Perioperative Nutritional Support or Perioperative Fasting?

Traditionally, overnight fasting before elective surgery has been the routine in medical practice for risk reduction of pulmonary aspiration of gastric contents. Several original study and international societies recommend a 2‐h preoperative fast for clear fluids and a 6‐h fast for solids in most elective patients. We conducted a narrative review of the literature, searching electronic databases (Medline and CINAHL). We used PICO approach. The results of our review suggest that nutrition support in the perioperative period is very important to reduce length of hospital stay and reduced postoperative complication.

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Aspiration Pneumonitis

10.1093/med/9780190226459.003.0016 ◽

2017 ◽

Author(s):

Agnieszka Trzcinka

Keyword(s):

Risk Factors ◽

Delayed Gastric Emptying ◽

Perioperative Period ◽

Pulmonary Aspiration ◽

Aspiration Pneumonitis ◽

Anesthesia Induction ◽

Supportive Treatment ◽

Gastric Contents ◽

Upper Abdominal ◽

Risk Of Aspiration

Aspiration pneumonitis during the perioperative period is a serious complication and involves passage of sterile gastric contents into the airway resulting in alveolar damage. The mechanism of aspiration pneumonitis is characterized by a significant inflammatory reaction. The risk of aspiration is highest during anesthesia induction, but it is also present during emergence and extubation. The risk factors include delayed gastric emptying (gastritis, pain, pregnancy, obesity, elevated intracranial pressure), emergency surgery, upper abdominal surgery, and difficulty securing the airway. Anesthesiologists should focus on prevention of pulmonary aspiration with consideration of the patient’s NPO status and risk factors when planning anesthesia induction and emergence. If aspiration of gastric contents occurs, the patient may exhibit a variety of symptoms, with severity based on the volume and pH of the aspirate. Subsequently, patients with observed or suspected aspiration need supportive treatment that varies depending on the severity of symptoms.

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Ultrasonographic estimation of gastric volume in patients after overnight fasting and after ingestion of clear fluids two hours before surgery

Anaesthesia, Pain & Intensive Care ◽

10.35975/apic.v24i3.1283 ◽

2020 ◽

Vol 24 (3) ◽

Author(s):

Manjunath C. Patil ◽

B. Prajwal

Keyword(s):

Gastric Volume ◽

Pulmonary Aspiration ◽

Gastric Aspirate ◽

Two Dimensional ◽

Non Invasive ◽

The Past ◽

Gastric Contents ◽

Overnight Fasting ◽

Risk Of Aspiration

Pre-operative fasting aims to decrease the volume and increase the pH of gastric contents, hence reducing the risk of aspiration. According to the past literature gastric contents of 25 ml (0.4 ml/kg) and with pH ≤ 2.5 predisposes the patient to pulmonary aspiration hence pre-operative fasting was recommended. Use of two-dimensional ultrasonography is an accurate non-invasive tool to determine gastric volume. We compared the gastric volume using ultrasonography and pH of gastric aspirate by pH strip in patients after overnight fasting and after ingestion of 200 ml clear fluids (water) 2 h prior to surgery.

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Case Report: The use of gastric ultrasound to assess risk of pulmonary aspiration

POCUS Journal ◽

10.24908/pocus.v1i2.13254 ◽

2016 ◽

Vol 1 (2) ◽

pp. 8-9

Author(s):

James Cheng, PGY-4

Keyword(s):

Mechanical Ventilation ◽

Case Report ◽

General Anesthesia ◽

Elective Surgery ◽

Prolonged Mechanical Ventilation ◽

Pulmonary Aspiration ◽

Preoperative Fasting ◽

Patient Morbidity ◽

Gastric Contents ◽

American Society

Pulmonary aspiration of gastric contents is a dreaded complication of general anesthesia, as it carries significant patient morbidity and mortality. Subsequent aspiration pneumonia can lead to prolonged mechanical ventilation, and a mortality rate of up to 5%. To minimize the risk of pulmonary aspiration, patients are required – as per the American Society of Anesthesiology’s “Practice Guidelines for Preoperative Fasting” – to fast prior to elective surgery in order to ensure that the stomach is empty prior to induction of general anesthesia.

