Downloaded from http://heart.bmj.com/ on December 6, 2014 - Published by group.bmj.com
PostScript
CORRESPONDENCES
Preprocedural fasting for coronary interventions: is it time to change practice? Dear Editor, Patients undergoing invasive cardiac procedures are routinely fasted for varying periods of time even though there is no clearly applicable evidence base to support current practices. We read with great interest the study by Hamid et al1 exploring the occurrence of emergency endotracheal intubation and peri-procedural aspiration pneumonia following elective and planned inpatient percutaneous coronary intervention (PCI) in their practice. This is the first published study in the peer-reviewed literature that specifically addresses the issue of fasting prior to any cardiac procedure. Considering that it involved retrospective analysis of existing data, the wider applicability of the results may be limited, but their paper would crucially serve to raise awareness among the profession on this issue. The custom of fasting patients prior to cardiac procedures appears to have evolved from fasting guidelines for general anaesthesia (GA) in the operating theatre. Induction of GA results in depression of cough and swallow reflexes, which can predispose individuals to aspiration of gastric contents. There is a theoretical risk that conscious sedation may depress the cough and swallow reflexes similar to GA. It is interesting to read that the cardiology teams at the authors’ host institutions have ‘abandoned’ the non-evidence-based practice of fasting patients prior to PCI and observed no adverse patient outcomes, although these patients had varying amounts of intravenous sedation. In a Cochrane review in 2003, it was concluded that there is no evidence to suggest a shortened fluid fast results in increased risk of aspiration or related morbidity compared with the traditional ‘nil by mouth from midnight’ policy for patients undergoing GA.2 Although there have been some recent small studies on fasting, the evidence base to determine the optimal period of preprocedural fasting has been exceedingly slow to develop. Recent European anaesthetic guidelines have recommended clear fluid intake to be continued for up to 2 h prior to GA.3 Similar recommendations have been made by the Association of Anaesthetists of Great Britain and Ireland and the American Society of Anaesthesiologists. There are no consensus guidelines on the optimal period of fasting required prior to Heart July 2014 Vol 100 No 13
the wide spectrum of invasive cardiac procedures that may involve local anaesthetic, conscious sedation or GA. This probably reflects the poor evidence base. As a result, practice is largely based on often poorly referenced local guidelines that differ between institutions. It is incredible how, within a specialty as evidence-based as cardiology, we have managed to accumulate such little evidence on appropriate fasting (indeed if at all needed) prior to any cardiac procedure. The study by Hamid et al is refreshing; however, a more robust evidence base would be crucial to (1) establish best practice and (2) promote consistency of such practice within the cardiology community. Is there any rationale in advising patients to fast at all prior to cardiac procedures under local anaesthetic (eg, diagnostic left and right heart catheterisation or implantation of a loop recorder) where there is a negligible risk of complication involving peri-procedural intubation? How long should patients fast prior to cardiac procedures such as pacemaker implantation or lead revision under conscious sedation (if at all)? There is a crucial and ever-pressing need for well-designed, multicentre prospective randomised controlled trials and engagement within the international cardiology community to attempt to address these questions.
REFERENCES 1
2
3
Hamid T, Aleem Q, Lau Y, et al. Pre-procedural fasting for coronary interventions: is it time to change practice? Heart 2014;100:658–61. Brady M, Kinn S, Stuart P. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev 2003;(4):CD004423. Smith I, Kranke P, Murat I, et al. Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 2011;28:556–69.
Yanushi Dullewe Wijeyeratne,1 Renate Wendler,2 Dominic Spray,2 Nick Bunce3 1
Cardiovascular and Cell Sciences Research Institute, St George’s University of London, London, UK 2 Division of Anaesthesia, St George’s Hospital, London, UK 3 Department of Cardiology, St George’s Hospital, London, UK Correspondence to Dr Yanushi Dullewe Wijeyeratne, Department of Cardiology, St George’s Hospital and St George’s University of London, London, UK, SW17 0RE: [email protected] Contributors All authors contributed substantially to the letter. Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed.
To cite Wijeyeratne YD, Wendler R, Spray D, et al. Heart 2014;100:1065.
