Nil By Mouth Research Articles

Comfort feeding in hospitalised people with dementia: a retrospective study of survival following comfort feeding recommendations

ObjectivesPersistent and significant swallowing impairment can occur in individuals with dementia. Determining prognosis and establishing realistic goals of care in this population is complex and comfort feeding may be recommended. This study aimed to establish evidence relating to patient outcomes following recommendation of comfort feeding to aid informed decision making. DesignA multi-centre, retrospective audit was conducted for a two-year period to establish the survival and readmission rates for hospitalised people with dementia, following recommendation of a comfort feeding plan. SettingThe study was conducted at three acute care hospitals in Adelaide, South Australia. ParticipantsA total of 163 participants were included, 90 male and 73 female, with a median age of 88 years. MeasurementsMortality within 30 and 90 days of admission and readmission rates within 30 days of discharge were calculated. ResultsForty-two percent of participants died during the admission during which a comfort feeding plan was recommended. Overall median survival time and one month survival was 13 days and 25%, respectively. Readmission rates were low (7.4% of those discharged). Comfort feeding recommendations aligned with dysphagia severity and those for whom Nil By Mouth (NBM) or ice chips only were recommended were at highest risk of dying in hospital, those recommended thickened fluids +/− ice chips were most likely to be alive 30 days after their original admission date. ConclusionDementia and comfort feeding were associated with high mortality rates, high rates of discharge to a supportive care facility and low readmission rates. Dysphagia severity associated with the consistency of fluids recommended.

EP33 - Nil by mouth in GI surgery: are we starving our patients longer than we need to?

Abstract Aim Fluid intake preoperatively reduces postoperative nausea, vomiting and headache, and oral intake allows the patient to be metabolically active to respond better to surgery. However, a known risk to oral intake preoperatively is aspiration. Current guidelines state that a patient should be fasted from 6 hours preoperatively and should take clear fluids up to 2 hours preoperatively. We assessed how long GI patients admitted to the Surgical Assessment Unit (SAU) remained nil by mouth (NBM). Method Data was collected throughout November from SAU. Inclusion criteria was GI surgical patients and exclusion criteria was patients on home leave. We used electronic and paper notes to determine how long patients were kept NBM and their surgical outcome. We assumed that a patient was kept NBM from their admission (as per local protocol), until either noted to no longer be NBM, having surgery or being discharged. Results 50 patients were identified. We found that only 20% of patients kept nil by mouth went on to have surgery. Of the remaining 80%, 60% were kept nil by mouth for >6 hours, with no surgical procedures. Conclusions Many patients are kept NBM unnecessarily. We need to reduce this as well as the time patients are starved. Furthermore, clearer documentation is needed for commencing patients NBM, and when they can resume eating. We can move away from the culture of prolonged fasting in surgical patients by improving organisation and planning as well as increasing education on preoperative fasting.

Nil per os in the management of oropharyngeal dysphagia-exploring the unintended consequences.

Nil per os (NPO), also referred to as Nil by Mouth (NBM), is a health-related intervention of withholding food and fluids. When implemented in the context of a person with dysphagia, NPO aims to mitigate risks of aspiration. However, evidence demonstrating that NPO is beneficial as an intervention for people with dysphagia is lacking. This paper explores the theoretical and empirical evidence relating to the potential benefits and adverse effects of NPO and asserts that NPO is not a benign intervention. This paper argues for applying an ethics framework when making decisions relating to the use of NPO as an intervention for dysphagia, in particular addressing informed consent and a person's right to self-determination.

Psychosocial impacts of being nil-by-mouth as an adult: A scoping review.

