Prolonged Preoperative Fasting Research Articles

Adherence to Preoperative Fasting Guidelines in Elective Surgical Patients.

Preoperative fasting is recommended by international guidelines as a means to minimize the risk of aspiration of gastric content during induction of anesthesia or surgery. Prolonged preoperative fasting is, however, discouraged due to the associated side effects such as dehydration and electrolyte imbalance, which can negatively impact recovery after surgery. An initial quality improvement study revealed poor implementation of the best practice guidelines on preoperative fasting in three departments of a hospital and an institutional action plan was devised to enforce adherence to these guidelines. This present study aimed to assess compliance with the action plan and for that matter, adherence to international consensus on preoperative fasting in three surgical departments. Adult patients undergoing elective cardiac, thoracic, and vascular surgery at a university teaching hospital were surveyed over four months (September October, November, and December of 2023). Data on the length of preoperative fasting was collected using a standardized questionnaire. A total of 306 patients who were scheduled for elective surgery were included in the study. Of the 306 patients, 139 (45.4%) had vascular surgeries, 108 (35.4%) received cardiac surgeries, and 59 (19.3%) had thoracic surgeries. For clear fluids, the overall median fasting time (Q1, Q3) was 4.5 (2.7, 7.4) hours, and for solid food, 14.5 (12.1, 19.0) hours. Extended abstinence from clear fluids and solid food for more than 12 hours was observed in 43 (14.1%) and 231 (75.5%) instances, respectively, while abstinence from solid food for more than 24 hours was noticed in 40 (13.1%)cases. When compared to patients having operations in the morning, those scheduled for afternoon surgery had longer median fasting periods from clear fluids and solid food, p<0.001: 6.2 (4.0, 12.0) hours vs. 3.4 (2.0, 5.2) hours for clear fluids and 16.7 (12.6, 22.6) hours vs. 13.2 (9.6, 15.2) hours for solid food, respectively. Patients continue to abstain from clear fluids and solid food for extended periods of time, despite the fact that there is worldwide agreement regarding shorter periods of preoperative fasting. Compared to patients undergoing morning surgery, individuals hospitalized for afternoon procedures were more likely to fast for extended periods of time.

Preoperative clear fluids fasting times in children: retrospective analysis of actual times and complications after the implementation of 1-h clear fasting

BackgroundPreoperative fasting before elective pediatric surgery is a matter of ongoing debate. The objectives of this study were to evaluate the compliance to a recently implemented preoperative fasting protocol (clear fluids until 1 hour from the induction of anesthesia), to identify predictors of prolonged preoperative fasting time, and to determine whether duration of preoperative fasting was associated with adverse outcomes.MethodsRetrospective single-center study in an operating theater of a tertiary pediatric hospital.ResultsIn a 6-month period, 1820 consecutive patients were analyzed. The data collected in the questionnaire reporting the time of last food, milk and/or liquid intake, and eventual reasons for nonadherence was analyzed. Median (interquartile range) preoperative fasting time was 186 (110–345) min. In 502 patients (27.6%), duration of preoperative fasting to clear fluid ranged from 60 to 119 min, whereas in 616 (34%) it was 120–240 min. The reasons for not respecting fasting time rules are mostly related to communication issues or unwillingness by the patients. A significant difference in fasting times was evident between infants and children older than 10 years (188, 105–290 vs. 198, 115–362; p = 0.02). Fasting times were significantly shorter in the inpatient group and in the first scheduled patients of the morning. Clear fluids fasting times were significantly longer in patients with hypovolemia complications than in those without, 373 (185–685) vs. 180 (110–330) min (p < 0.0001). Longer fasting times to clear fluids, younger age, and scheduled surgery time were independently associated with the odds of experiencing complications.ConclusionsIn this single pediatric center study, median clear fluids fasting time was three times higher (180 min) than those recommended by the preoperative fasting protocol. Compliance to the protocol was observed in approximately 1 out of 4 patients (27.6%). Longer fasting times were associated with an increased risk of complications, which might be due to dehydration and/or hypovolemia.

