An audit investigating the practice of preoperative fasting and the administration of medication to patients during the nil per mouth period in Metro East district hospitals

Introduction: Preoperative fasting which is defined as “abstinence from all foods and liquids for a specified period of time before induction of anaesthesia and/or commencement of surgery”, is a time-tested practice that is undertaken for the benefit of patients presenting for surgery globally.Aim: To assess the current practice of preoperative fasting (POF) and to investigate the complications associated with prolong fasting among adult patients scheduled for elective surgery at Teaching Hospital Anuradhapura.Method: This clinical audit was performed using an interviewer-administered questionnaire. 430 adult patients awaiting elective surgery were interviewed following informed consent.Results: 95.3% thought POF was important but 55.6% lacked knowledge on the reason for POF. 52.8% of patients received instructions on POF by nurses, but only 32.6% of them were educated on the correct standards of POF. 67.4% of respondents who were educated by nurses were not told of the standards of POF. On average respondents fasted for 12.85 hours for solids and 7.38 hours for fluids. 85.7% fasted for more than 2 hours for clear fluids and 94.1% fasted for more than 6 hours for solids. 55.8% of the respondents complained of thirst and 11.6% and 5.1% had features of dehydration and postoperative nausea and vomiting respectively.Conclusions: Most patients fasted for both food and fluid longer than the fasting time recommended by the European Society of Anaesthesiology guidelines. It underscores the importance of educating the healthcare staff and patients on the updated guidelines.

In East, Central and Southern Africa (ECSA), district hospitals (DH) are the main source of surgical care for 80% of the population. DHs in Africa must provide basic life-saving procedures, but the extent to which they can offer other general and emergency surgery is debated. Our paper contributes to this debate through analysis and discussion of regional surgical care providers' perspectives. We conducted a survey at the College of Surgeons of East, Central and Southern Africa Conference in Kigali in December 2018. The survey presented the participants with 59 surgical and anaesthesia procedures and asked them if they thought the procedure should be done in a district level hospital in their region. We then measured the level of positive agreement (LPA) for each procedure and conducted sub-analysis by cadre and level of experience. We had 100 respondents of which 94 were from ECSA. Eighteen procedures had an LPA of 80% or above, among which appendicectomy (98%), caesarean section (97%) and spinal anaesthesia (97%). Twenty-one procedures had an LPA between 31 and 79%. The surgical procedures that fell in this category were a mix of obstetrics, general surgery and orthopaedics. Twenty procedures had an LPA below 30% among which paediatric anaesthesia and surgery. Our study offers the perspectives of almost 100 surgical care providers from ECSA on which surgical and anaesthesia procedures should be provided in district hospitals. This might help in planning surgical care training and delivery in these hospitals.

BackgroundIn East, Central and Southern Africa (ECSA), district hospitals (DH) are the main source of surgical care for 80% of the population. DHs in Africa must provide basic life-saving procedures, but the extent to which they can offer other general and emergency surgery is debated. Our paper contributes to this debate through analysis and discussion of regional surgical care providers' perspectives.MethodsWe conducted a survey at the College of Surgeons of East, Central and Southern Africa Conference in Kigali in December 2018. The survey presented the participants with 59 surgical and anaesthesia procedures and asked them if they thought the procedure should be done in a district level hospital in their region. We then measured the level of positive agreement (LPA) for each procedure and conducted sub-analysis by cadre and level of experience.ResultsWe had 100 respondents of which 94 were from ECSA. Eighteen procedures had an LPA of 80% or above, among which appendicectomy (98%), caesarean section (97%) and spinal anaesthesia (97%). Twenty-one procedures had an LPA between 31 and 79%. The surgical procedures that fell in this category were a mix of obstetrics, general surgery and orthopaedics. Twenty procedures had an LPA below 30% among which paediatric anaesthesia and surgery.ConclusionOur study offers the perspectives of almost 100 surgical care providers from ECSA on which surgical and anaesthesia procedures should be provided in district hospitals. This might help in planning surgical care training and delivery in these hospitals.

