BMJ Open: first published as 10.1136/bmjopen-2021-060716 on 8 July 2022. Downloaded from http://bmjopen.bmj.com/ on December 8, 2023 at Pakistan:BMJ-PG Sponsored.

Protected by
Open access Original research

Current practice of postoperative

fasting: results from a multicentre
survey in China
Lifei Lai,1 Lianghua Zeng,2 Zhijing Yang,3 Yingling Zheng,4 Qianqian Zhu ‍ ‍1

To cite: Lai L, Zeng L, Yang Z, ABSTRACT

et al. Current practice Objective A gap between clinical practice and evidence is STRENGTHS AND LIMITATIONS OF THIS STUDY
of postoperative fasting: common. The present multicentre study was designed to ⇒ The present study was a multicentre survey con-
results from a multicentre ducted in a large city in China.
explore the actual postoperative fasting practice, including
survey in China. BMJ Open ⇒ The present study provides unique data on post-
the instructed fasting time from the ward staff and the
2022;12:e060716. doi:10.1136/
actual postoperative fasting time. operative fasting times in a large cohort of patients
bmjopen-2021-060716
Design Multicentre survey. from four tertiary hospitals.
► Prepublication history for Setting Four tertiary hospitals in Shenzhen City, China. ⇒ This study may support the rationale for interven-
this paper is available online. Participants A total of 988 patients completed a survey tions targeting postoperative oral intake time in fu-
To view these files, please visit ture studies.
on instructed and actual postoperative fasting.
the journal online (http://dx.doi.​ ⇒ The results of this study may not be generalisable to
Outcomes All patients received postoperative instructed
org/10.1136/bmjopen-2021-​
fasting time from the ward staff. The median instructed other regions or countries.
060716).
fasting time for fluids from ward staff was 6 hours (IQR,
LL, LZ and ZY are joint first 4–6 hours), and the median instructed fasting time for
authors. solid food was also 6 hours (IQR 5–6 hours) after surgery.
The actual postoperative fasting time, including fluid and care in major gynaecologic surgery even
Received 30 December 2021 solid food intake, was significantly longer than the time recommends oral intake immediately after

copyright.
Accepted 13 June 2022
recommended by the ward staff (both p<0.001). surgery.5 6 Meanwhile, a gap between clinical
Results The median time to postoperative first flatus (FFL) practice and feeding evidence or guidelines
was 16.5 hours (IQR 8–25.5 hours), and the median time is common.7 8 Even in guidelines, there were
to postoperative first faeces (FFE) was 41 hours (IQR 25– little data about how early is ‘early’.9 Patients
57 hours). The fasting time was significantly shorter than were also confused about when to start oral
the time to FFL and the time to FFE, regardless of surgery intake, and had to endure thirst and hunger.
type or anaesthesia type (all p<0.001). Postoperative
Therefore, the present multicentre study was
nausea and vomiting (PONV) occurred in 23.6% of
designed to explore actual oral intake prac-
© Author(s) (or their patients. After surgery, 58.70% of patients reported thirst,
and 47.47% reported hunger. No ileus occurred. tices after surgery.
employer(s)) 2022. Re-­use
permitted under CC BY-­NC. No Conclusion Approximately half of the patients reported
commercial re-­use. See rights thirst and hunger postoperatively. Patients initiated
and permissions. Published by oral intake earlier than the time to FFL or FFE without
BMJ.
METHODS
increasing serious complications. This study may support Data were collected from four tertiary
1
Department of Anesthesiology, the rationale for interventions targeting postoperative oral
The Seventh Affiliated Hospital hospitals: the Seventh Affiliated Hospital of
intake time in future studies.
of Sun Yat-­sen University, Sun Yat-­sen University, Shenzhen Qianhai
Shenzhen, China Shekou Free Trade Zone Hospital, Integrated
2
Department of Anesthesiology, INTRODUCTION Traditional Chinese and Western Medicine
Shenzhen Qianhai Shekou Free
Traditional postoperative oral nutrition is Hospital and Shenzhen University General
Trade Zone Hospital, Shenzhen,
China usually initiated after the indication of return Hospital. This study was conducted in accor-
3
Department of Anesthesiology, of bowel function, including passage of flatus, dance with the principles of the Declaration
Shenzhen University General passage of stool and bowel sounds. This tradi- of Helsinki. Patients were assured that their
Hospital, Shenzhen, China tional approach has been used to prevent answers were confidential, and that no data
4
Department of Anesthesiology,
postoperative complications. It is believed that compromising privacy could be obtained.
Integrated Traditional Chinese
and Western Medicine Hospital, tradition can reduce the incidence of para- The patients were informed that they could
Shenzhen, China lytic ileus or anastomotic leakage. However, quit the survey at any time. Verbal informed
there is little evidence to support the tradi- consent was obtained from all patients before
Correspondence to they completed the survey. The requirement
tional postoperative oral nutrition regime. In
Dr Qianqian Zhu;
​zhuxx25@​mail.s​ ysu.​edu.c​ n and contrast, evidence indicates that early postop- for written informed consent was waived by
Ms Yingling Zheng; erative oral intake is safe and beneficial, even the Ethics Committee because the survey was
​1039902956@​qq.​com in gastrointestinal surgery.1–4 Postoperative retrospective.