Beyond Guidelines: The Persistent Challenge of Preoperative Fasting Times

Despite the advancements in evidence-based medicine, many hospitals still maintain high rates of patients undergoing prolonged preoperative fasting. The goal of this study is to determine the prevalence of prolonged fasting time among patients undergoing elective surgeries at a Brazilian university hospital and its associations with clinical and sociodemographic variables. This cross-sectional study was conducted between May and November 2019 and included patients of all ages undergoing elective surgeries. Out of the 293 patients analyzed, 64.2% were male, with ages ranging from 1 to 85 years, and 93.9% were classified as ASA I or II. The prevalence of preoperative fasting exceeding 8 h was 89.4%. An average fasting time exceeding 11 h was observed across all age groups. Patients who underwent procedures in the afternoon had an average fasting time that was 24% longer than those in the morning period (14.9 vs. 12 h, p &lt; 0.001). Surgery time (r = 0.134, p &lt; 0.03) and anesthesia times (r = 0.121, p &lt; 0.04) demonstrated a weak correlation with fasting time. Despite the international consensus on preoperative fasting time, our study demonstrated low adherence to current recommendations. Therefore, healthcare professionals should ensure the comprehension of fasting guidelines, and further studies should aim to identify effective solutions to mitigate prolonged fasting.

Knowledge, Implementation, and Perception of Enhanced Recovery After Surgery Amongst Surgeons in Pakistan: A Survey Analysis.

An increasing shift towards non-communicable diseases and an existing high surgical burden of disease in low-middle-income countries (LMICs), such as Pakistan, has driven the need for implementing Enhanced Recovery After Surgery (ERAS), a safe and cost-effective surgical service aimed at improving patient recovery and reducing post-operative complications. Despite countless benefits, there are few ERAS programs throughout Pakistan andsparse literature on healthcare professionals' views regarding ERAS. Without a deep understanding of healthcare professionals' perspectives on ERAS, underlying barriers and facilitators to a long-term ERAS implementation cannot be addressed and improved upon.Therefore, the purpose of this study is to better understand the knowledge, implementation, and perception of ERAS from the perspective of healthcare professionals across Pakistan. Upon receiving ethical approval from the McGill University Health Center (MUHC), a previously validated questionnaire was modified and a 29-question survey was developed and disseminated to healthcare professionals practising in Pakistan. Quantitative data was analyzed using descriptive statistics and potential correlations that exist between the implementation of ERAS and the participants' gender, employment setting, and surgical specialty were investigated using the chi-squared analysiswith a p-value of 0.05 as the cutoff. A total of 49 participants responded to this survey of whom 34 (69%) worked at a tertiary care teaching hospital whereas 15 (31%) worked at a private hospital. Surprisingly, 42 (85%) participants expressed being aware of the ERAS guidelines with only 30 (61%) either strongly agreeing or agreeing to successfully implementing ERAS into practice. The largest discrepancies in implementation were seen when discussing specific elements of the ERAS guidelines such as preoperative carbohydrate loading, practicing prolonged preoperative fasting, performing mechanical bowel preparation, performing active patient warming, and early postoperative removal of Foley's catheter. Surgeons employed at a private institution were more likely to discuss postoperative pain management and control, less likely to utilize prolonged fasting, more likely to perform regular body temperature monitoring, more likely to practice providing chewing gum to patients postoperatively, and more likely to perform early removal of the Foley's catheter. An understanding of ERAS, the implementation of various elements, and a positive attitude toward its benefits definitely seem to be prevalent among healthcare professionals in Pakistan. However, key barriers and enablers specific to the underlying healthcare environment seem to be hindering the long-term successful implementation of ERAS across Pakistan. It is crucial for future studies to explore these barriers in further detail and involve theperspective of these key stakeholders to help enhance long-term ERAS adoption.

