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* From the Department of Anesthesia Intensive Care and the Nutrition Service,
Assistance Publique- Hôpitaux de Paris Hôpital Antoine Béclère Clamart France.
Pr. Dan Benhamou, Department of Anesthesia and Intensive Care, Assistance Publique-Hôpitaux de Paris, Hôpital Antoine Béclère, 157 rue de la Porte de Trivaux, 92141 Clamart cedex, France. Phone: 33-1-45-37-42-73 or 43-35; Fax: 33-1-45-37-49-85; E-mail: dan.benhamou{at}bct.ap-hop-paris.fr
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Abstract |
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Methods: A quality-assurance program of 18 months duration was implemented because evaluation of traditional practice demonstrated significant deficiencies (phase I). Drinking was then allowed within one hour and feeding within six to eight hours after delivery. Gradual dietary expansion followed according to a detailed program. Three consecutive evaluations (phase II–IV) were performed: 1) to measure implementation by the ward nurses; 2) to record the type of food and the volume of water effectively received; 3) to evaluate patients’ gastrointestinal tolerance and patients’ levels of hunger and thirst and patients’ overall satisfaction.
Results: In phase I, 60% of patients received nothing by mouth and 28% received only water on the day of surgery (D0). Moderate or severe hunger and thirst were seen in a large portion of these patients (D0, hunger: 38%, thirst: 63%, D1, hunger: 40%, thirst: 28%). Introduction of the program significantly improved patient wellbeing as well as patient satisfaction. No side effects were encountered.
Conclusion: Hunger and thirst are frequently encountered after Cesarean delivery when patients are allowed to eat only after return of the first flatus. By using a quality-assurance program, it was possible to reduce the incidence and the severity of these distressing symptoms and to improve patients’ satisfaction while no side effects were encountered. These beneficial effects were maintained in phase IV suggesting a high acceptance rate from the nursing staff.
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Introduction |
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Methods |
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During phase I (and before), initiation of feeding was guided by the ward nurses. Water and the first food intake were not allowed during the first 24 hr and food was limited to light diet only. A solid diet was permitted after the first flatus was passed if nausea or vomiting had not occurred during this period. Women were allowed to choose the content of their meals only after ensuring that a normal diet could be tolerated.
Because important deficiencies (see results) were observed during the conservative phase (phase I) of the program, a protocol of early feeding was prepared by a dietician (C.B.) to ensure that a normal diet was given at the third meal at the latest. This protocol allowed administration of clear water in the postanesthesia care unit (PACU) within one hour and solid food within six to eight hours after the end of the procedure. Patients were allowed to choose the content of their meals. A standardized form describing the general rules and the contents of each meal for the first three postoperative days was attached to the postoperative drug order. Results of patients’ interviews obtained during phase I were presented to and discussed with the personnel of the maternity unit.
Phase II (from December 9, 1996 to February 14, 1997) evaluated implementation of the new protocol but personnel of the maternity unit was now aware of the ongoing evaluation. Data obtained during this phase showed almost immediate implementation of the program and this was associated with increased patient satisfaction (see results). However significant failure to implement early drinking required a phase III study. Hospital personnel were again brought together to present data of phase II and to emphasize the importance of early drinking. The standardized protocol was slightly modified to state more clearly that early drinking should be encouraged.
Phase III (from April 1 to June 16, 1997) was based on the same principles as phase II and again the personnel of the maternity was aware of the evaluation. Data obtained from patients and nurses during phase III were very satisfactory. Because initial success of a program has been followed in previous studies by a gradual return to the pre-program situation,8 a phase IV study was constructed three months later (from September 5 to September 29, 1997). During this period, no further encouragement (except for the continuing use of the standardized menu order) was given to the personnel and phase IV evaluation was performed in a blinded manner to avoid audit-related improvements.
