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 cough, T 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

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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 including 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.

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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 of Anesthesiologists for Nava-Ocampo, 2005). Patients in the NPO group Healthy Patients Undergoing Elective Surgery fasted for an average of 13.2 ± 3.3 hours and had = Minimum increased complaints of irritability (odds ratio [OR] Liquid and Food Intake Fasting Period 4.5; 95% confidence interval [CI] [1.9, 10.3]) and Clear liquids (water, tea, black coffee, 2 hours dehydration (OR 21.6; 95% CI [5.9, 79.0]). Another fruit juice without pulp, carbonated study evaluated hunger ( p < .05) and thirst (p < .05) beverages) and found decreased rates in those who received water Breast milk 4 hours prior to surgery compared who those who were NPO (Agarwal, Chari, & Singh, 1989). Nonhuman milk, including infant formula 6 hours Avoiding prolonged preoperative fasting can also Light meal (e.g., toast and clear liquids) 6 hours decrease risk of hospital-acquired malnutrition. A sur- Regular or heavy meal (may include 8 hours vey of practices at the University of Louisville Hospital, fried or fatty food, meat) a large U.S. tertiary and academic care center, reported Source: Data from American Society of Anesthesiologists, 2011. that 22% of patients admitted to the hospital were NPO or received a clear liquid diet for 3 or more days ( Franklin et al., 2011). Prolonged postoperative avoid- The European Society for Parenteral and Enteral ance of oral nutrition would clearly be complicated by Nutrition recommendations state that it is unnecessary an extended preoperative fasting and may contribute for most patients to fast at midnight before surgery to overall malnutrition. (Braga et al., 2009). Its recommendations further state Malnutrition in the hospital setting has been esti- that preoperative oral carbohydrate loading is recom- mated at 35% with an additional 30%–35% of mended for most patients and intravenous carbohy- patients who are at risk for developing malnutrition. drate administration can be considered for those unable Extending preoperative fasting times beyond those to safely take oral nutrition. absolutely essential creates an unnecessary delay in providing nutrition to the patient. Malnutrition has Survey of Fasting Practices been associated with increased infection rates, impaired A diverse and changing fasting practice has been wound healing, and increased hospital length of stay reported in the literature. In 1996, a survey determined (Barker, Gout, & Crowe, 2011). A prospective obser- that 49% of responding chairpersons in university vational study in a surgical intensive care unit deter- anesthesiology programs and medical directors of mined that negative energy balance from inadequate ambulatory surgery centers in the United States require nutrition correlated with statistically significant patients to fast at midnight whereas 24% allow clear increased length of stay ( p < .001), infectious compli- liquids up to 4 hours before surgery (64.6% response cations ( p < .0042), and days on mechanical ventila- rate; Green, Pandit, & Schork, 1996). Four years later, tion ( p < .0002) ( Villet et al., 2005 ). a similar survey was sent to members of the Society of The American Society for Enteral and Parenteral Ambulatory Anesthesia in the United States. Of the Nutrition, in conjunction with the Society for Critical 59.6% of participants who responded, 62% reported Care Medicine, published guidelines for the nutrition having policies that allow clear liquids 2–3 hours care of critically ill adult patients in 2009 ( McClave before surgery (Pandit, Loberg, & Pandit, 2000). More et al., 2009 ). These guidelines state that efforts should recently, Shime et al. evaluated the fasting practices of be made to minimize the time a patient is NPO before, chief anesthesiologists in anesthesia-teaching hospitals during, and after any test or procedure in an effort to in Japan. Fifty-seven percent of the surveys were prevent inadequate provision of nutrition. returned with a median time for abstaining from liq- There has been a trend in the past several decades to uids of 6–9 hours reported by 90% of the respondents adopt liberalized preoperative fasting guidelines. A (Shime, Ono, Chihaba, & Tanaka, 2005). Cochrane review published in 2003 concluded that decreasing preoperative fasting did not increase aspira- Actual Fasting Practices tion events after receiving anesthesia (Brady, Kinn, Actual fasting time ranged from 3.75 to 29 hours with Stuart, & Ness, 2003). Updated American Society of a mean of 11 hours (SD = 4 hours) in a survey by Anesthesiologists (2011) guidelines from 2011 are Chapman (1996). In 2002, a study of 155 patients outlined in Table 1. The American College of undergoing elective surgery showed that the majority Gastroenterology guidelines for colorectal cancer screen- abstained from liquids for an average of 11.9 ± 3 hours ing published in 2009 support consuming clear liquids with 97% of the patients abstaining from liquids for until 2 hours before receiving sedation ( Rex et al., 2009 ). more than 6 hours (Crenshaw & Winslow, 2002).

