ABSTRACT
Context:
Preoperative fasting is one of the pre-requisite for patients undergoing a surgery. Despite clear instructions, patients frequently fast for extended periods before elective surgeries. Longer periods of fasting may cause discomfort, thirst, hunger, and other physiological problems.
Aims:
To assess the quality of postoperative recovery among adult patients having different preoperative fasting hours by using the postoperative Quality of Recovery40 (QoR40) score.
Settings and Design:
This was an observational study that was conducted for adult patients undergoing elective surgery during four weeks between 19th September and 13th October 2022 at Security Forces Hospital Riyadh, Kingdom of Saudi Arabia.
Methods and Material:
We excluded pediatric patients, patients undergoing spine or neurosurgery, emergency cases, or local anesthesia cases. Non-probability convenient sampling technique was used in this study. The postoperative quality of recovery-40 (QoR-40) questionnaire was distributed among 200 patients.
Statistical Analysis Used:
All analyses were performed with Statistical Package for the Social Sciences software (SPSS) v25. Descriptive statistics (frequency, percentage, median, and IQR) were used for the questionnaire’s variables. The difference between the variables was analyzed using Kruskal-Wallis, and a P value <0.05 was considered statistically significant.
Results:
Out of 200 patients, 172 patients responded but 16 responses were excluded. A total of 156 adult patients’ responses were included in this study. The majority were female (53%), 31% were older than 45 years. More than 50% of patients reported fasting for more than 6 hours for drinking and more than 8 hours for eating. On the positive scale, the comfort score was significantly affected by the fasting hours for drinking (P value = 0.045). On the negative scale of the questionnaire, the emotions were significantly affected by fasting hours for both drinking (P value = 0.027) and eating (P value = 0.043).
Conclusions:
The study results showed better comfort for patients with lesser fasting hours for drinking. Moreover, the results strongly suggest the need of following the fasting guidelines without prolonging the fasting duration. However, further studies with larger sample sizes are recommended.
Keywords: Anesthesia, fasting hours, pulmonary aspiration, quality of recovery, Saudi Arabia
Introduction
Pulmonary aspiration is a rare and undesirable complication of anesthesia and is associated with significant mortality and morbidity postoperatively.[1] Therefore, preoperative patient assessment and preparation include steps to prevent perioperative pulmonary aspiration. There are guidelines available that mainly focus on preoperative fasting duration. These guidelines also mention instructions regarding administering drugs preoperatively to adjust gastric content acidity and volume. The main goal of fasting hours is to prevent the risk of pulmonary aspiration.[2]
The latest update of the American Society of Anesthesiologists (ASA) and other international anesthesia societies recommends a fasting period for at least 6 hours for light meals and 2 hours for clear fluids before any elective surgical procedure.[3] Our hospital also follows 8 hours fasting for meals and 2 hours for water and clear fluids. A common practice for implementing this in many hospitals is to order nil per oral (NPO) from midnight in elective surgeries.[4] These recommendations are then frequently enforced even in situations where surgeries are scheduled later in the day which increases the overall fasting times.[5] Unnecessarily prolonged fasting hours could lead to thirst, hunger, and also patient distress, anxiety, and discomfort.[6] Similarly, it can lead to hypovolemia which causes dehydration and hypoglycemia. Moreover, it can result in insulin resistance that increases the level of insulin in the blood leading to the risk of numerous other postoperative complications as well.[7]
Postoperative quality of recovery has become a significant indicator in recent years, reflecting the performance of the surgeon, anesthesiologist, and the institution where the operation is conducted. It is a multifaceted process of resuming normalcy based on comparisons to pre-illness norms in numerous areas, such as physical, physiological, psychological, social, and economic variables.[8] In surgery, evaluating the relative effect of an emergency or elective operation on the level of postoperative recovery is essential for improved distribution and planning of healthcare resources attempting to improve quality of recovery (QoR). According to Gornall et al.,[9] the quality of recovery-40 (QoR-40) demonstrated sound psychometric properties for evaluating the quality of postoperative recovery. Our study aimed to assess the quality of postoperative recovery among adult patients after having different fasting hours.