Evaluation of the patients’ food and water intake was performed daily during the first five days after delivery. An anesthesiologist (M.T.) interviewed all women on the ward each morning and reviewed the patients’ charts to detect any deviations from the program. The following variables were recorded: time to first water/food intake, hunger and thirst felt during the previous 24 hr using a 0–3 verbal scale (0 = no hunger or no thirst; 1 = mild; 2 = moderate; 3 = severe). Extra food and drink brought to the patient by her family were recorded. Time to first flatus and to first stools (interval between surgery and flatus/stools in hours) was also recorded. Nausea and vomiting that occurred in the previous 24 hr were also evaluated using a similar (0–3) verbal scale. The computer-printed menus of the last 24 hr were collected and compared to theoretical requirements. The amount of fluids ingested each day was recorded as well as the amount of food ingested by the patient at each meal ("complete" suggests that all the food provided in the meal had been eaten and "partial" identified meals that had been only partially eaten). Maternal satisfaction using a 0–100 mm verbal numeric scale (where 0 represents complete dissatisfaction and 100 represents complete satisfaction) was recorded at the end of the five-day evaluation.9
Data are presented as mean ± SD or median (range) for data which are not normally distributed. Statistical analysis was performed using ANOVA or chi square analysis with or without Bonferroni corrections as appropriate. P < 0.05 was considered significant.
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Results |
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In phase I (i.e., before implementation of the program), the first meal with a completely normal diet was obtained on the eighth meal (Table I
). Ninety-two percent of patients received a light diet and 8% received only water on the day of surgery (D0, Table I). Thirty-eight percent of patients experienced moderate or severe hunger (Figure 1-A) and 63% of them moderate or severe thirst on the day of surgery (Figure 1-B). There was no difference in the incidence or severity of hunger and thirst among elective or emergency Cesarean delivery patients. On D1, similar results were obtained for hunger (40% moderate or severe hunger) while significant thirst was less frequently encountered (28%). No patient could choose her menu before the fifth meal in phase I (Figure 2). For 13% of our patients, additional food and/or drink was brought by the family. Six percent of patients had access to water in the PACU in phase I. First flatus occurred after a mean delay of 18 ± 9 hr while patients passed their first stool 80 ± 27 hr after surgery. On the day of surgery (D0) nausea was observed in 6% and vomiting in 9% of patients. The mean amount of water drunk by patients on the day of surgery (D0) was 257 ± 52 mL and 537 ± 318 mL on the first postoperative day (D1).
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). However a regular diet was given for the first time to patients of phase I significantly later than in phases II and III (Table I). Extra-food and drink were brought by families to 15.2% of patients in phase II and to 1.7% of phase III patients (P < 0.008 phase III vs phase II and phase I). Complete implementation of the program increased from phase II to phase III (74.7% vs 88.1%, P = 0.01). Patients were allowed by the hospital personnel to choose the content of their meal earlier in phase II and in phase III than in phase I (Figure I). Significantly fewer patients experienced hunger and thirst on the first two days after implementation of the program (Figure 1-A and 1-B). However the benefit was more difficult to obtain for thirst than for hunger. On the day of surgery, the incidence of patients with moderate or severe hunger declined to 10.0% (phase I vs phase II, P < 0.001) while the incidence of moderate or severe thirst was still at 30.4% (phase I vs phase II, P < 0.001). Implementation of phase III led to a significant reduction in the incidence of thirst (3.3% moderate or severe thirst). Patient satisfaction steadily increased from phase I to phase III (Table II).
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). Similarly, the time to first stools increased significantly in phase III but this was observed neither in phase II nor in phase IV. Nausea and vomiting occurred with a similar incidence in all four phases (Table II).
Phase IV (designed to evaluate the long-term effect of the program) essentially demonstrated a continuing improvement in the implementation of the program while patient hunger and thirst and satisfaction all significantly improved when compared with phase III results (Tables I and II and Figures 1 and 2).