Lai L, et al. BMJ Open 2022;12:e060716. doi:10.1136/bmjopen-2021-060716 1

 BMJ Open: first published as 10.1136/bmjopen-2021-060716 on 8 July 2022. Downloaded from http://bmjopen.bmj.com/ on December 8, 2023 at Pakistan:BMJ-PG Sponsored. Protected by
Open access

Participants Table 1 The sociodemographic characteristics of patients

No previous study has calculated the sample size. There-
Variables N Percentage
fore, referring to a previous survey which explored preop-
erative fasting,10 we conducted surveys for four consecutive Gender
work weeks from the four hospitals mentioned above.  Male 425 43.0%
Inclusion criteria were adult patients with American  Female 563 57.0%
Society of Anesthesiologists (ASA) physical status I–III
Age 44.24±0.43*
without cognitive impairment who underwent elective
surgery from 13 September 2021 to 17 October 2021 ASA
and were administered anaesthesia by anaesthesiologists.  I 268 27.1%
The exclusion criteria were day surgery, cardiovascular  II 702 71.1%
surgery, neurosurgery and transplant surgery. Patients  III 18 1.8%
whose anaesthesia was managed by the interviewers were
Post opioids used 107 10.8%
also excluded. Patients who refused to complete the
survey or who were lost to follow-­up were excluded from Surgery type
the final analysis. Gastrointestinal surgery 65 6.6%
Non-­gastrointestinal 923 93.4%
Survey surgery
Patients were surveyed by the researchers from the second  Abdominal non-­ 91 9.2%
day after surgery until the day they were discharged gastrointestinal surgery
from the hospital. The questions included whether they
 Thyroid, breast and 143 14.5%
received instructions and who they received them from body surface surgery
about when to initiate postoperative oral intake, the
 Gynecologic surgery 186 18.8%
actual time that they started oral intake, whether they
endured postoperative nausea and vomiting (PONV), the  Obstetric surgery 17 1.7%
time to postoperative first flatus (FFL) and the time to  Thoracic surgery 57 5.8%
postoperative first faeces (FFE). Other clinical data were  Otolaryngology surgery 87 8.8%
collected from the medical records if the patients agreed  Urological surgery 213 21.6%

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to complete the survey.
 Orthopaedic 109 11.0%
Statistical analysis  Spinal surgery 20 2.0%
The Statistical Package for the Social Sciences (V.21.0) Anaesthesia type
was used to perform statistical analyses. Qualitative and General anaesthesia 815 82.5%
ordinal data are expressed as absolute frequencies.
 Endotracheal 524 53.0%
The normality of the distribution of quantitative data intubation (EI)
was tested using the one-­ sample Kolmogorov-­ Smirnov
 Laryngeal mask (LMA) 203 20.5%
test. Quantitative data are expressed as the mean±SE or
median values with IQRs for normally and non-­normally  Intravenous without EI 88 8.9%
distributed data, respectively. The Wilcoxon signed-­rank or LMA
test was used to compare differences between paired data Regional anaesthesia 173 17.5%
that were not normally distributed. The Mann-­Whitney  Intraspinal anaesthesia 133 13.5%
U test was used to compare differences between different  Peripheral nerve block 40 4.0%
populations. Differences were considered statistically
Complications
significant when two-­tailed p values were <0.05.
 PONV 233 23.6%
Patient and public involvement  Ileus 0 0
No patients or public members were involved in the devel-  Thirsty 580 58.70%
opment of the research question, recruitment, outcome  Hungry 469 47.47%
measures or design of the study. There are no plans to
disseminate the results of this study to the participants.
*Mean±SE error.
ASA, American Society of Anesthesiologists; PONV, postoperative
nausea and vomiting.
RESULTS
In total, 1086 patients were approached to participate
in the survey. After excluding 98 patients who refused in table 1. Of the 988 patients, 268 were ASA I, 702 were
to participate or were lost to follow-­ up, 988 patients ASA II and 18 were ASA III. In total, 107 patients were
completed the survey and were included in the final prescribed opioids for postoperative analgesia. A total
analysis. The characteristics of these patients are shown of 815 patients underwent general anaesthesia, and 173

