Common Surgery Rules that Do More Harm than Good

By Eva Martin, MD of Elm Tree Medical, Inc.

Have you ever had surgery? If so, you know recovery can feel like getting hit by a bus. Even after minimally invasive surgeries, it can take weeks or months to regain full functioning. A set of surgical recovery principles called "Enhanced Recovery Pathways" provide surgeons and patients alike with a set of evidence-based "life hacks" for speeding recovery. You might be surprised to see that many are the opposite of traditional teachings and hospital practice!

It all started in the 1990s, when surgeons theorized that the body experiences surgery as an injury that causes it to deviate from its normal functioning. They began to use the scientific method to come up with Enhanced Recovery Pathways. Enhanced Recovery Pathways provide a set of things to do and avoid around the surgical period to get patients back to normal faster. Most surprising is that this body of research has shown that many of our traditional surgical rules are actually doing more harm than good.

1. NPO at Midnight

Traditionally, surgeons prescribed "NPO at Midnight" for their patients the night before surgery. NPO stands for "nothing per os (mouth)," and means no food or water after midnight in preparation for surgery the next day. The traditional teaching is that eating too close to intubation for anesthesia increases the risk of aspiration. However, a Cochrane review recently debunked this longstanding myth. Scientists also theorize that fasting leads to low glycogen (energy) stores, which increases insulin resistance and leads to more complications. Now, the American Society of Anesthesiologists recommends not eating for 6 hours prior to surgery and not drinking for 2 hours.

2. Don't Eat After Surgery

Providers used to stop patients from eating right after surgery because it made them nauseous. Now, early eating is one of the staples of Enhanced Recovery Pathways. The longer patients wait to eat, the higher their insulin resistance rises and the longer they are in a catabolic (energy break-down) state. "Early re-feeding" leads to shorter hospital stays and faster return of bowel function without leading to increased complications. Patients may feel nauseous and vomit, but these side effects do not lead to downstream harms.

3. Continuous IV Fluids

Both too much fluid and too little fluid in the body can lead to complications. Therefore, the goal is to be Goldilocks Just Right. It is standard to give patients a lot of IV fluids during surgery and to leave fluids running for hours or days afterwards. However, when doctors restricted IV fluids after surgery in research trials, patients had fewer complications involving their heart and lungs, faster return to bowel function, and shorter hospital stays. It turns out that IV fluids should be stopped as soon as possible, when the patient is taking in fluids or post-op day 1.

We want to hear from you! Have you changed your practice to reflect Enhanced Recovery Pathways? Do you believe that they are really better than the old ways, or just another fad?