Comparison of Enhanced Recovery After Surgery (ERAS) Pathway Versus Standard Care in Patients Undergoing Elective Stoma Reversal Surgery- A Randomized Controlled Trial

BackgroundPractices such as prolonged preoperative fasting, bowel preparation, delayed ambulation and resumption of orals result in morbidity in 15-20% of stoma reversal cases which can be improved by Enhanced Recovery After Surgery (ERAS) pathways. AimTo evaluate the safety, feasibility and efficacy of ERAS pathway in patients undergoing elective loop ileostomy or colostomy reversal surgery MethodsThis was an open-labeled, superiority randomized controlled trial in which patients undergoing loop ileostomy or colostomy reversal were randomized to standard or ERAS care. Patients with ASA class ≥3, needing laparotomy for stoma reversal, cardiac, renal and neurological illnesses were excluded. Components of ERAS protocol included pre-operative carbohydrate loading, avoidance of mechanical bowel preparation, goal directed fluid therapy, avoidance of long-acting opioid anesthetics or analgesics, avoidance of drains, urinary catheter or nasogastric tube, early mobilization and early enteral feeding. The primary outcome was length of stay (LOS) while the secondary outcomes were postoperative recovery and morbidity parameters. ResultsForty patients each were randomized to standard care and ERAS. Demographic and laboratory parameters between the two groups were comparable. ERAS group patients had significantly reduced LOS (5.3±0.3 vs 7 ± 2.6; mean difference: 1.73 ± 0.98; p=0.0008). Functional recovery was earlier in the ERAS group compared to the standard care group, such as early resolution of ileus (median-2 days; p<0.001), time to first stool (median-3 days; p=0.0002), time to the resumption of liquid diet (median-3 days; p<0.001) and solid diet (median-4 days; p<0.001). Surgical site infections (SSI) were significantly lesser in ERAS group (12.5% vs 32.5%; p=0.03) while postoperative nausea/vomiting (p=0.08), pulmonary complications (p=0.17) and urinary tract infections (p=0.56) were comparable in both groups. ConclusionERAS pathways are feasible, safe and significantly reduces LOS in patients undergoing elective loop ileostomy or colostomy reversal surgery.

Real-World Evidence: How Long Do Our Patients Fast?-Results from a Prospective JAGO-NOGGO-Multicenter Analysis on Perioperative Fasting in 924 Patients with Malignant and Benign Gynecological Diseases.

Despite the key role of optimized fasting in modern perioperative patient management, little current data exist on perioperative fasting intervals in routine clinical practice. In this multicenter prospective study, the length of pre- and postoperative fasting intervals was assessed with the use of a specifically developed questionnaire. Between 15 January 2021 and 31 May 2022, 924 gynecology patients were included, from 13 German gynecology departments. On average, patients remained fasting for about three times as long as recommended for solid foods (17:02 ± 06:54 h) and about five times as long as recommended for clear fluids (9:21 ± 5:48 h). The average perioperative fasting interval exceeded one day (28:23 ± 14:02 h). Longer fasting intervals were observed before and after oncological or extensive procedures, while shorter preoperative fasting intervals were reported in the participating university hospitals. Smoking, treatment in a non-university hospital, an increased Charlson Comorbidity Index and extensive surgery were significant predictors of longer preoperative fasting from solid foods. In general, prolonged preoperative fasting was tolerated well and quality of patient information was perceived as good. Perioperative fasting intervals were drastically prolonged in this cohort of 924 gynecology patients. Our data indicate the need for better patient education about perioperative fasting.