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Nearly all patients (91%) were ordered to fast starting outcomes from preoperative consumption of carbohy- at midnight including patients scheduled for the after- drate-rich clear liquid beverages (carbohydrate loading) noon surgery (79%). appear to be related to both a decrease in insulin resist- Great efforts have been undertaken to liberalize the ance and promotion of an anabolic state (Ljungqvist, antiquated extended preoperative fasting time. Crenshaw 2009). These factors appear to ameliorate the surgical and Winslow (2008) completed an aggressive campaign stress response. to decrease fasting times in a hospital. This quality Use of an intravenous glucose infusion during sur- improvement initiative included providing physician gery was found to decrease insulin resistance and nurse education, updating policies and procedures, (Ljungqvist, Thorell, Gutniak, Ha¯ ggmark, & Efendic, revising standing order forms, and disseminating current 1994; Nygren, Soop, et al., 1998; Nygren, Thorell, research and practice guidelines for preoperative fasting. et al., 1998). Unfortunately, peripheral vein adminis- A follow-up survey published in 2008 showed that tration of concentrated dextrose produces phlebitis patients abstained from clear liquids an average of 11 ± ( Ljungqvist, 2009). Thus, using a specialized oral car- 3 hours, which is statistically less than the previously bohydrate-rich clear liquid beverage to stimulate a measured 11.9 ± 3 hours ( p < .005), but unfortunately state similar to that after a meal (fed state) reduces not clinically relevant (Crenshaw & Winslow, 2008). insulin resistance while limiting risks of adverse effects There was no statistical improvement in the percentage of intravenous dextrose administration. Initial studies of patients instructed to remain NPO after midnight used a 12.5% carbohydrate iso-osmolar (300 mOsm/L) throughout the initiative (p = .19). The instructed time beverage that was composed mainly of maltodextrin (a for abstaining from liquids was 9 ± 3 hours, signifi- rapidly absorbed polysaccharide). cantly more than the recommended 2 hours. The As previously stated, osmolality may be an impor- authors reported understandable frustration with their tant component of gastric emptying and beverages results after a strong and comprehensive effort to with an osmolality of more than 300 mOsm/L may improve fasting practices. This study highlights difficul- decrease gastric emptying rate. A study of healthy vol- ties clinicians may experience when trying to liberalize unteers determined that the average gastric emptying institutional fasting guidelines. rate for 400 ml of a preoperative iso-osmolar beverage is about 90 minutes (Nygren, Thorell, Jacobsson, Metabolic Effects of Fasting and Use of Larsson, Schnell, Hylen, & Ljungqvist, 1995). Residual Carbohydrate-Rich Clear Liquids gastric volumes were evaluated between groups that During an overnight fast, breakdown of glycogen to consumed a carbohydrate-rich drink and those that maintain serum blood glucose levels through glycogen- fasted. Gastric volumes were not statistically different olysis can deplete hepatic glycogen stores (Ling & between the groups ( p = .61) (Yagci et al., 2008). McCowen, 2007). Gluconeogenesis (using muscle pro- When soy peptides were added to a carbohydrate-rich tein) is then required for glucose production. Postoperative clear liquid beverage, this appeared to have no signifi- glucose metabolism is further altered by insulin resistance cant impact in gastric emptying rates as well (Henriksen caused by inhibition of nonoxidative glucose disposal et al., 2003). In a randomized, blinded, three-way (Soop, Nygren, Myrenfors, Thorell, & Ljungqvist, 