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Interrupted Nutrition Support in Patients With Burn Injuries: A Single-Centre Observational Study

Plastic Surgery ◽

10.1177/2292550319880917 ◽

2019 ◽

Vol 27 (4) ◽

pp. 334-339

Author(s):

Nancy Coutris ◽

Justin P. Gawaziuk ◽

Nora Cristall ◽

Sarvesh Logsetty

Keyword(s):

Total Body Surface Area ◽

Length Of Hospital Stay ◽

Retrospective Chart Review ◽

Perioperative Period ◽

Feeding Tube ◽

Nutrition Support ◽

Burn Patients ◽

Start Time ◽

Total Body ◽

Injured Patients

Background: Enteral nutrition (EN) is essential to meet the increased metabolic requirements of burn-injured patients. However, feeds are often suspended for care. This study examines the interruptions in EN (IEN). Objective: To determine the frequency and duration of IEN and whether these interruptions are predictable or unpredictable. Design: This retrospective chart review of 27 adult burn patients examined age, sex, body mass index, percentage of total body surface area, length of hospital stay, predicted energy requirements from equations and indirect calorimetry, EN start time, time EN reached goal rate, and interruptions to EN. Results: Predictable interruptions accounted for 74.5% (frequency) and 81.6% (duration) of total interruptions. The most frequent and time-consuming interruptions were perioperative period, extubation, and tests/procedures (predictable) versus high gastric residual volume, emesis/nausea, and feeding tube displacement (unpredictable). Conclusions: Most IEN were due to predictable events. Based on these findings, compensating for predictable interruptions to meet nutritional requirements in burn patients is recommended.

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Perioperative fasting: A review

Journal of Perioperative Practice ◽

10.1177/1750458919877591 ◽

2019 ◽

Vol 30 (7-8) ◽

pp. 204-209

Author(s):

Mark Dorrance ◽

Michael Copp

Keyword(s):

Best Practice ◽

Perioperative Period ◽

Pulmonary Aspiration ◽

Surgical Patients ◽

Preoperative Fasting ◽

Healthcare Staff ◽

Gastric Contents ◽

Current Guidelines ◽

Future Practice ◽

Review Current

Preprocedural/preoperative fasting is a key part of preparing a patient for undergoing sedation or anaesthesia to minimise the risk of pulmonary aspiration of gastric contents. As part of caring for elective surgical patients it is important that healthcare staff in the perioperative environment have a good understanding of both the current guidelines and underpinning evidence so that they can effectively manage preoperative patients. This article looks to summarise the latest guidelines regarding perioperative fasting for adult and paediatric patients, the underlying evidence behind these guidelines and finally review current literature which will inform future practice. This article therefore looks to reinforce best practice, to ensure that the safety and comfort of patients in the perioperative period is optimised.

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FASTING IN ELECTIVE SURGICAL PATIENTS: COMPARISON AMONG THE TIME PRESCRIBED, PERFORMED AND RECOMMENDED ON PERIOPERATIVE CARE PROTOCOLS

ABCD Arquivos Brasileiros de Cirurgia Digestiva (São Paulo) ◽

10.1590/s0102-6720201500040008 ◽

2015 ◽

Vol 28 (4) ◽

pp. 250-254 ◽

Cited By ~ 9

Author(s):

Saionara Cristina FRANCISCO ◽

Sandra Teixeira BATISTA ◽

Geórgia das Graças PENA

Keyword(s):

Elective Surgery ◽

Length Of Hospital Stay ◽

Perioperative Period ◽

Well Being ◽

Cross Sectional Study ◽

Diabetes Diagnosis ◽

Preoperative Fasting ◽

Fasting Period ◽

Cross Sectional ◽

Fasting Time

Background: Prolonged preoperative fasting may impair nutritional status of the patient and their recovery. In contrast, some studies show that fasting abbreviation can improve the response to trauma and decrease the length of hospital stay. Aim: Investigate whether the prescribed perioperative fasting time and practiced by patients is in compliance with current multimodal protocols and identify the main factors associated. Methods: Cross-sectional study with 65 patients undergoing elective surgery of the digestive tract or abdominal wall. We investigated the fasting time in the perioperative period, hunger and thirst reports, physical status, diabetes diagnosis, type of surgery and anesthesia. Results: The patients were between 19 and 87 years, mostly female (73.8%). The most performed procedure was cholecystectomy (47.69%) and general anesthesia the most used (89.23%). The most common approach was to start fasting from midnight for liquids and solids, and most of the patients received grade II (64.6%) to the physical state. The real fasting average time was 16 h (9.5-41.58) was higher than prescribed (11 h, 6.58 -26.75). The patients submitted to surgery in the afternoon were in more fasting time than those who did in the morning (p<0.001). The intensity of hunger and thirst increased in postoperative fasting period (p=0.010 and 0.027). The average period of postoperative fasting was 18.25 h (3.33-91.83) and only 23.07% restarted feeding on the same day. Conclusion: Patients were fasted for prolonged time, higher even than the prescribed time and intensity of the signs of discomfort such as hunger and thirst increased over time. To better recovery and the patient's well-being, it is necessary to establish a preoperative fasting abbreviation protocol.