Preoperative Fasting of More Than 14 Hours Increases the Risk of Time-to-Death after Cardiothoracic Surgery in Children: A Retrospective Cohort Study

Background: Prolonged preoperative fasting can cause hypoglycemia, hyperglycemia, and intravascular volume depletion in children. We aimed to examine whether prolonged preoperative fasting is associated with in-hospital mortality and other morbidities in pediatric cardiothoracic surgery. Methods: This retrospective cohort study included children aged 0–3 years who underwent cardiac surgery between July 2014 and October 2020. The patient demographic data, surgery-related and anesthesia-related factors, and postoperative outcomes, including hypoglycemia, hyperglycemia, sepsis, length of intensive care unit stay, and in-hospital mortality, were recorded. The main exposure and outcome variables were prolonged fasting and time-to-death after surgery, respectively. The associations between prolonged fasting and perioperative death were analyzed using multivariate Cox regression analysis. Results: In total, 402 patients were recruited. The incidence of perioperative mortality was 21% (85/402). The proportion of perioperative deaths was significantly higher in the prolonged fasting group than that in the normal fasting group. The proportion of postoperative bacteremia and hypoglycemia was significantly higher in the very prolonged fasting group than that in the prolonged fasting group. After adjusting for preoperative conditions and anesthesia- and surgery-related factors, preoperative prolonged fasting >14.4 h was significantly associated with time-to-death (HR [95% CI]: 2.2 [1.2, 3.9], p = 0.036). The 30-day survival rates of fasting time >14.4 h, 9.25–14.4 h, and

Preoperative meal practices: An observational study

Background: In this era of enhanced recovery after surgery (ERAS), prolonged fasting has been discouraged. This study is an appraisal on the fasting practice in a tertiary hospital in India. Materials and Methods: Over a period of 1 year, 118 patients were taken into the study. The attending anesthesiologist noted the time of their last meal and the type of meal that was taken on the morning of surgery. Data were analyzed using STATA™ and Microsoft Excel version 2016. Results: Our study found that the fasting period for large and light meals was more and for clear fluids was 10.28 ± 3.63. For light meals and clear fluids, the fasting period was more than recommended. Conclusion: Prolonged preoperative fasting is still practiced despite existing guidelines. Prolonged preoperative fasting is still prevalent in today's era of ERAS. Education on the existing fasting guidelines and its implementation is needed.

Progress in the study of the effect of preoperative oral carbohydrates on postoperative delirium in elderly patients

As the population ages, the number of elderly patients who choose to undergo surgical procedures is gradually increasing, but the incidence of postoperative delirium in elderly patients is gradually increasing due to their physiological changes, preoperative malnutrition, and prolonged preoperative fasting. The role of preoperative carbohydrates as a contemporary element of the rapid recovery surgery (ERAS) paradigm in preventing the onset of postoperative delirium has become a clinical research hotspot. A full understanding of the safety and feasibility of preoperative oral carbohydrates for elderly patients will help to reduce the incidence of postoperative delirium and promote early recovery of elderly patients. This paper presents a review of the effects of preoperative oral carbohydrates on POD in elderly patients.

Prevention of post-operative nausea and vomiting with honey as a pre-operative oral carbohydrate: A randomised controlled pilot trial

