Pre-Operative Fasting in Nursing Practice - Literature review Example

? Preoperative fasting Preoperative fasting Preoperative fasting Introduction. Strict fasting regimens had been instituted for the past seventy yearsprior to elective surgery after Mendelson discovered that pulmonary aspiration was a fatal complication resulting from the intake of food prior to surgery. Patients were then not allowed to take anything by mouth from midnight before surgery. The period of pre-operative fasting or starvation of adequate length was found necessary when surgery was under general anaesthesia or regional anaethesia to prevent the regurgitation of stomach contents into the lungs causing the chemical pneumonia. The pathophysiological basis of the aspiration pneumonia was the aspiration of acidic stomach contents into the lungs and the consequent harmful damage to the lung tissues known as chemical pneumonia. As the years went by, the innovative techniques of anaesthesia including the endotracheal intubation led to rethinking on the duration of fasting times. Frequent discussion and research led to the Guidelines from the Royal College of Anaesthetists, the Royal College of Nurses and the Anaesthetists of the US: they stipulated specific periods for fasting for worldwide use (AAGBI, 2001; RCN, 2005; ASA Practice guidelines, 1999). The guidelines sanctioned the shortening of the pre-operative fasting durations but the message was not taken in the right spirit by the nurses and the patients did not enjoy the benefit. The nurses were the ones who instructed the patients about the fasting. Promotion of evidence-based fasting times was to be enforced by them (Crenshaw, 2008). They also had to monitor the patient’s compliance. The scientific evidence related to the liberalized fasting times were to be initially understood by the nurses themselves before efficacious implementation. Research indicated many fallacies in the system whereby fasting practices were still not conforming to the guidelines. Medication instructions also were not accurately transferred to patients (Crenshaw, 2008). Recent researches were moving away from the strict fasting regimen to a partial fasting method whereby a carbohydrate drink or oral carbohydrate nutrients were administered to improve the outcomes of surgery. The nurses were the ones who actually conveyed the right information about the fasting to the patients. The role of the nurses also involved the promoting of evidenced-based guidelines apart from monitoring the patients to check for compliance and untoward effects (Crenshaw and Winslow, 2006).This paper will be written with the intention of unearthing evidence suitable to provide more alterations in the implementation of pre-operative fasting or partial fasting to conform to the evidence-based guidelines. The aim of this research will be to search for methods that could ensure that the elective surgery patients had the benefit of shorter pre-operative fasting times as per guidelines and the improved outcomes of having the pre-carbohydrate drink and how the nurses were to be encouraged to conscientiously perform their work where the pre-operative fasting was concerned. Review of RCTs Brady et al (2003) studied 22 randomised control trials or quasi RCTs. Healthy patients were included as the controls. Permitted intake of food was a small breakfast in the morning before surgery posted for the afternoon. Liquid intake was limited to not more than 30 ml. to help swallow medicine. Methodological quality was maintained by the randomisation method. “Allocation concealment, blinding, a prior sample size calculation, and whether analysis was by intention to treat” were additional methods of maintaining quality (Brady et al, 2003). Regurgitation and aspiration were complications just after the surgery and death was a possibility in many trials. The review of the research articles revealed some limitations. The RCTs were mostly small sampled trials with less than 100 patients. The quality of methodology was inadequate in some trials. The variety in the populations too was minimal and the samples were mostly healthy adults and non-pregnant ladies. The synthesis of the data obtained was therefore not possible (Brady et al, 2003). Brady concluded that the provision of fluids 1.5 to 3 hours pre-operatively did not possess a greater risk than those who fasted as usual for aspiration to occur. This supported the guidelines. The review was thus helpful to the theatre nurses. They could allow patients to have clear fluids 1.5 hours before surgery. Limitations were that some studies focussed