To map existing evidence and identify gaps in the literature concerning psychosocial impacts of being nil by mouth (NBM) as an adult. A scoping review of the literature was undertaken using JBI guidance. A protocol was registered on the Open Science Framework (osf.io/43g9y). Reporting was guided by Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR). A comprehensive search of six databases (CINAHL, Embase, MEDLINE, PsycINFO, SCOPUS and Web of Science) was performed for studies published up to February 2023, with no restriction to study type. A scope of the grey literature was also undertaken. Two authors independently assessed eligibility and extracted data. Descriptive statistical analysis and narrative synthesis were used, and patient and public involvement included in funding discussions. A total of 23 papers were included in the review, consisting of 14 primary studies (7 qualitative and 7 quantitative) and 9 grey literature. Both global psychological distress and distress specific to being NBM (thirst, missing food and drink) were reported. Caregivers also experience distress from their family member being NBM. Furthermore, social impacts were reported for both patient and caregiver, primarily social isolation and subsequent low mood. Furthermore, research is needed to understand the prevalence of this population, how best to measure psychosocial impacts and to explore whether (and how) psychosocial impacts change over time. Advancement in this area would enable better service development to optimize care for this patient group. WHAT IS KNOWN ABOUT THIS TOPIC?: Eating and drinking provides more than nutrition and hydration. A wide range of conditions can lead to recommendations for no longer eating and drinking (nil by mouth). Being nil by mouth (NBM) for short periods such as pre-operative fasting causes distress; however, little is understood about impact on longer-term abstinence from eating and drinking. WHAT THIS PAPER ADDS?: Psychosocial consequences of being nil by mouth (NBM)have been investigated by both quantitative and qualitative studies. Being NBM impacts both patients and caregivers in various psychosocial aspects, including distress and social isolation. Several gaps remain, however, regarding ways to measure psychosocial impact of being NBM.

Perioperative clinical management in relation to emergency surgery for perforated peptic ulcer: A nationwide questionnaire survey.

Perforation is a severe complication of peptic ulcer disease. Evidence regarding perioperative management of patients undergoing surgery for perforated peptic ulcer is scarce without any clear guidelines. This study aimed to investigate the clinical practice and possible differences in the perioperative management of patients undergoing emergency surgery for perforated peptic ulcers in Denmark. The study was an anonymous, nationwide questionnaire survey. All doctors working at general surgical departments in Denmark were included. The questionnaire consisted of four parts; 1) demographic details including job position, subspecialty, geographic location, and surgical experience, 2) pre- and postoperative use of nasoenteral tubes, 3) routine use of nil-by-mouth (NBM) regime, 4) questions regarding postoperative nutrition.Subgroup analyses were performed according to job position and subspecialty. In total, the questionnaire was answered by 287 surgeons, of which 74% were experienced surgeons being able to perform surgery for perforated peptic ulcers independently.Pre- and postoperative nasoenteral tubes were used routinely by the majority of the respondents. One of five surgeons routinely practiced a postoperative NBM regime. Generally, the respondents allowed clear fluids postoperatively without restrictions but were reluctant to allow free fluids or solid foods. Two of three surgeons routinely used tube- or parental nutrition. The results varied depending on job position and subspecialty. After emergency surgery, the postoperative management of patients with perforated peptic ulcers varies considerably among general surgeons in Denmark. Evidence-based national or international guidelines are needed to standardize and optimize the clinical practice.

