A recent AORN Journal article estimates the average surgical patient fasts for 11 hours. Total abstinence typically starts at midnight before the day of surgery — no matter the actual time of the scheduled procedure. While we can clinically justify prolonged fasting from solids, similar fasting from clear liquids is a non-evidence-based dinosaur that begs for extinction.

What's so special about midnight?
Fifteen years ago, the American Society of Anesthesiologists (ASA) published its first Fasting Guidelines for Healthy Patients Having Elective Surgery, essentially targeting the majority of patients with whom we deal every day. Based on best evidence and expert opinions, the ASA declared it safe for such patients to "have clear liquids up to 2 hours prior to surgery." Many hospitals and surgery centers rushed to make those guidelines a part of their policy and procedure manuals.

Today, however few surgical facilities have actually implemented their "new fasting guidelines." An Outpatient Surgery Magazine online survey of 516 surgical facility leaders found that most are subjecting their patients to the unpleasant, if not grueling, consequences of a pre-operative fast that may last for 12 to 16-plus hours, depending on the actual start times of their procedures.

• 54% follow the traditional NPO: nothing by mouth from midnight for all patients.
• 28% say no solids after midnight, but clear liquids up to a few hours before surgery are okay.
• 18% allow a light breakfast up to 6 hours before surgery and clear liquids up to 2 hours before surgery.

Starvation and dehydration
Not only does fasting from midnight cause unnecessary metabolic stress for patients, but it also makes them needlessly and often extremely uncomfortable. Merely drinking water, tea or coffee does not interrupt the metabolic fast. We're still literally starving and dehydrating our patients. They're still hungry, thirsty, anxious, nauseated and generally uncomfortable as they face the major stress of surgery. There are a couple explanations at work:

• Fear of regurgitation and aspiration. There is the non-evidence-based fear that healthy patients who ingest a clear liquid 2 to 3 hours before surgery are at higher risk of regurgitation and aspiration. The assumption is that, following such ingestion, the patient's residual gastric volume (RGV) and/or residual gastric acidity (RGA) will be greater than that of patients who traditionally fasted. Actually, several peer-reviewed trials have demonstrated the exact opposite: the resultant RGVs and RGAs are equal to or less than those found in patients who fasted from midnight.
• Fear of cancellation. There is the economic concern that letting patients drink up to 2 hours before surgery could compromise the efficiencies of the surgery schedule. An example might include the cancellation, for any reason, of a procedure in a busy surgeon's lineup and the inability to move up a subsequent procedure because that patient would not have fasted for the requisite 2 hours after consuming a clear liquid.

PRE-OPERATIVE NUTRITION Clearfast is a carbohydrate-rich beverage for pre-op hydration and nutrition.

PRE-OP BEVERAGE
The Inventor of a Pre-Surgery Drink

Ever since anesthesiologist M. Lou Marsh, MD, found that most surgery postponements and cancellations were due to violations of the pre-op fasting rules, she's focused on her 2 passions: pre-op patient hydration and nutrition. She formulated and patented a clear liquid, carbohydrate-rich, pre-op beverage, Clearfast, which is designed for patient consumption 2 hours before surgery. Clearfast is quickly absorbed by the body, leaving the stomach empty and the patient not starving. Patients who had Clearfast 2 to 3 hours pre-op versus those who fasted traditionally from midnight were 6 times more likely to describe themselves as comfortable, studies have found.

— Dan O'Connor

The new pre-operative fast
Over the last several years, a new paradigm of perioperative patient care, Enhanced Recovery After Surgery (ERAS), has swept Europe and the U.K., finally arriving in the United States over the last year or so. The protocol consists of 17 evidence-based care elements that, when implemented, have reduced the incidence of several post-op complications with the results of reduced length of stays in and re-admissions to hospitals. Pre-op loading with carbohydrate-rich beverages (12% concentration of complex carbohydrates) 2 hours before anesthesia puts the patients in a metabolically fed state. Such loading was found to be an independent predictor of post-op clinical outcomes, including post-op nausea and vomiting. Further, it was viewed as beneficial in the reduction of the post-operative insulin resistance that is seen in both non-diabetics and diabetics and that leads to hyperglycemia and surgical wound infections.

In truth, there's nothing magic about fasting from midnight for healthy patients undergoing elective procedures. On the contrary, that dated practice could be placing patients at risk, unnecessarily, for the very consequences that inspired the fasting rule: regurgitation and aspiration. At the very least, for many patients it is perpetuating a miserable pre-op experience. We can and should do better for our patients by implementing the "new fast."