Background Post-operative nausea and vomiting (PONV) is the secondmost common post-operative complication. Prolonged pre-operative fasting is common in Australia despite guidelines recommending reduced fasting to improve patient outcomes, such as PONV. Commercially prepared preoperative oral carbohydrate (OC) drinks may be used to reduce fasting time. In this study commercial products were replaced with honey, an inexpensive and common food item. Design Partially blinded, four parallel arms randomised controlled noninferiority trial compared pre-operative OC loading with overnight fasting. Methods Adult elective laparoscopic cholecystectomy and thyroidectomy patients having two or more risk factors for PONV were allocated into intervention and control groups by simple randomisation. The intervention group ingested 60g of honey in 100 ml of water at least two hours before surgery as pre-operative OC loading to reduce PONV. Participants and assessors to the group assignment were blinded to the study outcomes. Early PONV (0–6 hours) was measured with Rhodes index of nausea, vomiting and retching (R-INVR) and a numeric rating scale (NRS). Results The four groups (N = 142) were control and intervention groups of thyroidectomy patients (n = 72: C = 37, I = 35), and control and intervention groups of laparoscopic cholecystectomy patients (n = 70: C = 37, I = 33) and had similar distributions of variables. The estimated effect size was 140 with a 95 percent confidence interval. The PONV incidence (Pearson χ2 = 4.54; df = 1; p = 0.03) and severity were significantly lower in the laparoscopic cholecystectomy intervention group (R-INVR: Mann–Whitney U = 446.5; p = 0.01; NRS: Mann–Whitney U = 444.5; p = 0.01) and results were not conclusive in the thyroidectomy group (NRS: Mann–Whitney U = 629.5; p = 0.95; R-INVR: Mann–Whitney U = 629.5; p = 0.76). Conclusion Honey could be recommended as an inexpensive pre-operative OC to reduce PONV in adult patients receiving general anaesthesia.

Effect of a carbohydrṇate lollipop on the gastric volume of fasted pediatric patients.

BackgroundPreoperative fasting is part of routine practice. Children subjected to prolonged preoperative fasting often suffer adverse effects. Consuming a preoperative lollipop may lessen their anxiety and have clinical benefits.AimsTo assess the effect of consuming a lollipop on gastric volume and the feasibility of administering a lollipop to a child preoperatively.MethodsIn this prospective, repeated measures interventional study, we measured gastric antrum volume using ultrasound in children aged 2–18 years. We measured antrum volumes after participants had fasted for a minimum of 6 h for solids and 2 h for clear fluids. They then consumed a standard carbohydrate lollipop, and we repeated the antrum volume measurements after 1 h.ResultsOf the 38 patients enrolled, 32 completed the study; four had ingested additional food or liquid, and two were diagnosed with systemic disease the day after data collection. The gastric volume data were normally distributed. The mean volume change was 0.01 ml kg−1 (95% CI −0.02 to 0.05; p = .460). The mean postlollipop volume was 0.51 ml kg−1 (95% CI 0.43 to 0.58).ConclusionsConsuming a standard lollipop did not affect the gastric volume of fasted pediatric patients.

Application of enhanced recovery after cesarean delivery. A review

Caesarean section is the most common surgical intervention over the world, so the development of the enhanced recovery after cesarean delivery is turning out to be a vital problem. The practical application of the enhanced recovery after cesarean requires multidisciplinary collaboration and well-coordinated teamwork of an anesthesiologist, an obstetrician-gynecologist, nursing staff and other specialists. In this review, we have studied recent domestic and foreign articles dedicated to the enhanced recovery after cesarean. Particular attention was paid to the case management at all stages of the perioperative period, especially preoperative preparation, postoperative care and womens awareness raising. The presented studies included such program criteria as avoidance of prolonged preoperative fasting accompanied by early postoperative feeding, early breastfeeding attachment of the newborn, the use of multimodal analgesia in the postoperative period, the early activation of the postoperative patient, and the minimization of the detention period of hospital stay. The reviewed articles indicated the positive impact of this program on maternal and newborn outcomes and demonstrated the need for detailed further study of several issues and standardization of the enhanced recovery after cesarean methods.

Perioperative challenges in management of diabetic patients undergoing non-cardiac surgery.