P-P16 Management of acute pancreatitis in a busy district general hospital

Abstract Background Pancreatitis is a common surgical presentation and can be life threatening, with complications such as acute respiratory distress syndrome and necrosis occurring. Due to high hospital incidence, it is important to ensure patients are managed appropriately using available guidelines. This audit aims to assess the management of acute pancreatitis in a busy district general hospital and identify areas for improvement to better patient safety. Methods Only cases of acute pancreatitis were used in this audit. Case notes for the period between October and December 2020 were collected respectively. A data collection proforma was created using guidelines from the British society of gastroenterology for the management of acute pancreatitis. Data was then analysed using Excel. Results 23% of cases had documented scoring, with Glasgow-Imrie the only scoring tool used. 41% had documented oxygen saturation. 33% had been reviewed by alcohol liaison team for pancreatitis secondary to high alcohol consumption. No patients were given the guideline’s recommended rate of fluid resuscitation (5-10ml/kg/hr). All patients had amylase/lipase in their blood profile. 80% of patients had antiemetics prescribed should they require them, whilst 95% of patients had opioids prescribed for analgesia. 50% of patients were given antibiotics despite them not being indicated. 18% were kept nil by mouth (NBM) whilst having abdominal pain. Conclusions Our results suggest that guidelines for acute pancreatitis are not adequately adhered to. Many aspects of the guidance were not followed including documentation of oxygen saturation, antibiotic use, IV fluid resuscitation and alcohol liaison review for patients who required review. We have developed a proforma to use for the management of acute pancreatitis to ensure that cases are managed in accordance with evidence-based literature and to make the management of these cases easier. We will reaudit to analyse the effects of our intervention and determine whether there has been an improvement in the management of acute pancreatitis.

303 Adherence to Nil by Mouth Guidelines in A Tertiary Centre

Abstract Aim Fasting before general anaesthetic aims to decrease the volume and acidity of stomach contents during surgery, which therefore reduces the risk of aspiration. This is a second cycle closed loop reaudit which had implemented Nil by mouth (NBM) guidelines during the first cycle as an intervention to improve knowledge. Preoperatively, adult patients should remain fasted for a minimum duration as below: During the second cycle interventions were included such as: teaching to junior doctors and nurses including specific teaching during induction of new surgical doctors and posters displaying the NBM guidelines were placed in surgical wards. These were carried out despite restrictions during the COVID-19 pandemic. Method The same questionnaire was redistributed amongst staff members (nurses and HCA) throughout various surgical wards and junior doctors. Results were compared with the initial audit during this second cycle to assess whether any improvements had been made after implementation of interventions. Results Total number of staff: Conclusions A significant improvement in knowledge and understanding of the NBM guidelines was demonstrated with all members of staff and practice was in accordance with NICE guidelines.

Early Post-operative Feeding: An Investigation of Early Functional Outcomes for Oral Cancer Patients Treated with Surgical Resection and Free Flap Reconstruction

Traditionally patients can remain nil by mouth (NBM) for up to 12 days after oral tumour resection with free flap reconstruction to reduce the risk of flap dehiscence, poor healing and fistulae. The literature reports that patients could on average remain an inpatient for up to 20 days post-surgery. An evaluation of the impact of a defined early oral feeding protocol was undertaken investigating functional outcomes and complications rates. We prospectively reviewed tracheostomy use, length of hospital stay, non-oral feeding status and swallowing function using the Performance Status Scale for Head and Neck Cancer (PSS-HN) within a defined early feeding protocol. Twenty-nine patients underwent surgical resection with free flap reconstruction for advanced primary oral cancer between January 2018 and December 2019. Average age was 59.5 (range 24–88). Tumour sites included oral tongue (n = 10), maxilla (n = 6), mandible (n = 6), floor of mouth (n = 5) and buccal mucosa (n = 2). Median time to decannulation was 7 days (range 3–20 days, n = 11). The majority of patients were able to tolerate at least oral fluids on day 1 post-operatively (86%, n = 25). In addition to oral intake, non-oral feeding was required in 90% (n = 26), the majority of which included a nasogastric tube (NGT) placed intraoperatively 54% (n = 14), others required gastrostomy 46% (n = 12). Median time to nasogastric tube removal was 6 days (range 3–15 days). Median length of hospital stay was 10 days (range 3–51). Mean PSS-Normalcy of Diet (NOD) score at point of hospital discharge was 36.55 (95% CI 30.9–42.2). Flap failure was noted in 3% (n = 1). The adoption of an early oral feeding protocol suggests that there is the potential for a shorter hospital stay and earlier swallowing rehabilitation.