2001). crossover study of healthy volunteers, 10 people were Surgery may also result in an increased production of provided a carbohydrate-rich clear liquid beverage, an counterregulatory hormones such as catecholamines as iso-caloric equivalent containing carbohydrate and well as an increase in inflammatory cytokines leading glutamine, or carbohydrate and lipid containing bever- to a state of hypermetabolism. age. The 90% mean gastric emptying time was lowest Hypermetabolism results in a catabolic environment in the group that received the carbohydrate and lipid- characterized by breakdown of glycogen, fat, and pro- containing beverage ( p = .017) ( Awad et al., 2011 ). tein (Smiley & Umpierrez, 2006). Increased levels of In addition to improved gastric emptying, patient insulin and blood glucose further lead to an increased satisfaction may improve with administration of carbo- rate of gluconeogenesis. Glucose control is beneficial hydrate-rich clear liquid beverages. Postoperative dis- during conditions of metabolic stress to decrease hos- comfort may be decreased when patients consume a pital length of stay (Thorell et al., 1999), decrease preoperative carbohydrate-rich clear liquid beverage. postoperative infection rates ( Pomposelli et al., 1998 ), Hausel et al. reported decreased nausea and vomiting in and reduce mortality rates (Finney, Zekveld, Elia, & laparoscopic cholecystectomy patients who consumed a Evans, 2003). Preoperative administration of carbohy- carbohydrate-rich clear liquid beverage (p < .001) with drate is, therefore, expected to increase glucose oxida- the highest incidence of nausea and vomiting occurring tion rates, which decrease peripheral tissue glucose 12–24 hours after surgery in the fasting group (p < disposal. In addition, the rate of protein breakdown .039) (Hausel, Nygren, Thorell, Lagerkranser, & may be decreased with glucose administration. Improved Ljungqvist, 2005). In an earlier study of 252 elective

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abdominal surgery patients by Hausel et al. (2001) , the carbohydrate loading have shown both a decreased carbohydrate-rich clear liquid beverage group experi- length of stay and a decreased 30-day morbidity rate enced decreased rates of hunger (p < .05) and anxiety (Walter, Collin, Dumville, Drew, & Monson, 2009). (p < .001). No statistically significant difference in postoperative appetite (p = .392), pain (p = .228), Barriers to Change nausea (p = 1.000), vomiting (p = .336), total minutes Clinicians may believe that a prolonged fast before of sleep (p = .830), or the number of night movement surgery improves safety (Crenshaw & Winslow, 2008). arousals (p = .846) was observed when a carbohy- One survey of 100 elective surgery participants found drate-rich clear liquid beverage was consumed com- that 82% knew fasting practices were related to anes- pared to a placebo (Bisgaard et al., 2004). thesia and patient safety. Aspiration and risk for com- Postoperative clinical benefits of providing preoper- plications were cited as the rationale for fasting by ative oral carbohydrate-rich clear liquid beverage also 73% of the nurses surveyed (Baril & Portman, 2007). include increased muscle strength (Henriksen et al., It may also be easier for clinicians to offer one set of 2003; Yuill, Richardson, Davidson, Garden, & Parks, instructions rather than individualizing preoperative 2005), improved insulin sensitivity (Nygren, Soop, et al., recommendations (Crenshaw & Winslow, 2008). 