on highlighting insignificant features while ignoring the perioperative complications which were more important. There were hardly any studies focusing on the at-risk populations including obstetric cases, diabetic patients or obese patients or those with the gastro-oesophageal reflux or having emergency surgery (H. Power in Brady et al, 2003). The critical values for the risk of patients were not assessed: this could be due to the risk of aspiration in such an attempt. Brady was thus unable to provide recommendations for patients-at-risk following the review. Future research had to focus on peri-operative complications and the at-risk populations of obstetric cases, diabetic patients or obese patients or those with the gastro-oesophageal reflux or having emergency surgery. Attempts needed to be made to estimate the critical values with reservations. A review research Oshodi had reviewed literature pertaining to the various aspects of pre-operative fasting (2004). Significant key points were noted. Fasting from midnight prior to surgery was the accepted traditional practice. The fasting was interpreted as being done for the better theatre management. The implementation of research findings and lack of guidelines were thought to be the barriers for not practicing evidence-based pre-operative fasting (Oshodi, 2004). Review had indicated that clear fluids 3 hours before and a light breakfast 6 hours before anaesthesia increased the patient’s comfort. Nurses were duty-bound to provide evidenced-based practices. Oshodi’s review proposed several recommendations for improvement in implementation of shorter fasting periods by guidelines. Research had to identify factors or barriers to the right implementation of practice (Oshodi, 2004). Research could also identify the methods to overcome the barriers. Audit of the pre-operative fasting times was a good suggestion for frequent evaluation which also kept nurses on their toes for the practice (Oshodi, 2008). Where guidelines were not instituted, the nurses had to feel empowered to discuss with the surgeon on the issue and decide on certain policies of fasting duration. Close collaboration with the surgeon and anaesthetist could provide information on cancellations and decision on who was next to start the fast (Oshodi, 2004). Ongoing education was essential to provide the ward nurse sufficient information on the fasting times and the imparting of necessary information to the patients. Oshodi indicated that NICE had a responsibility to make guidelines for pre-operative fasting. Oshodi’s research had produced many ideas to improve the situation for nursing. Study of pre-operative fasting in different centres Adult surgical patients who were posted for elective surgery were investigated from five operating theatres (Khoyratty, 2010). The 200 patients provided information on when they had the last fluid and solid intake before surgery and how they attained the information as to when to start their fast. Questioning was done before they had their anaesthesia. The surgeries done were “breast, endocrine, colorectal, upper gastro-intestinal, hepatobiliary and urological operations” (Khoyratty, 2010). This study found that hunger and thirst worsened the stress of the patients. This study had findings which differed widely from the recommendations of guidelines. The findings were that fluid was to be last taken 8 hours before surgery and food 12 hours before. The older studies had these findings (Maclean and Renwick, 1993). This was in contrast to the findings of various researchers who reported that consumption of fluids 2 hours prior to surgery decreased vomiting after surgery and adverse events were also not increased by their findings in comparison to patients who were starved (Adanir et al 2008, Adudu 2008, Meisner et al 2008). The procedure of providing drinks elicited subjective feelings of well-being around the time of surgery and after (Bopp et al, 2009). Improved communications verbal and written could reduce the fasting times. Future research could investigate the difference in fasting times following verbal and written communications and the result of using both in the patients. Semi-structured interviews The participants in Baril and Portman’s study were the anaesthesiologists, registered nurses and the surgical patients (2007). Patient fasting was 12-14 hours (Baril and Portman, 2007). The study revealed that practitioners were doubtful about patient compliance of duration of fasting. They were not confident on who was responsible for instructing patients. Patients did not fully know the rationale