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NURSESPERCEPTIONOFPREOPERATIVELY
FASTINGPATIENTSANDCOMMUNICATION
WITHTHEATRESTAFF
&
HOWTHISDIFFERSTOWHATCURRENT
EVIDENCEBASEDRESEARCHSUGGESTS
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CONTENTS
TITLE ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PAGE. 1
CONTENTS ~~~~~~~~~~~~~~~~~~~~~~~~ PAGE. 2
INTRODUCTION ~~~~~~~~~~~~~~~~~~~~ PAGE. 3-4
DEFINITION OF TERMS ~~~~~~~~~~~~~~ PAGE. 4-6
HISTORY & PATHIOPHYSIOLOGY
OF ASPIRATION PNEUMONITIS ~~~~~~~ PAGE. 7-9
LITERATURE REVIEW ~~~~~~~~~~~~~~~ PAGE. 10-18
CODE OF CONDUCT
LEGAL IMPLICATIONS ~~~~~~~~~~~~~~ PAGE. 18-19
PREOPERATIVE FASTING IN THE
UK & OVERSEAS ~~~~~~~~~~~~~~~~~~~~ PAGE. 19-22
RECOMMENDATIONS ~~~~~~~~~~~~~~~ PAGE. 22-25
CONCLUSION ~~~~~~~~~~~~~~~~~~~~~~ PAGE. 26-28
REFERENCE LIST ~~~~~~~~~~~~~~~~~~~ PAGE. 29-33
APPENDIX 1 ~~~~~~~~~~~~~~~~~~~~~~~ PAGE. 34-35
APPENDIX 2 ~~~~~~~~~~~~~~~~~~~~~~~ PAGE. 36-37
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Introduction
From my time as a student nurse I have worked on both surgical and
medical wards. I have found in both these areas patients who have been
preoperatively fasted have often been Nil by mouth from midnight if
they are on the next day morning list. Those on the afternoon list are nil
by mouth after a light breakfast on the day of surgery. It has, become
custom and practice in many clinical settings to deprive patients both
food and fluids for unnecessarily long periods of time. Often when I asked
the nurse in charge why patients were fasted for so long, I was been told
Its always been done this way or The theatre staff like us to do it this
way. So I decided to look at the research available and see how long a
patient should be fasted from food and fluids? How this is reflected in
current nursing practice and how it impacts the patient in a psychosocial
and psychological aspect.
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The preoperative fasting of surgical patients before having a general
anaesthetic is a widely established clinical practice. It is considered
essential in reducing the chances of vomiting and regurgitation and the
possible aspiration of gastric contents during anaesthesia (Seymour 2000).
However most hospital trusts dont appear to have standard policies or
guidelines of the specific times a patient should be fasted for. The
decision is then left up to the anaesthetist or the nurse in charge of the
ward.
Definition of Terms
To fast which means to abstain from eating and drinking for a limited
period as stated by the Cambridge English dictionary is the commonly
used term in nursing. Anyone having elective surgery is fasted for a
period of time to reduce the risk of vomiting during induction. Hamilton-
Smiths study (1972) found that health professionals understanding of how
long this period of time should be were very varied often based on
tradition rather than evidence based. In the National Health Service
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(NHS) under the current Labour government the term evidence based
means the process of systematically finding, appraising and using
research findings as the basis for clinical decisions Royal College of
Nursing (2005). The Royal College of Nursing goes on to describe
evidence based clinical practice as involving making decisions about
care of individual patients, based upon the best available research
evidence, rather than nurses personal opinion or common practice (which
may not be evidence based). Evidence based clinical practice involves
integrating individual clinical expertise and patient preferences with the
best available evidence from research. If we as nurses are to bring nursing
as a profession up to date we need to utilize this evidence to provide the
best care for our patients.
Dimatteo (1994) sees Communication as the fundamental instrument by
which health care professionals and patient relate to each other in an
attempt to achieve therapeutic goals. Where as Owens (2002) defines
Communication as the process of exchanging information and ideas.
According to Light (1997) communication involves relating to others,
affecting them and letting them affect you. Light (1997) further claims
that the four main purposes of communication are exchanging
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information, conveying wants and needs, establishing social closeness and
adhering to social etiquette.
Communication is defined as an interchange of thoughts feelings and
opinions among individuals. Verbal communication is effective when it
satisfies basic desires for recognition, participation and self-realization by
direct personal contact between persons. There is general assumption that
effective communication is achieved when open two-way communication
takes place, and patients are informed about the nature of their illness and
treatment and are encouraged to express their anxieties and emotions.
