Show Me the Evidence

Transcription

1 Show Me the Evidence Fasting Guidelines and the Preoperative Carbohydrate Drink Roy Soto, M.D. April 2016 Overview NPO or clears after midnight: Safe? Benefits of hydration? Benefits of carbohydrates? 1

2 Putting it all together Level of Functional Ability Prehabilitation + Enhanced Recovery Traditional PreOp Recovery Surgery Preoperative Fasting 2

3 Are all patients the same? Patient 1: Young healthy male having inguinal hernia repair at 7am Patient 2: Elderly diabetic having sigmoid colectomy at 3pm 3

4 1999 & 2011 Recommendations: Infants, Children, & Adults Recommendations for Clear Liquids. It is appropriate to fast from intake of clear liquids at least 2h before elective procedures requiring general anesthesia, regional anesthesia, or sedation/analgesia. Examples of clear liquids include, but are not limited to, water, fruit juices without pulp, carbonated beverages, clear tea, and black coffee. These liquids should not include alcohol. The volume of liquid ingested is less important than the type of liquid ingested. (Food 6-8hrs, breast milk 4hrs) Guideline Evidence If allowed to drink up until 2hr prior to surgery: Gastric volumes decrease Gastric ph increases No increased risk of regurgitation/aspiration Decreased patient thirst Decreased anxiety Improved patient satisfaction Decreased risk of headache (?) 4

5 Our Old Script Please remember nothing to eat or drink after midnight. That includes water. No gum, hard candy or breath mints If you have been instructed to take medication the morning of your procedure you may do so with a small sip of water. Our New Script Please remember nothing to eat after midnight. Clear liquids, including water, fruit juices (apple and cranberry juice), sports drinks such as Gatorade, carbonated beverages, clear tea, and black coffee are fine up until two hours prior to your scheduled arrival time Milk and thicker drinks are considered food, so none after midnight. October

6 Nurses Surgeons CRNAs Anesthesiologists Does the Type of Fluid Matter? 6

7 7

8 Hyperglycemia: Evidence Review Many of our patients are diabetics Some of our patients don t know they re diabetics Hyperglycemia/IR occurs in non-diabetics Starvation leads to hyperglycemia and IR Hyperglycemia à increased risk of wound infection Wound infections prolong length of stay Wound infections cost money 8

9 CHO/IR: Evidence Review CHO drink evening and morning of surgery prevents starvation state CHO drink morning of surgery prevents development of IR (if enough given) Preop CHO beneficial to all patients undergoing major surgery (ESPEN Grade B) Colorectal, urology, pancreatic, hip/knee May reduce LOS May speed return of bowel function OK with DM, bowel prep What is a carbohydrate drink? Commercially Available CHO? Source: McGill University Dept of Anesthesiology 9

10 Pogatschnik. Nutr Clin Prac Maltodextrin? Synthetic polysaccharide Absorbed as quickly as sucrose Lower osmolarity to deliver same amount of CHO Europe: Nutricia PreOp USA: BevMD ClearFast, SOF Health GED Benefits unclear, but that s where the research is (Especially in the endurance sports literature) 10

11 Summary If you re NPO after midnight you re a dinosaur Fasting after midnight is bad Drinking before surgery is safe and improves care CHO before surgery makes sense and has positive measurable results Which CHO is best is unclear Questions? 11