|Year : 2019 | Volume
| Issue : 5 | Page : 350-355
A prospective survey on knowledge, attitude and current practices of pre-operative fasting amongst anaesthesiologists: A nationwide survey
Pratibha Panjiar1, Anjali Kochhar2, Homay Vajifdar1, Kharat Bhat1
1 Department of Anaesthesiology and Critical Care, Hamdard Institute of Medical Sciences and Research, New Delhi, India
2 Department of Anaesthesia and Critical Care, Vardhman Mahavir Medical College and Safdarjang Hospital, New Delhi, India
|Date of Web Publication||13-May-2019|
Dr. Pratibha Panjiar
16, Sadhna Enclave, Second Floor, New Delhi - 110 017
Source of Support: None, Conflict of Interest: None
Background and Aims: Pre-operative fasting is a routine practice to minimise the risk of pulmonary aspiration. The leading societies of anaesthesia have adopted more liberal fasting guidelines to avoid the adverse effect of prolonged fasting. This survey was conducted to assess the knowledge, attitude and current practice of fasting guidelines among Indian anaesthesiologists and to analyse the reasons for non-compliance of these guidelines. Methods: A questionnaire consisted of 11 questions was distributed via 'Survey Monkey' software to 621 anaesthesiologists who attended the annual conference of the Indian Society of Anaesthesiologists held in Ludhiana, in 2016. American Society of Anaesthesiologists (ASA) practice guidelines for fasting were the standard of assessment. Results: The response rate to the survey was 52%. Of the respondents, 69% described correctly the practice guidelines to pre-operative fasting. Only seven percent respondents were aware of the benefits of liberalised fasting. More than 2/3rd of the respondents advised fasting as per ASA guidelines during pre-anaesthetic check-up (PAC). However, only about 50% respondents confirmed that these guidelines are actually followed in their institution. Not having control on scheduling of cases in operation theatre and poor knowledge of ward nurses and surgeons were the common reasons for non-compliance of these guidelines. Twenty four percent respondents did not use routinely any drug for aspiration prophylaxis. Conclusion: Majority of the respondents were aware of the ASA fasting guidelines. However, the implementation of the guidelines and knowledge regarding benefits of liberalised fasting is poor among respondents.
Keywords: Clear fluids, preoperative fasting, survey
|How to cite this article:|
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
|How to cite this URL:|
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 [serial online] 2019 [cited 2020 Aug 5];63:350-5. Available from: http://www.ijaweb.org/text.asp?2019/63/5/350/258063
| Introduction|| |
In 1946, the paper published by Mendelson claimed a very high incidence of pulmonary aspiration during general anaesthesia (GA) in obstetrics. As a result, the traditional practice of NPO (Latin: Nulla per os; or nothing by mouth) after midnight before elective surgery was a routine clinical practice for many years.
Recently, various anaesthesia societies like the American Society of Anaesthesiologists (ASA), The Association of Anaesthetists of Great Britain and Ireland (AAGBI), Royal College of Nursing (RCN) revised practice guidelines for preoperative fasting in healthy patients undergoing elective procedures and recommended a fasting period of 2 hours for clear fluids, 4 hours for breast milk and 6 hours for light meal/formula milk (Liberalised fasting).,,
These new, liberal fasting guidelines were based on studies showing that pulmonary aspiration occurs rarely as a complication of modern anaesthesia. The survey conducted by Shime N et al. revealed that there was no significant difference in the rate of pulmonary aspiration between the institutes that were applying the minimum period (4.8/100000) and institutes with longer fasting periods (9.1/100000).
