"He was reluctant to change. But I nagged him."

July 23, 2006 -- Today the Baltimore Sun ran David Kohn's "Slow demise for long preoperative fasts." The long piece reports that recent research shows the practice of barring patients from consuming anything after midnight the day before surgery confers no benefit--and may even cause harm. In this piece, the leading representatives of the modern view are two Texas nurses, Elizabeth Winslow, PhD, RN, FAAN, and Jeannette Crenshaw, MSN, RN. Their joint research supports more nuanced pre-op instructions. The piece fails to note Winslow's doctorate (despite identifying physicians as "Dr."), fails to identify Crenshaw as a nurse, and fails to mention nurse anesthetists, despite extensive discussion of anesthesiologists. But overall the story is an impressive example of a media piece that highlights nursing research and influential patient advocacy, with many quotes from the nursing scholars. We commend Mr. Kohn and the Sun.

The piece suggests that the nurses and anesthesiologists who support less stringent pre-op dietary restrictions have encountered resistance from surgeons and other anesthesiologists. There's little question where the piece comes down. An early paragraph says that the traditional pre-op fasting "torment" has "little evidence to back it up," and that "critics" say physicians who follow it are "choosing discredited tradition over up-to-date science--perhaps for their own convenience." Those who still support the "NPO after midnight" policy argue that patients get overwhelmed with more complex instructions, that permitting additional consumption closer to surgery will lead to abuse by patients, and that more relaxed rules limit the flexibility to rearrange surgical schedules at the last minute.

The nurses and and their anesthesiologist allies seem to have addressed these arguments. Winslow and Crenshaw appear to be among the researchers who have shown since the 1980's that long fasting does not reduce the incidence of pulmonary aspiration, which was apparently the main reason the policy developed. Researchers reportedly found that patients could consume clear liquids up to two hours before surgery with no ill effects, as Crenshaw notes. The piece notes that as a result of the "new evidence," the American Society of Anesthesiologists (ASA) actually adopted new guidelines in 1998. For most surgeries, these guidelines permit clear liquids up to two hours before, a light meal up to four hours before, and a heavy one up to eight hours before. The piece also notes that longer fasts might actually increase risks to patients. That's because clear liquids can help the stomach empty more quickly, and hungry, dehydrated patients "tend to have less stable vital signs." Winslow says that patients may also suffer from headaches, dizziness, and nausea, which can lead to stress. In answer to the surgeons' scheduling argument, the piece notes that Crenshaw and Winslow actually published a paper showing that "allowing shorter fasts did not gum up the flow of operations."

Crenshaw finds the idea that patients can't handle the new instructions "patronizing." And a University of Maryland anesthesiologist notes that it's "pretty rare" for patients to get confused. Indeed, a couple of anesthesiologists who enforce the midnight rule actually tell patients who call with questions or objections they may follow something like the more permissive ASA rules. This suggests that the anesthesiologists can't defend application of the rule to specific situations, rather than as an extremely broad prophylactic.

There are a few problems with the way the piece treats nursing, none of them unusual. Though Winslow has a doctorate, she is never identified as "Dr.", even though six quoted physicians are. As we have explained, there is no principled basis to restrict this honorific to physicians. Inexplicably, Crenshaw is not even identified as a nurse, though she has a masters degree in nursing. And perhaps most glaring is the total failure to mention the policies and practices of the nation's 34,000 nurse anesthetists, who now give the majority of anesthesia given in the U.S. The piece might have made an effort to get the view of the American Association of Nurse Anesthetists.

The piece stresses that "NPO after midnight" remains alive and well in hospitals throughout the U.S., despite all the research and the ASA guidelines. In a 2002 study, Crenshaw and Winslow showed that the average fasting times for elective surgery patients at a Dallas hospital were many times longer than the ASA guidelines, including an average clear liquid fast of 12 hours. Crenshaw suggests that the practice continues because "[o]ld habits die hard...It has very little to do with evidence." She and Winslow do "praise children's hospitals and pediatric clinics" for being particularly open to the more relaxed guidelines.

The piece closes with an anecdote about how Winslow overcame resistance to changing the "NPO after midnight" policy from one eye surgeon--her husband. She says: "He was reluctant to change. But I nagged him." We're uneasy with the traditional connotations of that phrasing. But the "nagging" (or patient advocacy) was actually how Winslow ensured that, as the piece puts it, "science vanquished custom." And that is not a stereotypical vision of a nurse persuading a physician to make a change.

See the article "Slow demise for long preoperative fasts" by David Kohn from the July 23, 2006 edition of the Baltimore Sun.

Author David Kohn can be reached at david.kohn @ baltsun.com