1998; Nygren, Thorell, et al., 1998; Perrone et al., 2011; There is a concern that patients would have a diffi- Soop et al., 2001; Svanfeldt et al., 2005), and improved cult time determining what liquids are considered clear cellular immune function (Melis et al., 2006). Only a liquids and that “NPO at midnight” directions may 5% loss of muscle mass was reported 1 month postsur- lead to greater compliance. However, a study of elec- gery in an elective bowel surgery group that received a tive colorectal resection patients instructed to consume carbohydrate-rich clear liquid beverage, compared with a carbohydrate-rich clear liquid beverage and complete a 13% decrease seen in the group that consumed only mechanical bowel preparation showed that 74% of water ( p < .05) ( Henriksen et al., 2003 ). In a study of patients complied with preoperative orders ( Hendry 15 patients undergoing total hip replacement, the car- et al., 2008 ). Fourteen of the 124 subjects (11%) did bohydrate-rich clear liquid beverage group had an 18% not consume the carbohydrate-rich beverage because decrease in whole-body insulin sensitivity compared the medical staff failed to provide the product. Failure with a 43% decrease in the placebo group ( p < .05) to tolerate the oral carbohydrate-rich clear liquid bev- (Soop et al., 2001 ). erage, vomiting, and incomplete records are responsible A decrease in nitrogen losses and a 50% reduction for nine subjects who did not complete the protocol. in insulin resistance have been reported in the litera- Only 2 of 124 subjects refused to consume the carbo- ture (Ljungqvist, 2009). Table 2 provides additional hydrate-rich drink. Although the instructions for con- studies investigating insulin resistance after consuming suming preoperative carbohydrate-rich clear liquids a preoperative carbohydrate-rich clear liquid beverage. beverages may initially appear more confusing, they Melis et al. (2006) evaluated carbohydrate beverages are likely not more difficult to understand than other in 30 orthopedic surgery patients. The fasting group pre- and postoperative nutrition, medication, and life- experienced a significant decrease in human leukocyte style instructions. antigen expression that correlates to risk an increase in Another concern expressed by surgical facilities is postsurgical infections. Not all studies have shown that changing fasting policies would limit flexibility in improved outcomes in the carbohydrate-rich clear liq- surgery schedules, but research has failed to substanti- uid group ( Bisgaard et al., 2004). However, a sum- ate this finding (Murphy, Ault, Wong, & Szokol, mary of literature by Ljungqvist (2009) reported that 2009). In a survey of ambulatory anesthesiologists in more than 2000 patients have been studied and more the United States, 65% of anesthesiologists would not than 2 million patients have received a preoperative delay surgery if toast and tea were consumed 6 or more carbohydrate-rich clear liquid drink in clinical practice hours before surgery and another 32% would delay with no apparent adverse effects. the surgery to later in the day (response rate of 59.6%) Following major operations, including colorectal ( Pandit et al., 2000 ). surgery, multimodal early recovery programs have There are certain patient populations that may be been implemented to decrease morbidity and mortality need to be excluded from more liberal fasting guidelines. rates ( Teewen et al., 2010 ). These programs recom- Obese patients have been identified as a population at mend avoiding bowel preparation, limiting the use of risk for delayed gastric emptying, but Horowitz et al. nasogastric decompression tubes, and utilizing liberal reported that there is no difference in gastric emptying of fasting guidelines to ultimately decrease surgical stress liquids in the obese patient (Horowitz, Collins, Cook, and reduce postoperative complication rates ( Lassen Harding, & Shearman, 1983). Matlby et al. specifically et al., 2009). Studies evaluating the impact of multi- included obese (body mass index > 30 kg/m2 ) patients modal early recovery programs using preoperative undergoing elective surgery in a randomized study to