of the fasting. Practitioners were not sure about the hospital policy on pre-operative fasting (Baril and Portman, 2007). They believed that patients could be confused when new instructions on drinking of clear fluids before surgery was advised. Three themes identified were perceptions, safety concerns and knowledge. Anaesthetists’ perception was that the patients did not have enough knowledge and could make mistakes about timing. Nurses perceived that patients could not have understood instructions or they were not given proper ones. Anaesthetists and nurses both believed that patients did not comply with instructions and could cause postponement of surgery (Baril and Portman, 2007). Anaesthesia care providers thought that if patients were to strictly follow timings, a change of schedule could mess things up because the next patient would not have fasted for the minimum time. As cancellations and rescheduling occurred 15% of the time, strict short regimens could play foul. The hospital policy made concessions for pregnant ladies only at the moment of research (Baril and Portman, 2007). Safety concerns were not taken care of by most patients as believed by the anaesthesia care providers and nurses. However they knew that the anaesthesia and full stomach did not go together. The rationale for fasting was understood by 82% of patients. This was not in line with the perceptions of the anaesthesia care providers and nurses. Eight percent of anaesthesia care providers and 66% of nurses could articulate the hospital policy while 13% of nurses and 16 % of anaesthesia care providers knew the ASA guidelines (Baril and Portman, 2007). The limitation of the study was that it was done in a single small centre and so could not be generalized. Research was necessary to understand the compliance of the policy by patients and the change in the surgical schedule following the policy change (Baril and Portman, 2007). Study could also be done for determining the relationships of fasting times and symptoms of headache, nausea, vomiting and dehydration. Quality improvement project Crenshaw and Winslow performed a quality improvement project in 2008 as a follow-up to an earlier study of 2000 (2008). The following was the background on which the researchers conducted their project. Patients had been unnecessarily liquid-fasting for nine and ten hours while guidelines had proposed a maximum period of 4 hours. The patients, who reported that nurses also gave them the instructions, came to 63% of the investigated population. 32% indicated that only nurses gave the instructions. Due to lack of instructions patients had not taken medications while fasting because they were not sure whether they could take them (Crenshaw and Winslow, 2008). Crenshaw and Winslow had implemented an earlier effort to improve the newer practices in pre-operative fasting. Following the study in 2000, a policy had been implemented in 2002 by their Medical Board (Crenshaw and Winslow, 2008). The Nurses Conference in Texas discussed the subject, several articles were published and newsletters and flyers had been distributed. Their aim for the quality improvement project was to investigate whether practices of pre-operative fasting had improved after the implementation of an evidence-based policy and educational efforts for the health care professionals at one centre (Crenshaw and Winslow, 2008). Fifteen nurses collected data from 275 patients (Crenshaw and Winslow, 2008). The tool was a modified version of the tool used earlier in Crenshaw’s studies. The validity or reliability had not been mentioned. Data analysis used SPSS version 15.0 (Statistical Package for Social Sciences, version 15.0, 2006) and MS Excel 2002 statistical functions. Chi test and chi square were used to test for independent samples of the 2000 and 2004 populations. Implications for nursing practice (Crenshaw and Winslow, 2008) It was found that nurses had not changed their practices after the educational efforts as reported earlier by Bosse et al (2006). They said that nurses were reluctant to alter their practices. The problem could exist all over the world (Shime et al, 2005). People were still having unnecessarily long fasting periods before surgery. Fluids were not allowed for nine hours while guidelines allowed a minimum of 2 hours. This large discrepancy had to be corrected. Resistance to change was the problem (Crenshaw and Winslow, 2008). Fasting instructions needed to distinguish between fluids and solids. Afternoon surgery patients could have a small breakfast on the day of surgery. Prolonged fasting produced