Pre-Operative Fasting in Patients with Primary Liver Cancer: A Best Practice Implementation Project

Special Article – Liver Surgery

Austin J Surg. 2019; 6(2): 1161.

Pre-Operative Fasting in Patients with Primary Liver Cancer: A Best Practice Implementation Project

Xiao WJ¹, Ren HL¹, Xu JM¹, Cang J¹, Hu Y², Yu JX¹* and Shigm³

¹Department of Nursing, Zhongshan Hospital, Fudan University Centre, China

²School of Nursing, Fudan University, China

³Department of Liver Surgery, Zhongshan Hospital, China

*Corresponding author: Yu JX, Department of Nursing, Zhongshan Hospital, Fenglin Road, Xuhui District, Shanghai, China

Received: November 23, 2018; Accepted: January 11, 2019; Published: January 18, 2019


Introduction: Shorter fasting time is recommended by the current European and US guidelines of pre-operative fasting in patients receiving elective surgery under general anesthesia, but has not yet been practiced in primary liver cancer surgery in our unit. Thus, this study aims to improve pre-operative fasting practices in patients with primary liver cancer.

Methods: According to the standards of Joanna Briggs Institute (JBI) in Australia, we follow the standard procedures of Practical Application of Clinical Evidence System (JBI-PACES). In total, 25 patients and 15 nurses were selected. The time of fasting, incidence of complications after operation, and comfort in patients, and pre-operative fasting knowledge in nurses were used to evaluate the effects of this project.

Results: There was a statistical trend for reduction in actual fasting time for food, from 14.49 (3.10) hours to 13.06 (3.76) hours (P=0.088). Fasting time for water was reduced from 12.94 (3.12) to 2.70 (1.14) hours (p<0.0001). No anesthetic accident of vomiting or aspiration was observed. The number of hungry patients and thirsty patients dropped from 76% to 28% and 16% to 4% separately. The questionnaire accuracy of nurses’ knowledge on pre-operative fasting increased from 35% to 95%.

Conclusion: The awareness of pre-operative fasting among nurses and patients was strengthened. The pre-operative fasting protocol (6 hours for fasting food; 2 hours for fating water) could effectively reduce the actual fasting time before liver surgery and improve patients’ satisfaction. Future audits in other surgical department may be conducted to sustain evidence-based practice.

Keywords: Pre-operative fasting; Evidence-based nursing; Liver surgery; Primary liver cancer


OR: Operation Room; JBI: Joanna Briggs Institute; Grip: Getting Research into Practice


The purpose of fasting and abstinence before elective surgery is to empty the stomach adequately and prevent reflux, vomiting and aspiration of gastric contents during anesthesia and during operation. Traditional preoperative fasting for 12 hours and drinking forbidden for 4 hours as routine nursing care has always been an important part of preoperative preparation during perioperative period. The adverse reactions such as dehydration, thirst, hunger, irritability and hypoxemia caused by long-term fasting and drinking have attracted much attention. A large number of studies have shown that the main causes of patients’ long fasting and water fasting are the continuation of routine methods based on the convenience of ward management, lack of knowledge, lack of professional knowledge and inconsistent practice among medical staff. A study abroad showed that the time of fasting and drinking prohibition was too long, reaching an average of 11.94 hours. After the implementation of the plan, it was found that the average time of fasting and drinking was reduced to 5.4 hours. The purpose of this study is to apply the best evidence of preoperative fasting and drinking to clinical nursing of hepatic surgery, so as to reduce complications, improve clinical compliance with evidencebased recommendations for preoperative fasting and drinking, and increase nurses’ knowledge of preoperative fasting and drinking, so as to strengthen patients’ optimal preoperative fasting and drinking. Drink time to achieve the goal of ensuring patient safety and improving patient comfort.

Rapid recovery after surgery, known as Early Recovery after Surgery (ERAS) [1], was developed in early 2000s, consisting of a series of per-operative optimal managements with the goal to expedite patient recovery after surgery. Among others, appropriate pre-operative fasting time is one of guideline contents to get early recover. The primary goal of pre-operative fasting in patients undergoing elective surgery is to prevent vomiting and accidental aspiration during surgery [2]. For many years, the standard protocol has been pre-operative fasting of 12 and 6hours for food and water, respectively [3]. A clinical research which culminated in a change in practice in a large district general hospital has indicated that such a fasting protocol is based on convenience, rather than best evidence [4]. Specifically, the conventional pre-operative fasting protocol was suggested too long and not necessary [5]. One study showed that the actual fasting time for food in clinical practices is 11.94 hours on average. A previous study showed that the ERAS protocol was feasible: fasting time for food could be reduced to 5.4 hours through patient education by ward staff members [6].