Subjects and Methods
This was an observational study that was conducted on adult patients admitted for elective surgery during 4 weeks between 19 September and 13 October 2022 at Riyadh’s Security Force Hospital Program (SFHP). This study was approved by the Security Force Hospital’s institutional review boards (IRB) (code H-01-R-069) IRB Registration Number with KACST. KSA: H-01-R-069 Date: 14 December 2021. The study population included adult patients undergoing elective surgery under general anesthesia. We excluded pediatric patients, patients who underwent spine or neurosurgery, emergency cases, or local anesthesia cases. A total of 200 study questionnaire were distributed to patients. Non-probability convenient sampling technique was used. The questionnaire used a validated scoring system called QoR-40 to collect data regarding the postoperative quality of recovery. The QoR-40 was created and validated in Australia in 2000 to assess the patient-reported outcome, including quality of life.[10] The Arabic version of the QoR-40 was also validated in May 2017.[11]
The questionnaire consists of 5 parts. The first part is a cover letter that contains a consent form. The second part consists of demographic data like age, sex, education level, region, etc. The third part consists of surgery related questions such as type of operation and duration of fasting for liquids and meals. The fourth part consists of the four domains that are considered positive domains and include 4, 3, 5, and 6 items, respectively. The fifth part consists of the four remaining domains that are considered negative domains and include 8, 6, 1, and 7 items, respectively.
The overall score and subscales of the QoR-40 are calculated using a five-point Likert scale (1 = none of the time, 5 = all of the time; for negative questions, the scoring was inverted), and individual scores are added together, with a minimum score of 40 points and a maximum score of 200 points.[10]
The questionnaire was given to a patient who underwent elective surgery under general anesthesia after obtaining informed consent. An iPad was used to view and answer the questionnaire or to scan the barcode by patients. All data were entered and analyzed in SPSS version 25. Descriptive statistics (frequencies, percentages, mean, SD, median, and IQR) were used for the questionnaire’s variables. The Kolmogorov–Smirnov test was used to test the normal distribution. Non-normally distributed data were analyzed using Kruskal-Wallis, and a post hoc analysis with Bonferroni correction was performed. However, we did not perform the paired comparison as there with no significant differences found in the Kruskal-Wallis test. A P value less than 0.05 was considered statistically significant.
Results
The response rate was 86% as we received a total of 172 responses. However, we included 156 in our study. Sixteen patients were excluded from the study; three did not meet the inclusion criteria, three refused to answer, and ten failed to complete the questionnaire. Among 156 patients, 31% were older than 45 years. More than 50% of the patients were female. Less than half of the patients had an education at Bachelor level (42.3%), while smaller proportions had secondary level (32.7%), elementary level (16.0%), and intermediate level (9.0%). Most of these patients belonged to the middle region of Saudi Arabia (76.3%) while about 16% were from the southern region.
The highest percentage of patients underwent General surgery (37.2%) followed by Urology (14.7%), Obstetrics and gynecology (12.2%), and the rest with other specialties. More than half of the patients fasted from drinking for more than 6 hours (55.8%) and about 38.5% patients fasted from drinking for more than 12 hours, while half of the patients fasted from eating for more than 8 hours (50.6%) followed by 43.6% patients who fasted from eating for more than 12 hours.
There was no statistical difference in the total QoR40 scores for patients who had different durations of fasting from drinking and from eating as shown in Table 1. Also, there was no significant difference in positive domains of QoR-40 score due to the difference in total fasting hours from drinking (p > 0.05) as shown in Table 2. Although comfort item was significantly better in the lesser fasting hour groups (p = 0.045). Post hoc comparisons using the Bonferroni correction indicated that the mean rank score for the more than 12 hours fasting (71.1) was significantly different from the patients having more than 2 hours fasting (112.9). Also, there was no significant difference in negative domains of QoR-40 scores due to total fasting hours from drinking (p > 0.05) as shown in Table 2. Although, the emotion item was significantly different in three groups (p = 0.027). Post hoc comparisons using the Bonferroni correction indicated that the mean rank score for the patients with more than 12 hours fasting (68.8) was significantly different from the patients with more than 6 hours fasting (84.0).
Table 1.
Comparison of total QoR40 score according to the total fasting hours from drinking and eating before the operation
| Total fasting hours from drinking | ||||
|---|---|---|---|---|
|
| ||||
| > 2 hours n=7 | > 6 hours n=87 | > 12 hours n=60 | P | |
| Total QoR40 score | 185 (149-192) | 180 (164-190) | 175 (163-192) | 0.971 |
|
| ||||
| Total fasting hours from eating | ||||
|
| ||||
| 6-8 hours n=9 | > 8 hours n=79 | > 12 hours n=68 | P | |
|
| ||||
| Total QoR40 score | 180 (177-184) | 179 (163-190) | 176 (163-193) | 0.824 |
Values represent the median (interquartile range) P value calculated by the Kruskal-Wallis test
Table 2.
