Thursday, April 11, 2013

Drinking Before Surgery

It is one of the cardinal rules of surgical preparation; NOTHING by mouth after midnight, or NPO after MN. That is one of the easiest and most clear cut ways for an anesthesiologist to cancel a case. The surgeon will rarely argue with an anesthesiologist on this point. Some anesthesiologists adhere to this rule so strictly that they will cancel a procedure if the patient is even found chewing gum before surgery.

The reason we discourage patients from eating or drinking anything before receiving anesthesia is that we don't want any contents in the stomach during the procedure. If the stomach is full of food or liquids, there is a risk that the patient will vomit the half digested gastric bolus while under sedation and aspirate it into the lungs. This could lead to severe aspiration pneumonia and possibly death. The doctors and the hospital frown upon unexpected operating room deaths.

But now NPO after MN maybe getting a closer scrutiny. The American Society of Anesthesiologists has for years recommended that cases can proceed if the patient has only clear liquids up to two hours before surgery. Clears means anything that one can see through. Water is obviously considered clears. So is apple juice, grape juice, and, surprisingly, black coffee. Milk, orange juice, and coffee with cream are not clear liquids.

Now a study has been released that may actually encourage doctors to recommend patients have a drink before an operation. As Anesthesiology News reported, researchers at Texas Tech University Health Sciences Center had one group of patients drink a carbohydrate rich clear drink two hours before surgery and another group remain fasting after midnight. Not surprisingly, the group who got to drink before surgery felt less thirsty before their operation. But they also felt significantly less anxiety and greater comfort overall. The researchers concluded that perhaps patients should be allowed to drink clear liquids before they have their surgeries.

First of all I think that is a fine idea that should be further explored. While I would hesitate to let a patient drink as much as these study patients did, 360 mL of fluid which is a little more than one can of soda, I think a couple of gulps wouldn't hurt. We frequently ask our patients to take their medications with small sips of water before coming to the hospital and I don't know of anybody who has aspirated because of that.

Instead of using some specialized "carbohydrate rich beverage" that the researchers used (Clearfast and BevMD) which sounds very expensive, how about just letting patients get a small bottle of Gatorade or other sports drink? It is cheap and readily available. They also contain the electrolytes that are missing from plain drinking water.

Let's face it, NPO after MN is rather barbaric. No elective surgery starts at 2:00 AM. It is especially cruel if the patient's operation isn't scheduled until the early afternoon like 1:00 PM. Is the patient supposed to go without food or water for that long? They can do it but it is not comfortable. Plus by the time the patients comes to preop, they are so dehydrated that it makes starting an IV more difficult. The only reason we tell patients not to eat or drink anything after midnight, even for late starting procedures, is that just in case an early procedure gets cancelled, we can move another patient up without worrying about whether he had just drank something. The last thing the hospital wants is for an expensive operating room to sit empty while we wait for the two hour window to pass.

So let's do patients a favor and consider letting them drink a refreshment up to two hours before surgery. They will feel better when they come to preop. If they are happy, they will make your life better too.


  1. First of all, you should do your homework before advocating a sports drink for a patient going through a surgical marathon. Secondly, as you stated, Gatorade is a sports drink, not a perioperative approved nutritional beverage as is Clearfast. Thirdly, Clearfast meets ASA Perioperative Fasting Guidelines for Clear Liquids and is an FDA Medical Food; Gatorade is not. Lastly, Clearfast contains the ideal formula of poly-saccharides (maltodestrin = 69 grams), Calories (230), and Osmolarity (280), which are vital to the rate of gastric emptying; Gatorade (above) contains zero (0) poly-saccharides, only 80 calories, and an osmolarity of 350 (normal osmolarity is between 280-300mosm. Lastly, research shows that Clearfast clearly outperforms Gatorade with regard to Length of Stay, significant reductions in infections and re-admissions, not to mention the need for less fluids post surgically. I wonder what you would give your family prior to a surgical procedure; I think I know? In closing, please get your facts straight before making such uninformed recommendations.

    1. Looks like the Clearfast representative is here...

    2. Rep for company; fear of losing job?????


    4. I too drank Gatorade and it did bother me one bit. Maybe you sbpuld get your facts straight. That was just plain ride!