This view assumes that open communication, full information about a
disease and its prognosis, has benefits for all patients.
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History and Pathophysiology of Aspiration Pneumonitis
The current practice of recommending nil by mouth after midnight until
the time of surgery is widely believed to have originated from
Mendelsons study in 1946. Mendelson described the pathophysiology of
acid aspiration through research in to 44016 obstetric patients receiving
general anaesthesia in a New York hospital between 1932 and 1946.
Mendelson recorded 45 cases of aspiration, 40 aspirated liquid while the
remaining 5 aspirated food which caused an obstruction and led to the
deaths of two patients from suffocation. These two patients had ingested a
full meal, one 8 hours previously and the other 6 hours previously. In his
conclusion he proposed that a reduction in aspiration under general
anaesthesia would be achieved by: emptying of the stomach before
general anaesthesia; and adequate equipment (a tilting table, transparent
anaesthetic masks, suction and equipment for tracheal intubation. Later
on, these preventative measures were extended to other forms of surgery.
The number of aspirations in all patients having a general anaesthetic was
reduced to 1-10 in 10,000, which equates to 0.01-0.1% (Mellin-Olsen et al
1996; Flick et al 2002). Less than 5% of these aspirations resulted in
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Aspiration pneumonitis
This does represent a small percentage risk, but in absolute terms this
could be a large number of patients, given that an estimated 6 million
people in the UK alone have surgery under a general anaesthetic each
year, Department of Health (2005).
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Literature Review
My literature search included: textbooks on preoperative fasting,
metabolic effects of fasting and surgery textbooks; manual journal
searches; and the use of various computerized databases. These databases
included Medline, CINAHL & Nursing Collection. Keywords for
database searches included the following: nil by mouth, fasting
guidelines, preoperative care, and evidence based research. These
searches yielded over a five hundred articles, of which around 40 were
relevant to my project.
I initially decided to compare and analyse Hamilton Smiths (1972) study
and Hung's (1992) study. The reason behind this was that Hungs (1992)
study replicated Hamilton Smiths (1972) study which investigated the
practice of preoperative fasting procedures in hospitals. As there was a 20
year gap between the two studies I could review these and compare the
findings and analyse if and how things had changed. Then from this I
could review current studies and proposed recommendations that had
taken place up to 2006 and further compare and analyse this to see how
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the role of the nurse had changed and how the available evidence based
research had been utilised by nurses in clinical practice.
Hamilton Smiths (1972) study found there was no hospital or ward policy
regarding preoperative fasting procedures. Without an agreed policy or
guidelines there was no clear means of establishing a uniformity of
practice and there were considerable variations in the interpretation and
execution of this specific preoperative care. Hungs (1992) study also
came across the same problem of there being no clear hospital or ward
policy. Hamilton Smith (1972) found that anaesthetists acknowledged
ultimate responsibility for patients having surgery under a general
anaesthesia and decided how long they should be preoperatively fasted
for. However this differs with Hungs (1992) study which found that the
majority of anaesthetists left the responsibility and execution of minimum
fasting times up to the nurses on the ward. Jester and Williams (1999)
sides with Hamilton Smith (1972) that;
Wherever possible, the anaesthetists should prescribe the latest
time for food and fluids. When this is not done, nurses should feel
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empowered enough to ensure patients receive fluid preoperatively up until
a safe and appropriate time.
Hamilton Smith (1972) found nurses agreed that the minimum time
should be between 4 and 6 hours for food (65%) and 4 hours for fluids
(58%). However there was no established or agreed maximum fasting
time. This was similar to Hung (1992) but anaesthetists and nurses cited a
variety of maximum fasting times ranging from 4 to 24 hours without
intravenous infusion. The average maximum fasting time agreed by a
significant proportion of anaesthetists and nurses was 12 hours. Opinions
on when solids or milky fluids (containing fat, which has been proven to
be slower to digest) can be taken between 4 and 8 hours preoperatively.
The American Society of Anaesthesiologists (1999) recommends solids or
milky drinks should not be taken for 6 hours preoperatively. They also
suggested that clear fluids should be stopped 2 hours preoperatively and
went on to clarify clear fluids to include, but are not limited to water, fruit
juices without pulp, carbonated beverages and tea or coffee without milk.
In 2005 the Royal College of Nursing published guidelines for the UK
after analysing evidence from American Society of Anaesthesiologists
(1999). They concluded that adults who are in good health without GI
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disorders can drink water up to 2 hours before induction of anaesthesia.
