Patients who drink clear fluids up to 2 hours before surgery are less likely to become hypotensive during anesthesia induction or experience PONV in recovery. They’re also happier and more prepared to handle the extreme physical stress of surgery. So why do you continue to starve patients by asking them to stay out of the fridge after the stroke of midnight? Maybe because NPO is a hard habit to break and attempts to alter established routines in surgery are as welcome as an add-on case on a Friday afternoon. Before a holiday weekend. But why settle for the change is hard excuse when improving surgical outcomes and patient satisfaction is as easy as (finally) sending one of surgery’s sacred cows out to pasture?

Established practice

Practice guidelines for pre-op fasting issued by the American Society of Anesthesiologists in 1999 said it was appropriate for patients to drink clear liquids at least 2 hours before elective procedures. The ASA reiterated that recommendation in its latest guideline update issued in 2011.

“The guidelines were never intended to drive a change in practice habits or do away with NPO altogether,” says anesthesiologist Joyce Wahr, MD, director of the University of Minnesota Health Preoperative Assessment Center. “They’re intended to inform about when it’s safe to anesthetize patients without having them aspirate.”

But fear of pulmonary aspiration remains a significant barrier to providers letting patients drink clear liquids before surgery, says TJ Gan, MD, MHS, FRCA, professor and chairman of the department of anesthesiology at Stony Brook (N.Y.) School of Medicine.

“A major concern is that oral intake before surgery will increase residual gastric volume and a decrease in gastric pH, causing a higher risk of aspiration,” he says.

Dr. Gan has some advice for hesitant providers: Don’t worry about it. Seriously. He says studies have shown that ingestion of clear liquids 2 hours before surgery results in smaller residual gastric volumes and higher gastric pH levels compared with longer fasts. In addition, the rate of gastric emptying in obese individuals is the same as it is in people of average weight, he says.

“There is absolutely no risk in letting patients drink clear fluid up until 2 hours before surgery,” he adds. “If fact, it promotes gastric emptying. It’s actually safer.”

Saying no to NPO has been slow to catch on because health care is stuck in emphasizing what providers need to accomplish instead of practices that optimize patient care, says Dr. Wahr. For example, Dr. Wahr, who refuses to name names, says some surgeons she works with are notorious for thinking they operate faster than they actually do. Go figure.

The surgeons are worried that moving their cases up from their scheduled time endangers patients who drink clear fluids under the assumption that their cases would start later. That concern isn’t enough to ignore a significant improvement in patient care, according to Dr. Wahr, who says surgeons aren’t often ahead of schedule in her facility. “Moving their cases up happens about 5% of the time,” she says.

She suggests removing NPO after midnight from your surgical orders. If surgeons resist, she says, politely listen, address their concerns with clinical data that backs the practice of pre-op fluid consumption and carry on with your day.

Healthy sips

There are 2 main reasons for letting patients drink 2 hours before surgery — to keep patients hydrated and comfortable, and to optimize outcomes.

• Hydration. Pulp-free fruit juices, sports drinks, water and even black coffee keep patients hydrated and comfortable. Consider that a liter of normal saline IV solution contains 9 grams of salt. Is it any wonder your patients can easily become dehydrated during surgery? “Thirst is a powerful primitive drive,” says Dr. Wahr. “It can be physically painful not to drink.”
• Outcomes. Carb-rich, pre-surgery drinks have the added potential of optimizing outcomes. Drinks that contain at least 50 g of carbohydrates — especially those containing the complex carbohydrate maltodextrin — have been proven to decrease insulin resistance, which can slow down and complicate post-op recovery, says Dr. Gan.

He suggests giving patients 2 bottles of pre-surgery nutrition drinks at pre-op screenings in the clinic, where you can educate patients about why fluids before surgery are beneficial and how to comply with the directives. At Stony Brook University Hospital, they instruct patients to drink 1 300-ml bottle of a complex carbohydrate drink the night before surgery and a second 300-ml bottle the next morning at least 2 hours before their scheduled procedure.

Dr. Wahr would like to add pre-surgery drinks to her health system’s pre-op protocols, but finds it hard to justify adding $24 (the drinks cost about $12 a piece and patients should down 2 before surgery, she says) to case costs. Instead, for now, they tell patients to drink apple juice. Black coffee is OK, too. Dr. Wahr points out that patients can head to a health food store to get maltodextrin pouches that marathon runners use to carbo-load before races.

Roschelle Heuberger, PhD, RD, a professor of dietetics and nutrition at Central Michigan University in Mt. Pleasant, Mich., says adding carbohydrates to the bloodstream before surgery stimulates the body’s cells, including those that are responsible for decreasing inflammation and tissue repair.

“The body needs nutrients to recover from surgery and if it doesn’t have sufficient calories, it ends up cannibalizing its own muscle,” says Dr. Heuberger. “That releases inflammatory cytokines, which disrupt glucose metabolism. It becomes a harmful cascade.” She recommends having patients drink a mix of one-third apple juice and two-thirds water, but also says diluting an electrolyte-replenishing drink or low-sodium chicken are good options.

Liquids now, food later?

Dr. Wahr thinks patients should be allowed to eat buttered toast or yogurt before surgery, but acknowledges that there aren’t enough published studies to support giving patients food before surgery. Besides, she says, there’s a more immediate step you can take to improve how patients feel before surgery and how well they recover afterward.

“Let’s first focus on getting clear liquids into more patients,” says Dr. Wahr. “That’s a good place to start.” OSM