adverse effects (Crenshaw and Winslow, 2008). Frequent evaluation of fasting was necessary to ensure that beneficial changes were occurring in the nurses who provided the advice on pre-operative fasting. The staff too could get motivated with the frequency of evaluation. The inclusion of all health personnel and the families in the waiting room in the evaluation process could provide reliable information on the status of pre-operative fasting. Education of consumers was another possible concept. Nurses could have reminders of the fasting times printed in posters where they work (Crenshaw and Winslow, 2008). The figures 2-4-6-8 could stand for the 2 hours for clear liquids, 4 hours for breast milk, 6 hours for milk or a light meal and 8 hours for a regular meal, all pre-operative fasting durations. The conclusion was disappointing in that patients and their carers were having a long duration of fasting prior to elective surgery in spite of the interventions. It was probably due to nurses’ resistance to change (Crenshaw and Winslow, 2008). The reasons for the barriers were attributed to “political, organizational, financial, cultural, and scientific interests”. However there was one significant improvement: more patients were being advised on the evidence-based practices of pre-operative fasting and medications to be taken by nurses. More information will be obtained on proceeding with further research. Future research needed to focus on instructions for clear fluids at least. Pre-operative carbohydrate loading-Randomised controlled trial Fasting produced alterations in the glucose, protein and fat metabolism causing a decreased sensitivity of insulin postoperatively (Shanley, 2009). The consequences were a good surgical outcome and better patient recovery. Shanley reviewed evidence regarding the loading of carbohydrate prior to surgery. He considered the post-operative complications, patient well-being and duration of hospital stay. The selected 13 randomised controlled trials showed good outcomes after a pre-carbohydrate load. Samples varied from 12 to 252 in the trials. Nine trials had a placebo group and 6 had a control group for comparison. All the studies reported outcomes relating to clinical features, metabolism and nutrition (Shanley, 2009). A pre-operative loading was found to decrease the insulin resistance. This research had limitations in that the studies were small. Statistical evidence had not been reached for duration of stay, reduced loss of lean muscle mass and patient well-being. Future research could have a meta-analysis which could provide more answers. Statistical evidence also needed to be found for duration of stay, reduced loss of lean muscle mass and patient well-being (Shanley, 2009). Two doses of carbohydrate loading Hendry et al administered more carbohydrates prior to surgery (2008). One more dose of carbohydrate 400 ml and some oral nutrient supplements were given on the day prior to the surgery. This pre-operative conditioning helped the patients to enter the operation theatre in the fed state. The carbohydrate fluid loading diminished the hyperglycemia of the post-operative period and helped the recovery (Yuill et al, 2005). Decreased post-operative insulin resistance led to a better postoperative outcome as reported in Dahlin’s study of 2009. Patients were undergoing elective colon surgery or rectal resection. Mechanical bowel preparation (MBP) was also commonly done (Nygren, 2005). The benefit of MBP had been questioned (Bucher et al, 2004) and now it was left to the surgeon to decide (Lassen et al, 2005). Only 110 out of 147 patients selected could be given the preoperative carbohydrate loading in the study. The nurse was in charge of administering the oral supplements and drinks (Fearon et al, 2005). Compliance with pre-operative loading and oral nutritional supplements was found in 74% of patients (Hendry et al, 2008). This study also confirmed that supplemental oral nutrients and the carbohydrate overloading together produced a good level of compliance. Following the mechanical bowel preparation, solids could not be given, hence the extra oral nutrient supplementation and carbohydrate overload in the pre-operative period for colon or rectal surgery. The post-operative insulin resistance was decreased by the drink given 2 hours prior to anaesthesia. The 800 ml. drink on the evening before did not do this or improved the metabolic status (Swanfeldt et al, 2005, Hendry et al, 2008). Prolonged fasting would increase the post-operative insulin resistance and hinder the favourable outcomes in turn. The pre-loading