Clear fluids (those which newsprint can be read through) including clear
tea and coffee up to 2 hours before induction of anaesthesia. Food to
include tea or coffee with milk can be taken 6 hours before induction of
anaesthesia. The Royal College of Nursing Perioperative fasting in
adults and children guidelines can be seen in Appendix 2.
In both Hamilton Smith (1972) and Hung (1992) studies the practice of
preoperative fasting procedures was predominantly governed by nursing
tradition and ritualistic based practice. Seymour (2000) identifies that
tradition and custom often dictate preoperative fasting regimens rather
than the patients need. This view is supported by Pandit and Pandit
(1997). This meant that patients on the morning theatre list were all fasted
at the same time (midnight) irrespective of their position in the list. All
patients on the afternoon theatre list were fasted on the morning of
surgery after a light breakfast. This resulted in the majority of
preoperative patients being deprived of food and fluid for a considerable
length of time. Other reasons often cited by nurses for such long fasting
times included the constantly changing operating lists. Since it was
expected that all patients on the same list were fasted at the same time,
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keeping wards informed of changes by theatre staff to the operating list
seemed pointless as this didnt alter the patients fasting regime. It was no
surprise to find communication between theatre staff and ward nurses was
poor and there was confusion as to who should be overall responsible for
keeping the wards up to date in the event of changes to the list. From this
Hung (1992) observed that the procedures in place were more for the
conveyance of theatre staff and ward nurses, than for the wellbeing of
patients.
The detrimental effects of prolonged preoperative fasting can be divided
in to two broad categories psychosocial and physiological. Hamilton
Smith (1972) conducted a study assessing the opinions of anaesthetists
and nurses regarding preoperative fasting. Twenty years later Hung
(1992) replicated this same study to ascertain whether preoperative fasting
procedures had changed. Both of these studies concluded that despite a
good knowledge of the possible complications caused by prolonged
preoperative fasting, anaesthetists and nurses reported that it was still
common for patients to be fasted in excess of 12 hours. A summary of
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potential complications caused by excessive preoperative fasting is set out
below:
PSYCHOSOCIAL PHYSIOLOGICAL
Confusion Dehydration
Irritability Headaches
Social isolation of missed meals Hypoglycaemia
Anxiety due to lack of information Electrolyte imbalance
and poor communication Nausea/vomiting
Jester & Williams (1999)
Patients who are fasted for long periods of time may experience some or
all of these effects, depending on their health prior to fasting.
Rowe (2000) adds that, when patients are fasted for long periods of time,
the body will draw on its own reserves and enter in to a period catabolism
that might leave the patient with considerably less strength and energy to
negotiate post-operative recovery. Also older people, often chronically
dehydrated, might be at a greater risk in these circumstances (Jester and
Williams 1999). Arndt (1999) states that patients who have fasted for
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more than eight hours are more prone to hypothermia, due to the loss of
heat produced by digestion. This has a greater importance for older people
as they have relatively less body fat than healthy adults. However,
OCallaghan (2002) points out that the reason for prolonged preoperative
fasting may be a lack of nursing knowledge regarding long term
complications.
Having performed a literature search I wanted to know why, when so
much evidence based research is now easily available, do patients still go
through such long periods of preoperative fasting?. A summary of the
main reasons that patients have to endure such long periods of fasting is
provided below:
Lack of knowledge
Evidence based material relating to preoperative fasting used to be mainly
found in anaesthetic journals; however this information is slowly
becoming more widely available to all health professionals.
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No uniformity of practice
In many hospitals there are no recorded policies or guidelines relating to
preoperative fasting. Practice tends to be tradition led rather than evidence
based.
Custom and routine
Governed by custom and routine means patients on the same theatre list,
irrespective of their position, are fasted for the same amount of time. This
relates as fasting from midnight for the morning list or, fasting after a
light breakfast on the day of surgery for the afternoon list.
Changes in theatre lists
Apparent difficulty in obtaining accurate operating times further prevents
the planning of individual regimes. Lack of communication and, poor
communication between theatre staff and ward nurses can lead to
confusion over whose responsibility it is to inform ward nurses of any
changes.
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practitioners. This includes ensuring practitioners have adequate
knowledge in order to facilitate appropriate fasting regimes. The findings
of Seymour (2000) and Pandit and Pandit (1997) go on to suggest that this
in fact is not happening. If nurses are not up to date with current evidence
based research and practices, it is not a legal defence against misconduct.
