anesthesia, regional anesthesia, or sedation/analgesia (MAC) Clear fluids rapidly empty from the stomach within 30 min. Response indicating awareness about clear fluids. For clear fluid, there is good evidence in children that emptying can occur well within the advocated 2 h guidelines. This may result in surgeries getting rescheduled, causing inconvenience to all concerned. This article has an associated podcast which can be accessed at https://academic.oup.com/bjaed/pages/Podcasts. Two thirds responded that solid food must be stopped 8 hours prior. 8 Surveys have shown that only a few hospitals still keep their patients NPO after midnight, but any culture change in medicine is a slow process. In addition to these neural and hormonal regulatory mechanisms, blood glucose also affects emptying. Smith, I., Kranke, P., Murat, I., Smith, A., O'Sullivan, G. & Søreide, EEuropean Society of Anaesthesiology. Preoperative Fasting. Perioperative fasting in adults and children: Guidelines from European Society of Anaesthesiology. Three reminders approximately 1 week apart were sent during this duration. For a population size of 5,800, the 95% confidence interval with 4% margin sample size was calculated to be 545. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. This survey consisted of 22 questions; they were sent either via e-mail or as a URL to the mobile telephones of nurses at 50 branch facilities for Fortis Hospitals. Nevertheless, fasting protocols that minimize gastric volume are believed to reduce pulmonary aspiration.9. During fasting, metabolism slows and the primary source of glucose gradually becomes hepatic glycogenolysis. Full meals, with high fat content, may not empty fully even at 8–9 h. Paediatric fasting guidelines are intended to reduce the risk of pulmonary aspiration and facilitate the safe and efficient conduct of anaesthesia. It is during these latter contractions that the stomach empties particles > 2 mm. The survey was sent to approximately 5,000 nurses, with more than 600 responding to the survey. Several anaesthesia societies now recommend a 2‐h preoperative fast for clear fluids and a 6‐h fast for solids in most elective patients. Antral contraction is influenced by gastric volume, the secretion of gut hormones, and the composition of chyme entering the duodenum. Because worse outcomes may be associated with aspiration of particulate matter, acidic contents, or large volumes of any gastric content, guidelines aim to eliminate particulate matter and decrease the volume and acidity of these contents at the time of induction of anesthesia . Adherence to NPO guidelines enhances safety by preventing aspiration of gastric contents while administering anesthesia (Ljungqvist & Søreide, 2003). §§. It may be wise to inform the patients that despite adhering to the advice, aspiration of gastric contents might still occur because of various factors such as electrolyte abnormality, pregnancy, old age, diabetes mellitus, and alcohol consumption. Ingadottir, B., Olafsdottir, A.M., Sveinsdottir, H., Asmundsdottir, L.B., Torp, M.S. Most of the respondents were aware of the preoperative fasting guidelines. In general, clear fluids are allowed up to 2 h before anaesthesia, and light meals up to 6 h. The same recommendations apply for children and pregnant women not in labour. • Dennhardt N. Ped Anesth 2016. The syllabus of nursing education consists of chapters on the importance of preoperative fasting (Royal College of Nursing, 2005). Residual gastric volume is a poor surrogate for the risk of aspiration, and there appears to be no causal link or critical volume threshold. Why is fasting necessary before surgery? In general, nurses follow guidelines and mandatory requirements well; it is easier to inculcate good habits in them. Children undergo a preoperative fast in an attempt to minimize the fluid and solid food component of gastric contents. The duration of the first phase is related to the caloric content of the food. Laffey, J.G., Carroll, M., Donnelly, N. & Boylan, J.F. Lee, D.S. Lack … Liddle, C. (2014). The hospital administration must spend resource and manpower to encourage teaching in this regard. Beach ML, Cohen DM, Gallagher SM, Cravero JP. Patients should have preoperative ECG before undergoing a high-risk procedure. Can the patient take his regular medications when he or she is fasting? The American Society of Anesthesiologists (2011), Association of Paediatric Anaesthetists of Great Britain and Ireland (2007), Royal College of Nursing (2005), and European Society of Anaesthesia (“Preoperative fasting,” 2005; Smith et al., 2011) have all recommended preoperative fasting of 2 hours for clear fluids, 4 hours for breast milk, and 