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Discussion |
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The anesthesiologist’s traditional role is more oriented around procedures and intraoperative care but it is now often proposed that our role must extend into the postoperative period where it should not be limited solely to pain relief.10,11 Indeed, many experts now believe that this change offers the best chances for the specialty to survive despite current threats and prosper.12 Although our specialty may not commit to the totality of perioperative medicine and probably cannot include postoperative routine ward management because of demographic constraints, anesthesiologists are certainly among the best prepared specialists to understand most physiological derangements that occur in the postoperative period. Interactions between surgical trauma following abdominal surgery, patient dissatisfaction related to hunger and postoperative analgesic-induced nausea and vomiting or ileus are well known to anesthesiologists. Also, anesthesiologists are at the crossroads between surgeons and medical specialists, nurses and midwives and thus are in position to implement changes designed to improve patient care. This program is such an example of our expanding role in perioperative care.
This study was not performed to demonstrate the favourable risk/benefit ratio of the technique (because this has already been demonstrated)1,5 but to evaluate if traditional reluctance to early feeding after Cesarean section can be easily overcome by a quality-assurance program.
Several reasons may explain why this program was successful. It is often stressed that a major factor in obtaining successful implementation is recognition of the dysfunctional status quo by people involved. Although the nurses who were in direct contact with patients did not initiate the program, they were well aware of the problems and accepted the proposed changes with enthusiasm. Their lack of initiative is probably related to the fact that early feeding after Cesarean delivery has only recently been evaluated in structured studies1–5 although this had been said to be feasible a long time ago.13 The success of the program is also probably related to the immediate increase in patient satisfaction and to the modest effort required by the hospital personnel. Education of the staff and provision of a written program (feeding order) for each patient probably played a significant role.14 Finally, the program required more effort from nurses than from physicians and it is well known that nurses are more prone to adhere to guidelines than physicians who demonstrate resistance to guidelines.15
Phase IV was designed because a long-term decline in the implementation was suspected, following previous examples in the literature.8 We found no such decline and, conversely, a continuing improvement was observed confirming the initial enthusiasm.
An interesting finding was that thirst was more a problem for patients than hunger. The incidence of significant thirst (qualified as moderate or severe) was greater than for hunger at each phase of the program. Moreover we noted that when patients asked their family for extra food, they were more often brought drinks or juicy fruits (such as oranges) than solid food.
No significant increase in gastrointestinal side effects was observed except for a transient and unexplained delay in the return of bowel function in phase III. The safety of early feeding has also been observed in most studies.2–4 Time to first flatus was shorter in the present study than in most other evaluations. One possible explanation is that our analgesic regimen includes regular administration of non steroidal anti-inflammatory drugs (NSAIDs) during the first three days after Cesarean delivery. NSAIDs have indeed been shown to have beneficial effect on bowel motility through either their analgesic effect or the reduction of production of prostaglandin synthesis.16
In conclusion, this study has shown the successful implementation of an early feeding and drinking program after Cesarean delivery. Both hunger and thirst were reduced and this led to increased patient satisfaction while no side effects were observed.
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Acknowledgments |
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Revision received June 10, 2002. Accepted for publication August 15, 2001.
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References |
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2 Kramer RL, Van Someren JK, Qualls CR, Curet LB. Postoperative management of cesarean patients: the effect of immediate feeding on the incidence of ileus. Obstet Gynecol 1996; 88: 29–32.[Abstract]
3 Soriano D, Dulitzki M, Keidar N, Barkai G, Mashiach S, Seidman DS. Early oral feeding after cesarean delivery. Obstet Gynecol 1996; 87: 1006–8.[Abstract]
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12 Rock P. The future of anesthesiology is perioperative medicine. Anesthesiol Clin North America 2000; 18: 495–513.[Medline]
13 Crawford JS. Postpartum pulmonary embolism and deep venous thrombosis (Editorial). Obstetric Anesthesia Digest 1988; 8: 1–3.
14 Dexter F. Application of practice guidelines to anesthesiology (Editorial). Anesthesiology 1997; 87: 1031–2.[Medline]
15 Ellrodt AG, Conner L, Riedinger M, Weingarten S. Measuring and improving physician compliance with clinical practice guidelines. Ann Intern Med 1995; 122: 277–82.
16 Kelley MC, Hocking MP, Marchand SD, Sninsky CA. Ketorolac prevents postoperative small intestinal ileus in rats. Am J Surg 1993; 165: 107–12.[Medline]
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