Underrecognition and undertreatment of thirst among hospitalized patients with restricted oral feeding and drinking

Thirst is distressing but overlooked by healthcare professionals. Patients experience thirst due to comorbidities, physical or cognitive limitations, and iatrogenesis. Nasogastric tube (NGT) use and nil-by-mouth(NBM) orders are common practices that can lead to thirst. However, thirst in these populations has never been formally studied. We aim to examine prevalence of recognition and treatment of thirst among NGT + NBM and NBM patients. Our descriptive study was conducted intermittently over 25 weeks, across 1.5 years, in 12 adult general medicine wards of a tertiary hospital. Cognitively intact NGT + NBM or NBM inpatients, defined as Abbreviated Mental Test score ≥ 8, were studied. One-time questionnaire was administered. Variables included: demography, co-morbidities, clinical condition, feeding route, thirst defined by thirst distress and/or intensity ≥ 3, pain, hunger and volume status. 88 NGT + NBM and NBM patients were studied. 69.3% suffered from thirst. Thirsty patients experienced significant thirst-related distress (mean score ± SD: 5.7 ± 2.5). Subjects with previous stroke and who were euvolemic tended towards thirst. 13.6% were asked about thirst by doctors or nurses. Thirst was a major source of patient distress in our study. We suggest that thirst needs to be actively identified and targeted to achieve person-centred care.

Network Mapping of Time to Antithrombotic Therapy Among Patients With Ischemic Stroke and Transient Ischemic Attack (TIA).

Background: There is emphasis on timely administration of thrombolysis and clot retrieval but not antithrombotic therapy within 48 h for ischemic stroke (frequency of 64% in Australia and 97% in North America). We planned to assess the time metrics and variables associated with delaying antithrombotics (antiplatelet and anticoagulant therapy) administration.Methods: This was a retrospective study at Monash Health over 12 months in 2015. We plotted the cumulative event and mapped the key drivers (dimensionless variable Shapley value/SV) of antithrombotics.Results: There were 42 patients with transient ischemic attack/TIA and 483 with ischemic stroke [mean age was 71.8 ± 15.4; 56.0% male; nil by mouth (NBM) 74.5 and 49.3% of patients received “stat” (immediate and one off) dose antithrombotics]. The median time to imaging for the patients who did not have stroke code activated was 2.3 h (IQR 1.4–3.7), from imaging to dysphagia screen was 14.6 h (IQR 6.2–20.3), and from stopping NBM to antithrombotics was 1.7 h (IQR 0–16.5). TIA patients received antithrombotics earlier than those with ischemic stroke (90.5 vs. 86.5%, p = 0.01). Significant variables in regression analysis for time to antithrombotics were time to dysphagia screen (β 0.20 ± 0.03, SV = 3.2), nasogastric tube (β 19.8 ± 5.9, SV = −0.20), Alteplase (β 8.6 ± 3.6, SV = −1.9), stat dose antithrombotic (β −18.9 ± 2.9, SV = −10.8) and stroke code (β −5.9 ± 2.5, SV = 2.8). The partial correlation network showed that the time to antithrombotics increased with delay in dysphagia screen (coefficient = 0.33) and decreased if “stat” dose of antithrombotics was given (coefficient = −0.32).Conclusion: The proportion of patients receiving antithrombotics within 48 h was higher than previously reported in Australia but remained lower than the standard achieved in North American hospitals. Our process map and network analysis show avenues to shorten the time to antithrombotic.