This assertion is supported by the Nursing and Midwifery Council (2004)
which states that practitioners have a professional responsibility to deliver
care that is based on current advice, best practice and where applicable,
validated research when it is available. If patients are fasted for excessive
periods of time or have not been fasted sufficiently and therefore suffer
discomfort or complications during the anaesthetic procedure as a result,
this can become a legal matter.
Preoperative Fasting in the UK and Overseas
The guidelines of the Scandinavian Society of Anaesthesiology and
Intensive Care Medicine for preoperative fasting in elective patients
(2006) represent the most recent up to date research and summarize the
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recommendations of various other national and society guidelines. Table
below:
Patients (adults and children) may drink clear fluids up to 2hours
prior to general or regional anaesthesia
Patient should not take solid food 6 hours prior to induction of
anaesthesia
Breast-feeding should be stopped 4 hours prior to induction of
anaesthesia; the same applies to formula milk
Adults may drink up to 150ml water with preoperative oral
medication up to 1 hour prior to induction of anaesthesia
Use of chewing gum and any form of tobacco should be
discouraged the last 2 hours prior to induction of anaesthesia
The Scandinavian Society of Anaesthesiology and Intensive Care
Medicine 2006) defines clear fluids as non-particulate fluids without fat:
for example, water, clear fruit juice, tea or coffee. Both cows milk and
powdered milk are treated as solid food. These Scandinavian Society of
Anaesthesiology and Intensive Care Medicine (2006) guidelines differ
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compared to the UKs Royal College of Nursing (2005) guidelines in that
adults are allowed 150ml of water when taking medication up to 1 hour
before induction of anaesthesia, and children up to 75ml. Whereas the
Royal College of Nursing (2005) guidelines only allow 30ml fluid when
taking medication for adults and 0.5ml per kg for children. Another
difference with the Scandinavian Society of Anaesthesiology and
Intensive Care Medicine (2006) guidelines includes chewing gum and any
form of tobacco should be discouraged 2 hours prior to induction of
anaesthesia. Whereas the RCN states that chewing gum is not permitted
on the day of surgery. It doesnt specify whether or not the patient can
take or smoke tobacco preoperatively. So in theory a patient in the UK
under the Royal College of Nursing (2005) guidelines can chew gum up
to midnight the day before surgery and if smoking facilities are available
within the hospital they can smoke right up until they go to theatre. The
remaining guidelines for both countries are the same in every aspect. The
common argument against modern fasting guidelines is that the
traditionally followed nil by mouth from midnight is believed to allow
the greatest flexibility for the operating team. Soreide and Ljungqvist
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(2006) state in their experience, this fear is unsubstantiated. They go on to
say
The change of guidelines develops better communication between
operating staff and the ward where the patient is waiting. This has in
many cases improved patient flow through the system.
Recommendations
A patient who is fasted preoperatively for the correct amount of time
before elective surgery is integral to safe practice. Nurses should be aware
that patients should be treated as individuals by promoting the interests of
patients in their care. It is essential that this practice must become patient
centred rather than restricted by theatre or ward traditions Nursing and
Midwifery Council (2004).
The literature I have reviewed taken from current evidence on
preoperative fasting has made little change to the traditional ward
orientated management of fasting regimes. The lack of implementation
has resulted in prolonged preoperative fasting of patients. This can have a
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detrimental effect both psychosocially and psychologically to patients.
This resulted in the recommendations below proposed by Oshodi (2004).
For evidence based practice to be a reality, factors that can hinder
the application of research to practice should be identified and
addressed
More up to date research in to how nurses could implement
evidence based individualised preoperative fasting is needed
Where trust guidelines are not yet in place, nurses should feel
empowered to negotiate with other professionals appropriate fasting
periods that are based on current evidence, as they have to act in the
patients best interest
Nurses on the ward should collaborate more with surgeons,
anaesthetists and theatre staff to keep abreast with changes in the
theatre list. This would help nurses to act responsively if there was
a cancellation or addition to the theatre list ( i.e. to withhold fluid
from patients whose name has to move up the list; to provide food
for patients whose name has been cancelled from the list to prevent
unnecessary starvation; or to provide clear fluids or toast up to a
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safe limit for patients whose names have been pushed down the
theatre list)
Ongoing education on preoperative fasting evidence and the
detrimental effects and complications of excessive preoperative
fasting should be provided to surgical nurses at ward level to
reaffirm the importance of patients being fasted appropriately
It wasnt until 2005 that the Royal College of Nursing published its own
recommendations gathered from evidence based research entitled
Perioperative fasting in adults and children The Royal College of
Nursing (2005) provided as part of the publication an A4 poster shown in
Appendix 2. This states that clear fluids can be taken up to 2 hours before
induction of anaesthesia for elective surgery in healthy adults, and that
this improves the wellbeing of the patient. Hillier (2006) agrees with this
recommendation based on current research and evidence.