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Extrinsic Pathway Inhibitor in Elective Surgery: A Comparison with other Coagulation Inhibitors

Thrombosis and Haemostasis ◽

10.1055/s-0038-1651017 ◽

1989 ◽

Vol 62 (03) ◽

pp. 856-860 ◽

Cited By ~ 28

Author(s):

P M Sandset ◽

H E Høgevold ◽

T Lyberg ◽

T R Andersson ◽

U Abildgaard

Keyword(s):

Vascular Surgery ◽

Protein C ◽

Elective Surgery ◽

Perioperative Period ◽

Acute Phase Reactant ◽

Hip Surgery ◽

Albumin Concentration ◽

Extrinsic Pathway ◽

Heparin Cofactor Ii ◽

Coagulation Inhibitors

SummaryExtrinsic coagulation pathway inhibitor may be an important regulator of haemostasis to prevent thrombosis after tissue damage. The functional activity of this inhibitor was determined using a chromogenic substrate assay, and compared to the activities of anti thrombin, heparin cofactor II and protein C during the perioperative period of elective hip replacement (n = 28), cholecystectomy (n = 11), and vascular surgery (n = 5). Peroperatively, all the inhibitors decreased rather similarly and to the same degree as the decrease in albumin concentration. The decreases during hip surgery were about 2-fold the decreases observed during cholecystectomy. A significant peroperative increase in extrinsic pathway inhibitor activity was observed in vascular surgery, probably due to a bolus injection of heparin. Antithrombin, heparin cofactor II and protein C levels normalized on days 3-5 postoperatively in all three patient groups. Sustained low levels of extrinsic pathway inhibitor were observed on postoperative days 1 to 7 in hip surgery patients. Apparently, extrinsic pathway inhibitor is not an acute phase reactant. In uncomplicated surgery, the decreases of the coagulation inhibitor levels are mainly due to hemodilution.

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Preoperative preparation of alcohol and psychoactive substances-addicted patients

Acta chirurgica iugoslavica ◽

10.2298/aci1102151d ◽

2011 ◽

Vol 58 (2) ◽

pp. 151-155

Author(s):

Ivan Dimitrijevic ◽

Zoran Zoricic ◽

Miodrag Milenovic ◽

Ivan Palibrk ◽

Draga Dimitrijevic ◽

...

Keyword(s):

Substance Abuse ◽

Postoperative Care ◽

Surgical Intervention ◽

Elective Surgery ◽

Perioperative Period ◽

Psychoactive Substance ◽

Preoperative Preparation ◽

Psychoactive Substances ◽

Key Issues ◽

Proper Diagnosis

Proper diagnosis of psychoactive substance abuse and addiction, as well as acute intoxication, withdrawal syndrome and overdosing are of great importance in patients who are preparing for surgical intervention. There are some specific details in their preoperative preparation whether they underwent emergency or elective surgery. Good knowledge of the characteristics of psychoactive substance abuse and addiction, interaction of psychoactive substances and anesthetics and any other drugs that could be used in the perioperative period is important especially for anastesiologist. In this work we present key issues for recognizing theese patients as well as some guidelines for adequate preoperative preparation and postoperative care.

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Bilateral Nephrectomy in Patients with Autosomal Dominant Polycystic Kidney Disease and End-Stage Chronic Renal Failure

Nephron ◽

10.1159/000513168 ◽

2021 ◽

pp. 1-7

Author(s):

Alexander E. Lubennikov ◽

Nicolay V. Petrovskii ◽

German E. Krupinov ◽

Evgeniy M. Shilov ◽

Roman N. Trushkin ◽

...