A PROSPECTIVE STUDY ON EARLY ENTERAL NUTRITION FOLLOWING GASTROINTESTINAL SURGERY

Background: The word anastomosis originates from the Greek word meaning communicating opening. Gut anastomosis is one of the frequently performed surgeries. As conventional practice following gut anastomosis, patients are kept “NIL BY MOUTH” till bowel sounds return. During this time period, patient remains with nasogastric tube for decompression of stomach and providing rest to the gut. Aim of the study on early enteral nutrition following gastrointestinal surgery. Methods: A prospective study was carried out over a period of 18 months in dept of General Surgery BMCH Burdwan. The aim of this study was to determine whether early enteral feeding (within 48hrs) after gastrointestinal surgery is tolerable and beneficial to the patient or not. Results: OF 54, 34 were male, 20 were female with a percentage of 63% and 37%. Every patient were given early enteral nutrition and only 6(11.1%) developed paralytic ileus, 16 (29.6%) patients developed gastrointestinal disturbances. Among 29 who underwent anastomosis 3(10.3%) patients had anastomotic leak. Among 54, 9(16.7%) developed SSI (11.1%) developed chest infection. Conclusion: It can be concluded that early enteral feeding induces quicker recovery of postoperative gastrointestinal movements in patients. Early enteral feeding reduces SSI> It is safe and effective I postoperative patients, even if there is apparent ileus. There is no significant correlation between early enteral nutrition and development of complications (ie anastomostic leak, paralytic ileus and postoperative chest infections).

The changes in Blood Pressure in Patients Undergoing Spinal Anesthesia According to the Size of Spinal Needle (G22 versus G24): Case Reference Study

Background: Previous studies of patients with spinal anesthesia prior to sympathectomy revealed that vasodilatation and hypotension, with subsequent reduction in arterial pressure, were the most common side effects (observed in more than 30% of patients). Hypotension in epidural anesthesia was stated to be more gradual and less extreme than in spinal anesthesia when a comparable amount of anesthesia was given. Aim of the study: In the current study, we are aiming to evaluate the effect of different size of spinal needle on development of possible blood pressure changes throughout the spinal anesthesia procedure. Patients and Methods: The current observational case reference study was carried out at Al-Diwaniyah Teaching Hospital in Al-Diwaniyah Province, Iraq. The beginning of the study is dated back to the 3rd of April 2018 and the study continued till September the 15th 2019. It included 60 patients undergoing spinal anesthesia for various surgical operations. In 30 patients a spinal needle of 22 gauge was used whereas in the second group (n = 30), a spinal needle of gauge 24 was used. All patients were instructed to be nil by mouth overnight. Results: In group 1 (22G), mean systolic blood pressure showed gradual reduction, 139.00 ±8.35 mmHG, 120.67 ±11.43 mmHg, 106.00 ±11.02 mmHG and 97.33 ±10.15 mmHg; similarly, in group 2 (24G) mean systolic blood pressure showed gradual reduction, 144.00 ±10.37 mmHG, 138.00 ± 7.61 mmHg, 131.33 ±9.00 mmHG and 131.67 ±11.40 mmHg; however, the rate of reduction in group 2 (G24) was less than that seen in case of group 1 (G22). In group 1 (22G), mean diastolic blood pressure showed gradual reduction, 84.00 ±7.24 mmHG, 72.00 ±6.64 mmHg, 61.33 ±9.73 mmHG and 54.00 ±8.94 mmHg; similarly, in group 2 (24G) mean diastolic blood pressure showed gradual reduction, 87.33 ±7.85 mmHG, 81.33 ±7.30 mmHg, 77.33 ±10.15 mmHG and 78.00 ±5.51 mmHg; however, the rate of reduction in group 2 (G24) was less than that seen in case of group 1 (G22). Conclusion: It appears that the use of narrower spinal needle is recommended as it is associated with significantly less drop in both systolic and diastolic blood pressure, thus less hemodynamic disturbances in patients undergoing spinal anesthesia for various indications

The Rate of Post-Spinal Puncture Headache in Patients Undergoing Spinal Anesthesia According to the Size of Spinal Needle (G22 versus G24): Case Reference Study