Introduction: Traditional pre-operative fasting practice often involves extended periods without fluids, and can be a source of discomfort and anxiety for patients. This can lead to negative experiences and potentially contribute to complications. Evidence suggests that these practices may not be necessary to minimise the risk of pulmonary aspiration during surgery. This quality improvement project implemented a nurse-led liberal fluid fasting regimen for pre-operative patients. The aim was to improve patient comfort and wellbeing while maintaining safety. Process: Utilising the ‘knowledge-to-action’ framework for implementation science, the project implemented a nurse-led liberal fluid fasting regimen. This involved reviewing relevant literature, developing the regimen, educating staff and addressing potential barriers. Monitoring and evaluation included tracking adverse events and collecting surveys. The project ensures sustainability through ongoing staff training and observational audits. Outcomes: The project demonstrated the safety of the regimen, with no reported cases of pulmonary aspiration or other serious adverse events. Statistically significant outcomes were observed in changes in nurses’ perceptions of patient wellbeing (p < 0.001), reduction in clinical signs and symptoms of dehydration (p < 0.001) and patients’ reports of emotional distress related to waiting times (p < 0.001). Discussion: The project has not only addressed longstanding challenges in pre-operative fluid fasting practices but has also set a new standard for patient-centred care. It has demonstrated effectiveness in achieving a delicate balance between patient safety and enhanced comfort while fostering a culture of compassionate care provision, placing patient wellbeing at the forefront. This evidence-based approach offers a patient-centred alternative to traditional fasting practices and has the potential to be adopted by other health care facilities seeking to improve patient experience and streamline pre-operative care.

Letter to the Editor: Which Surgical Operations Should be Performed in District Hospitals in East, Central and Southern Africa? Results of a Survey of Regional Clinicians.

We conducted a nationwide survey to investigate the current practice of the preoperative fasting period in Japanese anesthesia-teaching hospitals. Acceptance of the clinical practice guideline published by the American Society of Anesthesiologists (ASA) was also surveyed. A written type of questionnaire was mailed to 795 teaching hospitals. The response rate of the questionnaires was 57%. Most (>90%) of the respondents had been applying a longer fasting period than the ASA-recommended minimum period specifically in adults; the median duration of fasting was 12-13 h for solids and 6-9 h for liquids. Children or infants were allowed a more liberalized fasting period, frequently being permitted an oral intake of clear fluids up to 3 h before anesthesia. The incidence of pulmonary aspiration was 1/12,500 general anesthesia cases, and application of the ASA guideline appeared not to affect the incidence. Japanese anesthesiologists were still reluctant to depart from their traditional long fasting periods, as most of them could find little benefit in reducing the fasting periods. The long preoperative fasting period is still common practice in Japanese anesthesia-teaching hospitals. A national guideline for a preoperative fasting policy is worth exploring to change the current practice.

BackgroundRational preoperative fasting can reduce the risk of regurgitation and aspiration, enhance anesthesia safety and efficiency, and mitigate the adverse effects of prolonged fasting. This study investigates the existing practices of preoperative fasting management in Chinese pediatric patients and explores the real duration of preoperative fasting.MethodsThis is a cross-sectional study. A questionnaire on fasting management in children was developed and an online survey was conducted among anesthesiologists. The survey mainly included the real implementation of pediatric fasting protocols, anesthesiologists’ understanding of pediatric fasting management, and the application of gastric ultrasound. Moreover, data on pediatric preoperative fasting durations were collected from different hospitals across China.ResultsA total of 770 questionnaires and 1285 records of preoperative fasting cases were obtained. The survey indicated variations in preoperative fasting protocols among hospitals. Most hospitals recommended fasting for clear fluids for 2 h, while the new 1-h regimen and the liberal regimen were less implemented due to concerns regarding regurgitation and aspiration risks. Fasting for breast milk, formula milk, and solid food was mainly based on traditional protocols, with fasting durations of 4 h, 6 h, and 8 h, respectively. Most anesthesiologists have experienced regurgitation and aspiration, but there were significant differences in their awareness of the prevention and prognosis of regurgitation and aspiration. Utilization of gastric ultrasound was limited, with a lack of equipment and familiarity among anesthesiologists. Real preoperative fasting durations for children were significantly longer than those recommended in the guidelines. Factors contributing to prolonged fasting were identified.ConclusionsThere is a big gap between preoperative fasting practices and the guidelines, and the real fasting durations of children before surgery are significantly longer than the guideline recommendations. Anesthesiologists should strengthen their understanding of preoperative fasting management in pediatric patients, master the skills of gastric ultrasound assessment, and timely address inefficiencies in pediatric preoperative fasting management.