QoR-40 scores (Positive and negative domains) according to total fasting hours from drinking before the operation
| All n=156 | >2 n=7 | >6 Hours n=87 | >12 Hours n=62 | P | |
|---|---|---|---|---|---|
| Positive Domains | Median (IQR) | ||||
| Comfort | 17 (14-20) | 20 (19-20) | 18 (14-20) | 16 (14-19) | 0.045* |
| Emotions | 15 (10-15) | 15 (12-15) | 15 (9-15) | 13 (10.5-15) | 0.56 |
| Physical Independence | 23 (18-25) | 25 (21-25) | 23 (18-25) | 23.5 (17-25) | 0.672 |
| Support | 30 (29-30) | 30 (30-30) | 30 (29-30) | 30 (28.7-30) | 0.229 |
| Negative Domains | Median (IQR) | ||||
| Comfort | 36 (32-39) | 38 (33-39) | 37 (32-39) | 34 (28.7-38.2) | 0.167 |
| Emotions | 30 (28-30) | 30 (30-30) | 30 (29-30) | 30 (27-30) | 0.027* |
| Support | 5 (4-5) | 5 (5-5) | 5 (4-5) | 5 (4-5) | 0.511 |
| Pain | 30 (27-32) | 30 (29-33) | 30 (27-32) | 29.5 (26-32.2) | 0.588 |
Values represent the median (interquartile range) P value calculated by the Kruskal-Wallis test. * at P<0.05
There was no statistically significant difference in positive and negative domains of QoR-40 scores due to different fasting hours from eating (p > 0.05) as shown in Table 3. However, only the emotions item was found to be statistically different (p = 0.043). Post hoc comparisons using the Bonferroni correction indicated that the mean rank score for the patients having more than 12 hours fasting from eating (70.2) was significantly different from the patients having more than 8 hours fasting (86.1).
Table 3.
QoR-40 scores (Positive and Negative domains) according to total fasting hours from eating before the operation
| All n=156 | 6-8 Hours n=9 | >8 Hours n=79 | >12 Hours n=68 | P | |
|---|---|---|---|---|---|
| Positive Domains | Median (IQR) | ||||
| Comfort | 17 (14-20) | 13 (10-20) | 18 (14-20) | 17 (14.3-19.8) | 0.617 |
| Emotions | 15 (10-15) | 14 (6-15) | 15 (9-15) | 14.5 (12-15) | 0.711 |
| Physical Independence | 23 (18-25) | 23 (17-24.5) | 23 (16-25) | 24 (20.3-25) | 0.607 |
| Support | 30 (29-30) | 29 (27.5-30) | 30 (29-30) | 30 (29-30) | 0.276 |
| Negative Domains | Median (IQR) | ||||
| Comfort | 36 (32-39) | 34 (32-38) | 37 (32-39) | 35 (29.3-39) | 0.356 |
| Emotions | 30 (28-30) | 30 (28.5-30) | 30 (29-30) | 30 (27-30) | 0.043* |
| Support | 5 (4-5) | 5 (4-5) | 5 (4-5) | 5 (4-5) | 0.994 |
| Pain | 30 (27-32) | 30 (29.5-32) | 30 (26-32) | 30 (27-32.8) | 0.872 |
Values represent the median (interquartile range) P value calculated by the Kruskal-Wallis test
Discussion
This study assessed the quality of postoperative recovery among adult patients after having different fasting hours by using the QoR-40 score.[10,11] According to the findings, more than 50% of the patients reported fasting for more than 6 hours from drinking and more than 8 hours from eating. On the positive scale, the comfort score was significantly affected by the fasting hours from drinking (p = 0.045). The median comfort scores in the positive outcome section were significantly higher in patients with lesser fasting hours from liquids. Similarly, emotions, physical independence, and support scores in positive outcome sections were also higher in patients with lesser fasting hours from liquid, even though these scores did not achieve statistical significance. On the negative scale of the questionnaire, the emotions were significantly affected by fasting hours from drinking (p = 0.027) and eating (p = 0.043). There was no statistical difference in scores of comfort, emotions, physical independence, and support among the three groups with different fasting times for liquid. However, emotion scores were significantly better in the group with lesser fasting times for eating.