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TABLE 2. Literature Reports of Blood Glucose and Insulin Levels After Carbohydrate-Containing Preoperative Beverage Author Sample Size Design Results Comments Nygren, Soop, 14 colorectal 800-ml iso-osmolar Whole-body glucose disposal The authors con- et al. (1998); surgical 12.5% CHO drink at was decreased in the fasting cluded that a pre- Nygren, patients night and 400 ml. 2 group (−49% ± 6%) when operative CHO Thorell, et al. hours before surgery, or compared with the CHO drink might (1998) NPO at midnight; pro- group (−26 ± 8%; improve insulin spective controlled trial. sensitivity. p < .05). Glucose oxidation was also decreased and fat oxidation was increased in the fasting group ( p < .05). Soop et al. 15 total hip 800 ml iso-osmolar The treatment group experi- The authors reported (2001) replacement 12.5% CHO at night enced 18% decrease in increased glucose surgery and 400 ml within 2.5 whole-body insulin sensitivi- oxidation rates in patients hours of surgery, or a ty vs. 43% in the placebo the CHO group. placebo; double-blind group ( p < .05). RCT. Soop et al. 14 total hip 800 ml iso-osmolar Endogenous glucose release No significant differ- (2004) replacement 12.5% CHO at night was lower in the carbohy- ences in length of surgery and 400 ml within drate group (−19 ± 5 vs. stay noted patients 2.5 hours of surgery, or −37 ± 7%; p < .05) when between the CHO a placebo; double-blind compared with the placebo or placebo RCT. group. groups. Svanfeldt et al. 6 healthy NPO at midnight, 800 ml Nonoxidative glucose disposal The authors con- (2005) volunteers of iso-osmolar 12.5% was highest in the group cluded that insulin CHO at night, or that consumed the drink in action is amplified 400 ml in the morning, the morning (5.0 ± 1.5 and by 50% within 3 or both night and 5.6 ± 1.9 mg/kg/minute vs. hours of con- morning drinks; rand- ± ± sumption of a pre- omized crossover 2.9 1.4 and 3.1 1.6) vs. operative carbo- unblinded trial. fasting or consuming only hydrate beverage. an evening drink, p < .01. Breuer et al. 160 elective 800 ml of an iso-osmolar No statistical difference in Thirst may be (2006) cardiac 12.5% CHO beverage postoperative insulin resist- decreased when a surgery at night and 400 ml 2 ance between the groups. clear liquid is patients hours before surgery, or allowed to be a placebo, or NPO at consumed prior to midnight; double- cardiac surgery. blinded RCT. Svanfeldt et al. 12 elective 800 ml iso-osmolar Whole-body protein break- The group that con- (2007) colorectal 12.5% (125 mg/ml) down was higher in the low sumed the higher surgery CHO at night and 200 CHO group (p < .009) and CHO beverage patients ml every hour while protein synthesis was more experienced waiting for surgery negative in the low CHO decreased affects (600–800 ml) or the group (p < .007). on whole-body same volume of a protein balance. lower CHO beverage (25 mg/ml); RCT. Perrone et al. 17 cholecystec- 474 ml 6 hours prior to Insulin resistance (5.72 ± 1.16 A preoperative CHO (2011) tomy or surgery and 237 ml and whey protein vs. 2.75 ± 0.72; p < .03) inguinal 3 hours before surgery ± beverage can herniorrhaphy of water or a drink con- and serum insulin (19.9 decrease insulin patients taining 86% CHO and 3.9 vs. 10.7 ± 2.9; p < .05) resistance and 14% milk whey protein; were higher in the water acute phase double-blind RCT. group than in the CHO and response. whey group.

Note. CHO = carbohydrate; NPO = nothing by mouth; RCT = randomized controlled trial.