The Royal College of Nursing (2005) defines clear fluids as tea and
coffee without milk or any other fluid through which newsprint can be
read. Hillier (2006) explains that the term clear fluids is too vague and
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should be removed and substituted with a short list of fluids acceptable to
anaesthetists.
The intake of solid food should have a minimum fasting period of 6 hours
as recommended by the Royal College of Nursing (2005). Whereas Hillier
(2006) recommends patients should only be starved of solids for 4 to 6
hours. Chewing gum should not be permitted on the day of surgery and,
sweets should not be eaten 6 hours before induction of anaesthesia Royal
College of Nursing (2005).
Hillier (2006) goes further in recommending that the lack of practitioners
knowledge needs to be addressed by implementing agreed well published,
trust wide policies for preoperative practice. Also changes to theatre lists
should be kept to a minimum for safety reasons and through good
communication skills between theatre staff and ward staff nurses are able
to manage patients preoperative fasting time effectively.
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Conclusion
The current practice used on most wards of prolonged fasting carries
potential risks and therefore needs to be addressed and changed. Many
valuable and practicable suggestions have been proposed by anaesthetists
and nurses, as well as guidelines and recommendations from respected
organisations. Agreed policies can be achieved through constructive and
open communication by surgeons, anaesthetists and nurses. Some nurses
may be reluctant to put evidence based preoperative fasting in to practice
if clinical guidelines or trust policies are not in place suggests Hung
(1992). However patients with factors likely to delay gastric emptying
were excluded from this review investigating the effects of shorter fasting
periods. So in reality these findings cannot be applied to all patients.
Similarly, the Scandinavian Society of Anaesthesiology and Intensive
Care Medicine (2006) guidelines and the Royal College of Nurses (2005)
recommendations were made for healthy patients. Implementing those
guidelines and recommendations is important for professional
accountability, but nursing assessment is crucial to identify at risk patients
such as those with hiatus hernia, diabetes mellitus and those who are
obese. Evaluate the risk and benefit of their shortened preoperative fasting
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and negotiate their fasting periods with theatre staff and anaesthetists. The
role of the nurse should be to implement individualised fasting and
exercise clinical judgement based on current evidence and their
knowledge of the patients, as they spend more time with patients than do
theatre staff or anaesthetists.
Aspiration pneumonitis is a rare complication of modern general
anaesthesia but still carries a small risk, yet patients are still being fasted
for excessive periods affecting both physiological and psychological
wellbeing. It could be argued that in respect of this practice, nurses could
be deemed negligent, and being ignorant of current evidence is not a
defence against negligence states Beauchamp and Childress (2001).
Nurses belong to a profession whose standards are derived from
fundamental ethical principles of autonomy, beneficence and justice
further clarifies Beauchamp and Childress (2001). In demonstrating these
principles it could be presumed that in exercising their responsibility for
patient care, nurse would be concerned to do good and prevent harm to
the patient. By researching and implementing evidence based preoperative
fasting, patients would not be put at risk but would receive many benefits
in the form of reduced anxiety, discomfort, thirst and hunger; reduced
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postoperative nausea and vomiting, and reduced dehydration. Nurses
should always act in the patients best interest based on their knowledge,
expertise and skills.
This places a professional duty on nurses to keep up to date with changes
and developments in their clinical field of practice by delivering care
based on current evidence based research states the Nursing and
Midwifery Council (2004). Nurses should feel empowered to negotiate
appropriate fasting periods as equals with anaesthetists and surgeons.
They should also feel empowered to instigate change in practice which is
reflective of the evidence because, ensuring that nursing practice is
evidence based is essential for professional accountability. The Nursing
and Midwifery Council (2004) concludes that nurses are personally
accountable and answerable for their actions and omissions, irrespective
of whether they are using their initiative or following advice or directions
from other professionals. Therefore, nurses should see themselves as
instigators of change rendering care that is evidence based by ensuring
that patients are fasted for an appropriate period of time. It is regarded as
an essential part of care that is crucial to the quality of a surgical patients
care experience.