carbohydrate drink could overturn the unfavourable outcomes of prolonged fasting. Future research in different centres was necessary to prove that carbohydrate loading was indeed useful in improving the outcome of surgery. Quality of life and the carbohydrate drink The incidence for aspiration pneumonia did not change when the fasting time was reduced to 2 hours prior to anaesthesia induction and this was in total agreement with the guidelines (Maltby, 2006; Dahlin and Ljungberg, 2009). The role of energy in the peri-operative period and the post-operative period was significant (Svanfeldt et al., 2007; Dahlin and Ljungberg, 2009). Dahlin and Ljungberg (2009) believed that the energy-providing pre-operative carbohydrate drink could decrease the duration of hospitalisation. It could also facilitate the drinking of more fluids on the first postoperative day which in turn could facilitate the rapid emptying of the gastrointestinal tract and allow the quick return to work (Dahlin and Ljungberg, 2009). Patients who had open radical nephrectomy or prostatectomy were participants. Random assignment of the 170 patients to the treatment group and the control group was done. The control group went through the usual routine of the fasting. The treatment group was given 800 ml of Nutricia which had 12.6% of carbohydrates in the evening on the pre-operative day. Two hours before surgery another 400 ml. were given. Worry reduced and total health improved in the treatment group of radical prostatectomy patients. Total quality of life also indicated improvement but after 1 month, the quality-of-life variables were worse (Dahlin and Ljungberg, 2009). The nephrectomy patients showed a lesser impairment in the quality of life variables. Weight loss was found in both groups after a month but the difference was lesser in the nephrectomy group. Age, sex, gender and stages were not influenced. The element of worry was positively less for all patients. The other factors like hospitalization time, emptying of the gut and postoperative drinking were not influenced. Rapid recovery after surgery could be helped if the metabolic alterations were handled well. Other studies had reported the reduction of postoperative hospitalization period and earlier recoupment of the gut functions (Noblett et al, 2006). The pre-carbohydrate drink showed a reduction in 3 factors of quality of life after nephrectomy in the post-operative period: worry, tension and social activities. Weight loss was also lesser. No improvements were evident in post-operative drinking, hospital stay or a return to normal. Future research for investigating the role of the pre-operative carbohydrate in urology surgery and other surgeries need to be repeated to determine how they affected quality of life in the post-operative period. Summary The scope and requirement for future research was collected from the literature review. It was evident that strict pre-operative fasting regimens were now being replaced by carbohydrate loading in the form of drinks or oral nutrients before surgery. Another significant point suggested was the importance of the nursing profession in transferring messages of import to the population. Whatever the method, the aim was to improve outcome of surgery and anesthesia and not have aspiration incidences into the bargain and nurses were to convey the information and ensure the implementation of altered health care policies. This summary contains the ideas expressed in the various reports for future research. Pre-operative fasting researches had to focus on peri-operative complications in the at-risk populations of obstetric cases, diabetic patients or obese patients or those with the gastro-oesophageal reflux or having emergency surgery so that more information was available for the pre-operative fasting of these patients (Brady, 2003). Attempts needed to be made to estimate the critical values with reservations. Research had to identify factors or barriers to the right implementation of practice and also the methods to overcome them (Oshodi, 2008). Audit of the pre-operative fasting times was a good suggestion for frequent evaluation which also kept nurses on their toes for the practice (Oshodi, 2008). The compliance of the policy by patients and the change in the surgical schedule following the policy change was to be studied (Baril and Portman, 2007). Study could also be done for determining the relationships of fasting times and symptoms of headache, nausea, vomiting and dehydration. The implications for nursing practice by Crenshaw and Wilson (2008) had useful instructions for