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evaluate effects of clear liquid intake 2 hours before the The beverage most frequently used is preOp, which scheduled surgery (Maltby, Pytka, Watson, Cowan, & is available in Europe, but is not available in the United Fisk, 2004). No difference in gastric volumes was noted States. This drink provides 50 g of carbohydrate per (p = .46). 400 ml. Only one study used Resource Breeze, which There are also concerns that diabetic patients have is available in the United States ( Perrone et al., 2011). delayed gastric emptying; however, a study of 14 dia- To receive 50 g of carbohydrate using apple juice betic patients who received 400 ml of a 12.5% carbohy- would require the patient to consume 430 ml. However, drate beverage (preOp) reported that gastric emptying apple juice is different from preOp in that it is hyper- was similar to that of healthy individuals (Nygren et al., osmolar (690 vs. 240 mOsm/L), which may delay 2004). Those with gastrointestinal disorders, delayed gastric emptying. gastric emptying, ileus, or intestinal obstruction may Vermeulen et al. (2011) evaluated gastric emptying not be candidates for liberalized fasting guidelines and comparing preOp to a fruit-based lemonade that was use of preoperative carbohydrate-rich clear liquid bever- hyperosmolar (805 mOsm/kg). Gastric emptying was age (Doswell, Jones, & O’Donnell, 2002; Ljungqvist & delayed in the lemonade group; however, this did not Søreide, 2003; Crenshaw & Winslow, 2008; Winslow, reach statistical significance (p = .600). Sports drinks Crenshaw, & Warner, 2002). are typically iso-osmolar; however, the patient would Pregnant women have been considered a popula- need to consume 860 ml to obtain 50 g of carbohy- tion at higher risk for aspiration during anesthesia and drate. Table 3 reviews the osmolarity and carbohydrate may also not be appropriate for preoperative carbohy- content of various clear liquid beverages. Because drate-rich clear liquid beverages (Søreide et al., 2005). preOp has been available in Europe, Ljungqvist (2009) Elderly patients and those with dysphagia and inabil- reported that more than 2 million patients had received ity to safely consume thin liquids should be evaluated preOp. One U.S.-based company has a Web site adver- for their ability to safely consume any liquid prior to tising a carbohydrate-rich beverage specifically designed anesthesia. to be used during the preoperative period. However, at the time of this publication, no ordering information, Recommendations availability, or cost was available on the Web site. Based on the available evidence, it would appear that the use of preoperative carbohydrate-rich clear liquid Summary beverage should be a standard of care. However, the Although NPO at midnight has been standard practice most significant limitation to utilizing carbohydrate- before elective surgery for decades, this practice has rich clear liquids in the United States is the lack of a little to no scientific support. Liberal fasting guidelines commercially available, specifically designed, preoper- allowing clear liquids 2–3 hours before surgery have ative carbohydrate loading beverage. Most of the stud- been published and supported by professional organi- ies to date provided 800 ml of a 12.5% carbohydrate zations in the United States since 1999. Surveys of iso-osmolar beverage the night before surgery and then practice policies and actual fasting times indicate that another 400 ml 2–3 hours before surgery. current practice is not consistent with these guidelines.

TABLE 3. Carbohydrate (CHO)–Containing Clear Liquid Beverages CHO g/dl or Osmolarity Name % CHO (mOsm/L) CHO Source Prune juice 18.6 g/dl 1,265 Fructose, glucose, sucrose Apple juice 11.6 g/dl 690 Fructose, glucose sucrose Orange juice 11.4 g/dl 620 Sucrose, fructose, glucose Regular cola 9.7 g/dl 550–700 Fructose, sucrose Oral rehydration solutions 2–4 g/dl 245–310 Glucose, dextrose, fructose Sports drinks 5.8 g/dl 330–380 Fructose, sucrose, glucose Resource breeze 23 g/dl 750 Sugar, corn syrup Nutricia preOp (not available in the United States) 12.6% 240 Polysaccharides, sugars Polycose liquid 50 g/dl 630 Glucose polymers Note. Some of the beverages contain electrolytes including potassium. Use in patients with renal disease should be evaluated on an individual basis.

