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Nothing by Mouth at Midnight Saving Or Starving? a Literature Review

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Nothing by Mouth at Midnight Saving Or Starving? a Literature Review Laura Brown , MS, RD, CNSC Roschelle Heuberger , PhD, RD, CWMS Nothing by Mouth at Midnight Saving or Starving? A Literature Review ABSTRACT Historical use of fasting at midnight before anesthesia and surgery has been based on tradition instead of evidence. Research has challenged this practice and determined consuming clear liquids (e.g., water, apple juice, black tea, black coffee) 2–3 hours before surgery does not increase gastric residual volume or risk for aspiration. Liberal fasting guidelines have been published to support this research; however, there continues to be a disparity between practice and evidence. Metabolic alterations occur in the starved state and current available evidence suggests the use of a carbohydrate-rich clear liquid beverage to stimulate the fed state. The fed state is characterized by insulin secretion that stimulates the storage of macronutrients for fuel and promotes protein synthesis. Implementing this practice may decrease insulin resistance and support immune function. Allowing the patient to consume carbohydrate-rich clear liquid beverages may reduce postoperative nausea and vomiting and improve patient reports of anxiety, hunger, and thirst. This article evaluates the evidence for providing clear liquids and carbohydrate-rich clear liquid beverages to healthy adults undergoing surgery to optimize postoperative recovery. raditional fasting guidelines before elective anesthesia. Although being “nil per os” (NPO [nothing surgery have required the patient to fast by mouth]) at midnight was often considered a safe starting at midnight before their procedure. practice with minimal patient impact, new research The use of general anesthesia can alter gag, indicates that preoperative fasting may increase the Tcough, and swallow reflexes that protect the lungs risk of complications. In addition, the use of a carbo- from stomach contents. Fasting is intended to reduce hydrate-rich clear liquid beverage prior to surgery may stomach content acidity as well as volume in an actually improve patient outcomes. This article reviews attempt to decrease morbidity and mortality rates from the science behind fasting, current guidelines and prac- anesthesia-related aspiration. However, clinical studies tices, and studies evaluating the use of preoperative and practice recommendations do not always support carbohydrate-rich clear liquid beverages. this tradition and encourage the use of more liberal fasting guidelines. These fasting guidelines generally Literature Review allow patients to consume clear liquids (e.g., water, It is estimated that 1 of every 2000–3000 elective sur- apple juice, black tea, black coffee) up to 2–3 hours geries results in aspiration (Janda, Scheeren, & Noldge- before their scheduled surgery or procedure requiring Schomburg, 2006). However, a review of 83,844 surgical cases receiving anesthesia reported only five Received March 2, 2012; accepted September 15, 2012. episodes of aspiration (Fasting & Gisvold, 2002). Complications of aspiration include acid-associated About the author: Laura Brown, MS, RD, CNSC, is Clinical Dietician, Poudre Valley Hospital, Fort Collins, Colorado. aspiration pneumonitis, bacterial infection, and parti- Roschelle Heuberger, PhD, RD, CWMS, is Professor of Nutrition and cle-associated aspiration. Aspiration pneumonia may Director, Graduate Program in Nutrition and Dietetics, Central Michigan result in increasing length of stay up to 15 days and University, Mt Pleasant, Michigan. additional costs of $22,000 (Kozlow, Berenholtz, The authors declare no conflict of interest. Garrett, Dorman, & Pronovost, 2003). Correspondence to: Laura Brown, MS, RD, CNSC, 1024 S Lemay Ave., It is difficult to determine at what point NPO at Fort Collins, CO 80524 ( [email protected] ). midnight before elective surgery became routine. DOI: 10.1097/SGA.0000000000000018 Maltby (2006) provides a historical perspective on 14 Copyright © 2014 Society of Gastroenterology Nurses and Associates Gastroenterology Nursing Copyright © 2014 Society of Gastroenterology Nurses and Associates. Unauthorized reproduction of this article is prohibited. GGNJ-D-12-00017R1.inddNJ-D-12-00017R1.indd 1144 11/21/14/21/14 88:02:02 AAMM Nothing by Mouth at Midnight preoperative fasting guidelines and suggests that in the Multiple studies have evaluated if allowing clear 1960s, NPO at midnight became standard practice. liquids up to 2 hours before surgery increases the risk These initial recommendations to fast before surgery of increased RGVs. McGrady and MacDonald (1988) were made to decrease the discomfort of nausea, not to provided 100-ml water before surgery or required the protect the patient