2 Lai L, et al. BMJ Open 2022;12:e060716. doi:10.1136/bmjopen-2021-060716

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Table 2 The instructed postoperative fasting time, actual postoperative fasting time and the time to FFL and FFE in different
population
Instructed Instructed
fasting time fasting time Actual fasting Actual fasting
for fluids for solid time for fluids time for solid Time to FFL Time to FFE
(hours) food (hours) (hours) food (hours) (hours) (hours)
Total populations* 6 (4–6) 6 (5–6) 6.5 (5.5–7.5) 7 (6–8) 16.5 (8–25.5) 41 (25–57)
† 6.18±0.19 7.52±0.28 7.46±0.18 9.72±0.31 18.57±0.44 44.58±0.87
Surgery type
Non-­gastrointestinal 6 (4–6) 6 (5–6) 6.5 (5.5–7.5) 7 (6–8) 16 (8–25) 41 (25–58.0)
surgery*
† 6.12±0.19 7.44±0.28 7.35±0.18 9.59±0.32 18.33±0.45 44.73±0.90
Gastrointestinal* 6 (4–6) 6 (4–6) 7 (6–8.25) 7.5 (6–12.75) 20 (10.75–28.25) 36.5 (22–55.5)
† 7.05±0.90 8.71±1.36 9.02±0.89 11.65±1.34 21.92±1.65 42.49±2.97
Anaesthesia type
General anaesthesia* 6 (4–6) 6 (4–6) 6.5 (5–7.5) 7 (6–8) 16 (8–25.5) 40.5 (25–57)
† 6.22±0.22 7.55±0.31 7.47±0.21 9.66±0.35 18.32±0.48 44.19±0.94
Regional anaesthesia* 6 (6–6) 6 (6–6) 7 (6–8) 7.5 (6.5–8.75) 18 (9–25) 41 (24–62)
† 6.00±0.28 7.36±0.61 7.41±0.30 9.99±0.65 19.71±1.00 46.45±2.23
*Median with IQR.
†Mean±SE error.
FFE, first faeces; FFL, first flatus.

underwent regional anaesthesia. Considering the surgery who underwent gastrointestinal than those who underwent

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distribution, 65 patients underwent gastrointestinal un-­gastrointestinal surgeries (9.02±0.89 vs 7.35±0.18 hours,
surgery and 923 underwent non-­gastrointestinal surgeries p=0.032 for fluids, 11.65±1.34 vs 9.59±0.32 hours, p=0.036
(table 1). for solid food; table 2, figure 2).
Considering the differences between anaesthesia types,
Instructed and actual postoperative oral feeding time among the instructed postoperative fasting times did not differ
patients significantly between general and regional anaesthesia
All patients received postoperative instructions on fasting (figure 3). Intriguingly, the actual postoperative fasting
time after surgery from the ward staff. However, only 124 time differed significantly between general and regional
(12.55%) patients received information about the postop- anaesthesia (7.47±0.21 vs 7.41±0.30 hours, p=0.006 for
erative fasting time from anaesthesiologists. The median fluids, 9.66±0.35 vs 9.99±0.65 hours, p=0.002 for solid
instructed fasting time for clear fluids from ward staff was food; table 2, figure 3).
6 hours (IQR, 4–6 hours; table 2). The median instructed
fasting time for solid food from ward staff was also 6 hours The time to postoperative FFL and FFE
(IQR, 5–6 hours; table 2). The median time to FFL was 16.5 hours (IQR, 8–25.5
The instructed fasting time for fluids by ward staff was hours, table 2), and the median time to FFE was 41 hours
significantly shorter than that for solid food (6.18±0.19 (IQR, 25–57 hours; table 2).
vs 7.52±0.28 hours, p<0.001, table 2 and figure 1). The The time to FFL or FFE was significantly longer than
actual fasting time for fluids was also significantly shorter the patients’ actual fasting time (including fluids and
than the actual fasting time for solid food (7.46±0.18 vs solid food), regardless of surgery or anaesthesia type (all
9.72±0.31, p<0.001; table 2, figure 1). p<0.001; figures 1–3, table 2). The time to FFL was signifi-
Furthermore, regardless of the intake of oral fluids cantly longer in patients who underwent gastrointestinal
or solid food, the actual postoperative fasting time was surgery than in those who underwent non-­gastrointestinal
significantly longer than that instructed by the ward surgery (figure 2), whereas no significant difference was
staff (both p<0.001, figure 1). The above phenomenon observed between the two surgery types when considering
was observed regardless of surgery or anaesthesia type FFE (figure 2). There were no significant differences
(figures 2 and 3). between general and regional anaesthesia with regard to
When comparing gastrointestinal and non-­gastrointestinal FFL or FFE (figure 3).
surgeries, the instructed postoperative fasting times did not Complications
differ between them (figure 2). Of note, the actual post- PONV occurred in 23.6% of patients (table 1). A total of
operative fasting times were statistically longer in patients 98 patients experienced nausea after the first oral feeding,