Prolonged preoperative fasting leads to increased patient anxiety, discomfort, thirst, hunger, and irritability in adults., Children may develop dehydration, hypovolaemia and hypoglycaemia. The advantages of liberalised fasting are clear but surveys done in other countries showed that despite fair knowledge of fasting guidelines, their implementation is poor., The implementation of these guidelines in India has not yet been evaluated. We therefore conducted this survey to assess the knowledge, attitude and current practice of fasting guidelines among Indian anaesthesiologists. In addition, we also analysed the reasons for non-compliance of these guidelines.
| Methods|| |
Following approval from the institutional ethical committee, this prospective, cross-sectional survey was conducted to obtain an insight into preoperative fasting routines. The questionnaire consisted of 18 questions and was developed after having reviewed previous national surveys.,,, Closed multiple-choice design for the questionnaire was selected to meet the criteria of objectivity and to exclude the possibility of interpretational errors. A panel of qualified anaesthesiologists reviewed the questionnaire, items were modified, and 14 questions were shortlisted by consensus. The document was then validated by seven experts using a standardised model of content validity index. The questions with item content validity index <0.78 were not included in the final version of the questionnaire (n = 11). Scale content validity index (SCVI) was also calculated by SCVI universal agreement method (0.666) and SCVI average method (0.95). Values computed by both methods were within acceptable limits. The final version of the questionnaire [Appendix 1 is available online [Additional file 1]] was then tested in a small group of anaesthesiologists, twice at an interval of one month for checking reliability.
The questionnaire consisted of three sections. The first section was related to general information like practice setting of the respondents and years of experience in anaesthesia. The second section pertained to the anaesthesiologists' knowledge of the ASA published fasting guidelines and its importance. The third section was intended to gain information regarding current practices and attitude towards fasting guidelines.
The survey was distributed via the commercially available 'Survey Monkey' software (www.surveymonkey.com) to the 621 anaesthesiologists who attended the annual conference of the Indian Society of Anaesthesiologists held in Ludhiana, in November 2016. The email addresses of the anaesthesiologists attending the conference were manually collected (randomly) after explaining the purpose of the survey. Sharing of the email addresses by the anaesthesiologists implied their consent. After initial emailing, 10 subsequent reminders (twice every month for five months) were sent.
Considering 16,000 anaesthesiologists, the sample size was calculated to be 265 (5% margin of error and 95% confidence interval). ASA 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 published in 1999 was the standard of assessment. Statistical analysis was performed using Statistical package for Social Sciences (SPSS) version 22 (SPSS Inc., Chicago, IL, USA). Data pertaining to respondent demographics, knowledge of fasting guidelines and its practice characteristics were collected and analysed descriptively using frequencies and percentages.
| Results|| |
A total of 395 questionnaires were returned as shown in CONSORT diagram [Figure 1]. However, 127 questionnaires were excluded from the final analysis as they were partially filled. The response rate to the survey was 52% (268). The majority of the respondents (n-110, 41%) to our survey were from government teaching hospital and 87 (32%) were from private teaching hospital. Only 15 (6%) respondents were working in government non-teaching institute and 35 (13%) in private non-teaching institutes. Twenty-one (8%) respondents were working as free lancers. Of the 268 respondents, 100 (37%) had more than 10 years of experience, while 66 (25%) respondents had 5-10 years and 102 (38%) had 0-5 years of experience.
Of the respondents, 69% (185) described correctly the ASA published practice guidelines to preoperative fasting in non-laboring individuals (adult + paediatric) undergoing elective procedures. The responses to the question (multiple choice) regarding benefits of allowing clear liquids 2 h before surgery were shown in [Figure 2].
|Figure 2: Knowledge of Anaesthesiologists regarding benefits of liberalised fasting|
Click here to view
More than 2/3rd of the respondents (86.56%) reported that during pre-anaesthetic check-up, they advised 6-8 hours of fasting for solids and 70.14% respondents advised 2 hours of fasting for clear fluids in adults. However, only 51.86% and 40.67% respondents confirmed that 6-8hours of fasting for solids and 2 hours of fasting for clear fluids, respectively were actually followed in their institution [Figure 3].
