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Literature Review on Fasting Guidelines for Older Adults Undergoing Monitored Care Anesthesia in Rural Area Settings


Patient satisfaction is one of the most significant qualities of quality in care. This review identifies the evidence regarding the fasting guidelines for adults being monitored for anesthesia, fasting periods and ensuring compliance to the guidelines among other factors revolving around fasting among patients undergoing anesthesia. Rural areas lack of protocols what are EBP. They are not complaint with ASA guidelines. Older adults are more vulnerable due to physiological changes, as well as inability to compensate when adverse events occur. This is why McDonald (2013) argues that there is a necessity to ensure that old people undergoing monitored care anesthesia in rural area settings are supposed to follow the necessary fasting guidelines to ensure eliminate any form of complications.

Consumption of Clear Liquids Prior to Anesthesia

An increased body of literature shows that the oral intake of clear fluids for close to 2 hours prior to an elective operation prevents the prevailing risks. Pimenta & De (2014) indicates that lack of fluids for a prolonged period of time before surgery is disadvantageous to the patients, especially the elderly and young children. They opine that shortened preoperative fasting is not only safe, but decreases in insulin resistance as well as the acute phase response following a trauma. Furthermore, the study indicates that the uptake of CHO-rich beverages possess the potential to curtail the post-operative discomfort and decrease the duration of the post operative stay. In concurrence with the Pimenta & De (2014) findings, the trials taken by Awad, Varadhan, Ljungqvist & Lobo (2013) showed that new formulas consistent of a protein source such as the whey protein or glutamine are potential oral supplements for the enrichment of the CHO drinks for the early preoperative treatment. However, further studies are necessary for the confirmation of these claims. Similar effect of carbohydrates on insulin were got from another study by Bilku, et al, (2014) that was characterized by 17 randomized controlled trials and a total of 1,445 patients. They were found to significantly enhance the resistance of insulin and improve the patient safety. However, this study did not make any definite conclusion on the preservation of the muscle mass.

CHO has also been found to have the potential to reduce preoperative discomfort and enhances satisfaction for the patients undergoing the anesthesia care. In a prospective randomized clinical trial that was conducted in a Brazilian hospital with patients that were undergoing surgery for hip fracture, Imbelloni, Nasiane & de (2015) found out that the use of CHO enhanced comfort and improved the patient satisfaction.

Preoperative administration of clear fluids orally has recently been identified as one of the most efficient ways of improving the postoperative outcomes. According to the findings of the study by Nakamura, et al., (2014) oral rehydration solution (ORS) mixed with certain glucose portrayed a higher rate of gastric emptying making it more suitable for preoperative application. In the same study that also involved the application of oral nutritional supplement (ONS) consistent of 18% glucose, and supplementing it with arginine, it was found out that gastric emptying took longer despite the fact that it showed a sustained increase in the level of the glucose in the blood (Nakamura, et al., 2014).

Preoperative complications and the health of the adult patients characterized by the various conditions such as nausea, thirst and hunger were analyzed for a certain paper involving 38 randomized studies. Whether the groups were allowed to fast pre-operation or not, the results indicated that there was no significant difference in the volume of the content of the stomach and the pH of the participants (Gareth & Edwards, 2010). The fluids that were evaluated in the study include fruit juice, coffee, water as well as the other clear fluids characterized by carbohydrates or isotonic drinks. Participants that were given water exhibited lower volume of gastric contents compared to the ones with the normal fasting regimen. Studies that focused on children found out that eating and drinking without limitation can be allowed up to 2 hours prior to surgery (Power, et al., 2011). An increase in the pH was also observed when the participants were exposed to preoperative fasting. One explanation for the increase in the pH of the gastric compartments related to the fact that anxiety related to the anticipation of food among children leads to an increase in the release of hydrochloric acid same case like that of the cephalic phase of the gastric secretion. The study further found out that the cases of aspiration and regurgitation were minimal in the conditions of these studies. Therefore, as per the results of this study, children that are allowed to ingest liquids were less hungry and thirsty and also felt more comfortable and better behaved compared to the ones that were exposed placed under fasting conditions.

Aspiration related to anesthesia was not identified among the randomized and prospective studies conducted among participants that ate high carbohydrate drink. In their study characterized by a sample of 375 patients undergoing anesthesia and provided with a solution of 400ml of 12.5% dextrinomaltose prior and 200ml two hours prior, lacked any regurgitation of the contents of the stomach as well as any other complications related to anesthetic complications (Manchikanti, et al., 2011).

