The hunger games - when nil by mouth goes too far - an interview with Sharon Carey, APD, PhD
No marathon runner would fast for 12 hours before a race, yet it’s often expected of patients facing another endurance test: major surgery.
“Instead of fasting, patients should be carb loading so their body can cope better with the stress of surgery. Being well nourished before surgery reduces the risk of infection, wound breakdown and other complications and the length of stay in hospital,” says Sharon Carey, Head of Nutrition and Dietetics at Sydney’s Royal Prince Alfred Hospital.
Prolonged fasting is a particular problem for patients having abdominal surgery who may be already undernourished because of their condition, such as gastrointestinal cancer or severe inflammatory bowel disease adds Dr Carey, a gastrointestinal specialist dietitian.
The ‘no solids for six hours before surgery and no fluids for two hours’ rule is to reduce the risk of patients aspirating gastric contents during anaesthesia. But changes to operating schedules or poor communication between staff can stretch this recommended period for 12 hours or even more than 24 hours, says Sharon Carey whose study of 200 people having abdominal surgery published in the Asia Pacific Journal of Clinical Nutrition last year found that ‘fasting leads to fasting’. In other words, extended fasting before surgery can make it harder for patients to resume eating solids after surgery because of a higher risk of complications and a loss of confidence with eating.
This can delay recovery and resumption of bowel movements, she says.
“The timing of surgery can be unpredictable because cancellations and emergency surgery can disrupt the schedule - if a liver transplant suddenly comes in, for example, other operations will be delayed. Or you might be booked in for surgery on Tuesday afternoon but a doctor may insist you fast from midnight on Monday in case there’s a cancellation and your surgery is brought forward,” she says. “There are also instances where people are routinely fasted for procedures that don’t need a general anaesthetic - such as a wound dressing. It’s a clunky system. “
But she’s aiming to improve it with the help of an NHMRC fellowship grant for research into fasting patients before gastrointestinal surgery.
“I’m trying to identify the barriers to reducing fasting time. One is the ‘just in case’ mentality where people having afternoon surgery still have to fast from midnight, for instance; another is fear - junior doctors are often so frightened of getting into trouble from senior doctors that they become over-cautious,” she says. ”I’m also looking at ways of better communication such as alerts on patients’ records that show if someone has been fasting for too long, and a better way or working out who’s to decide about fasting time - at the moment there are too many people involved and no one taking responsibility.”
She’s also been seconded to help improve training and education for junior doctors in Royal Prince Alfred Hospital’s cardiothoracic unit after it lost its accreditation to train doctors last year.
“I’m setting up a training program to help surgeons and trainees have a more structured approach to education, including a system for providing constructive feedback, and hopefully improving communication” she says.
How does a dietitian get tasked with tackling communication in a surgical unit? Partly because she’s used to working closely with surgeons.
“When I worked in a UK hospital I was put in the upper GI unit because no one else wanted to work with the surgeons there - they were some difficult personalities. It was a very hierarchical system and you had to be able to stand up to the surgeons and prove that your experience as a dietitian counts. Working with surgeons is all about developing trust.
“People are often surprised that an allied health professional like a dietitian is given the job of improving communication and behaviour issues involving surgeons - but there are skills you acquire as a dietitian like good communication, negotiation, conflict resolution and project management that surgeons can learn from. But the cardiothoracic surgeons have been great to work with and if I want to address the fasting issue with them in the future, I know that they’ll listen because I have earned their respect.”
Sharon Carey has presented several webinars for Education in Nutrition. Her latest webinar is Gastroparesis and dysmotility disorders