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increased post-op morbidity and mortality. He also says the fasting state promotes an aggressive and harmful inflammatory stress response to surgery. "Traditional NPO guidelines are not best practice for patients," says Dr. Bisch. "They have been debunked and are no longer sup- ported by the majority of world anesthesia societies. The safety of carbohydrate loading and shortened fasting periods has been well proven, and is a key component of ERAS pathways." Shortened pre-op fasting periods lead to improved glycogen stores, diminished stress response and less insulin resistance, according to Dr. Bisch. "That results in shorter post-op stays, lower complication rates and ultimately lower healthcare costs," he says. He points out that optimizing the nutritional sta- tus of patients by minimizing fasting and with carbo- hydrate-rich pre-surgical drinks have been shown to improve outcomes as part of ERAS protocols and, importantly, improve quality of life for patients. (Dr. Bisch highlights an important caveat: The safety of shortened fasting periods has not been well studied in patients with impaired stomach emptying, such as those with diabetes, functional gastroparesis, severe acid reflux, significantly elevated estrogen levels or acute abdominal inflammation.) Dr. Bisch says drinks specially formulated for surgical patients ensure an appropriate carbohy- drate load, and provide electrolytes and proteins that modulate the immune system to maximize healing. Their downside is cost, and access for patients. "In many centers with robust ERAS pro- grams, simple clear juices or sports drinks are uti- lized with benefits shown to patients," says Dr. Bisch. "Unfortunately, larger comparative studies and cost-effectiveness analyses are needed before any definitive statements can be made in this area." Patients at high risk for malnutrition should be referred to a registered dietician familiar with peri- operative care, according to Dr. Bisch. He suggests universal nutritional screening of patients with easy- to-implement tools such as Strong for Surgery from the American College of Surgeons (osmag.net/BoK7Pv), and recommends patients commit to a well-balanced diet rich in protein and iron leading up to their procedures. Nutritional sup- plementation should start at least 10 to 14 days before scheduled surgeries for patients at high risk for malnutrition, he says, and iron-deficiency anemia should be identified and corrected before surgery. Relatively healthy individuals are less likely to experience negative outcomes related to periopera- tive malnourishment, but the risk still exists. "Most patients undergoing elective procedures are fairly well nourished by rough standards, yet numerous studies show major complications can occur that are preventable with short-term pre-op nutrition enhancement," says Lary Robinson, MD, a thoracic surgeon at Moffitt Cancer Center in Tampa, Fla. Dr. Orlovich says even elective procedures can cause significant physiological shifts that may not be readily apparent. "The surgery may be elective, but the physical impact is not," he says. "It's still impor- tant to optimize the nutritional status of patients because the interventions are low-cost, easy to implement and may yield positive outcomes." There's still work to be done to promote the ben- efits of optimized pre-op nutrition, however. Dr. Robinson believes most providers are unaware of the potential for simple pre-op nutritional measures that can decrease complications, even in patients who are well nourished. "Educating surgeons about the importance of perioperative nutrition is desper- ately needed, and could save the healthcare system enormous amounts of money," he says. Dr. Orlovich believes it's now time to reimagine how care is delivered outside of the OR to match the tremendous strides that have been made in how F E B R U A R Y 2 0 2 1 • O U T P A T I E N T S U R G E R Y . N E T • 3 9 Traditional NPO guidelines are not best practice for patients. — Steven Bisch, MD, FRCSC, BMSc