Fasting Practices

Fasting prior to anesthesia is important in avoiding the risk of pulmonary aspiration. The fear related to the gastric aspiration of the gastric contents and its association with life threatening episodes has forced many medical practitioners to adhere to the conservative policies guiding on clear liquid and fluid intake prior to surgery (Ghorashi, Ashori, Aminzadeh & Mokhtari, 2014). The suggestions to fast before an operation is associated with the assumption that food which is consumed just before an operation remains in the gastric system, thus increasing the risk related to aspiration. Additionally, there is also an assumption that abstaining from food before a surgery is likely to reduce the chances of aspiration.

Various studies have demonstrated the benefit of the application of various solutions such as carbohydrates and oral rehydration solution (ORS) in the improvement of the patient conditions during operations (Bilku, Dennison, Hall, Metcalfe & Garcea, 2014). In a study that focused on investigating the impact of the preoperative oral carbohydrate loading on pre- and post-operation discomforts and complications, Cakar, Yilmaz, Cakar & Baydur (2016) found out that the use of carbohydrate-rich drink (CHD) for treatment before thyroidectomy leads to an increase in comfort among patients. This is through the reduction of preoperative discomfort such as thirst, fatigue and hunger as well as early postoperative complications related to pain and vomiting. The study further identified that the level of these discomforts were found to be significantly higher in the fasting and glucose groups as compared to CHD groups. Thus, CHH treatment can be applied in enhancing comfort for patients that are about to undergo thyroidectomy. Ludwig, Paludo, Fernandes & Scherer (2013) also suggest that reducing the time for preoperative fasting with high solution of carbohydrate until two hours prior to the operation because early postoperative feeding has various benefits to the client. The study showed good results from the new behaviors and suggested that they should be encouraged to reduce the recovery time of the patients undergoing surgery. With a decrease in the fasting time, patients that drank CHO just before surgery did not portray any form of hunger and/or thirst. In more detailed analysis of the manner in which CHO supplementation plays a protective role in surgical processes, Gjessing, et al (2015) argue that CHO supplementation in the preoperative phase reduces the trauma resulting from surgery. The intake of CHO acts to enhance the protective role of preoperative CHO supplementation on the development of insulin resistance after surgery.

Although various studies have discovered that the carbohydrate-rich fluids are beneficial in improving the postoperative recovery, the effectiveness of the fluids in reducing the length of hospital is uncertain. In a study that focused on the assessment of the effectiveness of preoperative loading with the carbohydrates on postoperative outcomes, Webster, et al, (2014) found a positive association between the use of preoperative high carbohydrate fluids and recovery. However, the study was unable to confirm or refute the benefits CHO for a shorter period of hospital stay following a surgery. The findings of another randomized trial by Aguilar-Nascimento, Canevari-de-Oliveira, Caporossi, Cunha, Metelo & Tanajura (2014) showed that the recommendations of fasting up to 2 hours while taking a supplement comprised of protein and carbohydrate was safe and did not complicate the sedation for the digestive endoscopy.

However, not all studies have found the administration of carbohydrates effective in the improving the conditions of an operation procedure. For instance, in a prospective, randomized, controlled clinical trial of 134 patients about to undergo the surgical procedures of the body surface, Cakar, Yilmaz, Cakar & Baydur (2016) found out that the preoperative administration did not have any positive impact on the quality of recovery among the patients undergoing the minimally invasive surface surgery.

Studies comparing the preoperative fasting and fluid intake three to 4 hour prior to preoperative procedure have shown that the intake of the fluids is safe and does not interfere with the procedure through the various risks such as mortality, aspiration or mortality (Varadhan, Lobo & Ljunggvist, 2010). A case control study involving non-randomized adult patients that were undergoing elective surgical procedures found out that light eating before the procedure reduced the procedural complications during surgery as compared to the traditional midnight fasting (Gareth & Edwards, 2010). Aspiration was also absent in both scenarios.

However, fasting has been identified to be ineffective in preventing the complications associated with medical surgery. For instance, an observational study by Hamid, et al. (2014) demonstrates that patients undergoing percutaneous coronary intervention (PCI) are not supposed to be fasted prior to the medical procedures, meaning that fasting in this case possess effect on the medical operation. Pre-procedural fasting has also been found ineffective in improving comfort and satisfaction. According to Thorpe & Benger (2010) the risk attached to aspiration during the emergency procedural sedation is low while there is no evidence that support the pre-procedural fasting. Ghorashi, Ashori, Aminzadeh & Mokhtari (2014) also found no evidence to suggest that taking of clear liquids for one hour for women undergoing the caesarean section is likely to increase the risk of regurgitation. The results of the study confirm the necessity of following safer and flexible fasting policies before an operation, including the ones guiding the intake of oral fluids. Also, the results of this study indicate that taking of clear fluids preoperatively in a parturient is safe, and in the cases requiring urgent cesarean, the risks of regurgitation and aspiration are not likely to increase.