A reason for exceeding the recommended fasting time is the surgery schedule. According to a national survey measuring anesthesiologists’ knowledge, attitudes, and current practices of preoperative fasting, only 50% of respondents confirmed that the institution adhered to fasting guidelines. Also, they found that the main reason is the inability to manage the case plan in the operating room and the inadequate knowledge of the ward nurses and surgeons.[12]
Scientific literature showed that healthy persons who drink water or other clear liquids up to two hours before the disorientation stage of anesthesia do not experience an increase in stomach fluid volume or acidity.[13] de Andrade Gagheggi Ravanini et al.[14] demonstrated that shortened fasting while ingesting a carbohydrate and protein solution does not increase the risk of pulmonary complications related to bronco-pulmonary aspiration. Faria et al.[15] randomly assigned adult women undergoing elective laparoscopic cholecystectomy to 200 mL of a carbohydrate beverage containing 12.5% maltodextrin 2 or a brief drink 8 hours prior to surgery. They demonstrated that decreasing preoperative fasting reduced insulin resistance and the body’s natural response to trauma.
Similarly, Çakar et al.[16] showed that consuming 400 ml of oral carbohydrates 2 hours preoperatively can decrease tiredness, headache, nausea, and vomiting. However, Lee et al.[17] found that patients receiving preoperative carbohydrate loading did not significantly improve their preoperative wellbeing or recovery when compared to the control group. Our study found that patients with lesser fasting hours from liquids intake report a better level of comfort regarding breathing and general physical comfort.
Our results showed no statistically significant relationship between the prolonged fasting hours from eating and the negative section of comfort (nausea, vomiting, feeling cold, and dizzy). Although, it was proven in a previous study that patients fasting more than 8 hours complained of nausea and vomiting.[18] Also, it has been reported that longer than recommended preoperative fasting hours are inessential and are have no relationship with improved safety of general anesthesia (GA). Hunger and thirst make patients uncomfortable and increase surgical stress, and excessive hunger may be related to increased postoperative nausea and vomiting.[19]
A better emotional outcome in a positive section of the questionnaire could not be found in our study. This could be due to the inability to assess all the domains in the preoperative period as the questionnaire was only introduced to the patients postoperatively. Therefore, the domains of comfort, emotions, physical independence, and support were not assessed preoperatively. Also, we did not follow up with the patients after an immediate postoperative period. Another limitation of the study was that a new electronic documentation system was started in the hospital setting during the data collection period that led to a smaller number of operation room bookings. Thus, fewer number of patients were included in the study. Also, the short time for data collection resulted in lower sample collection. Lastly, some patients were discharged before we could reach them to fill out the questionnaire. Although, as a strong point, this is the first study conducted in Saudi Arabia to link the QoR-40 scores with the fasting hours before anesthesia. In conclusion, our study found better comfort for patients with lesser fasting hours from drinking. However, we could not prove that the lesser fasting hours from eating improves the quality of recovery. Our results strongly suggest that following the guidelines is highly recommended without prolonging the fasting duration before the surgery.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgement
Mr. Abdullah Alghamdi for his administrative support for data collection.