Lai L, et al. BMJ Open 2022;12:e060716. doi:10.1136/bmjopen-2021-060716 3

 BMJ Open: first published as 10.1136/bmjopen-2021-060716 on 8 July 2022. Downloaded from http://bmjopen.bmj.com/ on December 8, 2023 at Pakistan:BMJ-PG Sponsored. Protected by
Open access

Figure 1 The instructed and actual postoperative fasting time, and the time to FFL and FFE. *P<0.05; **p<0.01; and
***p<0.001. #1, comparison between the time to FFL and actual postoperative fasting time (fluids or solid food); #2, comparison

copyright.
between the time to FFE and actual postoperative fasting time (fluids or solid food). FFE, first faeces; FFL, first flatus.

Figure 2 The comparisons between gastrointestinal and non-­gastrointestinal surgery. *P<0.05 and ***p<0.001. $1, comparison
between the time to FFL and actual fasting time (fluids or solid food) regardless of surgery type; $2, comparison between the
time to FFE and actual fasting time (fluids or solid food) regardless of surgery type. FFE, first faeces; FFL, first flatus.

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Figure 3 The comparisons between general and regional anaesthesia. **P<0.01; and ***p<0.001. &1, comparison between the
time to FFL and actual fasting time (fluids or solid food) regardless of anaesthesia type; &2, comparison between the time to
FFE and actual fasting time (fluids or solid food) regardless of anaesthesia type. FFE, first faeces; FFL, first flatus.

and 81 vomited after the first oral feeding. Furthermore, could avoid nausea, vomiting and ileus and accelerate

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both the time to oral fluids and solid food were signifi- postoperative recovery.15–18 As an important part of
cantly shorter in patients without PONV than those with perioperative nutrition, early feeding after surgery has
PONV (6.72±0.15 vs 9.86±0.58 hours, p<0.001 for fluids, been shown to accelerate postoperative bowel function
8.40±0.26 vs 14.00±0.95 hours, p<0.001 for solid food, recovery.19 20 Previous studies have supported early intake
results are not shown in table 1). after gastrointestinal surgery and total laryngectomy, with
Paralytic ileus was not observed. Of the patients, some guidelines recommending early oral feeding after
58.70% reported thirst, and 47.47% reported hunger surgery.21–24 A guideline from the European Society of
after surgery (table 1). No cases of ileus were observed. Anaesthesiology and Intensive Care recommends that
patients resume drinking soon after elective surgical
procedures.14 However, the evidence for the guideline
DISCUSSION
was from only four articles, of which two evaluated oral
This multicentre study demonstrated that all patients
fluid intake after caesarean delivery under regional
received information regarding postoperative intake initi-
anaesthesia.25 26 A survey of French anaesthesiology prac-
ation from ward staff. The actual initiation times for oral
tices demonstrated that the majority of anaesthesiologists
fluid and solid food intake were significantly higher than
those instructed by the ward staff. Notably, the instructed allowed fluid intake 2 hours or immediately after surgery,
postoperative fasting time did not differ regardless of the and solid food 4 hours after surgery, based on airway
surgery or anaesthesia type. Furthermore, the time to management.8 In the present study, patients’ actual post-
initiate drinking or eating was significantly earlier than operative fasting times were significantly longer than
the time to FFL or FFE. PONV occurred in 23.6% of the those instructed by ward staff. In line with the preop-
patients, and no paralytic ileus was observed. erative fasting in our previous study, the patients might
A previous study demonstrated that risk factors, always be conservative.27 Notably, in the present study,
including opioid use, surgical complexity and fluid over- patients initiated oral intake before the passage of flatus
load, are associated with postoperative ileus.11 Chewing or stool, and no serious ileus occurred.
gum, the advent of laparoscopy, and perioperative nutri- In addition to postoperative ileus, PONV is another
tion are beneficial in the recovery of bowel function concern for postoperative oral intake. Early oral intake
and prevention of postoperative ileus.12 Various studies (within 24 hours), irrespective of the presence or absence
and guidelines have clearly recommended preopera- of the indicated return of bowel function after major
tive fasting times,13 14 and preoperative fasting abbrevia- abdominal gynaecologic surgery, although safe, was asso-
tion protocols such as enhanced recovery after surgery ciated with increased PONV.28 In contrast, another study

