Special Article – Liver Surgery
Austin J Surg. 2019; 6(2): 1161.
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) , 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 . For many years, the standard protocol has been pre-operative fasting of 12 and 6hours for food and water, respectively . 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 . Specifically, the conventional pre-operative fasting protocol was suggested too long and not necessary . 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 .
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 . 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 . 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 . 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 .
Hazards of prolonged fasting include dehydration, low blood glucose, electrolyte disturbances, nausea, vomiting, confusion, and irritability . A previous study showed that multi-disciplinary cooperation among nurses, anesthetists and surgeons is required in implementation of the shorter pre-operative fasting protocol . Improvement in patient outcome could seemingly be attributed to reduced adverse reactions in patients receiving ERAS . 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 .
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 . There is also a clear consensus that patients should be prohibited from eating within 6 hours prior to induction of anesthesia . Foods that require longer time for gastric emptying (e.g., meat and fried foods) must be prohibited within 8 hours before the surgery .
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 +).
Method to measure
A pre-operative fasting protocol is available and accessible to all staff caring for surgical patients.
15 nurses in the department
Survey of the number of nurses who received the information of the pre-operative fasting protocol.
A pre-operative assessment that includes a review of pertinent medical records, a physical examination and a patient interview has been undertaken for every patient to determine potential conditions that can increase their risk of pulmonary complications.
25 patients undergoing liver resection
Survey of the number of patients who completed the pre-operation assessment sheet designed by the project team.
All patients have received education about the benefits of pre-operative fasting.
25 patients undergoing liver resection
Survey of the number of patients who received the education of pre-operative fasting and the benefits from it.
All patients have received verbal and written instructions about their fasting requirements sufficiently in advance of the procedure.
25 patients undergoing liver resection
Survey of the number of patients who fully understood the instructions about the fasting requirements.
All staff involved in the care of the patient have received education about evidence-based pre-operative fasting practices.
15 nurses in the department
Survey of the number of nurses who have attended the training sessions on pre-operative fasting practices given by the project team.
Table 1: Audit criterion, sample, and methods to measure.
The baseline audit was conducted by the project team members using the PACES program. All data were collected by nurses of the project team and recorded on forms. After the auditing process was completed, the project team discussed the results of the audit data obtained using the PACES program and the compliance rates of each criterion were documented.
Phase 2 Strategic plan and implementation
Phase 2 was conducted over eight weeks from Sept 11th to Oct 31th, 2016. Based on the results of the baseline audit, the project team identified the barriers of the implementation regarding each criterion and developed strategies with available resources to overcome those barriers. The GRIP period lasted for seven weeks, from Sept 19th to Oct 31th of 2016. During Phases 2, we identified 6 main barriers and developed strategies to cope with them, which are listed in (Table 2) together with the corresponding resources and outcomes. A set of questionnaires were developed by the project team as convenient tools for quick assessment of patients’ anesthetic risk and recording of patients’ actual fasting time, their satisfaction upon pre-operative fasting and the blood glucose level before the surgery (Table 3).
Lacking a unified protocol which conforms to the evidence included in the JBI Evidence Summary
We modified the pre-operative fasting protocol to conform to the JBI standards (6-h and 2-h for light meal and water, respectively), as shown in Table 3
A printed out pre-operative fasting protocol
Nurses were informed of and fully understood the newly developed pre-operative fasting protocol
Lacking a convenient assessment tool to evaluate patients' risk of anesthesia
We designed a 1-page checklist (Figure 1)to assess the risk of aspiration during anesthesia and post-operative pulmonary infection. The checklist included 12 items recommended by the 2011 ASA Guidelines, as risk assessment well as information needed to identify the patient and fasting records.
A printed out 1-page checklist for anesthesia risk assessment
Completed and signed checklist was available (as a part of the medical records) in all 25 cases.
Lacking educational material to explain the benefits of fasting time
A set of tools, including a poster, a pamphlet, and a 2-minute video, were newly developed by project team members based on evidence included in the JBI Evidence Summary.
Poster, pamphlet and video
Nurses were informed of the set of educational materials to provide education to patients
Having difficulties to decide when to provide the last drink solution for the patient since the picking time of patients to surgery is uncertain
The project team decided to develop an operation schedule system linking the ward and the OR for the real-time operation schedule communication. The proposal was approved by the hospital executive committee and supported by the network engineers and OR staffs. The real-time operation schedule system was established with a month with joint efforts.
The real-time operation schedule system
Nurses were informed of the instruction of the newly developed real-time operation schedule system. The last drink solution for all 25 patients was given on appropriate time before the surgery.