Prediabetes and diabetes are important disease processes which have several perioperative implications. About one third of the United States population is considered to have prediabetes. The prevalence in surgical patients is even higher. This is due to the associated micro and macrovascular complications of diabetes that result in the need for subsequent surgical procedures. A careful preoperative evaluation of diabetic patients and patients at risk for prediabetes is essential to reduce perioperative mortality and morbidity. This preoperative evaluation involves an optimization of preoperative comorbidities. It also includes optimization of antidiabetic medication regimens, as the avoidance of unintentional hypoglycemic and hyperglycemic episodes during the perioperative period is crucial. The focus of the perioperative management is to ensure euglycemia and thus improve postoperative outcomes. Therefore, prolonged preoperative fasting should be avoided and close monitoring of blood glucose should be initiated and continued throughout surgery. This can be accomplished with either analysis in blood gas samples, venous phlebotomy or point-of-care testing. Although capillary and arterial whole blood glucose do not meet standard guidelines for glucose testing, they can still be used to guide insulin dosing in the operating room. Intraoperative glycemic control goals may vary slightly in different protocols but overall the guidelines suggest a glucose range in the operating room should be between 140 mg/dL to 180 mg/dL. When hyperglycemia is detected in the operating room, blood glucose management may be initiated with subcutaneous rapid-acting insulin, with intravenous infusion or boluses of regular insulin. Fluid and electrolyte management are other perioperative challenges. Notably diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic state are the two most serious acute metabolic complications of diabetes that must be recognized early and treated.

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.

Risk factors and outcomes of postoperative aspiration pneumonia in abdominal surgery patients: An exact matching and weighting analysis

BackgroundPostoperative aspiration pneumonia is a feared complication contributing significantly to postoperative morbidity and mortality. Over decades, there has been little progress in reducing incidence and mortality of postoperative aspiration pneumonia. Here, we assessed risk factors for postoperative aspiration pneumonia in general and abdominal surgery patients. MethodsPatients undergoing surgery between January 2012 and December 2018 were included in this exact matched and weighted case-control study. Data from a prospectively acquired clinical database were retrospectively analyzed. ResultsAmong 23,647 patients undergoing 32,901 operations, 144 (0.44%, 95% Confidence Interval: 0.37%–0.52%) cases of postoperative aspiration pneumonia were identified. Ninety-day mortality was 27.8% (n = 40). Major risk factors for postoperative aspiration pneumonia were emergency surgery in patients with prolonged preoperative fasting (>6 hours; odds ratio: 3.25, 95% confidence interval: 1.46–7.26; P < .001), older age with increasing risk in octogenarians compared to seniors (65–80 years: n = 69; odds ratio 5.23, 95% confidence interval: 2.18–12.51; >80 years: n = 50; odds ratio 13.72, 95% confidence interval: 4.94–38.09; P < .001), American Society of Anesthesiologists scores >II (American Society of Anesthesiologists III: n = 90; odds ratio 3.38, 95% confidence interval: 1.08–16.01; American Society of Anesthesiologists IV/V: n = 18; odds ratio 5.20, 95% confidence interval: 1.48–27.61; P < .001), and body mass index <18 kg/m2 (n = 9; odds ratio: 2.53; 95% confidence interval: 1.04–6.11; P = .029). Laparoscopies (odds ratio 0.45, 95% confidence interval: 0.23–0.88; <0.001) and female sex were associated with a decreased risk for postoperative aspiration pneumonia (odds ratio 0.40, 95% confidence interval: 0.23–0.69; P < .001). ConclusionPreventive measures to reduce postoperative aspiration pneumonia should focus on older patients with American Society of Anesthesiologists scores ≥III undergoing open surgery. Cachectic patients and patients undergoing emergency surgery with prolonged preoperative fasting require increased attention. Laparoscopy was associated with a lower risk for postoperative aspiration pneumonia and should be preferred whenever appropriate.

SHORTEN PREOPERATIVE FASTING AND INTRODUCING EARLY EATING ASSISTANCE IN RECOVERY AFTER GASTROJEJUNAL BYPASS?

