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Preoperative fasting of patients undergoing elective surgery Philip Hung, Anglia Polytechnic, Essex Preoperative fasting regimens tend to be based in ritualistic practice causing physical and psychological harm to patients. This research study investigates current nursing practice and concludes that it must be research based.

n eneral anaesthesia has always carr­ ied with it the risk of the patient vomiting during induction, causing aspiration of gas­ tric contents and subsequent respiratory complications. This may have fatal conse­ quences and it is therefore a medical and legal requirement that a patient must not be anaesthetized without a period of starva­ tion and oral fluid deprivation. The excep­ tion is when operations have to be perform­ ed in emergencies. Dietary restriction for 4-6 hours before general anaesthesia is an almost universally accepted procedure; however, there are wide variations in inter­ pretation and execution in clinical practice. This descriptive research study replicates Hamilton-Smith’s study (1972) which in­ vestigated the practice of preoperative fast­ ing procedure. Following a pilot study, the original structured questionnaire was mod­ ified and semi-structured questions were added to collect qualitative data and explore issues that had not been previously examin­ ed. Twelve anaesthetists, 38 qualified day and night nurses and 29 patients from four surgical wards in a large general hospital were interviewed.

Sum m ary of findings

Mr Hung is Nurse Tutor at Anglia Polytechnic in the Associate Department of Nursing and Midwifery Education (South Essex), Education Centre, Southend Hospital, Prittlewell Chase, Westcliff-on-Sea, Essex

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It was found that there was no hospital or ward policy regarding preoperative fasting procedures. Anaesthetists and nurses were not aware of there being any guidelines for junior anaesthetists in the department of anaesthesia. In the absence of agreed policy or guidelines there were no means of estab­ lishing a uniformity of practice and there were variations in the interpretation and ex­ ecution of this specific preoperative care. There was a high level of agreement con­ cerning the minimum fasting times for food and fluid. However, there was less unanim­ ity regarding the maximum fasting time, an issue that previous research studies and lit­ erature has not explored. Anaesthetists and nurses cited a variety of maximum times in the study, ranging from 4 to 24 hours.

Without intravenous infusion, 12 hours was regarded as the maximum fasting time by a significant proportion of the participants. The practice of preoperative fasting pro­ cedures was predominantly governed by the traditional routine. This meant that pa­ tients on the same operating lists were fast­ ed at the same time irrespective of their po­ sition in the list. As a result, most preoperative patients were being deprived of food and fluid for a considerable length of time, far beyond the acceptable maxi­ mum fasting time. Despite recognizing the possible complications of prolonged fast­ ing, e.g. dehydration, hypoglycaemia and confusion, the procedure was carried out for the convenience of ward/theatre man­ agement rather than the wellbeing and in­ terests of the patients. There were exceptions to this ritualistic approach. A small number of nurses did not follow the unwritten traditional rule and strived for an individualized fasting regi­ men or took action to ensure that patients received adequate nutrition. These nurses were experienced senior nurses with expert­ ise in negotiating patients’ care with doctors and collaborating with the ward team. They made sound decisions based on the avail­ able information and provided solutions to practical problems. Their nursing skills were distinguishable from those of less ex­ perienced nurses who followed the traditional rule even though it was unwrit­ ten and harmful to patients. In the study, expert nurses were small in number and their knowledge and skills were not readily transmitted to the less ex­ perienced nurses. Innovations to reduce preoperative fasting times to a minimum and meet patients’ nutritional needs were practised in isolation without either the knowledge of or support from other nurses. There was a general assumption that every­ body was doing the same as everybody else. This assumption reinforced the tradition and reflected the deficiency of the clinical