Keyword(s):

Kidney Disease ◽

Large Bowel ◽

Elective Surgery ◽

Length Of Hospital Stay ◽

Bowel Injury ◽

Polycystic Kidney ◽

Group I ◽

Group Ii ◽

Autosomal Dominant Polycystic Kidney ◽

End Stage

Background: In patients with autosomal dominant polycystic kidney disease (ADPKD) and end-stage kidney disease, bilateral nephrectomy (BN) is currently performed predominantly via the laparoscopic approach. We analysed the results of BN depending on the approach and preoperative and perioperative factors. Patients and Methods: This was a single-centre retrospective study carried out from April 2010 to March 2020, including a total of 142 patients presenting with ADPKD who were treated by BN. Of these, 108 patients meeting the inclusion criteria were selected to analyse the results. We compared therapeutic outcomes depending on the surgical approach (laparotomy or laparoscopy) and the type of the operation (emergent or elective). Results: Of the 108 eligible patients, 36 (group I) underwent laparoscopic BN and the remaining 72 patients (group II) were subjected to midline laparotomy. Sixty-nine patients underwent elective surgery and 39 endured emergent operations. The most frequent indications (87 patients, 80.6%) for surgical treatment were urinary tract infection and infected cysts. The median length of hospital stay for group I and group II patients amounted to 8 days (IQR: 7.5–9) and 12.5 days (IQR: 9–16.5), respectively (p < 0.001). However, comparing the patients operated on electively, the actual difference in the length of hospital stay was inconsiderable: median 8 days (IQR: 7–9) in group I and 9 days (IQR: 9–11.5) in group II. The median duration of the operation was significantly (p < 0.001) longer in group I amounting to 217.5 min (IQR: 197.5–305) than in group II equalling 115 min (IQR: 107.5–145). The frequency of postoperative complications, lethal outcomes, and blood loss volume did not statistically significantly differ depending on the surgical approach. Only patients operated on emergency underwent releparotomy due to intraoperative large bowel injury. Lethal outcomes (n = 18, 16.7%) after surgery were observed only in emergent patients. Sepsis prior to surgery, systemic inflammation response syndrome (SIRS) with the CRP level above 173 mg/mL, prolonged preoperative antibacterial therapy, and undiagnosed large bowel injury were associated with a lethal outcome after BN. Conclusion: The results of open and laparoscopic BN in elective surgery were comparable. Emergency operations for infected renal cysts and SIRS were associated with increased incidence of large bowel injury and lethal outcomes.

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Modulation of post-operative insulin resistance by pre-operative carbohydrate loading

Proceedings of The Nutrition Society ◽

10.1079/pns2002168 ◽

2002 ◽

Vol 61 (3) ◽

pp. 329-336 ◽

Cited By ~ 112

Author(s):

Olle Ljungqvist ◽

Jonas Nygren ◽

Anders Thorell

Keyword(s):

Insulin Resistance ◽

Heart Surgery ◽

Surgical Stress ◽

Elective Surgery ◽

Meta Analysis ◽

Open Heart Surgery ◽

Length Of Hospital Stay ◽

Cardiac Complications ◽

Intravenous Glucose ◽

Mortality And Morbidity

Insulin resistance develops as a response to virtually all types of surgical stress. There is an increasing body of evidence that suggests that insulin resistance in surgical stress is not beneficial for outcome. A recent large study in intensive-care patients showed that aggressive treatment of insulin resistance using intravenous insulin reduced mortality and morbidity substantially. Similarly, in burn patients, intensive insulin and glucose treatment has been shown to improve N economy and enhance skin-graft healing. In surgical patients insulin resistance has been characterized in some detail, and has been shown to have many similarities with metabolic changes seen in patients with type 2 diabetes. This finding may be important since insulin resistance has been shown to be one independent factor that influences length of stay. When patients about to undergo elective surgery have been treated with glucose intravenously or a carbohydrate-rich drink instead of overnight fasting, insulin resistance was reduced by about half. A small meta-analysis showed that when post-operative insulin resistance was reduced by preoperative carbohydrates, length of hospital stay was shortened. Overnight intravenous glucose at high doses improved post-operative N economy. This type of treatment has also been shown repeatedly to reduce cardiac complications after open-heart surgery. Furthermore, if the carbohydrates are given as a drink pre-operatively, pre-operative thirst, hunger and anxiety are markedly reduced. In summary, preventing or treating insulin resistance in surgical stress influences outcome. Fasting overnight is not an optimal way to prepare patients for elective surgery. Instead, pre-operative carbohydrates have clinical benefits.

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