Nothing by Mouth at Midnight

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.

Evaluating Gaps in Care of Malnourished Patients on General Medicine Floors in an Acute Care Setting

“…Lastly, providing education to all team members and reinforcing updated guidelines that allow for clear liquids (especially carbohydrate-rich) 2-3 hours before anesthesia may help to avoid prolonged fasting. 19 Our initial hypothesis that RDN/MD communication would be a significant gap in care was not consistent with our results. This may be because of significant hospital initiatives, including our malnutrition identification initiative, which allowed us to increase staffing so that RDNs are more visible and involved with the care team.…”

“…In a different meta‐analysis, it was shown that about 50% of the meals held for patients could have been served . Such prolonged perioperative/periprocedure fasting has been shown to increase the risk for complications and is often unnecessary …”

“…It could also be useful to have a live timer in the chart indicating the total number of hours that a patient has remained NPO and perhaps include an electronic reminder that the patient remains NPO, although we acknowledge that such reminders may be overlooked or dismissed over time because of warning fatigue from repeated exposure. Lastly, providing education to all team members and reinforcing updated guidelines that allow for clear liquids (especially carbohydrate‐rich) 2–3 hours before anesthesia may help to avoid prolonged fasting …”

“…18 Such prolonged perioperative/periprocedure fasting has been shown to increase the risk for complications and is often unnecessary. 19,20 In an effort to improve excessive time spent NPO for procedures or testing, we are proposing that physicians be required to document the purpose for NPO status within the patient's order. This would give staff more clarity as to when food could be served postprocedurally.…”