Samantaray (2014) suggest that the pulmonary aspiration of the gastric contents causes aspiration pneumonia that is life threatening. Patients booked for elective surgery are always advised to refrain from eating or drinking after midnight of the previous day from when their surgery is scheduled. According to Maltby (2006) fasting before elective surgery prevents the incidences of regurgitation of the stomach contents. This is the reason why preoperative fasting was initially recommended for the reduction of the postoperative nausea and vomiting (Maltby, 2006). Obese patients without comorbid conditions are also advised to follow similar fasting guidelines as the non-obese patients and be allowed access to clear drinks two hours prior to the elective surgery.

Fortunately, the current death cases related to pulmonary aspiration during surgery are low. Samantaray (2014) attribute the low occurrences of aspiration during anesthesia to the increased awareness on pulmonary aspiration and improvement in anesthetic techniques rather than the use of the traditional fasting guidelines. According to Kyrtatos, Constandinou, Loizides & Mumtaz (2014), preoperative fasting is a crucial factor in the preoperative patient care. However, the implementation of the guidelines has been sometimes difficult making the aspect remain suboptimal. Additionally, the implementation of the guidelines is subject to other studies that found out that that the fasting guidelines can have the contrary results tom the ones proposed by the various studies. Nossaman, Richardson, Wooldridge & Nossaman, (2017) study that involved 168 patients combined did not observe the pulmonary aspiration of contents in their digestive system. As per the results of this study, pulmonary aspiration should not be a course worry much about during anesthesia. The decreased incidents of pulmonary aspiration, however, indicates that use of only 168 study patients could be leading to inaccurate results. However, another notable challenge with this study relates to the fact that this is one of the studies that have attempted to define the incidences of aspiration or pulmonary problems during anesthesia of children in relation to nil per os (NPO) status or a majority of other factors. These studies always find it difficult because these problems are rare among children. In another study that was characterized by a total of 139,142 procedural sedation/anesthesia cases collected between 2007 and 2011, Beach, Cohen, Gallagher & Cravero (2016) found out that aspiration is very uncommon, NPO status for the liquids is not an independent predicting factor for the significant complications or aspiration.

Gender differences

Studies have also identified the gender differences in the fasting practices for patients about to undergo anesthesia. In a study on High-risk residual gastric content in fasted patients undergoing gastrointestinal endoscopy: A prospective cohort study of prevalence and predictors, Phillips, Stewart, Liang & Formaz-Preston (2015) found out that males are likely to possess a higher content of gastric contents compared to females. The difference was noted to be less pronounced with the increase in age. These results were obtained from an examination of the residual gastric contents of 255 fasted patients that were under medication for gastrointestinal endoscopy, the study found out that the males presented for endoscopy. However, this study could not confirm or exclude the involvement of the various factors related to old age. The differences in the fasting results across gender were also found to be existent among children. In a study that involved a sample of 131 children between the age bracket of 1 to 16 years, Schmidt and his colleagues found out that the patient characteristic data was not similar between boys and girls (46/33 males in group A/B; p=0.002) (Schmidt, et al., 2015). The study concluded that fasting for one hour does not alter the pH significantly as compared to fasting for two hours.

Fasting Duration

Preoperative fasting practices normally prolong than the set practice procedures while the medical procedures are not always given to the patients before they are ushered into surgery. Crenshaw & Winslow (2008) found out that there is persistence of preoperative fasting beyond the safe minimum guidelines. The fasting guidelines for people having elective surgery published by ASA in 1999 relied on the analysis of more than 1000 studies, expert inputs and sophisticated statistical techniques. The guidelines were based on studies that showed that pulmonary anesthesia is a rare occurrence in the modern anesthesia, fasting for a long time is not an assurance that the stomach is empty, the relationship between the length of fasting and the volume of the stomach contents, and a long period of fasting is not an assurance that the stomach will be empty (Crenshaw & Winslow, 2008). Some of the guidelines include ensuring a minimum fast two hours from clear liquids, eight hours from heavy foods, six hours from a light meal or infant formula and fours from breast milk. However, these guidelines had been already suggested earlier. In a study that involved random assigning of 300 low-risk patients undertaking the morning surgery in 6 university affiliated hospitals to an oral rehydration solution (ORS) group or the fasting one, it was found out that the Oral rehydration therapy up to 2hours prior to the surgery is safe among the low-risk Japanese surgical population (Itou et al., 2012). According to this study, physicians have an obligation of using the practice for maintaining the amount of body water and electrolytes and ensuring the comfort of the patient.