Background: A number of disadvantages have been described in associations with spinal anesthesia such as short duration of pain relief, increased incidence of hypotension and post-spinal puncture headache (PSPH). Post-spinal puncture headache symptom has been explained by intracranial hypotension (low CSF pressure) because of CSF leak at site of puncture, causing traction on pain sensitive structures. Aim of the study: The present study was aiming at comparing the incidence rate of PSPH in relation to the gauge of used spinal needle. Patients and Method: The current observational case reference study was carried out at Al-Diwaniyah Teaching Hospital in Al-Diwaniyah Province, Iraq. The beginning of the study is dated back to the 3rd of April 2018 and the study continued till September the 15th 2019. It included 60 patients undergoing spinal anesthesia for various surgical operations. In 30 patients a spinal needle of 22 gauge was used whereas in the second group (n = 30), a spinal needle of gauge 24 was used. All patients were instructed to be nil by mouth overnight. Results: The Rate of post-spinal puncture headache (PSPH) show significant variation according to needle caliber size. Patients who experienced headache in the first group (gauge 22) were more frequent that those in group 2 (gauge 24), 22 (73.3 %) versus 8 (26.7 %) and the difference was highly significant (P < 0.001). In addition, severe headache was only seen in group 1 (gauge 22). Conclusion: The incidence and severity of post-spinal puncture headache (PSPH) is significantly related to spinal needle caliber size so that narrower needles are associated with less frequent and milder form of headache in comparison with wider bore needles

Gastrostomy dependency trends over 15 years of patients at a large tertiary referral center following the insertion of a prophylactic gastrostomy for chemoradiation for mucosal head and neck cancer.

The routine use of prophylactic percutaneous endoscopic gastrostomy (PEG) tubes for nutrition support during radical chemoradiation for head and neck cancer has been suggested to result in PEG dependency. This research aimed to determine the rates of gastrostomy dependency at the Calvary Mater Newcastle (CMN) where PEGs are routinely used and to identify potentially modifiable risk factors. All patients with head and neck cancer planned for curative chemoradiation with a prophylactic PEG inserted were included in this review. Medical records of 250 patients treated between 2000 and 2015 were examined. Overall, eight patients (3%) were unable to wean. At 12 months following treatment, 16 patients (6%) still required PEG tubes for feeding. A greater T extent (T4 or synchronous head and neck tumors) and number of days Nil By Mouth (NBM) remained as significant independent risk factors for PEG dependency at 12 months (Textent OR 6.96 P<.001; NBM OR 1.01 P=.004) and overall (Textent OR8.04 P=.02; NBM OR1.01 P=.001). Associations with NBM were investigated, which demonstrated that patients had less NBM days with intensity-modulated radiation therapy (IMRT) (β-13.3, P=.007) and seeing a speech pathologist during treatment (β-11.9, P=.026). More NBM days were associated with tumors with greater T extent (β+22; P<.001). The routine use of prophylactic PEGs has not resulted in significant rates of PEG dependency at the CMN. Seeing a speech pathologist during treatment and IMRT may decrease time NBM, which was identified as a potentially modifiable risk factor for PEG dependency.

Impact of nutritional status/risk and post-operative nutritional management on clinical outcomes in patients undergoing gastrointestinal surgery: a prospective observational study.

Malnutrition is prevalent in patients undergoing gastrointestinal (GI) surgery and has been linked to adverse outcomes. The present study aimed to determine the association between early post-operative nutritional status/risk, post-operative nutritional management and clinical outcomes. A prospective observational study was conducted in GI surgical patients with a minimum 3-day post-operative length of stay (LOS). Data on patient demographics, nutritional status/risk, post-operative nutritional management and clinical outcomes were collected. Four markers of nutritional status and risk were assessed: preoperative weight loss, nutrition risk, malnutrition status and hand grip strength. Clinical outcomes included: post-operative LOS, complication and readmissions rates. Multivariate linear and logistic regression were used to test for associations with clinical outcomes. One hundred and fifteen patients (55% female) with mean (SD) age of 60.8 (16.2) years were included. Median (IQR) post-operative LOS was 8.0days (4.5-11.5), 37% of participants developed at least one complication post-operatively and 24% were readmitted within 30-days of discharge. Mean number of nil-by mouth (NBM) days post-operatively was 0.7 (1.2) and the average time to commence feeding was 3.3 (2.2)days after surgery. Poor nutritional status/risk between days 3-5post-operatively assessed through all four markers was associated with longer post-operative LOS (all P<0.05). No association was found between number of NBM days, time to feeding and clinical outcomes. Poor early post-operative nutritional status/risk is associated with longer post-operative LOS in patients undergoing GI surgery, which may facilitate simple identification of patients at high priority for nutritional intervention. The present study highlights the heterogeneity in post-operative nutritional management practices.