▸ http://dx.doi.org/10.1136/heartjnl-2013-305289 Heart 2014;100:1065. doi:10.1136/heartjnl-2014-305911
1065
Downloaded from http://heart.bmj.com/ on December 6, 2014 - Published by group.bmj.com
Preprocedural fasting for coronary interventions: is it time to change practice? Yanushi Dullewe Wijeyeratne, Renate Wendler, Dominic Spray and Nick Bunce Heart 2014 100: 1065 originally published online April 17, 2014
doi: 10.1136/heartjnl-2014-305911 Updated information and services can be found at: http://heart.bmj.com/content/100/13/1065.1
These include:
References Email alerting service
This article cites 2 articles, 1 of which you can access for free at: http://heart.bmj.com/content/100/13/1065.1#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
PostScript
CORRESPONDENCES
Preprocedural fasting for coronary interventions: is it time to change practice? Dear Editor, Patients undergoing invasive cardiac procedures are routinely fasted for varying periods of time even though there is no clearly applicable evidence base to support current practices. We read with great interest the study by Hamid et al1 exploring the occurrence of emergency endotracheal intubation and peri-procedural aspiration pneumonia following elective and planned inpatient percutaneous coronary intervention (PCI) in their practice. This is the first published study in the peer-reviewed literature that specifically addresses the issue of fasting prior to any cardiac procedure. Considering that it involved retrospective analysis of existing data, the wider applicability of the results may be limited, but their paper would crucially serve to raise awareness among the profession on this issue. The custom of fasting patients prior to cardiac procedures appears to have evolved from fasting guidelines for general anaesthesia (GA) in the operating theatre. Induction of GA results in depression of cough and swallow reflexes, which can predispose individuals to aspiration of gastric contents. There is a theoretical risk that conscious sedation may depress the cough and swallow reflexes similar to GA. It is interesting to read that the cardiology teams at the authors’ host institutions have ‘abandoned’ the non-evidence-based practice of fasting patients prior to PCI and observed no adverse patient outcomes, although these patients had varying amounts of intravenous sedation. In a Cochrane review in 2003, it was concluded that there is no evidence to suggest a shortened fluid fast results in increased risk of aspiration or related morbidity compared with the traditional ‘nil by mouth from midnight’ policy for patients undergoing GA.2 Although there have been some recent small studies on fasting, the evidence base to determine the optimal period of preprocedural fasting has been exceedingly slow to develop. Recent European anaesthetic guidelines have recommended clear fluid intake to be continued for up to 2 h prior to GA.3 Similar recommendations have been made by the Association of Anaesthetists of Great Britain and Ireland and the American Society of Anaesthesiologists. There are no consensus guidelines on the optimal period of fasting required prior to Heart July 2014 Vol 100 No 13
the wide spectrum of invasive cardiac procedures that may involve local anaesthetic, conscious sedation or GA. This probably reflects the poor evidence base. As a result, practice is largely based on often poorly referenced local guidelines that differ between institutions. It is incredible how, within a specialty as evidence-based as cardiology, we have managed to accumulate such little evidence on appropriate fasting (indeed if at all needed) prior to any cardiac procedure. The study by Hamid et al is refreshing; however, a more robust evidence base would be crucial to (1) establish best practice and (2) promote consistency of such practice within the cardiology community. Is there any rationale in advising patients to fast at all prior to cardiac procedures under local anaesthetic (eg, diagnostic left and right heart catheterisation or implantation of a loop recorder) where there is a negligible risk of complication involving peri-procedural intubation? How long should patients fast prior to cardiac procedures such as pacemaker implantation or lead revision under conscious sedation (if at all)? There is a crucial and ever-pressing need for well-designed, multicentre prospective randomised controlled trials and engagement within the international cardiology community to attempt to address these questions.
REFERENCES 1
2
3
Hamid T, Aleem Q, Lau Y, et al. Pre-procedural fasting for coronary interventions: is it time to change practice? Heart 2014;100:658–61. Brady M, Kinn S, Stuart P. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev 2003;(4):CD004423. Smith I, Kranke P, Murat I, et al. Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 2011;28:556–69.
Yanushi Dullewe Wijeyeratne,1 Renate Wendler,2 Dominic Spray,2 Nick Bunce3 1
Cardiovascular and Cell Sciences Research Institute, St George’s University of London, London, UK 2 Division of Anaesthesia, St George’s Hospital, London, UK 3 Department of Cardiology, St George’s Hospital, London, UK Correspondence to Dr Yanushi Dullewe Wijeyeratne, Department of Cardiology, St George’s Hospital and St George’s University of London, London, UK, SW17 0RE: [email protected] Contributors All authors contributed substantially to the letter. Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed.
To cite Wijeyeratne YD, Wendler R, Spray D, et al. Heart 2014;100:1065.
▸ http://dx.doi.org/10.1136/heartjnl-2013-305289 Heart 2014;100:1065. doi:10.1136/heartjnl-2014-305911
1065
Downloaded from http://heart.bmj.com/ on December 6, 2014 - Published by group.bmj.com
Preprocedural fasting for coronary interventions: is it time to change practice? Yanushi Dullewe Wijeyeratne, Renate Wendler, Dominic Spray and Nick Bunce Heart 2014 100: 1065 originally published online April 17, 2014
doi: 10.1136/heartjnl-2014-305911 Updated information and services can be found at: http://heart.bmj.com/content/100/13/1065.1
These include:
References Email alerting service
This article cites 2 articles, 1 of which you can access for free at: http://heart.bmj.com/content/100/13/1065.1#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
