|Year : 2023 | Volume
| Issue : 1 | Page : 29-31
Preoperative meal practices: An observational study
Prerana Nirav Shah, Azho Kezo
Department of Anaesthesiology, GSMC and KEMH, Mumbai, Maharashtra, India
|Date of Submission||18-Nov-2022|
|Date of Acceptance||11-Apr-2023|
|Date of Web Publication||25-May-2023|
Dr. Prerana Nirav Shah
Department of Anaesthesiology, GSMC and KEMH, Parel, Mumbai - 400 012, Maharashtra
Source of Support: None, Conflict of Interest: None
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.
Keywords: Elective surgery, guidelines, perioperative care, prolonged fasting
|How to cite this article:|
Shah PN, Kezo A. Preoperative meal practices: An observational study. J Ind Coll Anesth 2023;2:29-31
| Introduction|| |
Mendelson in 1946 published his groundbreaking article where he stated that 70% of morbidities during labor were due to “avoidable aspiration” of gastric contents. He emphasized on the necessity of preoperative fasting in patients undergoing labor. Following this, guidelines were established along the years that pursued for preoperative fasting before induction of anesthesia.
Currently, enhanced recovery after surgery (ERAS) guidelines have advised against prolonged fasting but this practice has been known to continue. However, despite guidelines, the duration of prolonged fasting is much more than recommended. Hence, a study was planned to know the practice of preoperative fasting guidelines being practiced at a tertiary institute in India.
Aims and objectives
The primary endpoint of the study was to determine the duration of preoperative fasting in patients while the secondary endpoint was to find if standard preoperative guidelines are being adhered to.
| Materials and Methods|| |
After approval of the institutional ethics committee and written informed consent from the patients, 118 patients over a period of 4 months belonging to the American Society of Anesthesiologists physical status 1 and 2, and aged between 18 and 75 years coming for elective surgery were included in the study. Pregnant patients and those with diseases that could delay gastric emptying were excluded from the study.
The attending anesthesiologist noted the duration of fasting and type of meal last consumed (large meal, slice of toast or tea/coffee with milk, and clear fluids) of all the patients that were according to the above criteria. Standard meals served by the hospital to the patients included dal, vegetables, rice, and chapati. Patients consume as needed and recommended.
Using STATA™ and Microsoft Excel version 2016, the results were descriptive and calculated on the basis of proportions.
| Results|| |
Fifty-three males and 65 females were included in this study whose ages ranged from 18 to 75 years (mean age was 41.31 ± 14.39 years). Maximum and minimum duration for the last large meal was 20 h and 8 h, respectively, for light meals (i.e., slice of toast or tea/coffee with milk), it was 15 h and 6 h, respectively, while for clear fluids, it was 20 h and 2 h, respectively.
| Discussion|| |
Anesthesiology societies have recommended a minimum fasting of 2 h for clear fluids (water, black coffee, tea, and pulpless juice), 4 h for breast milk, 6 h for nonhuman milk and light meal (dry toast with back coffee or tea), and 8 h for fried fatty food or meat (as it may require longer gastric emptying time.,
They encourage intake of clear fluids up to 2 h before anesthesia. They also allow medications with a little water to be taken <2 h before anesthesia.
Our study showed a large deviation from the standard guidelines and recommendations [Figure 1]. The preoperative meal practices in the United Kingdom, the United States of America, and Australia as pointed out by a study by Andrew-Romit and Van de Mortel have been found to be similar. One study states that the maximum fasting time for clear fluid was more than 20 h and that for solid was 37 h in elective cases of nonobstetric and nongastrointestinal surgery.
|Figure 1: Comparison of findings in this study with that of the guidelines recommended by the European Society of Anaesthesia|
Click here to view
In 2013, an Indian study found that the mean fasting time for solids, liquids, and clear fluids was approximately 12 h. Our study found similar results with a mean fasting time of approximately 11 h. Despite guidelines, there seems to be no change in the duration of fasting recommended to patients.
Prolonged fasting causes an increase in plasma pancreatic glucagon causing lipolysis, gluconeogenesis (hence, hyperglycemia), and insulin resistance.