  2. I was so glad that you mentioned how hard it is to start the IV. I'm diabetic and simply can't go that long without liquid. When I do they can never find a vein to start the IV or get any blood to come out if I'm having a blood test. Last time I had oral surgery it took nearly an hour for them to get the IV started. Four or five different people tried and stuck me in about ten places. One of them hollered "Give her some nitrous" when I said I felt sick. They said one of my veins collapsed. Both of my arms turned black and blue from above the elbow to my fingertips. I'm having surgery tomorrow and I don't care what they say, I'm having some water when my mouth gets so dry I can't swallow.

  3. Using a drink like clearfast is highly recommended by so many in the know. You must learn why and read.

    Whoever suggested a sports drink clearly doesn't understand the effects that maltodextrin have on the body and it is all very positive...They also lack the understanding of what a sports drink has in sugar content, in fact it is almost all sugar and very few maltodextrin, like 3? Clearfast has 44 maltodextrin! Talk to a nutritionist please! If this person is an anesthesiologist who wrote this above, they really lack understanding...Have you ever heard of osmolarity? Do you know the osmolarity of sports drinks? Well into the 600s and higher. Clearfast? 280 osms the same as the body. So absorption is greatly enhanced. Sports drinks will not exit the system of a patient in two hours or less, Clearfast does. Did you know that the ASA overturned NPO in 1999? Did you know that the ASA updated the guideline in 2011 to include feeding?

    Read the Texas Tech Study and many others, you need to do your homework. The benefits are tremendous for the patient! All of the positive things that were mentioned clearly occur in addition whether it is more calm, veins are more palpable, insulin resistance reduced, patient length of stay reduced 50% in major cases and again all evidenced based. Is Duke wrong in their studies?

    Nestle has great products and many physicians try to use their products even though they contain protein! You cannot have any protein prior to surgery. So the lack of understanding by the medical community is immense. Outpatient Surgery Magazine did a study one year ago with docs. 54% are still NPO with their patients. Patients need to learn about products like Clearfast to assist them in a better outcome, even if the docs are afraid to change their own personal protocol of NPO which is so outdated. Docs need to read...all the documentation is out there.Get With It All!

  4. I'm scheduled for surgery in two weeks. My doctor wants me to drink 8 oz of Gatorade in the morning when I wake up and take two Tylenol.

  5. This is like playing spot the vegan game.

    Say something that relates to a person's field, they go off on it, and one can easily watch the world burn as they fight out their case in point.

  6. I was surprised when I was advised to drink apple juice the morning of my gallbladder surgery. 3 hrs prior and 400mg.

  7. I'm just scared to do anything wrong cause they told Ken clearly "NOTHING TO EAT NOR DRINK AFTER MIDNIGHT" I AM DESPERATE TO GET THIS HAND/WRIST SURGERY OVER & SAFELY. SAFETY FIRST AS I SAY BUT INSTEAD OF SMOKING I VAPE AND VAPING WILL DEHYDRATE ME OR ANYBODY WITHOUT DRINKING FLUIDS WITH IT,OYS A KNOWN FACT FROM ONE OF THE GREATEST ONLINE VAPE STORES "ECBLENDS" SO LOOK IT UP, LOL (HAHA as she laughs nervously) I'm so terrified! One main reason is I drank peppermint schnapps not long ago and I read where they want you alcohol free for a few weeks before surgery...??? Never worried in the past much and I've had several surgeries. Gallbladder,3 or more DNC's due to bleeding after miscarriage & then finally the major surgery my hysterectomy,then my latest last two in 2010 or 11 on my left knee twice for strep infection.I WASNT SCARED! ONLY ON MY VERY FIRST SURGERY I WAS.WHY NOW? I KNOW WHY! It's cause I'm much older. Well I was 47-48 when I had surgery on my left knee twice! One surgery almost after the other. OK I thought by writing my fears down it'd make me feel better. It did little bit.Well I wish myself a safe surgery that goes fantastic even if I drink a Mountain Dew with some cold water 2 hours before time.

  8. All the extremely offended comments about Gatorade are hilarious...given that a lot of ERAS (enhanced recovery after surgery) protocols around the country use ...GATORADE.