Post-caesarean surgical site infection (PCSI) is one of the most common cesarean section-related complications. In low- and middle-income countries (LMIC), PCSI prevalence is often under-reported and inaccurate because LMIC surveillance systems are often unable to detect PCSIs developed after discharge; this can ultimately wrongly inform the decision-making related to reducing PCSIs.This paper describes the establishment of a post-discharge PCSI surveillance system for identification of PCSI rate in a district hospital in Rwanda.A total of 540 women underwent CS in the hospital from November 2017 to February 2018, and 536 (99.3%) consented to participate in the surveillance. Among those consented, 22 had no telephone and 174 could not be reached by telephone despite multiple attempts. At the end of this study, a total of 340 women completed the entire surveillance period. The total PCSI rate was 11.5%.Out of all PCSIs, 21% were detected during hospitalization period and 79% were detected during the post-discharge period.The PCSI surveillance system developed in this project covered the 30-day period after surgery and provided a more accurate estimate of PCSI rate. The system was able to track PCSIs developed after a patient was discharged from the hospital. Long term sustainability of the project must be evaluated.

Estimating the Burden of Hospital-Acquired Venous Thromboembolism: The Argument for Implementation of Mandatory Risk Reduction Strategies

Music Therapy for Children with Severe Burn Injury

Knowledge of fasting or Nil Per Os (NPO) guidelines is an essential component of nursing care in the preoperative period. To describe registered nurses' (RNs) knowledge and management of the preoperative NPO period. Selected surgical wards in a tertiary hospital in the Western Cape, South Africa. 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%. 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). Inadequate knowledge of NPO times for various fluids and unsatisfactory practice of medication administration for oral and chronic medication require attention. 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.

Funding AcknowledgementsType of funding sources: Public hospital(s). Main funding source(s): Helsinki and Uusimaa Hospital District TYH2019309 and The Finnish Foundation for Cardiovascular ResearchBackground/IntroductionAcute myocardial infarction (AMI) and atrial fibrillation (AF) are commonly seen in a same patient. It is not unusual that patients are diagnosed with new-onset AF as a complication of AMI. Nevertheless, little is known about the temporal relations of these two diagnoses.PurposeWe evaluated the temporal relations of AMI and new-onset AF in the Nationwide Finnish Anticoagulation in Atrial Fibrillation (FinACAF) comprising all patients with AF during 2004-2018 in Finland.MethodsPatients with AF and AMI in Finland during 2010 to 2017 were analyzed, and individual patient data from the different registries were merged.ResultsOf the 157,658 patients with new-onset AF, a total of 16,971 (10.8%) patients were diagnosed with AMI at any point. The mean-age was 77.5 years (SD 10.6) and 72.3 years (SD 13.2), and the proportion of females 7,864 (46.3%) and 70,873 (50.4%) in AF patients with and without AMI, respectively.Altogether 8,889 (52.4%) of the AMI-AF patients had a history of established AMI diagnosis; whereas 4,278 (25.2%) were diagnosed with AMI during the same hospitalization period as new-onset AF or within 30 days; and 3,804 (22.4%) over 30 days after new-onset AF. A total of 6,928 (40.83%) of all AMI diagnoses were diagnosed within 1 year from new-onset AF. The temporal relation between new-onset AF and AMI are described in the Figure.ConclusionsAMI-AF patients are older than AF patients without AMI at the time of new-onset AF. The diagnoses of AMI and AF tend to accumulate close to one another. One fourth of all AMI-AF patients were diagnosed with both diseases occurring same hospitalization period or within 30 days from new-onset AF.

