Why Do Most Hospitals Ignore Guidelines on Fasting Before Surgery?

Baltimore anesthesiologist responds to Slate critique

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An article in the online magazine Slate made a strong case that the vast majority of surgical patients are made to fast for 8 hours or more before receiving anesthesia, despite current guidelines that allow patients to eat 6 hours prior to surgery and to drink fluids 2 hours prior. As a result, "most patients appear to still be getting outdated advice and arrive to surgery thirsty and irritable," the article said.

Several anesthesiologists told MedPage Today that this is an important issue, and one of them, Harrison Linder, MD, of Mercy Medical Center in Baltimore, offered a detailed response to the Slate article. Here is what he said:

Having trained with a background in anesthesiology, I can assure you that the topic of pre-operative fasting is absolutely an area of interest and importance in the surgical arena. There is nothing more important to an anesthesiologist than safety.

While a large majority of what we do involves keeping patients safe and comfortable during an operation, often it is our degree of preparedness and thoroughness before the case that sets us for success. The fundamentals of a good pre-operative evaluation include an airway examination, delving into a patient's history of comorbidities, and always inquiring regarding pre-operative oral intake. It is that last part that can very quickly cause a scheduled elective surgery to be cancelled or delayed.

I think the Slate article does a pretty good job reviewing the history and current situation regarding pre-operative fasting protocols in most hospitals. During my training I learned about the new discoveries regarding fasting physiology and gastric transit times. There were even some programs around the nation trying to be at the forefront and applying these changes, creating "fast-track surgery centers" aimed at "enhanced recovery after surgery."

However, despite all of the new studies and data, most health professionals outside of these few centers still relay "nothing to eat or drink for 8 hours prior to surgery" to patients preparing for surgery. I would argue that most anesthesiologists know the specific details of the newest American Society of Anesthesiologists' guidelines, but even then it may not matter when there are larger, overarching hospital policies at play.

Like much of the rest of medicine, many hospitals have created pre-operative protocols that dictate how certain situations are to be handled, in order to maximize efficiency, and decrease the chances of incorrect individual choices. As the guidelines continue to change and get more convoluted – the new guidelines have different suggested fasting times for clear liquids, full liquids, light meals, full solids, etc., – hospitals are hesitant to change their policies as this may decrease efficiency and further cause confusion among providers and patients. Even in a hospital system that employs the newest ASA fasting guidelines, it may be easier to ask a patient not to have anything to eat or drink for 8 hours, rather than risk them doing something incorrectly and ultimately causing a delay in their care.

Furthermore, there is always the hidden influence of malpractice in the back of every doctor's mind. Sure, the recent studies have shown that it's okay to drink clear liquids up until 2 hours before surgery, but if a patient aspirates during that subsequent procedure, are we positive that those studies and the recent ASA guidelines will hold up in court?

Sadly, it is sometimes just easier to stick with the accepted and safe way to do things rather than try and be revolutionary. That being said, I believe the data and research will continue to show that we can improve the way we prepare patients for surgery. Eventually, compensation and reimbursement will be tied to how quickly patients are discharged after surgeries, and hospitals will start prioritizing any method that will achieve that goal. Pre-operative optimization rather than simple pre-operative fasting will absolutely be one of those methods.

Unfortunately, in a world where insurance companies dictate patient care, and every action and written word can be scrutinized in court in the event of an adverse outcome, there will always be slow progress and resistance to change in the medical field.

Harrison A. Linder, MD, is a pain management specialist with The Center for Interventional Pain Medicine at Mercy Medical Center in Baltimore.