ABSTRACT Rational: The metabolic response to surgical trauma is enhanced by prolonged preoperative fasting, contributing to increased insulin resistance. This manifestation is more intense on the 1st and 2nd postoperative days and is directly proportional to the size of the operation. Aim:To compare whether preoperative fasting abbreviation and early postoperative refeeding associated with intraoperative and postoperative fluid restriction interfere in the evolution of patients undergoing gastrojejunal bypass. Methods:Eighty patients indicated for Roux-en-Y gastrojejunal bypass were selected. They were randomly divided into two groups: Ringer Lactate (RL) group, who underwent a 6 hours solids fasting, with the administration of 50 g of maltodextrin in 100 ml of mineral water 2 hours before the beginning of anesthesia; and Physiologic Solution (PS) group, who underwent a 12 hours solids and liquids fasting. Anesthesia was standardized for both groups. During the surgical procedure, 1500 ml of ringer lactate solution was administered in the RL and 2500 ml of physiological solution (0.9% sodium chloride) in the PS. In both groups, the occurrence of bronchoaspiration was analyzed during intubation, and the residual gastric volume was measured after opening the abdominal cavity. In the postoperative period in Group RL, patients started a liquid diet 24 hours after the end of the operative procedure; whilst for PS group, fasting was maintained for the first 24 hours, it was prescripted 2000 ml of physiological solution and a restricted liquid diet after 36 hours. Each patient underwent CPK, insulin, sodium, potassium, urea, creatinine, PaCO2, pH and bicarbonate dosage in the immediate postoperative period, and 48 hours later, the exams were repeated. Results:There were no episodes of bronchoaspiration and gastrojejunal fistulas in either group. In the analysis of the residual gastric volume of the PS and RL groups, the mean volumes were respectively 16.5 and 8.8, which shows statistical significance between the groups. In laboratory tests, there was no difference between groups in sodium; PS group showed a higher level of serum potassium (p=0.029); whilst RL group showed a higher urea and creatinine values; CPK values were even for both; PS group demonstrated a higher insulin level; pH was higher in PS group; sodium bicarbonate showed a significant difference at all times; PaCO2 values in RL group was higher than in PS. In the analysis of the incidence of nausea and flatus, no statistical significance was observed between the groups. Conclusions:The abbreviation of preoperative fasting and early postoperative refeeding of Roux-en-Y gastrojejunal bypass with the application of ERAS or ACERTO Project accelerated the patient’s recovery, reducing residual gastric volume and insulin level, and do not predispose to complications.

Prolonged preoperative fasting induces postoperative insulin resistance by ER-stress mediated Glut4 down-regulation in skeletal muscles.

Preoperative fasting aims to prevent pulmonary aspiration and improve bowel preparation, but it may induce profound systemic catabolic responses that lead to protein breakdown and insulin-resistant hyperglycemia after operation. However, the molecular mechanisms of catabolic reaction induced by prolonged preoperative fasting and surgical stress are undetermined. In this study, anesthetized rats were randomly assigned to receive a sham operation or laparotomy cecectomy. Fasting groups were restricted from food and water for 12 h before operation, while the feeding group had free access to food throughout the study period. Twenty-four hours after operation, the animals were sacrificed to collect blood samples and soleus muscles for analysis. Postoperative blood glucose level was significantly increased in the fasting group with elevated serum insulin and C-peptide. Continuous feeding reduced serum myoglobin and lactate dehydrogenase concentrations. Preoperative fasting activated inositol-requiring transmembrane kinase/endoribonuclease (IRE)-1α and c-Jun N-terminal kinase (JNK) mediated endoplasmic reticulum (ER)-stress, and reduced glucose transporter type 4 (Glut4) expression in the soleus muscle. Phospholamban phosphorylation was reduced and intracellular calcium levels were increased in the isolated skeletal muscle cells. Similar results were found in ER stress-induced C1C12 myoblasts. The expression of Glut4 was suppressed in the stressed C1C12, but was potentiated following inhibition of ER stress and chelation of intracellular free calcium. This study provides evidence demonstrating that prolonged preoperative fasting induces ER stress and generates insulin resistance in the skeletal muscle through suppression of Glut4 and inactivation of Ca2+-ATPase, leading to intracellular calcium homeostasis disruption and peripheral insulin resistance.

