Association of a Liberal Fasting Policy of Clear Fluids Before Surgery With Fasting Duration and Patient Well-being and Safety

Abstract

Importance: Current fasting guidelines for procedures under anesthesia are poorly implemented, leading to negative metabolic sequelae. Recent studies in children showed support of liberal clear fluid intake; adult physiology can support clear fluid intake, but implementation studies are lacking.

Objective: To evaluate the successfulness of implementation of a liberal clear fluid policy with regard to fasting duration, well-being, and safety in adults scheduled for anesthesia.

Design, setting, and participants: This was a quality improvement study conducted from January 2016 to July 2021 at a tertiary referral hospital in the Netherlands. Adults scheduled for nonemergency procedures under anesthesia were included in the study. Patients undergoing obstetrics procedures or those who were intubated preoperatively were excluded.

Interventions: Stepwise introduction of a liberal fluid fasting policy, allowing for ingestion of clear fluids until arrival at the operating room.

Main outcomes and measures: The primary outcome was change in fasting duration. Secondary outcomes were patient well-being, measured as preoperative thirst, amount of fluid ingested, postoperative nausea and vomiting (PONV), and administration of antiemetics. Safety was measured as incidence of regurgitation and aspiration (pneumonia).

Results: Of the 76 451 patients (mean [SD] age, 56 [17] years; 39 530 male individuals [52%] 36 921) included in the study, 59 036 (78%) followed the standard policy, and 16 815 (22%) followed the liberal policy. Time series analysis showed an estimated fasting duration decrease of 3:07 hours (IQR, 1:36-7:22; P < .001) after implementation of the liberal policy. Postimplementation median (IQR) fasting duration was 1:20 (0:48-2:24) hours. The incidence of regurgitation changed from 18 (95% CI, 14-21) to 24 (95% CI, 17-32) in 10 000 patients, and the incidence of aspiration changed from 1.7 (95% CI, 0.6-2.7) to 2.4 (95% CI, 0.5-4.7) in 10 000 patients. In the liberal policy, thirst feelings decreased (37% [4982 of 8615] vs 46% [3373 of 7362]; P < .001). PONV incidence decreased from 10.6% (6339 of 59 636) to 9.4% (1587 of 16 815; P < .001) and antiemetic administration decreased from 11.0% (6538 of 59 636) to 9.5% (1592 of 16 815; P < .001).

Conclusions and relevance: Results of this quality improvement study suggest that a liberal fasting policy was associated with a clinically relevant reduction in fasting duration and improved patient well-being with regard to preoperative thirst and PONV. Although a slightly higher incidence of regurgitation could not be ruled out, wider implementation of such a policy may be advocated as results are still within the clinically accepted risks margins. Results suggest that surgical procedures in patients who drink clear fluids within 2 hours before anticipated anesthesia should not be postponed or canceled.

Figure 1.. Autoregressive Integrated Moving Average Models for Observed and Fitted Median Fasting Duration Over Time

The vertical lines denote changes in policy or registration, and these moments were used as predictors. Step 1 (June 2016) is the change in registration forms in the remote locations, leading to better registration of glasses of fluid ingested. Step 2 (February 2017) is the change in registration forms in the operating rooms, leading to better registration of glasses of fluid ingested. Step 3 (June 2019) denotes implementation of the liberal fluid policy in ambulatory surgery (location 1). Step 4 (November 2019) denotes implementation of the liberal fluid policy in the inpatient minor surgery area (location 2). Step 5 (June 2020) denotes implementation of the liberal fluid policy in the inpatient major surgery area (location 3). Step 6 (September 2020) denotes implementation of the liberal fluid policy in the remote locations (location 4). The change in fasting duration over time is shown for total study population (A), location 1 (B), location 2 (C), location 3 (D), and location 4 (E).

Figure 2.. Flowchart With Incidences of Regurgitation, Aspiration, and Aspiration Pneumonia

Figure 3.. Autoregressive Integrated Moving Average Model of Observed and Fitted Values for Secondary Outcomes of Well-being

The vertical lines denote changes in policy or registration and these moments were used as predictors. Step 1 (June 2016) is the change in registration forms in the remote locations, leading to better registration of glasses of fluid ingested. Step 2 (February 2017) is the change in registration forms in the operating rooms, leading to better registration of glasses of fluid ingested. Step 3 (June 2019) denotes implementation of the liberal fluid policy in ambulatory surgery (location 1). Step 4 (November 2019) denotes implementation of the liberal fluid policy in the inpatient minor surgery area (location 2). Step 5 (June 2020) denotes implementation of the liberal fluid policy in the inpatient major surgery area (location 3). Step 6 (September 2020) denotes implementation of the liberal fluid policy in the remote locations (location 4). Depicted over time are the change in postoperative nausea and vomiting (PONV) in the recovery room (A), the change in administration of antiemetics in the recovery room (B), the change in preoperative thirst (C), and the change in percentages of patients who received 1 or more glasses of fluid preoperatively (D).