A systematic review found that in comparison to subjects receiving standard pre-operative fasting protocol, the risk of reflux and aspiration during the surgery in adult patients receiving oral fluid 2-3 hours prior to surgery was not significantly increased [7]. There was no close relationship between the contents of gastric contents and the length of fasting time. The patients were given 150 milliliters of water for 2 hours before operation, and the amount of gastric juice in the drinking group was less than that in the night fasting group. The pH value in the two groups was similar to that in the gastric juice of the two groups. Long time fasting did not increase the pH value of gastric juice, while drinking water diluted gastric acid could stimulate gastric emptying [8]. A study in patients receiving day surgery (which means shorter fasting time for food and water, and less degree of dehydration) also suggested the significant benefits of shorter fasting time [9]. A randomized controlled trial in patients receiving video-assisted cholecyst-ectomy showed that reducing preoperative fasting to 2 hours could reduce insulin resistance and adverse organ responses to surgical stress [10].

Hazards of prolonged fasting include dehydration, low blood glucose, electrolyte disturbances, nausea, vomiting, confusion, and irritability [6]. A previous study showed that multi-disciplinary cooperation among nurses, anesthetists and surgeons is required in implementation of the shorter pre-operative fasting protocol [7]. Improvement in patient outcome could seemingly be attributed to reduced adverse reactions in patients receiving ERAS [5]. Meanwhile, sufficient patient education of the new pre-operative fasting protocol (6 hours fasting for food; 2 hours fasting for water) could improve patient compliance [11].

Clinical practice guidelines recommend that patients may drink clear fluids (water, pulp-free juice, carbonated beverage, tea or coffee without milk) up to 2 hours prior to general or regional anesthesia [8]. There is also a clear consensus that patients should be prohibited from eating within 6 hours prior to induction of anesthesia [12]. Foods that require longer time for gastric emptying (e.g., meat and fried foods) must be prohibited within 8 hours before the surgery [13].

The objective of this evidence implementation project was to improve pre-operative fasting practices in patients undergoing liver resection due to primary liver cancer, thereby reducing the incidence of complications and improving patients’ comfort and recovery. The specific aims of this project were to improve nurses’ knowledge of best practices in pre-operative fasting, to educate patients regarding the optimal pre-operative fasting times and the complications associated with prolonged fasting, and to improve patients’ compliance of preoperative fasting with evidence-based recommendations.


This evidence implementation project was divided into 3 phases and was conducted over 4 months from September to December, 2016. The JBI Practical Application of Clinical Evidence System (PACES) and the Getting Research into Practice (GRiP) audit and feedback tool were used for building the framework of the project. This project was supported by the JBI-PACES and JBI-GRIP programs. There were 25 patients and 15 nurses involved in the baseline audit and the same number involved in the follow-up audit. The project was carried out in third level hospital in Shanghai, China.

Phase 1: Team establishment and baseline audit

From September 5 to September 11, 2016, we identified the audit topic, established the project team, identified the audit criteria, and conducted the baseline audit. The project team included one project leader (the chief head nurse of the department), one primary trainer (the head nurse of the department), two voting numbers (the head nurses of OR), two non-voting members (senior nurses of the department) and 3 consultants (a surgeon, an anesthetist and a professor from the College of Nursing, Fudan University). A project team meeting was held to discuss the audit criteria and the data collection methods before the baseline audit. The team members reviewed the project background and planned an outline for the project implementation. This ensured that all the team members were familiar with the audit criteria (see the next subsection) and implementation methods. The senior nurses informed all the nurses in the wards of the project and its objectives to ensure the smooth implementation of the project. Preparation for the audit was finalized by September 12th, 2016.

Baseline audit: The project team member summarized 5 audit criteria, listed in (Table 1), together with sample description and method to measure, regarding pre-operative fasting food/water based on clinical evidence from the database of JBI Online Clinical treatment and nursing Evidence Network (Clinical Online Network of Evidence for Care and Therapeutics, JBI COnNECT +).