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A REPORT PAPER SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS OF CURRENT TRENDS, ISSUES, AND CONCERNS IN NURSING IN THE MASTER OF ARTS IN NURSING PROGRAM
September 2011
Introduction:
The practice of pre-operative fasting aims to minimise residual gastric volume and acidity prior to surgery or other procedures. This helps to prevent regurgitation, inhalation and aspiration of gastric contents which may otherwise occur during general anaesthesia, regional anaesthesia or intravenous sedation. However, prolonged periods of fasting are unnecessary and may cause distress, dehydration, biochemical imbalance and hypoglycaemia, especially in children. There is also a tendency for gastric volume to increase after a prolonged fast. There is limited evidence based research to support the duration of the preoperative fast required. In 1999, the American Society of Anaesthesiologists produced practice guidelines on this subject. These were produced after a comprehensive literature review and world-wide survey of anaesthetists; taking into account the opinions of an expert panel. The Association of Anaesthetists of Great Britain and Irelands most recent guidelines are in agreement with their recommendations. A comprehensive review in the Cochrane Database of Systematic Reviews and a detailed guideline by the Royal College of Nursing came to very similar conclusions. It would seem prudent to use these guidelines as the basis for our recommendations. In addition to guidelines on minimal fasting periods, we have also included guidelines on maximum fasting periods, in an attempt to reduce prolonged fasting. These guidelines also apply to patients undergoing non-surgical procedures requiring general anaesthesia, regional anaesthesia or sedation. These include endoscopy, radiological procedures, DC cardioversion and electro-convulsive therapy. The term surgery is used throughout this document for conveniences sake but guidelines also apply to non-operative procedures. This document replaces all previous fasting guidelines and is to be used Trust-wide to guide the production of: Patient information materials Integrated Pathways of Care (IPOCs) and other patient management protocols Guidance for all staff carrying out pre-operative assessment Educational materials for nursing, medical and other staff Existing documentation must be reviewed to ensure that it complies with these guidelines and should be changed accordingly. GENERAL PRINCIPLES for ELECTIVE SURGERY
Clear fluids include: Water, diluting juice, black tea and black coffee. Milk (non-human) and milk-containing drinks curdle (become semi-solid) in the stomach and should be considered as solids. Previous guidelines have allowed a dash of milk in tea or coffee as well-diluted milk does not tend to curdle in the stomach. We feel that this is open to misinterpretation by patients and staff and have therefore removed this allowance from these guidelines. If milk is added to tea or coffee inadvertently, it is up to the discretion of the anaesthetist whether surgery should proceed. Non-clear fresh fruit juices containing pulp (e.g. fresh orange juice) should be avoided within 6 hours of surgery. Newsprint should be visible through a glass of the liquid. Clear jellies without fruit pieces leave no residue in the stomach and may be considered as clear fluids. These may be of particular use in paediatric practice. Fizzy drinks are probably as safe as still drinks as long as they contain no pulp. Some published guidelines advise against treating them as clear fluids but this is not supported by the clinical evidence. Patients may drink clear fluids up to 2 hours prior to the start of the list. Furthermore, all patients should be encouraged to take a drink of clear fluid 2 hours before the list begins, unless there is a surgical contra-indication. Alcohol containing drinks should not be consumed within the 24 hours prior to surgery as this may increase gastric emptying time. Breast fed infants should have their last feed 4 hours prior to surgery. Formula milk should usually be treated as non-human milk and the fasting period after a formula feed should be 6 hours. Some anaesthetists may allow a 4 -hour fasting period for formula milk to reduce the risk of hypoglycaemia in infants.
Patients for a morning list should eat nothing for six hours before surgery. Realistically, most patients will not usually eat after midnight and this is a convenient cut-off point. Children often do not eat after 6pm and a light snack at bedtime should be advised. Patients for an afternoon list should have a light breakfast (for example see below) at least 6 hours prior to the start of the list. Patients with diabetes mellitus should observe usual dietary guidelines prior to fasting. Light Breakfast - example A small bowl of cereals (Rice Krispies or Corn Flakes) with skimmed or semiskimmed milk. No high fibre cereals such as Weetabix, muesli, bran etc. OR A slice of white toast with honey, jam, syrup, or marmite but no butter.
In some cases, a longer fast may be necessary e.g. bowel preparation for gastro-intestinal surgery. Great care should be taken to ensure that adequate fluid replacement be given orally or intravenously to prevent dehydration.
EMERGENCY SURGERY
Fasting guidelines may need to be overridden in order to expedite surgery in urgent or emergency cases. Anaesthetists are able to take further steps to prevent regurgitation/aspiration e.g. rapid sequence induction of anaesthesia, use of antacids and prokinetic agents. If it is possible to delay surgery, the same guidelines should be followed i.e. 6 hours for solids, two hours for clear fluids. However, it should be borne in mind that trauma; pain, fear and alcohol intoxication may greatly prolong gastric emptying.Prolonged periods without fluid administration should be avoided. Maintenance intravenous fluids containing glucose should be administered to all
patients not receiving fluids for more than 6 hours. Many emergency cases will have received intravenous fluid resuscitation prior to surgery. Reference: http://www.dbh.nhs.uk/Library/Patient_Policies/PAT%20T%2024%20v.2%20%20Pre%20Operative%20Fasting%20Guidelines%20final%202.pdf