The reasons for prolonged fasting practices were found to be due to various reasons. Uniform clock-based fasting time (e.g., no food after 10 pm for all patients) was found to be convenient to put into action in the public tertiary care hospital where the manpower managing the number of patients is less. When exactly the patients would be taken for surgery is another unknown important factor for cases posted after the first case in a surgical list of multiple cases on a single operation table. A belief that this is the best way or that gastric emptying time is similar for all kinds of food or long fasting periods poses no harm. Different fasting times for different kinds of food may cause confusion. The morbid fear of case cancellation if inadequately starved is another factor.
Prolonged starvation can lead to distress, fatigue, restlessness, dehydration, electrolyte imbalances, and hypoglycemia. In addition, hunger stimulates gastric acid secretion, increasing gastric volume, and decreasing gastric pH, thus, increasing the risk of pulmonary aspiration of gastric contents. Fluid losses continue to occur during the fasting period through urine production and in the form of insensible fluid loss resulting in hypovolemia. Hypovolemia decreases tissue perfusion resulting in perioperative organ damage.
Results from a JAGO-NOGGO-Multicenter Analysis, also found that despite guidelines, optimized starvation management is poorly implemented in clinical routine practice., It also suggests the need for sensitizing the involved health-care personnel about perioperative fasting.,
Hamid encouraged patient-centered preoperative fasting using patient information leaflets and teaching sessions regarding the current guidelines. Correct fasting guidelines showed improved patient well-being and decreased need to cancel cases. Hence, health-care workers in direct contact with the preoperative care of patients should be well-educated regarding fasting guidelines and patients should receive preoperative counseling for the same.
The study could subsequently include knowledge of fasting guidelines among health-care personnel (especially, doctors and nurses directly involved in patient care). Repeated teaching of prolonged fasting guidelines to the concerned is needed along with an explanation of the consequences of prolonged fasting may go a long way in preventing it.
| Conclusion|| |
We conclude that prolonged preoperative fasting is still prevalent in today's era of ERAS, despite existing guidelines. To combat this, health-care personnel needs to be educated repeatedly on the existing fasting guidelines and preoperative counseling of patients is important. Regular audits may be vital for the implementation of guidelines.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mendelson CL. The aspiration of stomach contents into the lungs during obstetric anesthesia. Am J Obstet Gynecol 1946;52:191-205.
Auyong DB, Allen CJ, Pahang JA, Clabeaux JJ, MacDonald KM, Hanson NA. Reduced length of hospitalization in primary total knee arthroplasty patients using an updated enhanced recovery after orthopedic surgery (ERAS) pathway. J Arthroplasty 2015;30:1705-9.
American Society of Anesthesiologists Committee. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures: An updated report by the American Society of anesthesiologists committee on standards and practice parameters. Anesthesiology 2011;114:495-511.
Smith I, Kranke P, Murat I, Smith A, O'Sullivan G, Søreide E, et al.
Perioperative fasting in adults and children: Guidelines from the European society of anaesthesiology. Eur J Anaesthesiol 2011;28:556-69.
Andrew-Romit JJ, Van de Mortel TF. Ritualistic preoperative fasting: Is it still occurring and what can we do about it? ACORN J Perioper Nurs Aust 2011;24:14-9.
Crenshaw JT, Winslow EH. Preoperative fasting duration and medication instruction: Are we improving? AORN J 2008;88:963-76.
Kulshrestha M, Mathews JJ, Kapadia CM, Sanwatsarkar S. Breaking the midnight fast: An observational cross-sectional audit of preoperative fasting policies and practices at a tertiary care hospital. Indian J Anaesth 2013;57:414-7.
] [Full text]
Aguilar-Parada E, Eisentraut AM, Unger RH. Effects of starvation on plasma pancreatic glucagon in normal man. Diabetes 1969;18:717-23.
Shiraishi T, Kurosaki D, Nakamura M, Yazaki T, Kobinata S, Seki Y, et al.
Gastric fluid volume change after oral rehydration solution intake in morbidly obese and normal controls: A magnetic resonance imaging-based analysis. Anesth Analg 2017;124:1174-8.
Beck MH, Balci-Hakimeh D, Scheuerecker F, Wallach C, Güngor HL, Lee M, et al.
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. Cancers (Basel) 2023;15:1311.
El-Sharkawy AM, Daliya P, Lewis-Lloyd C, Adiamah A, Malcolm FL, Boyd-Carson H, et al.
Fasting and surgery timing (FaST) audit. Clin Nutr 2021;40:1405-12.
Hamid S. Pre-operative fasting – A patient centered approach. BMJ Qual Improv Rep 2014;2:u605.w1252.