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REFERENCE LIST
Agarwall 1989 Fluid Deprivation before Operation: The
Effect of a small Drink.
Anaesthesiology 44(8): 632-634
American Society of 1999 Practice Guidelines for Preoperative
Anaesthesiologists Fasting and the use of Pharmacological
Agents for the Prevention of Pulmonary
Aspiration: Application to Healthy Patients
Undergoing Elective Surgery.
Anaesthesiology 96: 742-752
Arndt K 1999 Inadvertent Hypothermia in the Operating
Room.Association of Operating Room
Nurses Journal70: 204-206
Beauchamp TL 2001 Principles of Biomedical Ethics. 5th Ed
& Childress Oxford University Press, Oxford
Chapman A 1996 Current Theory and Practice: A Study of
Pre-Operative Fasting.
Nursing Standard10(18): 33-36
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Department of 2005 Total Operations in England 2003-04.
Health Hospital Episodes Statistics
DH: London
Duthie G 2004 Physiology of the Gastrointestinal Tract
& Gardiner A Whurr Publishers, London
Flick RP, Schears GJ 2002 Aspiration in Paediatric Anaesthesia:
& Warner MA Is the a Higher Incidence Compared with
Adults? Current Opinion in
Anaesthesiology15(3): 323-327
Hamilton Smith SH 1972 Nil by Mouth?
RCN, London
Hillier M 2006 Exploring the Evidence aroundPreoperative Fasting Practices.
Nursing Times 102(28) 36-38
Hung P 1992 Preoperative Fasting.
Nursing Times88(48): 57-60
Jester R & 1999 Pre-Operative Fasting: Putting Research
Williams R Into Practice.
Nursing Standard13(39): 33-35
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Mellin-Olsen J 1996 Routine Preoperative Gastric Emptying is
Fasting J & Gisvold SE Seldom Indicated. A Study of 85,594
Anaesthetics with Special Focus on
Aspiration Pneumonia.
Anaesthesiologica Scandinavica
40(10): 1184-1188
Mendelson CL 1946 Aspiration of Stomach Contents into
Lungs during Obstetric Anaesthesia.
American Journal of Obstetric
Gynaecology 52: 191-203
Ng A & Smith G 2002 Anaesthesia and the Gastrointestinal Tract
Journal of Anaesthesia 16(1): 51-64
Nursing & Midwifery 2004 Code of Professional Conduct.Council NMC, London
OCallaghan N 2002 Preoperative Fasting.
Nursing Standard16(36): 33-37
Olsson GL 1986 Aspiration during Anaesthesia: AComputer Aided Study of 185,358
Anaesthetics.
Anaesthesiologica Scandinavica
30: 84-92
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Oshodi TO 2004 Clinical Skills: An Evidence Based
Approach to Preoperative Fasting
British Journal of Nursing13(16) 958-962
Owens R 2002 Development of communication,
Language and Speech. In G Shames & N
Anderson (Eds.)Human Communication
Disorders: An introduction 6th Ed.
Allyn and Bacon: Boston
Pandit VA 1997 Fasting before and after Ambulatory
& Pandit SK Surgery.Journal of Peri-Anaesthesia
Nursing12(3): 181-187
Philips S 1993 Pre-Operative Drinking does not affect
Gastric Contents.British Journal of Anaesthesia 70(1): 6-9
Rowe J 2000 Preoperative Fasting: Is it Time for a
Change?
Nursing Times96(17): 14-15
Royal College of 2005 Perioperative Fasting in Adults and
Nursing Children. An RCN Guideline for the
Multidisciplinary Team. RCN, London
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Scandinavian Society 2006 Scandinavian Guidelines for Preoperative
of Anaesthesiology & Fasting in Elective Patients.
Intensive Care Medicine SSAI, Stockholm
Seymour S 2000 Preoperative Fluid Restrictions: Hospital
Policy and Clinical Practice.
British Journal of Nursing9(14): 925-930
Soreide E 2006 Modern Preoperative Fasting Guidelines:
& Ljungqvist A Summary of the Present
Recommendations and Remaining
Questions.Best Practice & Research
Clinical Anaesthesiology 20(3): 483-491
Thomas A 1987 Pre-Operative Fasting: A Question of
Routine?Nursing Times 83(49): 46-47
Wicker P 2006 Caring for the Perioperative Patient
& ONeil J Blackwell Publishing, Oxford
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APPENDIX 1
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APPENDIX 2
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