Patients lacked the access to the knowledge of pre-operative fasting and its benefits.
The benefits of pre-operative fasting were explained to all 25 patients, with the aid teaching materials described in Barrier 3. Patients’ awareness of pre-operative fasting and their compliance were also evaluated.
Poster, pamphlet and video
Patients have access to teaching materials and understood the benefits and importance of pre-operative fasting.
Nurses lacked training and education for this project
Included nurses attended a 1-h educational session given by the team leader that explained the benefit of pre-operative fasting protocol.
A one-hour training session with a short quiz on the topic
All included nurses received 1-h training session. A 10-item quiz was conducted immediately after the training. The correct rate has been raised from 35% to 95%.
Table 2: GRip (Getting Research into Practice) matrix.
Phase 3: Follow-up audit post-implementation of change strategy
From Nov.1th to Dec 5th, 2016, the re-audit was conducted with the same audit criteria and in the same way as the baseline audit. 15 nurses and 25 patients were involved, and the data were collected using the same method as that of the baseline audit.
The baseline audit results showed that for the pre-operative fasting in patients with primary liver cancer, the compliance rates for Criteria 1 to 5 were 0% as shown in (Figure 1) below.
Figure 1: Follow-up audit.
The included nurses showed a better command of knowledge concerning pre-operative fasting according to the short quiz correct rate (Table 4), from 35% before the educational session and 95% after. Compliance rates of the patients were increased significantly in all 5 criteria from 0% in the baseline audit to 100% in the second audit (Figure 1).
1. The aim of preoperative fasting is to prevention ( ) during the operation and anesthesia.
D. A, B and C
2. The hazards of prolonged fasting may( )
A. low blood glucose
C. electrolyte disturbance
D. A, B and C
3. In 2011, ASA advised the correct fasting time. After eating meat or KFC, the patient need ( ) hours, after eating light diet, the patient need ( ) hours, after drinking water, the patient need ( ) hours.
4. The clear liquid which ASA means is ( ).
B. coca cola
D. orange juice
5. Measure to prevent excessive fasting include ( ).
A. cooperation among nurses, anesthetists and other multidisciplinary team members can be effective in preventing a long preoperative fasting time.
B. evidence that prolonged preoperative fasting can cause adverse reactions indicates that health education for medical personnel can effectively improve patient outcomes;
C. preoperative fasting of patients should include useful health education;
D. A, B and C
6. In China, the reason of long preoperative fasting time is ( )
A. practices are based not on the best evidence;
B. conventional methods based on ward practices;
C. for surgery safty;
D. A and B
7. Which one is correct ( )
A. all patients should follow the ASA fasting time;
B. the staff need not education;
C. no reason for patient education before surgery;
D. after eating KFC, the patient should fasting 8 hours
8. After drinking coca cola, the patient need stop drinking ( )
A. 4 hours
C. 3 hours;
D. 6 hours
9. Which side reaction of prolonged fasting is correct? ( )
D. A, B and C
Table 4: A short quiz.
There was a trend for decreasing fasting time for food after the project implementation from 14.49 (3.10) hours to 13.06 (3.76) hours (P=0.088). Fasting time for water was reduced dramatically from 12.94 (3.12) hours to 2.70 (1.14) hours (P<0.0001).
Patients’ blood glucose level upon entering the operation room did not differ between the two audits, and was 5.21 (0.66) mmol/L and 5.25 (0.69) mmol/L in the baseline and repeat audits respectively (P=0.745). The incidence of hypoglycemia or hyperglycemia did not occur in any cases during the audits. According to the patients’ satisfactory questionnaire, the percentage of the patients who answered “yes” to the question “Are you hungry?” upon entering the OR was 76% (19) and 28% (7) in the first and second audits, respectively (P<0.0001). The percentage of the patients who answered “yes” to the question “Are you thirsty?” upon entering the OR was 16% (4) and 4% (1) in the first and second audits, respectively (P=0.031).
This project aimed to improve pre-operative fasting practices in patients undergoing liver resection, which involved 15 nurses and 50 patients (25 in baseline and 25 in follow-up). Multiple barriers were identified and the corresponding strategies were developed to address the issues. Post-implementation data demonstrated significant improvements in compliance for each audit criterion. Compared with the baseline audit, the compliance rates for all 5 criteria were remarkably increased from 0% to 100% in the post-implementation audit. The poor performance in the baseline audit might be attributed to limited awareness of pre-operative fasting of both nurses and patients, as well as lack of efficient tools to implement the preoperative fasting protocol during clinical practices.