nursing. Barriers for evidence-based practices were to be identified and corrected. Future research could have a meta-analysis which could provide more answers than a review (Crenshaw and Wilson, 2008). Statistical evidence needed to be found for duration of stay, reduced loss of lean muscle mass and patient well-being following the pre-operative carbohydrate drink (Shanley, 2009). Research in different centres was necessary to prove that carbohydrate loading was indeed useful in improving the outcome of surgery when compared to strict pre-operative fasting (Hendry et al, 2008). The difference in fasting times following verbal and written communications and the result of using both in the patients remains to be investigated (Khoyratty, 2010). The research on the role of the pre-operative carbohydrate drink in urology surgery and other surgeries needs to be repeated to determine how they affected quality of life in the post-operative period (Dahlin and Ljungberg, 2009). The role of the nurses involved in the promotion of evidenced-based guidelines, apart from monitoring the patients to check for compliance and untoward effects, was significant (Crenshaw and Winslow, 2008). Conclusion Several concepts were obtained from the search. One was that only significant issues were to be studied. The main concept of pre-operative fasting was to be compared to the carbohydrate drink which was now advocated by many researchers. The concept of the fasting was to obtain a good post-surgical outcome and prevent aspiration complications. If the carbohydrate drink, which made the patients feel better during the peri-operative period, could produce a favourable surgical outcome with no complications in this period, it could very well be used. However more research was needed to be done before an alteration in anaesthetic policy was possible. The plight of the patients at-risk were also to be confirmed as to whether they could be allowed to fast or to take a drink which could be useful for their physical and mental well-being in the peri-operative period. For diabetics, it could be some other drink which did not enhance their diabetes. Future research will hopefully change the policy of fasting and progress to the carbohydrate drink or some other nourishment during the peri-operative period. Ways would also be found for speedy implementation of altered health policies through the nursing profession. References: Association of Anaesthetists of Great Britain and Ireland 2001 Pre-operative Assessment: the role of the anaesthetist London, AAGBI Adanir T, Aksun M. Ozgurbuz U. Altin F. Sencan A 2008 Does preoperative hydration affect postoperative nausea and vomiting? A randomized, controlled trial Journal of Laparoendoscopic & Advanced Surgical Techniques trial Part A 18 (1) 1-4 Adudu OP, Egwakhide EO. Adudu OG 2008 Parents and patients' compliance to revised preoperative fasting guidelines in Benin Nigeria Paediatric Anaesthesia 18 (10) 1013-4 Aylott S, Mercer L, Shaw C 2004 Nutritional support. In Dougherty L, Lister S (Eds) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Sixth edition. Blackwell,Oxford, 420-441. Bopp, C; Hofer, S, Klein, A, Weigand, MA. Martin, E, Gust, R 2009 A liberal preoperative fasting regimen improves patient comfort and satisfaction with anesthesia care in day-stay minor surgery Minerva Anestesiologica (in press) Bosse G, Breuer JP, Spies C. 2006 the resistance to changing guidelines—what are the challenges and how to meet them. Best Pract Res Clin Anaesthesiol.2006; 20(3):379-395. Brady, M, Kinn, S, Stuart P 2003 Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev ;(4):CD004423 (latest version 27 Aug 2003). Bucher P, Mermillod B, Gervaz P, Morel P. 2004 Mechanical bowel preparation for elective colorectal surgery: a metaanalysis. Arch Surg 2004; 139: 1359–64. Corcoran L (2005) Nutrition and hydration tips for stroke patients with dysphagia. Nursing Times. 