Enhancing the recovery of head and neck oncology patients through early feeding

Introduction/Aims Traditionally, head and neck cancer patients are nil by mouth (NBM) for 1-2 weeks post resection and reconstruction to reduce their risks of aspiration and developing a fistula. (1) We propose that patients may benefit from early feeding to improve their swallow rehabilitation and to reduce the duration of their hospital stay. The aim is that 100% of patients to be NBM for 2 days or less by June 2018.

The perils of 'risk feeding'.

'Risk feeding' policies, for when people continue to eat and drink despite a perceived risk of choking or aspiration have become common in recent years. We argue that 'feeding' is demeaning language if referring to a person who is eating and drinking rather than to a healthcare technique and that 'risk-anything' is not how decisions are reached. It is true that patients with dysphagia are often unnecessarily designated nil-by-mouth (NBM), especially after a decision has been made that tube feeding is not indicated or is unwanted. However, risk-feeding policies may perpetuate common misperceptions that there is a straightforward relationship between aspiration and pneumonia and that interventions like NBM or tube feeding will reduce the risk of pneumonia. Such policies may reduce the potential for individualised and flexible decision making: many people's swallowing abilities and preferences fluctuate, sometimes from hour to hour, and staff need to have, and be encouraged to use, common sense, flexibility and judgement in these circumstances. There is also the potential for delays in providing food, fluid and medications if meetings must be held and risk-feeding paperwork completed and signed by someone with the necessary seniority and confidence. Further debate and discussion is required before risk-feeding policies become an established standard of care.

Nutrition in Hip Fracture Units: Contemporary Practices in Preoperative Supplementation.

Introduction:Patients with hip fractures pose a significant burden on health services. Malnutrition, frailty, and cognitive impairment are common, and key to addressing the needs of this vulnerable patient group is nutrition optimization, including reduction in arbitrary nil by mouth (NBM) perioperative regimens. In order to understand current practices, we characterize preoperative nutrition in a regional hip fracture population.Methods:Prospective data were submitted to the National Hip Fracture Database by 6 hospitals in the north east of England over a 6-month period. Patients were stratified by preoperative nutritional intake, frailty, and cognitive function.Results:In all, 24.2% (n = 205) patients received no oral intake at all preoperatively; 15.3% of NBM patients were at risk of malnutrition; and 6.9% were malnourished at the time of assessment. Median time to surgery for NBM patients was 16.75 hours, and 6.34% of patients were fasted with no intake for >36 hours. In all, 6.5% (n = 44) of patients with an Abbreviated Mental Test Score (AMTS) of 8 or above were deemed to be at risk of malnutrition at admission, compared to 11.3% (n = 50) of patients with an AMTS of 7 or below. The NBM patients had similar mean Rockwood (4.97) and AMTS (6.51) scores to patients given oral nutrition.Conclusion:We have demonstrated contemporary preoperative nutritional practices in the management of over 800 hip fracture patients. Contrary to perception, nutrition practices vary little when stratified for age, cognition frailty, or comorbid burden. We have identified widespread prolonged NBM fasting and undersupplementation in patients sustaining hip fracture across a region. This work suggests a need to focus less on patient factors and more on systematic practices.