One major success of this project was the significant shortening of the average fasting time for food and water for patients undergoing liver resection. The pre-operative protocol revised by the project team was proved to be feasible and effective in clinical practices (Table 3). The average fasting time for food was slightly reduced from 14.49 hours to 13.06 hours, and the average fasting time for water was significantly reduced from 13.94 hours to 2.75 hours. The improvement may be attributed to the enhancement of the awareness of pre-operative fasting among nurses, the implementation of the preoperative fasting protocol, and the education and guidance for the patients via various newly developed educational materials including related poster, pamphlet and video. A previous study interpreted that giving water, tea or coffee 2-3 hours per-operatively does not enhance the rish of regurgitation and aspiration . Studies have confirmed that after 90 minutes of fluid intake, the stomach has been emptied and the liquid is taken at 2h before the operation, which does not increase the risk of vomiting and aspiration during anesthesia . A prospective observational non-inferiority cohort study shows that these fluids could provide only little energy . Studies by Yagmurdur H et al, preparation with CHO (CHO which means Carbohydrate) was effective in reducing hunger, thirst, malaise, unfitness, and, to some extent, anxiety . Drinking solution of 50ml 5% glucose-0.9% NaCl every 60 minutes on the day of surgery was proved secure during the audits, since no cases of anesthesia accidence occurred, nor did the incidence of hypo- or hyperglycemia among the patients. The water deprivation time was significantly shortened compared to the fasting time for food between the audits. This may be attributed to the difficulty of providing breakfast for patients on the day of surgery, since most surgeons and anesthetists consider it as an added risk for anesthetic accidents of regurgitation and aspiration. With the concept of 6 hours of fasting prior to the surgery, patients arranged for the second/third surgery could be permitted to have light diet for breakfast on the day of surgery, by which might further shorten the fasting time for food. According to the patients’ satisfactory questionnaire, 19 patients felt hungry and 4 patients felt thirsty in the first audit, while only 4 patients felt hungry and 1 felt thirsty in the second one, suggesting that patients’ satisfaction improved in line with the shortening of pre-operative fasting.
Patient's Name and Age
The day before surgery
Whether the age is 70 or more than 70 years old
Difficulty respiratory tract
Gastrointestinal motility disorders
A history of gastrointestinal surgery
Digestive tract ulcer
Abnormal liver function(total bilirubin>40mol/L)
Are you hungry?
Are you thirsty?
Did the patient have vomiting during operation?
Did the patient have aspiration during operation?
Blood glucose upon entering the operation room:________________
Fasting time (food)
Fasting time (water)
Table 3: Cheklist.
Another major achievement of this project is the establishment of the operation schedule system linking the ward and the OR for the real-time operation schedule communication. This system enabled the nurses to have fully access to the real-time operation schedule and to decide when to provide the last drink solution for the patient according to the estimated picking time of patients to OR, which was displayed on the system. The successful establishment of the system within a month wouldn’t have been realized without the approval of the hospital executive committee, the support of the network engineers and the cooperation with the staffs of OR, with joint efforts under the belief of promoting ERAS during the clinical practices.
This project had some limitations. The sample size of the project was limited, which might cause sample selection bias. In the future study, more patients, under different health conditions, may be included for the development of more individualized protocol. Another limitation was that this project only targeted patients undergoing liver resection, thus other types of surgery may be required in the future study to further verify the evidence and to broaden the scope of clinical applications of the pre-operative fasting protocol.
We agreed that follow-up cycles should be continued in the future to sustain the impact of this project. It is important for our nurses to participate in evidence-based practice education projects to update their knowledge as well as to integrate nursing practice with the evidence.
In conclusion, the aim of the project was successfully achieved. The pre-operative fasting protocol was proved to be feasible and effective to reduce the actual fasting time before liver surgery and to improve patients’ satisfaction during clinical practice. Multiple strategies including the pre-operative fasting education for both the nurses and the patients, the related educational materials, the checklist for anesthesia risk assessment, and the real-time operation schedule system were developed during the implement of the project to overcome identified barriers. Future audits, possibly in other surgical department with larger sample size, may be conducted to sustain evidence-based practice.
The authors would like to thank the JBI for organizing the Evidence-Based Clinical Fellowship Program that has provided them the chance to implement new changes in their workplace.
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Citation: Xiao WJ, Ren HL, Xu JM, Cang J, Hu Y, Yu JX, et al. Pre-Operative Fasting in Patients with Primary Liver Cancer: A Best Practice Implementation Project. Austin J Surg. 2019; 6(2): 1161.