101, 48, 24-27 Crenshaw JT, Winslow EH. 2006 Actual versus instructed fasting times and associated discomforts in women having scheduled cesarean birth. Obstet Gynecol Neonatal Nurs. 2006;35(2):257-264. Crenshaw JT, Winslow EH. 2008 Preoperative Fasting Duration and Medication Instruction: Are We Improving? AORN, vol. 88. no. 6 AORN Inc. Dahlin, B and Ljungberg, B. 2009. Preoperative carbohydrate drink improves postoperative quality of life after urological surgery: a randomized study. International Journal of Urological Nursing Vol 3 No 2. BAUN & Blackwell Publishing Ltd, Farooq, M, Tan, K and Crowe, S. 2008. Fasting times in caregivers of children presenting for ambulatory surgery. Pediatric Anesthesia 18: 820–822 doi:10.1111/j.1460-9592.2008.02654.x Fearon KC, Ljungqvist O, von Meyenfeldt MF et al. 2005 Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 2005; 24: 466–77. Hendry, PO, Balfour, A , Potter, MA, Mander, BJ, Bartolo, DCC, Anderson, DN, Fearon, KCH 2008 Preoperative conditioning with oral carbohydrate loading and oral nutritional supplements can be combined with mechanical bowel preparation prior to elective colorectal resection Colorectal Disease, 10, 907–910. Hughes, E 2004 Understanding the care of patients with acute pancreatitis. Nursing Standard 18,18, 45-52. Hughes E 2005 Caring for the patient with an intestinal obstruction. Nursing Standard. 19, 47 56-64. Khoyratty, S, Modi, BN, Ravichandran, D 2010 Preoperative starvation in elective general surgery. Journal of Perioperative Practice, vol.20 no. 2 Klemetti, S and Suominen, T 2008 Fasting in paediatric ambulatory surgery. International Journal of Nursing Practice 2008; 14: 47–56 Blackwell Publishing Asia Pty Ltd Klemetti, S, Kinnunen, I, Suominen, T, Antila, H, Vahlberg, T, Grennan, R et al 2010 The effect of preoperative fasting on postoperative thirst, hunger and oral intake in paediatric ambulatory tonsillectomy. Journal of Clinical Nursing, 19, 341–350 Blackwell Publishing Ltd, Lassen K, Hannemann P, Ljungqvist O et al. 2005 Patterns in current perioperative practice: survey of colorectal surgeons in five northern European countries. BMJ 2005; 330: 1420–21 Leiper, JB, Molla, AM, Molla, AM. 2003 Effects on health of fluid restriction during fasting in Ramadan. Eur J Clin Nutr 2003; 57: S30–S38. Maclean AR, Renwick C 1993 Audit of pre-operative starvation Anaesthesia 48 (2) 164-6 Maltby JR. 2006 Preoperative fasting guidelines. Canadian Journal of Surgery; 49: 138–139. Meisner, M, Emhofer, U. Schmidt, J 2008 Liberalisation of preoperative fasting guidelines: effects on patient comfort and clinical practicability during elective laparoscopic surgery of the lower abdomen Zentrablatt fur Chirur|; ie 133 (5) 479-85 Mendelson CL. The aspiration of stomach contents into the lungs during obstetric anesthesia. 1946 Amer J Obstet Gynecol. 1946;52:191-205. Noblett SE, Watson DS, Huong H, Davison B, Hainsworth PJ, Horgan AF 2006 Pre-operative oral carbohydrate loading in colorectal surgery: a randomised controlled trial. Colorectal Disease; 8: 563–569. Nygren J, Hausel J, Kehlet H et al. A comparison in five European centres of case mix, clinical management and outcomes following either conventional or fast-track perioperative care in colorectal surgery. Clin Nutr 2005; 24: 455–61. Oshodi, T.O. 2004 Clinical skills: an evidence-based approach to preoperative fasting British Journal of Nursing, Vol 13, No 16. Parish, C 2005 New guidelines give welcome drink to pre-operative patients Nursing Standard, vol 20 no 2: 2005 pp11 Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration, 2010. A report by the American Society of Anaesthesiologists, Slideshare. http://www.slideshare.net/anestesiasegura/guidellines-broncoaspirao. Royal College of Nursing 2005 Perioperative fasting in adults and children. Practice guideline London. RCN Available from: www.rcn.org.uk/pubiications/pdf/guidelines/ Shime N, Ono A, Chihara E, Tanaka Y 2005 Current practice of preoperative fasting: a nationwide survey in Japanese anesthesia-teaching hospitals, JAnesth. 2005;19(3):187-192, Statistical Package for Social Sciences, version 15.0, 2006 Chicago, IL: SPSS; 2006. Svanfeldt M, Thorell A, Hausel J, Soop M, Rooyackers O, Nygren J, Ljungqvist O 2007 Randomised clinical trial of the effect of preoperative oral carbohydrate treatment on postoperative whole-body protein and glucose kinetics. The British Journal of Surgery; 11: 1342–1350. Svanfeldt M, Thorell A, Hausel J et al 2005 Effect of ‘‘preoperative’’ oral carbohydrate treatment on insulin action – a randomised cross-over unblinded study in healthy subjects. Clin Nutr 2005; 24: 815–21. Turner, B 2004 Management of retained foreign bodies and rectal sexual trauma. Nursing Times. 100, 38, 30-32 Whiteing, N and Hunter, J 2008 Nursing management of patients who are nil by mouth Nursing Standard, vol.22 no. 26 pp40-45 Wood, S 2005 Nutrition and the surgical patient. In Pudner R (Ed) Nursing the Surgical Patient Second edition. Elsevier, Oxford, 71-83. Yuill KA, Richardson RA, Davidson HI, Garden OJ, Parks RW. The administration of an oral carbohydrate-containing fluid prior to major elective upper-gastrointestinal surgery preserves skeletal muscle mass postoperatively – a randomized clinical trial. Clin Nutr 2005; 24: 32–7. Read More