Association of NPO duration with glycemia in nondiabetic adolescents undergoing anesthesia for noncardiac surgery.

Children and adolescents are required to fast prior to undergoing anesthesia to minimize the risk of pulmonary aspiration of gastric contents. Pre-operative fasting times vary, with longer fasts (8 hours) for solid foods and shorter fasts for clear liquids (1-2hours). Pediatric patients are more sensitive than adults to pre-operative fasting secondary to smaller glycogen stores and resultant propensity to ketoacidosis.1 Prolonged pre-operative fasting is associated with suboptimal perioperative outcomes including insulin resistance, hypotension upon induction, patient thirst and malaise, and postoperative nausea and vomiting.2 While prior studies have shown that children younger than 36 months can present with low-normal blood glucose (BG) levels after prolonged pre-operative fasting, no correlation between nil per os (NPO) duration and BG has been found.1 We sought to study this phenomenon of glycemia in older children and adolescents, hypothesizing that with full hepatic maturity and increased glycogen reserves, absence of correlation between NPO duration and BG levels would be upheld.

Nulla Per Os (NPO) guidelines: time to revisit?

Preoperative fasting guidelines are generalized to elective procedures and usually do not distinguish between the ambulatory and inpatient setting. Prevalence of aspiration is low while prolonged preoperative fasting is common clinical reality. Recently, changes in preoperative fasting guidelines have been widely discussed. Rates of prolonged clear fluid fasting (>4 h) prior to surgery are reported in up to 80% of patients with mean fasting duration of up to 16 h and beyond. Prolonged fasting may result in adverse effects such as intraoperative hemodynamic instability, postoperative delirium, patient discomfort, and extended hospital length of stay. Liberal approaches allowing clear fluids up to 1 h prior to anesthesia or until premedication/call to the operating room have shown no increase in adverse events among children. Various anesthesia societies now encourage clear fluid intake up to 1 h prior to pediatric elective anesthesia. Similar reports in the adult cohort are scarce. Allowing sips of water until call to the operating room may help reducing prolonged preoperative fasting and improving patient comfort while keeping a flexibility in operating room schedule. The feasibility and safety of a liberal clear fluid fasting regimen among adults undergoing elective anesthesia needs to be evaluated in future studies.

Fasting and surgery timing (FaST) audit

SummaryBackground & aimsInternational guidance advocates the avoidance of prolonged preoperative fasting due to its negative impact on perioperative hydration. This study aimed to assess the adherence to these guidelines for fasting in patients undergoing elective and emergency surgery in the East Midlands region of the UK.MethodsThis prospective audit was performed over a two-month period at five National Health Service (NHS) Trusts across the East Midlands region of the UK. Demographic data, admission and operative details, and length of preoperative fasting were collected on adult patients listed for emergency and elective surgery.ResultsOf the 343 surgical patients included within the study, 50% (n = 172) were male, 78% (n = 266) had elective surgery and 22% (n = 77) underwent emergency surgery. Overall median fasting times (Q1, Q3) were 16.1 (13.0, 19.4) hours for food and 5.8 (3.5, 10.7) hours for clear fluids. Prolonged fasting >12 h was documented in 73% (n = 250) for food, and 21% (n = 71) for clear fluids. Median fasting times from clear fluids and food were longer in the those undergoing emergency surgery when compared with those undergoing elective surgery: 13.0 (6.4, 22.6) vs. 4.9 (3.3, 7.8) hours, and 22.0 (14.0, 37.4) vs. 15.6 (12.9, 17.8) hours respectively, p < 0.0001.ConclusionsDespite international consensus on the duration of preoperative fasting, patients continue to fast from clear fluids and food for prolonged lengths of time. Patients admitted for emergency surgery were more likely to fast for longer than those having elective surgery.