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New evidence has highlighted the importance of oral carbohydrate beverage with placebo before laparoscopic oral carbohydrate loading. Providing a 12.5% carbo- cholecystectomy. British Journal of Surgery , 91 , 151 – 158 . hydrate-rich clear liquid beverage during the preopera- Brady , M. , Kinn , S. , Stuart , P. , & Ness , V. ( 2003 ). Preopera- tive period may reduce insulin resistance by 50% and tive fasting for adults to prevent perioperative complications . Cochrane Database of Systematic Reviews , 4 , 1 – 127 . doi: decrease nitrogen losses ( Ljungqvist, 2009 ; Ljungqvist 10.1002/14651858. et al., 1994 ). Additional benefits include improved Braga , M. , Ljungqvist , O. , Soeters , P. , Fearon , K. , Weimann , A. , & patient comfort from decreased rates of postoperative Bozzetti , F. (2009 ). ESPEN guidelines on parenteral nutrition: nausea and vomiting along with decreased levels of Surgery. Clinical Nutrition , 28, 378 – 386 . anxiety, hunger, and thirst. When choosing a preop- Breuer , J. , von Dossow , V. , von Heymann , C. , von Schickfus , M. , erative beverage for carbohydrate loading, the clinician Mackh , E. , Hacker , C. , … Spies , C. (2006 ). Preoperative oral should look for the characteristics of the beverage carbohydrate administration to ASA III-IV patients undergo- most frequently studied: clear liquid beverage, 50-g ing elective cardiac surgery. Anesthesia & Analgesia , 103 ( 5 ), carbohydrate per 400 ml, iso-osmolar ( < 300 mOsm/L), 1099 – 1108 . and fiber free. Calbet , J. , & MacLean , D. (1997 ). Role of caloric content on gastric Most of the studies provided 800 ml of the carbohy- emptying in humans . Journal of Physiology , 498 , 553 – 559 . Castillo-Zamora , C. , Castillo-Peralta , L. , & Nava-Ocampo , A. drate-containing drink the evening before surgery and ( 2005 ). Randomized trial comparing overnight preoperative fast- then an additional 400 ml 2–3 hours before induction ing period vs oral administration of apple juice 06:00–06:30 AM of anesthesia. Certain patients may not be candidates in pediatric orthopedic surgical patients . Pediatric Anesthesia , for liberalized fasting guidelines and should receive a 15 , 638 – 642 . presurgical evaluation. These patients include those Chapman , A. ( 1996 ). Current theory and practice: A study of pre- who are obese, have a gastrointestinal disorder, are operative fasting. Nursing Standard , 10 ( 16 ), 33 – 36 . elderly, pregnant, exhibit, delayed gastric emptying, Crenshaw , J. , & Winslow , E. (2002 ). Preoperative fasting: Old hab- have an ileus or intestinal obstruction, or exhibit dys- its die hard . American Journal of Nursing , 102 ( 5 ), 36 – 44 . phagia with inability to safely consume thin liquids. Crenshaw , J. , & Winslow , E. ( 2008 ). Preoperative fasting duration Although clinicians may have assumed that longer and medication instruction: Are we improving? AORN Journal , fasting would save the patient from surgical complica- 88 ( 6 ), 963 – 976 . Doswell , W. , Jones , M. , & O’Donnell , J. (2002 ). One size may not fi t tions, starving them and keeping them in the fasted all . American Journal of Nursing , 102 ( 6 ), 58 – 61 . state may be the real danger. Revised fasting guidelines Fasting , S. , & Gisvold , S. ( 2002 ). Serious intraoperative problems—a and carbohydrate-rich clear liquid beverages should be fi ve-year review of 83,844 anesthetics. Canadian Journal Anes- utilized by clinicians for healthy individuals undergo- thesia , 49 ( 6 ), 545 – 553 . ing elective surgery. ✪ Finney , S. , Zekveld , C. , Elia , A. , Evans , T. (2003 ). Glucose control and mortality in critically ill patients . Journal of the American Medical Association , 290 ( 15 ), 2041 – 2047 . 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