Medicosnext
Words by Narendra Kumar Chaudhary
Anecdote 1
Around five years ago, a baby aged eleven months with an elbow joint fracture (supracondylar fracture) was planned for surgery the following day in a specialized orthopaedic and trauma care hospital in Kathmandu. The child was therefore on NPO (nothing per oral) and had not eaten anything since midnight despite shrieking for mother’s milk. He was finally allowed to feed after 2 PM since the operation got unfortunately cancelled due to a running nose (Acute respiratory tract infection) following long fasting of about 14 hours.
Anecdote 2
Four years ago, a pregnant lady had been scheduled for caesarean delivery at 10 AM in a renowned medical college teaching hospital of Kathmandu. However, she was sent to the operation theatre only at 4 PM in a prolonged fasting state of about 20 hours due to the arrival of other emergency patients. Pregnancy is itself a state of having different inconveniences like abdominal pain and distention, bleeding, high blood pressure, depression and anxiety, etc. Hunger further aggravates the condition which increases risk factors both for mother and the fetus. This often upsets the pregnant women, making the patient and patient party stressed. In fact, all these is linked to poor hospital management. These incidents are only a few examples that represent the protocol of surgery in which the patients are kept in ‘Nothing by Mouth’ (NPO, commonly termed as fasting) at least six hours prior to surgery but in practice they are not permitted to ingest anything orally since midnight to avoid the risk of pulmonary aspiration during surgery. Further, the unmanaged institutional set up elongates the NPO time. Do you not wonder if fasting is actually mandatory for longer periods of time prior to surgery, especially when the surgery is postponed by a few more hours?
Enhanced Recovery After Surgery (ERAS)
I conducted a literature review about preparing for surgery and keeping patients in NPO. I found various harmful effects of long fasting leading the patients to a catabolic state, worsening the stress response, increasing insulin resistance and hyperglycemia, delaying the recovery rate and creating different complications such as distress, confusion, instability, headache, dehydration, electrolyte imbalance, postoperative nausea, and vomiting. On the other hand, there is the concept of preoperative carbohydrate loading as a component of a new approach, so called Enhanced Recovery After Surgery (ERAS) in which patients are recommended to consume orally 100 g and 50 g of carbohydrates the night before and two hours before surgery respectively. It has been proved that mean gastric emptying time in preoperative carbohydrate loading is 90 minutes, so prolonged fasting for surgery is unnecessary. Different studies have revealed the benefits of this approach that it decreases insulin resistance by up to 50%, improves metabolic functions, minimizes the intraoperative core body temperature, reduces inflammation, improves muscle function, facilitates wound healing, and of course, reduces the length of postoperative stay at hospital minimizing the treatment costs to the patients. This excerpt is based on my research titled “The effect of preoperative carbohydrate loading in femur fracture: a randomized controlled trial” for which a provincial research grant was given in 2021. The research was conducted in 66 patients (33 in the control group and 33 in the intervention group) aged 50 years and above with femur fracture planned for surgery under spinal feature 30 Medicosnext…Issue 40 feature block anesthesia. The control group was kept fasting from midnight to the following day as in existence while the study group was intervened based on ERAS protocol in which patients consumed 100 g glucose in 200 ml water in the last night and 50 g glucose in 100 ml water before two hours surgery. The study showed the profound effect of preoperative carbohydrate loading that it facilitates the recovery rate, reduces the postoperative pain, decreases the inflammatory marker (serum albumin), increases ambulatory function, improves the degree of independency in daily life activities and shortens the length of hospital stay. Conducting a randomized controlled trial (RCT) research in the hospital setting was difficult for me. First, I had to inform the anesthesiologists and entire surgical team members about the advantages of preoperative carbohydrate loading and its safety issue in interventional studies. Second, as the participants were only 50 years and above with traumatic femur fracture planned for surgery, the number of such cases were limited; hence to find the cases were tough. It took more than six months to meet the sample size (66 participants). Third, the data collection was affected by the first wave of the COVID-19 pandemic in Nepal, distracting the data collection process due to stressful environment and lack of communication with participants. Fourth, the most difficult but not the last challenge was convincing the patients and patient party to participate in the study for ethical and professional integrity. Following the completion of the study, this scientific work was published in the BioMedCentral, BMC international journal. The full article published at BMC can be accessed at: https://bmcmusculoskeletdisord. biomedcentral.com/ articles/10.1186/s12891-022- 05766-z
Conclusion
In surgical practice, the conventional approach of prolonged fasting, often spanning midnight till surgery, is being challenged by the emerging paradigm of Enhanced Recovery After Surgery (ERAS). The tales of distress recounted here underscore the pressing need for a reevaluation of fasting protocols. The research journey presented, focusing on preoperative carbohydrate loading, not only unravels the flaws in the existing system but also advocates for a more patient-centric, evidencebased approach. As the study show cases the positive impact on recovery and patient wellbeing, it prompts the medical community to embrace ERAS, a transformative era in surgical care. The evidence is compelling; it’s time for medicine to prioritize nutritional interventions and ensure surgeries are not only successful but also marked by humane practices.
Acknowledgement
The author would like to express his appreciation to the collaborative doctors and beautiful souls of the diligent nursing staff of Nepal Orthopaedic Hospital who helped with data collection in the friendly environment of structured administration. He also conveys his gratitude to the volunteered patients and NHRC for providing a provincial