Background and ImportanceChildren are susceptible to medication deviations and adverse drug events. Several high-risk medicines are used both in hospitals and at home with paediatric patients. Written medication instructions play...

Introduction: The gastrointestinal stromal tumor (GIST) represents less than 3% of gastrointestinal neoplasms; however, is the most frequent mesenchymal tumor of the digestive tract, occurs mainly in elderly adults (60-65 years). GIST is expressed by the expression of the receptor tyrosine kinase growth factor, CD117, which differentiates it from other mesenchymal tumors such as leiomyomas, leiomyosarcomas, leiomyomablastomas and neurogenic tumors that do not express this protein. The symptoms are nonspecific and computed tomography (CT) is the method of choice for the diagnosis of the lesion, and the definitive diagnosis is made through the anatomopathological study of the lesion, with surgery being the main therapeutic option.Methodology: This is a case report, in which was recorded data from clinical observation and image exams of an individual without using a control group.Results: E. M. A. G., 65 years old, black female, with no family history of the disease, was diagnosed 9 years ago with gastrointestinal stromal tumor (GIST). She had dysphagia and difficulty singing, which encouraged her to go to the gastroenterologist. Were done endoscopy that did not reveal any findings and ultrasound of the thyroid showing two nodules, a liquid and a solid. 10 ml of blood accumulated locally was punctured. The day after the endoscopy, the patient reported severe and diffuse pain with a maximum scale on a scale of 1 to 10. She was hospitalized and medicated with analgesic and sedative. Cardiac involvement was suspected in addition to abdominal pain. An abdominal CT scan was performed, but there were no findings. Under suspicion that the first endoscopy might have perforated some compartment, a second one was made, however it did not reveal any findings. A second CT scan was performed to assess the stomach, but found nothing unusual. During this hospitalization period, laboratory tests did not show significant changes. There was a suspension of colored foods and the use of serum for 3 days. A third abdominal CT scan was performed with the appearance of a vascularized piece adhered to the peritoneum at the outer limit of the stomach. Surgery was performed with extraction of the 150 g of GIST and the material was sent for biopsy. She remained hospitalized for another 16 days with the administration of intravenous medication and subsequent release.Discussion: This case is interesting because it includes a rare tumor of the gastrointestinal system. Certainly, it´s important for all physicians to keep in mind GIST as a differential diagnosis in order to provide an early diagnose and, therefore, prevent complications an increase the patient´s chance of survival.Conclusion: Clinical findings and evaluation of complementary exams were not suggestive for the diagnosis of GIST, which generated diagnostic complexity. The clinical manifestations presented at the beginning did not indicate the triggering factor to arrive at the real problem due to the few studies, the small incidence of the disease and in addition without a history of the disease in the family.

Aim Even in the face of evidence-based recommendations, the ‘nil by mouth from midnight’ regimen has persisted because it is easy to administer and allows for theatre flexibility. We aimed to audit preoperative fasting practices at Kasturba Medical College Hospital Attavar, India against the Indian Society of Anaesthesiologists (ISA) national guidelines. Method Prospective clinical audit involving ASA 1 and 2 patients undergoing elective, non-obstetric surgery under general/regional anaesthesia or sedation. Data were collected from patient notes and from an interview on the morning of surgery (at least one hour prior to induction of anaesthesia). Results Baseline Data (N = 100) Median fasting durations of 10 hours and 12.5 hours from clear fluids and solids, respectively. 99% of patients gave an incorrect reason or did not know at all the reason for preoperative fasting. Interventions:Patient information leaflets (in English and the local language) were made and distributed to every ward; to be shown to elective surgery patients on the day before surgery.Surgical trainees, anaesthesiology trainees and nurses were made aware of the audit findings. Re-Audit (N = 40) Median fasting duration of 3 hours and 11 hours respectively clear fluids and solids. Thirty-five percent of patients knew the correct reason for preoperative fasting. 50% gave an incorrect reason, while 15% did not know the reason. Conclusions Prolonged fasting was observed initially despite guidelines. Significant reduction in clear fluid fasting duration was achieved (10 hours to 3 hours) by creating awareness.