Hospital policy following cancelled orthopaedic surgery and the patient experience—making the best of a bad situation

Background: Number of cancelled electiveorthopaedic surgeries has increased over the last decade as strains on surgicalservices exacerbates. Being told an operation is cancelled is disappointing forthe patient, the clinician and is not without a financial loss. This experienceis frustrating for patients who are often not informed of cancellations bydoctors and sent home dissatisfied without clarity of treatment plans.Alternatives have to be sought to safeguard the patient experience, maintaincommunication and avoid wastage of resources. Methods: Over a 1-year period, 117 patientswere prospectively shortlisted with a cancellation on the day of surgery in adedicated elective orthopaedic unit. Questionnaire data assessed adherence toAssociation of Anaesthetists of Great Britain and Ireland Theatre Efficiencyguidance, including: healthcare professional informing patients; time offeredfor explanation; patient understanding and satisfaction as well as perceptionof being kept nil by mouth (NBM) longer than necessary. Opinions of alternativesatisfactory professionals to lead cancellation discussion was also evaluated. Results: 35.04% of cancellations were informedby consultants, 23.77% by junior doctors and 38.46% by nurses. Out of 10,patient understanding was 8.31 and satisfaction 6.37 for consultant leddiscussions against 5.12 and 4.07 for nurses, respectively. Overall, 35.04% ofpatients felt they were kept NBM longer than necessary vs. 60% of the 45patients told by nurses. 90.60% felt consultants were the ideal professional tolead cancellation discussions however 70.94% stated a registrar would besatisfactory. Conclusions: Cancelledelective surgery that a patient has mentally prepared for is extremelydemoralising. Poor peri-operative communication and management further worsensthe patient experience and represents sub-standard care. It is paramount thatguidelines exist where patients are informed of reasons for cancellation by asenior surgeon in a manner that accounts for availability of resources.

A prospective randomized controlled study: early enteral nutrition following gastrointestinal surgery

Background: The word anastomosis originates from the Greek word (ἀναστόμωσις) meaning communicating opening. Gut anastomosis is one of the frequently performed surgeries in both emergency and elective setup. Anastomosis following gut resections in emergency set up is mostly done due to traumatic rupture, benign or malignant perforation or obstruction and in certain other inflammatory conditions. Anastomosis is also done in some elective conditions like mostly due to malignancy of GI system. As conventional practice following gut anastomosis, patients are kept “NIL BY MOUTH” till bowel sounds return.Methods: It’s a prospective study, carried out over period of 18 months in Department of General Surgery, Sri Guru Ramdas Institute of Medical Sciences and Research, Vallah, Amritar. The objective of this study was to whether early enteral feeding within 48 hours of small gut anastomosis is tolerable to the patient. Whether early enteral feeding within 48 hours of small gut anastomosis is beneficial to the patient.Results: This prospectively conducted comparative study was carried out on 60 patients, meeting inclusion criteria, undergoing gastrointestinal anastomosis either elective or emergency, in the Department of General Surgery, SGRD Medical College, between Jan 2012 to June 2013. Random selection of patients into group A (30) and group B (30) was done after having fulfilled inclusion and exclusion criteria. The group A was fed via enteral route within 48 hrs of enteric anastomosis. The group B was fed via enteral route after 48-72 hours or appearance of full peristaltic sounds following enteric anastomosis. These patients were followed in post-operative period for their drain output, any nausea, vomiting, or significant abdominal distension, prolonged ileus, clinical leakage, infective complications, hospital stay.Conclusions: The following inferences can therefore be drawn from this study: Appearance of intestinal peristaltic sounds is earlier in early enterally fed group, Mean duration of post-operative hospital stay is lower in early enterally fed group, mean post-operative day 4 albumin level is higher in early enterally fed group. The rate of infective complications (UTI, RTI, wound complications) is equal in both the groups. The rate of clinical leakage, nausea/vomiting are equal in both the groups. The rate of re-exploration for anastomotic leakage is equal in both the groups.