6 hours for solids, nonhuman, and formula milk in children (De Aguilar-Nascimento & Dock-Nascimento, 2010). Schmitz A, Kellenberger CJ, Liamlahi R, Studhalter M, Weiss M. Cantellow S, Lightfoot J, Bould H, Beringer R. Oxford University Press is a department of the University of Oxford. Only one fifth correctly responded that it was acceptable to allow intake of solid foods, which was up to 6 hours prior to surgery. The majority (91.6%) of the respondents correctly considered water as clear liquid, whereas a varying percentage of them considered fruit juice with or without pulp, black tea or coffee, carbonated aerated drinks, and milk as clear liquids (Figure). The belief that otherwise healthy patients with no risk factors for aspiration were also at risk stemmed from the work of Roberts and Shirley in 1974 who surmised that 25 ml (0.4 ml kg−1) of gastric fluid with a pH < 2.5 increased the risk of serious aspiration. Prepared by: Cathy Bachman MD. The associated MCQs (to support CME/CPD activity) can be accessed at http://www.oxforde-learning.com/journals/ by subscribers to BJA Education. 3. Use the teach-back method: Tool #5. Liberal pre‐operative fasting routines have been implemented in most countries. Reducing preoperative fasting time: A trend based on evidence. It was expected that nurses may use one or the other guidelines to respond. Confusion existed among the respondents (Table 2). 3,4 Meanwhile, pediatric anesthesia societies in Europe, New Zealand, and Australia have released consensus guidelines allowing shorter minimum clear fluid … Preoperative fasting is a requirement to be made by anesthesiologists, but they generally depend on nurses to ensure it is carried out by patients. A nurse may voice a concern should duration of fasting be more than necessary (e.g., in diabetic patients with autonomic dysfunction, internal obstruction and congestive heart failure), to prevent hypovolemia and its related complications in a pediatric subsect. These results show that although the nurses received training on various topics during nursing education, additional training about preoperative fasting must be provided, especially if the guidelines change. Discussion. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: An updated report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. The goal of fasting is to empty the stomach, thereby reducing the risk of aspiration of stomach contents during the anesthetic period. A possible reason for this was the work of Curtis Mendelson. Despite the guidelines, fasting periods are often exceeded in pediatrics .Long periods of fasting in children, however, may lead to symptoms of dehydration or discomfort , thus exceeding the fasting time may be more harmful than useful. Although patients are advised by the doctors, the opinion and knowledge of the nurses are relevant because they are the first point of contact with patients. Thus, aspiration of stomach contents that are passively regurgitated or vomited into the oropharynx may be more likely during sedation or anesthesia. These children were also less thirsty, less hungry, and less irritable than those who fasted for more than 6 h.21, Studies examining the incidence of paediatric aspiration and its complications. Addressing these problems by preoperative carbohydrate intake has not been a well-defined approach in children. Does my child have to fast before surgery? Respondent information and identity were not sought, and the survey responses were saved on a password-protected server accessible only to key study personnel. While there are physiological data to support preoperative carbohydrate drinks, studies investigating the type of drink and its clinical impact in children are limited.16, Perioperative pulmonary aspiration in children remains infrequent, is more likely in emergency rather than elective surgery, and serious respiratory complications are rare (Table 2).3,6,17–20 An updated Cochrane review of 25 trials involving 2543 children found only one reported incidence of perioperative aspiration. Furthermore, despite an empty stomach, aspiration can still occur due to large volumes of fluid regurgitating from the small and large intestines. This is a reassurance to anesthesiologists to whom the matter of preoperative fasting matters. Ahmed Mesbah, MB BCh FCAI FRCA, Mark Thomas, BSc (Hons) MB BChir FRCA FFFPM FAoMEd, Preoperative fasting in children, BJA Education, Volume 17, Issue 10, October 2017, Pages 346–350, https://doi.org/10.1093/bjaed/mkx021. This distinction carried on into the 1960s with paediatric instructions favouring sweetened liquids up to 2 h before operation. Therefore, the main objective of preoperative carbohydrate drinks