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Preoperative fasting of patients undergoing elective surgery

system in which ideas were not shared within the nursing team and between the professional disciplines. Apart from the powerful force of tradi­ tion, the fear of ever-changing operating lists was a significant factor that contribut­ ed to patients’ prolonged fasting. Numer­ ous reasons for the uncertainty of operating lists were given and it seemed to be almost impossible to predict accurately the operat­ ing time in order to plan individualized fasting regimens. Since it was expected that all patients on the same list were fasted at the same time, keeping wards informed of changes in the operating lists seemed to be pointless as these did not alter patients’ fast­ ing regimens. It was no surprise to find that communication between theatre and wards was poor and that there was confusion over who should be responsible for notifying the wards in the event of change. The desire to adhere to the minimum fasting time and provide adequate nutrition for preoperative patients alone would not necessarily render better care. Without the support of the surgeons and anaesthetists, changes were limited and generally beyond the capacity of a junior nurse who had no clear guidelines of how preoperative fasting procedures should be implemented. It was interesting to note that anaesthetists and nurses blamed each other for the errors. This is probably due to the differences be­ tween the two professional disciplines in terms of their specific objectives of operat­ ive care, practical problems and assump­ tions of each other’s role. The dilemma of patients’ welfare and medical authority was seen as a source of stress by many nurses. All the patients in this study were in­ structed by nurses or anaesthetists that they must not eat or drink from a certain time

before their operations. However, the rea­ sons for dietary restriction and minimum fasting times or the possible complications of prolonged fasting were not explained to patients. Unaware of the avoidable prolonged fast­ ing and risks involved, few patients com­ plained about the preoperative fasting pro­ cedure. Some patients would not comment upon the subject because they feared that they might be seen as disobedient or de­ manding. Most patients generally accepted the necessity for it and trusted the doctors and nurses.

Discussion The current practice of prolonged preoperative fasting carries potential risks and therefore needs to be changed. Many valuable and practicable sugges­ tions for improvement have been proposed by anaesthetists and nurses. These ideas do not necessarily require additional resources, e.g. policies can be achieved through con­ structive meetings between surgeons, an­ aesthetists and nurses. Other ideas, includ­ ing an experimental study of personalized fasting regimens and modification of exist­ ing routine fasting procedures are stimulat­ ing and worth considering. Attempts are being made to improve the quality of care by a few experienced nurses who refuse to accept the irrational tradi­ tion. Preoperative fasting times can be kept to a minimum to meet patients’ nutritional needs. The qualities of these nursing skills should be identified and transmitted to the less experienced nurses. Nurse education on basic and post-basic courses has an im­ portant role in providing learning oppor­ tunities to utilize this clinical expertise and educate nurses to adopt research-based practice.

K E Y P O IN T S • Preoperative fasting is predominantly governed by traditional and ritualistic based practice. • Most preoperative patients are being deprived of food and fluid far beyond the acceptable maximum fasting time of 12 hours. • Procedures are implemented more for the convenience of ward and theatre staff than for the wellbeing of patients. • Communication between theatre and ward staff is poor. • There are a small number of senior nurses who strive for individualized fasting regimens. • Policies and guidelines relating to preoperative fasting should allow flexibility.

British Journal o l Nursing. 1992, Vol I . No 6

Hamilton-Smith SH (1972) Nil by mouth? RCN, London

Further reading Bateman DN , Whittingham TA (1982) Measurement of gastric emptying by real-time ultrasound. Gut 23: 524-7 Hunt M (1987) The process of translating research findings into nursing practice. J Adv N un 12: 101-10

Schreniner MS, Triebwasser A, Keon TP (1990) Inges­ tion of liquids compared with pre-operative fasting in paediatric outpatients. Anesthesiology 72: 593-7 Summerskill H (1976) Measurement of gastric func­ tions during digestion of ordinary solid meats in man. G astroenterology 70: 203 Thomas EA (1987) Pre-operative fasting — a question of routine? Nurs Times 83 (49):

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Preoperative fasting of patients undergoing elective surgery.

Preoperative fasting regimens tend to be based in ritualistic practice causing physical and psychological harm to patients. This research study invest...
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