Fasting Guidelines and Recommendations

The modern guidelines regarding preoperative care currently recommend 6-8 hours fast for the food matter and allow the consumption clear fluids and beverages containing carbohydrate for up to 2 hours prior to the surgery (Aguilar-Nascimento, Canevari-de-Oliveira, Caporossi, Cunha, Metelo & Tanajura (2014). The necessity of preoperative fasting before elective surgery was steered by Mendel’s 1946 report on 66 cases of pulmonary aspiration when conducting the general anesthesia among 44, 016 pregnant women as well as an early paper by Vaughan and colleagues that reported that obese patients were faced with the danger of increased pulmonary aspiration resulting from the increase in gastric volumes and the decreased pH of stomach contents (Crenshaw & Winslow, 2008). Following the death of two women during the study, Mendelson recommended refraining from oral feeding during surgeries and even suggested that it is surgical safer to empty stomachs before the administration of anesthesia (Crenshaw & Winslow, 2008). Withholding the oral feedings when a person is about to undergo elective surgery and procedures is also one of the recommendations of the guidelines of American Society of Anesthesiologists (ASA) (Crenshaw & Winslow, 2008). However, the differences in the gastric contents between the obese and lean surgical patients cited by Mendelson (1946) and Vaughan, Bauer & Wise (1975) were not confirmed by subsequent studies. One of the most common forms of the failure to adhere to the set fasting guidelines occurs in the form of fasting beyond the set periods.

Fasting beyond the set requirements was also observed by Roberts (2013) in a clinical audit on preoperative fasting. According to them, most patients are needlessly fasting for a prolonged period of time from both food and water which might complicate their healing process. However, the article failed to give a clear reasoning on why since mo research was carried out. Prolonged pre-operative fasting is termed as an unpleasant experience that possesses the capacity to cause serious medical complications. Inappropriate pre-operative fasting was also revealed by Hamid (2014) in his audit on Moorfields South PAU whereby the fasting instructions was not concordant with the national guidelines leading to serious negative impacts on patients. Patients were found to be fast in an inappropriate manner and over prolonged period of time, leading to discomfort as well as the subjective and objective dehydration. According to Pimenta & De (2014) one of the most profound difficulties to the 2 hour protocol prior to an elective operation is its implementation. In addition to the challenges related to dogma, it is also easier to prescribe the “nil per os after midnight” that is more simple than undertaking the tedious process of educating the patients and the hospital staff on the new guidelines.

The failure to implement these guidelines is also associated with ignorance on the side of anesthetists. Despite the fact that anesthetists are fully aware of newly set preoperative guidelines, they are still following the strict preoperative NPO beginning from midnight (Salman, Asida & Ali, 2013). They indicate that the national published guidelines are essential for the promotion of shorter durations which are more effective than the previous ones. These guidelines have almost been rendered ineffective since various studies have not found link between their application and the pre- and post-operative safety: “Evidence to support ASA guidelines for fasting prior to general anesthesia, which have been extrapolated for use in emergency sedation, has minimal scientific support. Indeed, several randomized trials have failed to show any link between non-fasted patients and pulmonary aspiration. Therefore, there is no reason to recommend fasting patients prior to procedural sedation in the ED..” (Thorpe & Benger, 2010, p. 260).

The incidence of fasting and the negative preoperative/postoperative impacts that they try to avoid is noted to be more serious among the elderly, especially those undergoing Monitored Care Anesthesia. This is because their health conditions are characterized by a range of health conditions that may complicate the application of the fasting guidelines. According to Wei, et al., (2017) ageing the surgical operations being performed on old people may be risky due to increased risk of ageing and age-related diseases. In matters compliance, studies have found out that compliance does not necessarily mean that the patient understands the advantages of the guidelines. In their endeavor to find the compliance rates to fasting for patients admitted on the day of surgery, Lim, Lee & Ji (2014) surveyed patients scheduled for the same day of the surgery under regional or general anesthesia over a 4-week period. A total of 130 patients were put under survey through being asked to answer an 18-point questionnaire on the demographics, fasting before surgery and the attitudes related to fasting. The study found out that although 90% of the patients fasted, only 44.6% knew the reason why they were supposed to fast. Although this may led to unintentional compliance, there is a need of the health care givers to inform patients on the necessity of the practice to ensure that they intentionally and knowledgeably comply.

Kyrtatos, Constandinou, Loizides & Mumtaz, T. (2014) indicates that the compliance to fasting recommendations can only be attained through the application of a more direct approach and encourage patients to take in their water before they leave their residence. Although preoperative fasting durations are recommended by physicians, nurses are tasked with ensuring that these guidelines are adhered to through monitoring the patients for compliance (Crenshaw & Winslow, 2008). In this regard, it is important for the nurses to understand the scientific aspects that guide fasting practices and what they are supposed to teach patients. Hamid (2014) argues that there is a need to educate the health professionals on the changes related to the guideline practices and the new findings from the various scientific studies on the topic.

Utilization of the evidence- and patient-based approach to pre-operative fasting is essential in the improvement of patient satisfaction. According to Hamid (2014) correct fasting intervals are essential for curtailing the inconveniences related to delay in surgery, reducing the medical complications and improving the post operative wellbeing.


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