is to stimulate an insulin response similar to that of a regular meal and therefore switch the preoperative fasted state described above into a fed state with normal postprandial insulin levels and minimal glycogen store depletion. The authors have disclosed no potential conflicts of interest, financial or otherwise. Instructions for ambulatory surgery-patient comprehension and compliance. Preanaesthetic or preoperative fasting is a universally applied principle in elective cases to minimize the risk of pulmonary aspiration of gastric content posed by the combination of regurgitation and loss of protective airway reflexes by anaesthetic agents. Preoperative fasting. Yet another survey concluded there is a need for nurses to coordinate instructional practices to involve patients more in their own care with consistent information and comprehensive education and assist them in reducing fasting on clear fluids after hospital admission (Ingadottir et al., 2016; Lee & Lee, 2000). However, the years following World War II saw the widespread adoption of the ‘Nil per os (NPO) from midnight’ regimen, especially in North America, ignoring the previous distinction between solids and liquids. In 1948, Digby Leigh, in his textbook Pediatric Anesthesia, suggested that children should fast from clear fluids for 1 h prior to surgery. The stomach performs both mechanical and chemical breakdown of ingested food into a chyme, which is delivered, at a rate controlled by hormonal, neural, and metabolic mechanisms, to the duodenum for enzymatic degradation into molecular components and absorption through the gut wall. firstname.lastname@example.org. Several long-standing anaesthetic practices (preoperative patient fasting, rapid sequence induction of general anaesthesia, and the application of cricoid force following induction) owe their origin to the prevention of such an event. (2017). Minimum preoperative fasting time of 6 h recommended Whey-predominant formulae empty faster than casein-rich formulae and both are significantly faster than cow’s milk. ASA Guidelines for Preoperative Fasting. These same guidelines, when strictly adhered to, often result in much longer clear fluid fasting times than are desirable. Yes. As hepatic glycogen stores are depleted, hepatic gluconeogenesis and lipolysis ensue with subsequent fatty acid beta-oxidation and ketogenesis becoming the main energy sources. Premature and full-term neonates are often reported to have slower gastric emptying in comparison with older children and adults due to immature neuromodulation of gastric motility. Almost all national guidelines advocate the 6, 4, and 2 h regimen for clear fluids, breast milk, and solids, respectively; however, children continue to be fasted for significantly longer. The Checklist for Reporting Results of Internet E-Surveys (CHERRIES) was used for reporting the results of survey (Eysenbach, 2016). Despite this, there may be paucity of knowledge and a lack of application in practice. Sedation and anesthesia reduce or eliminate protective cough reflexes, unlike natural sleep. Magnetic resonance imaging (MRI) has been used to evaluate gastric residual volume, but its use is limited by expense and availability. Responses were automatically archived by the SurveyMonkey database and analyzed by the authors. Indeed, ketoacidosis has been demonstrated in children less than 3 years of age fasted more than 7 h with a subsequent reduction in ketone bodies and hypotension on induction of anaesthesia when an optimized fasting schedule was introduced.14, In contrast to the reduction in metabolic rate seen with fasting, the trauma of surgery triggers a neuroendocrine stress response that increases metabolism, which further depletes hepatic and skeletal muscle glycogen stores and releases free fatty acids and amino acids from the adipose tissue and skeletal muscle, respectively. It may be valuable to teach-back (i.e., a communication method to confirm whether a patient understands what is being explained to them) to evaluate patient and family understanding (Agency for Healthcare Research and Quality, 2015). Prolonged preoperative fasting times for healthy elective cases have been extrapolated from the aspiration risk of ‘full-stomach’ emergency cases. For full access to this pdf, sign in to an existing account, or purchase an annual subscription. Approximately two thirds of the respondents were aware that adults could be allowed milk up to 6 hours prior to surgery. The American Society of Anesthesiologists guidelines for preoperative fasting state that it is appropriate to fast from intake of clear liquids at least 2 hours before elective procedures requiring anesthesia. Do you educate the