LETTERS TO THE EDITOR I strongly agree with the authors’ recommendation for larger trials to determine the benefits of a preoperative high-carbohydrate fluid loading. I also concur that these trials need to include an assessment of patient perception of thirst, hunger, nausea, and anxiety before surgery, important discomforts that a preoperative high-carbohydrate oral fluid has been shown to reduce.6 M. LOU MARSH MD DIRECTOR OF ANESTHESIA SERVICES LA JOLLA PLASTIC SURGERY CENTER SAN DIEGO, CA http://dx.doi.org/10.1016/j.aorn.2014.03.006
References 1. Crenshaw JT, Winslow EH. Preoperative fasting: old habits die hard. Am J Nurs. 2002;102(5):36-44. 2. Chapman A. Current theory and practice: a study of preoperative fasting. Nurs Stand. 1996;10(18):33-36. 3. Murphy GS, Ault ML, Wong HY, Szokol JW. The effect of a new NPO policy on operating room utilization. J Clin Anesth. 2000;12(1):48-51. 4. Winslow EH, Crenshaw JT, Warner MA. Best practices shouldn’t be optional: prolonged fasts aren’t more effectivedor even safer. Am J Nurs. 2002;102(6):59-60, 63. 5. Gustafsson UO, Hausel J, Thorell A, et al. Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg. 2011; 146(5):571-577. 6. Crenshaw JT, Mischke A, Gilder RE. The effects of a prescribed preoperative carbohydrate-rich liquid beverage on elective surgery patients’ ratings of discomfort from prolonged fasting. Poster presented at: The Society of Ambulatory Anesthesia Annual Meeting; May 3-6, 2012; Miami, FL.
Author response. We thank Dr Marsh for his thoughtful comments and acknowledge the limitations of our study, which we clearly outlined in the article. We also thank Dr Marsh for supporting our call for larger, independent trials to test the effectiveness of preoperative consumption of highcarbohydrate fluids to improve patient outcomes. Dr Marsh mentions that we did not apply statistical tests to determine whether the groups were equal at baseline. Although it is possible that study outcomes may be affected by factors other than the
www.aornjournal.org
intervention, for example, imbalance in baseline characteristics, we chose to follow methodologists who argue that testing for differences in baseline characteristics is illogical and should not be performed.1 Randomization is designed to prevent selection bias but cannot necessarily prevent baseline imbalance. In our case, even with such a small sample size, groups were reasonably equivalent at baseline. We reported all adverse events that occurred during the study. Dr Marsh was concerned about “intraoperative regurgitation or aspiration of stomach contents.” It has been known for decades that the incidence of pulmonary aspiration during surgery is an extremely rare event,2 and we certainly would have reported it if it had occurred during our trial. Our research questions and the focus of our study were on the relationship between preoperative carbohydrate fluid intake and readiness for discharge as well as adverse outcomes related to the preoperative carbohydrate fluid. Clearly, if practice is to be based on best evidence, then there remains much to do to provide a strong case for the routine use of preoperative, high-carbohydrate fluids. JOAN WEBSTER BA, RN NURSING DIRECTOR OF RESEARCH ROYAL BRISBANE & WOMEN’S HOSPITAL HERSTON, AUSTRALIA SONYA RANEE OSBORNE PhD, RN SENIOR LECTURER SCHOOL OF NURSING QUEENSLAND UNIVERSITY OF TECHNOLOGY KELVIN GROVE, AUSTRALIA http://dx.doi.org/10.1016/j.aorn.2014.03.007
References 1. Altman DG, Schulz KF, Moher D, et al. The revised CONSORT statement for reporting randomized trials: explanation and elaboration. Ann Intern Med. 2001;134(8): 663-694. 2. Engelhardt T, Webster NR. Pulmonary aspiration of gastric contents in anaesthesia. Br J Anaesth. 1999;83(3): 453-460.
AORN Journal j 673
References 1. Crenshaw JT, Winslow EH. Preoperative fasting: old habits die hard. Am J Nurs. 2002;102(5):36-44. 2. Chapman A. Current theory and practice: a study of preoperative fasting. Nurs Stand. 1996;10(18):33-36. 3. Murphy GS, Ault ML, Wong HY, Szokol JW. The effect of a new NPO policy on operating room utilization. J Clin Anesth. 2000;12(1):48-51. 4. Winslow EH, Crenshaw JT, Warner MA. Best practices shouldn’t be optional: prolonged fasts aren’t more effectivedor even safer. Am J Nurs. 2002;102(6):59-60, 63. 5. Gustafsson UO, Hausel J, Thorell A, et al. Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg. 2011; 146(5):571-577. 6. Crenshaw JT, Mischke A, Gilder RE. The effects of a prescribed preoperative carbohydrate-rich liquid beverage on elective surgery patients’ ratings of discomfort from prolonged fasting. Poster presented at: The Society of Ambulatory Anesthesia Annual Meeting; May 3-6, 2012; Miami, FL.
Author response. We thank Dr Marsh for his thoughtful comments and acknowledge the limitations of our study, which we clearly outlined in the article. We also thank Dr Marsh for supporting our call for larger, independent trials to test the effectiveness of preoperative consumption of highcarbohydrate fluids to improve patient outcomes. Dr Marsh mentions that we did not apply statistical tests to determine whether the groups were equal at baseline. Although it is possible that study outcomes may be affected by factors other than the
www.aornjournal.org
intervention, for example, imbalance in baseline characteristics, we chose to follow methodologists who argue that testing for differences in baseline characteristics is illogical and should not be performed.1 Randomization is designed to prevent selection bias but cannot necessarily prevent baseline imbalance. In our case, even with such a small sample size, groups were reasonably equivalent at baseline. We reported all adverse events that occurred during the study. Dr Marsh was concerned about “intraoperative regurgitation or aspiration of stomach contents.” It has been known for decades that the incidence of pulmonary aspiration during surgery is an extremely rare event,2 and we certainly would have reported it if it had occurred during our trial. Our research questions and the focus of our study were on the relationship between preoperative carbohydrate fluid intake and readiness for discharge as well as adverse outcomes related to the preoperative carbohydrate fluid. Clearly, if practice is to be based on best evidence, then there remains much to do to provide a strong case for the routine use of preoperative, high-carbohydrate fluids. JOAN WEBSTER BA, RN NURSING DIRECTOR OF RESEARCH ROYAL BRISBANE & WOMEN’S HOSPITAL HERSTON, AUSTRALIA SONYA RANEE OSBORNE PhD, RN SENIOR LECTURER SCHOOL OF NURSING QUEENSLAND UNIVERSITY OF TECHNOLOGY KELVIN GROVE, AUSTRALIA http://dx.doi.org/10.1016/j.aorn.2014.03.007
References 1. Altman DG, Schulz KF, Moher D, et al. The revised CONSORT statement for reporting randomized trials: explanation and elaboration. Ann Intern Med. 2001;134(8): 663-694. 2. Engelhardt T, Webster NR. Pulmonary aspiration of gastric contents in anaesthesia. Br J Anaesth. 1999;83(3): 453-460.
AORN Journal j 673
