Enhanced Recovery Beaumont Anesthesiology
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1 Enhanced Recovery Preoperative Fasting & Carbohydrates Roy Soto, M.D. Professor of Anesthesiology & Residency Director, Beaumont Health System July 2014
2 Preoperative Fasting
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 Implications for NPO after midnight?
4
5 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.
6 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 (?)
7 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.
8 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.
9 Nurses Surgeons CRNAs Anesthesiologists
10 Carbohydrates Preoperative (hours) Preoperative (days)
11 Eat well before surgery
12 Evidence Review CHO drink evening and morning of surgery is better than water Up to 20% reduction in LOS Preop CHO beneficial to all patients undergoing major surgery (ESPEN Grade B) Colorectal, urology, pancreatic, hip/knee No need to avoid in diabetics What is a carbohydrate drink?
13 Iso-osmolar Maltodextrin
14 Nutritional Loading Carbohydrate loading (surgical patient, marathon runner) Maximizes glycogen stores for gluconeogenesis Preoperative malnutrition leads to prolonged length of stay and increased risk of infection Supplementing malnourished patients preoperatively reduces risk
15 Immunonutrition Supplementing non-malnourished patients (elective major GI surgery) reduces infection risk and shortens LOS Carbohydrates, protein, arginine, omega-3 fatty acids Drover. J Am Coll Surg. 2012
16 Infection Risk Drover. J Am Coll Surg. 2012
17 Length of Stay Drover. J Am Coll Surg. 2012
18 Society Guidelines? ASPEN/ESPEN recommendations: all patients undergoing major surgery, regardless of nutritional status What exactly is major surgery?
19 Recommendations Patients undergoing major GI procedures provided with Impact AR drink: 3 times daily for the 5 days before their surgery Patients provided with Clearfast drink: 2 hours before their scheduled surgical arrival time Alternative: CHO drink evening of/morning of Malnourished patients should undergo dietary consultation for continued postoperative supplementation
20 Marketing Jennifer Carbary Nutritionist Barb Main Anesthesiologist Roy Soto Nurse Maureen Cooper Researcher Cynthia Turzewski Librarian Andrea Rogers Snyr Pharmacist Stephanie Rybak ERAS Project Team Surgeon Kenneth Bark Administrator Abrar Founas Service Heather Slanda CRNA Carol Schmidt Physical Therapist Jose Kottoor Anesthesia Pre- Screening Linda Bailey Project Manager Rebekah Kelly Quality Sharon Kelln
Show Me the Evidence
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?
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