patient about potential risk of inadequate fasting? A possible duplicate submission was prevented by a mechanism called Internet protocol address check provided by SurveyMonkey. Improving the quality of web surveys: The Checklist for Reporting Results of Internet E-Surveys (CHERRIES). The literature supporting such … Appendices to the Guidelines of the Practice of Anesthesia. These guidelines are aimed at ensuring acceptable health of pediatric patients and optimizing the experience of … Their work was based on preliminary unpublished data from a single Rhesus monkey which had neither vomited nor regurgitated, but whose right main bronchus was instilled with 0.4 ml kg−1 of acid.5 A relationship between the residual gastric volume and the volume of fluid instilled into the lungs was never established but rather extrapolated to the average weight of a pregnant woman. Many professional societies have issued their guidelines on preoperative fasting. Knowledge About Allowed Water to Consume Regular Medicines in Adultsa, Knowledge About Allowed Water to Consume Regular Medicines in Pediatricsa. None of 30 dogs fasted 2-4 hours refluxed, whereas 4/30 (13.3 %) dogs fasted 12-18 hours had a reflux episode during anaesthesia (p=0.112) (Galatos … In our survey, 38.5% of the respondents were working in the intensive care unit, 26.7% were working on wards, 7.80% in the operation department, 7.1% in the emergency department, and 19.9% in other departments. For pulmonary aspiration to occur, gastric contents must overcome three protective mechanisms: first, they must exceed the lower oesophageal sphincter barrier pressure, then regurgitate up the oesophagus through the upper oesophageal sphincter, and finally pass down the trachea unimpeded by protective airway reflexes such as laryngospasm or coughing. The latest guidelines do not support preoperative fasting, as there is no difference in residual gastric fluid volume, pH or gastric emptying rate following semi-solid meals or … The survey link was sent via e-mail to approximately 5,000 nurses at Fortis hospitals; 628 responded (via e-mail invitation, n = 535; via web link, n = 93). Responsible individuals were described in descending order: nurses, anesthesiologist, surgeons, and hospital administration. A key feature of this perioperative shift of metabolism has been found to be the development of insulin resistance, the severity of which is proportional to the degree of surgical trauma.15 The development of insulin resistance impairs its anabolic effects and is a known risk factor for the development of postoperative complications and increasing length of hospital stay.15,16, Providing non-caloric clear fluids, such as water, 2 h prior to surgery does not provide the substrates required to change the metabolic effects of fasting and surgery. This survey serves as our baseline benchmark. & Dock-Nascimento, D.B. Preoperative teaching: How does a group of nurses do it? Adequate knowledge of nurses about fasting ensures quality nursing care during the preoperative period. Ljungqvist O. Preoperative fasting and carbohydrate treatment. The first phase is characterized by quiescence, the second by irregular contractions, and the third by continuous phasic contractions lasting up to 5 min. Prolonged preoperative fasting that exceeds guidelines by more than 2 h causes hunger, discomfort, headache, dehydration, and hypoglycemia. Preoperative fasting is the practice of a patient abstaining from oral food and fluid intake for a time before an operation is performed. Fasting period for regional anesthesia, compared with general anesthesia, Fasting period for monitored anesthesia care compared with general anesthesia. They are not intended for women in … Preoperative fasting in children undergoing anesthesia is recommended to decrease the risk of aspiration of gastric contents. & Hafsteinsdottir, E.J. Cow’s milk separates into liquid and solid (curd) phases on mixing with gastric acid, and therefore, its emptying is biphasic with a rapid initial liquid phase followed by a second-, zero-order, solid phase. Mendelson then demonstrated that hydrochloric acid, or un-neutralized human vomitus, injected into rabbit lungs, reproduced this picture, and concluded that pregnant women were at especially high risk of aspiration due to delayed gastric emptying. It is also necessary to mentor young anesthesiologists to inform the nurses that other forms of mild anesthesia, such as monitored anesthesia care, spinal anesthesia, and regional blocks, also require stringent fasting precautions. The incidence is 0.07–0.1% and the consequences of clear fluid aspiration are not catastrophic.
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