References
- 1.Nason KS. Acute intraoperative pulmonary aspiration. Thorac Surg Clin. 2015;25:301–7. doi: 10.1016/j.thorsurg.2015.04.011. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Witt L, Lehmann B, Sümpelmann R, Dennhardt N, Beck CE. Quality-improvement project to reduce actual fasting times for fluids and solids before induction of anaesthesia. BMC Anesthesiol. 2021;21:254. doi: 10.1186/s12871-021-01468-6. doi:10.1186/s12871-021-01468-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration:Application to healthy patients undergoing elective procedures:An updated report by the American Society of Anesthesiologists Task Force on preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration. Anesthesiology. 2017;126:376–93. doi: 10.1097/ALN.0000000000001452. [DOI] [PubMed] [Google Scholar]
- 4.Gul A, Andsoy I, Ozkaya B. Preoperative fasting and patients'discomfort. Indian J Surg. 2017;80:549–53. [Google Scholar]
- 5.Gül A, Andsoy II, Üstündağ, Özkaya BÖ. Assessment of preoperative fasting time in elective general surgery. J Macro Trends Health Med. 2013;1:1–8. [Google Scholar]
- 6.Ludwig RB, Paludo J, Fernandes D, Scherer F. Lesser time of preoperative fasting and early postoperative feeding are safe? Arq Bras Cir Dig. 2013;26:54–8. doi: 10.1590/s0102-67202013000100012. [DOI] [PubMed] [Google Scholar]
- 7.Kukliński J, Steckiewicz KP, Sekuła B, Aszkiełowicz A, Owczuk R. The influence of fasting and carbohydrate-enriched drink administration on body water amount and distribution:A volunteer randomized study. Perioper Med (Lond) 2021;10:27. doi: 10.1186/s13741-021-00198-0. doi:10.1186/s13741-021-00198-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Megari K. Quality of life in chronic disease patients. Health Psychol Res. 2013;1:e27. doi: 10.4081/hpr.2013.e27. doi:10.4081/hpr. 2013.e27. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Gornall BF, Myles PS, Smith CL, Burke JA, Leslie K, Pereira MJ, et al. Measurement of quality of recovery using the QoR-40:A quantitative systematic review. Br J Anaesth. 2013;111:161–9. doi: 10.1093/bja/aet014. [DOI] [PubMed] [Google Scholar]
- 10.Myles PS, Weitkamp B, Jones K, Melick J, Hensen S. Validity and reliability of a postoperative quality of recovery score:The QoR-40. Br J Anaesth. 2000;84:11–5. doi: 10.1093/oxfordjournals.bja.a013366. [DOI] [PubMed] [Google Scholar]
- 11.Terkawi AS, Myles PS, Riad W, Nassar S, Mahmoud N, Alkahtani M, et al. Development and validation of Arabic version of the postoperative quality of recovery-40 questionnaire. Saudi J Anaesth. 2017;11(Suppl 1):S40–52. doi: 10.4103/sja.SJA_77_17. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Panjiar P, Kochhar A, Vajifdar H, Bhat K. A prospective survey on knowledge, attitude and current practices of pre-operative fasting amongst anaesthesiologists:A nationwide survey. Indian J Anaesth. 2019;63:350–5. doi: 10.4103/ija.IJA_50_19. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.de Aguilar-Nascimento JE, Dock-Nascimento DB. Reducing preoperative fasting time:A trend based on evidence. World J Gastrointest Surg. 2010;2:57–60. doi: 10.4240/wjgs.v2.i3.57. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.de Andrade Gagheggi Ravanini G, Portari Filho PE, Abrantes Luna R, Almeida de Oliveira V. Organic inflammatory response to reduced preoperative fasting time, with a carbohydrate and protein enriched solution;a randomized trial. Nutr Hosp. 2015;32:953–7. doi: 10.3305/nh.2015.32.2.8944. [DOI] [PubMed] [Google Scholar]
- 15.Faria MS, de Aguilar-Nascimento JE, Pimenta OS, Alvarenga LC, Jr, Dock-Nascimento DB, Slhessarenko N. Preoperative fasting of 2 hours minimizes insulin resistance and organic response to trauma after video-cholecystectomy:A randomized, controlled, clinical trial. World J Surg. 2009;33:1158–64. doi: 10.1007/s00268-009-0010-x. [DOI] [PubMed] [Google Scholar]
- 16.Çakar E, Yilmaz E, Çakar E, Baydur H. The effect of preoperative oral carbohydrate solution intake on patient comfort:A randomized controlled study. J Perianesth Nurs. 2017;32:589–99. doi: 10.1016/j.jopan.2016.03.008. [DOI] [PubMed] [Google Scholar]
- 17.Lee JS, Song Y, Kim JY, Park JS, Yoon DS. Effects of preoperative oral carbohydrates on quality of recovery in laparoscopic cholecystectomy:A randomized, double blind, placebo-controlled trial. World J Surg. 2018;42:3150–7. doi: 10.1007/s00268-018-4717-4. [DOI] [PubMed] [Google Scholar]
- 18.Bilehjani E, Fakhari S, Yavari S, Panahi J, Afhami M, Nagipour B, et al. Adjustment of preoperative fasting guidelines for adult patients undergoing elective surgery. Open J Intern Med. 2015;5:115–8. [Google Scholar]
- 19.Khoyratty S, Modi BN, Ravichandran D. Preoperative starvation in elective general surgery. J Perioper Pract. 2010;20:100–2. doi: 10.1177/175045891002000302. doi:10.1177/175045891002000302. [DOI] [PubMed] [Google Scholar]