|Figure 3: Anaesthesiologists attitude towards fasting guidelines in “Adults”|
Click here to view
The attitude of anaesthesiologists towards paediatric fasting guidelines are shown in [Figure 4]. During pre-anaesthetic check-up, 88% respondents advised 6-8 hours of fasting for solids, 83% advised 4-6 hours of fasting for breast milk/formula milk and 79% respondents advised 2 hours of fasting for clear fluids. However, 53% respondents confirmed that 6-8 hours of fasting for solids and 50% respondents confirmed that 4-6 hours of fasting for breast milk/formula milk and 2 hours of fasting for clear fluids were actually followed in their institution.
|Figure 4: Anaesthesiologists attitude towards fasting guidelines in “Paediatrics”|
Click here to view
The barriers for not complying with the ASA guidelines are listed in [Table 1]. More than half of the respondents (55%) were of the opinion that not having control on scheduling of cases in operation theatre resulted in long fasting hours.
Attitude and practices of anaesthesiologists towards fasting guidelines is summarised in [Table 2]. Only 2% respondents confirmed that they always explained reasons for fasting to the patients. Most of the anaesthesiologists (83%, 93% and 76%) admitted that they would accept patients who took clear fluid 2 hours prior routine surgery for monitored anaesthesia care, regional anaesthesia and general anaesthesia, respectively. Twenty eight percent respondents confirmed that information about fasting a day before surgery was provided by nursing staff. Out of 268 respondents, only 24% confirmed that the drugs for aspiration prophylaxis were not routinely used in their institution. Majority of respondents (23%) still use combination of ranitidine and metoclopramide for aspiration prophylaxis.
|Table 2: Attitude and Practices of anaesthesiologists towards fasting guidelines|
Click here to view
| Discussion|| |
Pre-operative fasting is defined as a prescribed period of time before a procedure when patients are not allowed the oral intake of liquids or solids. The international preoperative fasting guidelines have been officially published by ASA in 1999 and revised recently in 2017. However, the current study presents the first nationwide survey conducted in India to obtain an insight into the practice and attitude of anaesthesiologists regarding the preoperative fasting guidelines.
The study showed that majority of the anaesthesiologists (69%) in India were aware of the ASA published practice guidelines to preoperative fasting in healthy patients undergoing elective procedures. Similar survey conducted in Sri Lanka by Gunawardhana showed that 70% of healthcare workers were aware of at least one of the recommended guidelines(ASA, Association of Anaesthetists of Great Britain and Ireland, Royal College of Nursing).
The knowledge related to the advantages of liberalised fasting was poor among respondents. More than 2/3rd of all respondents answered that prolonged fasting results in discomfort of the patient. However, prolonged pre-operative fasting can result in dehydration, hypotension, hypovolaemia and electrolyte imbalance., Moreover, it is associated with increase metabolic stress, hypoglycaemia and insulin resistance., It was recently demonstrated that oral administration of carbohydrate-rich drink2-3 hours before surgery results in decreased protein catabolism, reduces preoperative thirst, hunger, anxiety and facilitates accelerated recovery through early return of bowel function and shorter hospital stay, ultimately leading to an improved pre-operative wellbeing.,,
The study showed that during pre-anaesthetic check-up, majority of the anaesthesiologists advised fasting (for solids and clear fluids) as per ASA guidelines for both adult and paediatric patients. However the implementation of these guidelines in their institute is very poor. Our study revealed that only 50% of the anaesthesiologists confirmed that ASA guidelines for solids and clear fluids are actually followed in their hospital for paediatric patients. A survey conducted at Aga Khan University Hospital (Pakistan) found that only 4% of children had had the optimum fasting at the time of survey. Moreover, an observational study, conducted at a tertiary care teaching institute in India, also found majority of the patients following prolonged fasting routines.