from an adverse medical complica- patient to be NPO at midnight. Median RGV was tion. An unpublished study of Rhesus monkeys that lower for the water group (16.5 ml) than for the NPO were injected with an acidic fluid into their lungs group (25 ml), but this was not statistically different. prompted a recommendation in 1974 by Roberts and Maltby et al. studied 199 elective surgery patients and Shirley (1974) to limit gastric contents to 25 ml to provided unrestricted clear liquids until 3 hours before reduce aspiration risk. An additional evaluation of acid surgery and compared them with patients requested to fluid administered into the trachea of monkeys sug- be NPO at midnight (Maltby, Lewis, Martin, & gested that gastric contents should be limited to Sutherland, 1991). Again, there was no statistical dif- 0.8 ml/kg (Raidoo, Rocke, Brock-Utne, Marszalek, & ference in RGVs between the groups. Engelbrecht, 1990). Shevde and Trivedi (1991) measured RGV every 30 Alternately, multiple studies in the 1980s reported minutes after 240 ml of water, coffee, or pulp-free that survival rates in rats after hemorrhagic shock were orange juice was consumed. All of the healthy volun- lower in fasting rats than in fed rats (Alibegovic & teers had RGV of less than 25 ml within 2 hours of Ljungqvist, 1993; Ljungqvist, Jansson, & Ware, 1987; consumption and there was no statistically significant Nettelbladt, Alibegovic, & Ljungqvist, 1996). Studies difference between the groups. Several additional stud- investigating measured gastric volume in humans after ies in Figure 1 highlight the lack of consistency in RGVs various fasting periods were not undertaken until the after fasting or consuming liquids prior to surgery. late 1970s (Ong, Palahniuk, & Cumming, 1978). In The majority of studies compared RGVs between 1986, Maltby, Sutherland, Sale, and Shaffer (1986) experimental and control groups without determining published one of the first studies investigating gastric the associated risk for aspiration. The North American residual volumes after fasting or consuming water. The Summit on Aspiration in Critically Ill Patients: results showed that residual gastric volumes (RGVs) Consensus Statement reported that RGV correlates were statistically lower in the group that drank water poorly with gastric emptying and is not a reliable indi- than in those that had been fasting (17.6 ± 14.5 ml vs. cator of aspiration risk ( McClave et al., 2002 ). 26.7 ± 18.9 ml; p < .02) ( Maltby et al., 1986 ). Research in the critical care setting provides further However, in a follow-up study, there was no difference support that RGV is not a valid marker for risk of in RGVs in those who consumed coffee/tea or orange aspiration ( McClave et al., 2005 ). The mean RGV for juice or completed an overnight fast (Hutchinson, all aspiration events in a study of 1,118 gastric volume Maltby, & Reed, 1988). measurements was 30.6 ml (range, 0–700 ml) and the frequency of aspiration did not correlate with an Consumption of Clear Liquids Prior to increase in RGV. Anesthesia There are additional effects of NPO status beyond Although the theory of fasting before surgery to pre- aspiration risk. A pediatric study evaluated irritability vent or reduce the risk of aspiration seems intuitive, and dehydration rates in patients undergoing orthope- the physiology of gastric emptying does not support dic surgeries that were either made NPO at midnight the need for fasting 12 hours prior to anesthesia. Gastric emptying is dependent on many factors includ- ing hormonal stimulation, calorie and macronutrient content, volume consumed, size of food particles, and osmolality (Calbet & MacLean, 1997; Hellström, Grybäck, & Jacobsson, 2006). Osmolality of liquids is determined by the concentration of the particles in the solution and higher osmolality liquids may decrease gastric emptying (Vist & Maughan, 1995). Typically 90%–95% of iso-osmolar (300 mOsm/kg) fluids pass through the pylorus within 1 hour after consumption ( Hunt, 1956; Jolliffe, 2009). Because many factors are involved in gastric emptying, the patient should be FIGURE 1. Residual gastric volumes after fasting at instructed on the difference between clear liquids and midnight, drinking water or a placebo 2–3 hours before liquids containing additional components such as fat surgery, or consuming a carbohydrate-containing beverage or fiber. 2–3 hours before surgery. VOLUME 37 | NUMBER 1 | JANUARY/FEBRUARY 2014 15 Copyright © 2014 Society of Gastroenterology Nurses and Associates. Unauthorized reproduction of this article is prohibited. GGNJ-D-12-00017R1.inddNJ-D-12-00017R1.indd 1155 11/21/14/21/14 88:02:02 AAMM Nothing by Mouth at Midnight or provided with 250-ml apple juice about 2.5 hours TABLE 1. Preoperative Fasting Recommendations before surgery (Castillo-Zamora, Castillo-Peralta, & of the American Society
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