Lai L, et al. BMJ Open 2022;12:e060716. doi:10.1136/bmjopen-2021-060716 5

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Open access

demonstrated that in an outpatient setting, early postop- oral intake and bowel sounds in clinical settings was not
erative oral fluid intake was associated with a reduction in analysed in the present study. Third, the reason why some
the incidence of PONV.29 The present study found that patients were conservative and initiated oral intake later
the incidence of PONV was 23.6%, and fewer than 10% than instructed by medical staff remains to be clarified.
of patients reported nausea or vomiting after the first Fourth, 10.8% of patients were prescribed opioids for
postoperative oral feeding. Furthermore, both the time postoperative analgesia, which might affect postopera-
to first drink and eat was significantly shorter in patients tive feeding. Finally, the multicentre was from a big city
without PONV than those with PONV. Therefore, PONV in China. These results may not be generalisable to other
should not be the main concern of early oral intake. regions or countries.
Early oral intake after surgery was associated not only In conclusion, approximately half of the patients
with bowel function recovery and PONV incidence reduc- reported thirst and hunger after surgery; however, in
tion but also with fewer infectious complications and practice, postoperative fasting lasts longer than 6 hours
shortened hospitalisation.30 Irrespective of the different regardless of surgery or anaesthesia type. Most patients
scheduled surgeries, including those involving the gastro- initiate oral intake earlier than the time to FFL or FFE,
intestinal system, or different anaesthesia types, including without increasing the rate of serious complications. The
intraspinal anaesthesia, early oral intake has shown bene- present results might support the rationale for interven-
fits and no harm.3 20 22 However, the gap between clinical tions targeting postoperative oral intake time in future
practice and evidence is common.7 31 Patients scheduled studies.
for surgery usually undergo a much longer preoperative
fasting than the evidence-­based guidelines recommend,27 Acknowledgements The authors thank all the patients who participated in this
study. We would like to thank Editage (www.editage.cn) for the English language
and most patients still have to endure long postoper- editing.
ative fasting. In the present study, the ward staff always
Contributors LL, LZ, ZY and YZ: Submission for IRB approval, inclusion of
instructed the patients to initiate oral feeding 6 hours participants and data collection. QZ: Data analysis and drafting. QZ and YZ: Study
after surgery. The guidelines encouraged patients to design and critical revision of the manuscript. All authors have read and approved
drink when they were awake and nausea free after the the final manuscript. All authors had full access to all of the data (including
operation.18 An oral diet can usually be started within 4 statistical reports and tables) in the study and can take responsibility for the
integrity of the data and the accuracy of the data analysis.
hours after surgery.18 Approximately half of the patients
Funding This study was funded by the authors.
in the present study experienced thirst and hunger after

copyright.
surgery. There are several reasons for this finding; first, Competing interests None declared.
although guidelines recommend early oral intake after Patient and public involvement Patients and/or the public were not involved in
surgery, the exact time is not always as clearly mentioned the design, or conduct, or reporting, or dissemination plans of this research.
as that in preoperative fasting guidelines. Therefore, the Patient consent for publication Consent obtained directly from patient(s)
clinical staff were cautious and conservative about early Ethics approval This study involves human participants and was approved by
postoperative oral intake. The reason for the gap between the Institutional Review Board of the Seventh Affiliated Hospital of Sun Yat-­sen
University (chairperson: Professor Chun Chen, approval number: KY-­2021-­076-­01).
guidelines and clinical practice remains to be explored in
future studies. Second, the patients were more conserva- Provenance and peer review Not commissioned; externally peer reviewed.
tive than the clinical staff. Similar to preoperative fasting, Data availability statement All data relevant to the study are included in the
which lasted longer than the durations instructed by article or uploaded as supplementary information.
clinical staff from our previous observation,27 patients’ Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which
actual postoperative fasting time was also longer than that
permits others to distribute, remix, adapt, build upon this work non-­commercially,
instructed by clinical staff. The reason for the conserva- and license their derivative works on different terms, provided the original work is
tive nature of the patients also needs to be elucidated in properly cited, appropriate credit is given, any changes made indicated, and the use
future studies. is non-­commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
The present study has certain limitations. First, the ORCID iD
existing knowledge of the clinical staff on postoperative Qianqian Zhu http://orcid.org/0000-0002-6897-136X
fasting was not investigated, which might potentially
affect patients. Whether the instructions from anaesthesi-
ologists and ward staff influence the actual postoperative
fasting time differently remains to be explored. However,
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