According to the survey, the most common barrier for not complying with the fasting guidelines was not having control on scheduling of cases. However, the study conducted by Murphy et al. on the effects of liberalised preoperative fasting policy on operating room utilisation, found no increase in cancellations or delays of surgical procedures due to inappropriate oral intake. Other barriers suggested by respondents in our survey were, ward nursing staff follow surgeon's instructions than anaesthesiologists, poor knowledge of surgeons regarding importance of fasting guidelines. An audit conducted by Arun et al. in tertiary care hospital concluded that education of ward nurses and better coordination among the anaesthesiologists, surgeons and nurses can greatly reduce unnecessary preoperative starvation in children.
This study showed that 58% anaesthesiologists never explained the reasons for fasting to their patients. Poor understanding of the reason for fasting may lead to unintentional non-compliance. Majority of the respondents in our survey accepted patients for anaesthesia in situ ation where patients had already taken clear fluids 2 hours before surgery for monitored anaesthesia care, regional anaesthesia and even for general anaesthesia. This shows that problem is with implementation rather than acceptance of these guidelines by anaesthesiologists.
Our study reveals that most of the time, information about fasting a day before surgery to the patients was provided by either a nurse or surgeon. This could also be the reason for non- compliance of the guidelines.
This study showed that only 24% respondents did not use any drug routinely for aspiration prophylaxis. A number of randomised controlled trials have shown that the preoperative fasting status has no impact on gastric pH and residual volume. It has been shown that factors such as inadequate anaesthetic depth, patient positioning, insufficient airway protection, gastrointestinal pathology and emergency cases are much more associated with the risk of aspiration than the patient's fasting state.
There were certain limitations of our study. Theresponse rate was not above 70%, therefore, non-response bias cannot be completely excluded. However, our response rate of 52% was comparable to those reported by the other national surveys conducted in Japan and Mexico., Secondly, our data were based on subjective criteria; therefore, the value of the findings is less than that, using objective response criteria. Thirdly, it was not clear whether the survey respondents were representative of all the regions of India.
| Conclusion|| |
Our study showed that the majority of the respondents are aware of the ASA fasting guidelines. However, the implementation of these guidelines and knowledge regarding benefits of liberalised fasting is poor among respondents. The lack of control on scheduling cases in operation theatre and poor knowledge of nurses and surgeons are the common barriers for not complying with the guidelines. Therefore, comprehensive multi-professional educational programme to increase the awareness regarding fasting guidelines and its importance among ward nurses and surgeons is required to reduce the mean duration of fasting. Moreover, considering different Indian food habits, further research should be encouraged to design more specific fasting guidelines for Indian patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mendelson CL. The aspiration of stomach contents into the lungs during obstetric anesthesia. Am J Obstet Gynecel 1946;52:191-205.
American Society of Anesthesiologists Task Force on Preoperative Fasting. 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. Anesthesiology 1999;90:896-905.
Smith I, Kranke P, Murat I, Smith A, O'Sullivan G, Soreide E,et al
. Perioperative fasting in adults and children: Guidelines from the European society of anaesthesiology. Eur J Anaesthesiol 2011;28:556-69.
Perioperative fasting in adults and children- a RCN guideline for the multidisciplinary team. Clinical Practice Guidelines.RCN Publications; 2005.
Shime N, Ono A, Chihara E, Tanaka Y. Current practice of preoperative fasting: Anationwide survey in Japanese anesthesia-teaching hospitals. J Anesth 2005;19:187-92.
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.
Bopp C, Hofer S, Klein A, Weigand MA, Martin E, Gust R. A liberal preoperative fasting regimen improves patient comfort and satisfaction with anaesthesia care in day-stay minor surgery. Minerva Anaesthesiol 2009;75:1-7.
Jayasinghe V, Mahesh PK, Sooriaarachchi CM, Jayalath J, Karunarathne W, Liyanage SN. Evaluation of the effect of pre-operative over-fasting on post-operative vomiting in children undergoing bone marrow aspiration at a tertiary care center in Sri Lanka: A prospective cohort study. Indian J Anaesth 2018;62:366-70.
] [Full text]
Salman OH, Asida SM, Ali HS. Current knowledge, practice and attitude of preoperative fasting: A limited survey among Upper Egypt anaesthetists. Egypt J Anaesth 2013;29:125-30.
Breuer JP, Bosse G, Seifert S, Prochnow L, Martin J, Schleppers A,et al
. Pre-operative fasting: Anationwide survey of German anaesthesia departments. ActaAnaesthesiolScand 2010;54:313-20.
McGaw CD, Ehikhametalor E, Nelson M, Soogrim D. A national survey on preoperative fasting policies and practices in Jamaican hospitals. West Indian Med J 2004;53:227-33.
Polit DF, Beck CT. The content validity index: Are you sure you know what's being reported? Critique and recommendations. Res Nurs Health 2006;29:489-97.
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.
Gunawardhana SA. Knowledge, attitude and practice of preoperative fasting guidelines in the National hospital of Sri Lanka. Sri Lankan J Anaesthesiol 2012;20:92-5.
Dalal KS, Rajwade D, Suchak R. “Nil per oral after midnight”: Is it necessary for clear fluids? Indian J Anaesth 2010;54:445-7.
] [Full text]
Gebremedhn EG, Nagaratnam VB. Audit on preoperative fasting of elective surgical patients in an African academic medical center. World J Surg 2014;38:2200-4.
Soop M, Nygren J, Thorell A, Ljungqvist O. Stress-induced insulin resistance recent developments. CurrOpinClinNutrMetab Care 2007;10:181-6.
Mesbah A, Thomas M. Preoperative fasting in children. BJA Educ 2017;17:346-50.
Pal AR, Mitra S, Aich S, Goswami J. Existing practice of perioperative management of colorectal surgeries in a regional cancer institute and compliance with ERAS guidelines. Indian J Anaesth 2019;63:26-30.
] [Full text]
Kaska M, Grosmanova T, Havel E, Hyspler R. The impact and safety of preoperative oral or intravenous carbohydrate administration versus fasting in colorectal surgery- a randomized control trial. Wien KlinWochenschr 2010;122:23-30.
Hausel J, Nygren J, Lagerkranser M, Hellström PM, Hammarqvist F, Almström C,et al
. A carbohydrate-rich drink reduces preoperative discomfort in elective surgery patients. AnesthAnalg 2001;93:1344-50.
Alvi NI. A prospective, cross- sectional survey of pre-operative fasting of pediatricsurgical patients in a university hospital. Anaesth PainIntensive Care 2016;20:171-5.
Ruth MS, Josephine MS, Williams A. Preoperative fasting in the day care patient population at a tertiary care, teaching institute: A prospective, cross-sectional study. CHRISMED J Health Res 2018;5:105-109. [Full text]
Murphy GS, Ault ML, Wong HY, Szokol JW. The effect of a new NPO policy on operating room utilization. J ClinAnesth 2000;12:48-51.
Arun BG, Korula G. Preoperative fasting in children: An audit and its implications in a tertiary care hospital. J Anaesthesiol Clin Pharmacol 2013;29:88-91.
] [Full text]
Lim HJ, Lee H, Ti LK. An audit of preoperative fasting compliance at a major tertiary referral hospital in Singapore. Singapore Med J 2014;55:18-23.
Brady MC, Kinn S, Stuart P. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev 2003;4:CD004423.
Frykholm P, Schindler E, Sumpelmann R, Walker R, Weiss M. Preoperative fasting in children: Review of existing guidelines and recent developments. Br J Anaesth 2017;120:469-74.
Ramirez M, Garcia DM, Ocampo AA. Attitudes of Mexican anesthesiologists to indicate preoperative fasting periods: A cross-sectional survey. BMC Anesthesiol 2002;1471-225.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]