A retrospective review, published ahead of print in Heart, has found that patients who did not fast before a percutaneous coronary intervention (PCI) procedure—either for elective PCI or for acute coronary syndrome—did not develop intraprocedural or postprocedural aspiration pneumonia. This indicates that the traditional practice of keeping patients nil-by-mouth prior to elective PCI may not always be necessary.
Tahir Hamid (Department of Cardiology, Royal Albert Edward Infirmary, Wigan, UK) and others write that patients are usually kept nil-by-mouth for about four to six hours prior to a cardiac procedure, including PCI, to reduce the risk of vomiting and aspiration pneumonia. However, they add that no American or European guidelines give specific recommendations that fasting is necessary in these patients and that “there is little evidence available about the benefits of preprocedural fasting”. “Patients who are kept nil-by-mouth are potentially at risk of dehydration, contrast-induced nephropathy, hypoglycaemia, and poorly controlled hypertension (particularly in older patients). However, a period of fasting is still considered to be beneficial should the patient need to undergo emergency endotracheal intubation in the event of cardiac arrest or emergency cardiac surgery,” the authors note. The aim of Hamid et al’s study, therefore, was to demonstrate that “low-to-medium risk percutaneous coronary procedures could be safely performed without preprocedural fasting”.
The authors reported that they performed a retrospective review of patients who underwent PCI at two UK institutions that have “abandoned” the current standard UK practice of keeping patients nil-by-mouth prior to elective PCI because of a “lack of supporting data” in this area. Therefore, patients (admitted for elective PCI or acute coronary syndrome) were advised to have a light breakfast in the morning with no instruction to keep them nil-by-mouth for four hours prior to their procedure.
Of the 1,916 PCI procedures performed at the two institutions over a three-year period, no patient required emergency intraprocedural endotracheal intubation and none developed either intraprocedural or postprocedural aspiration pneumonia. Nearly 80% of patients who were admitted for elective PCI were discharged on the same day.
Hamid et al comment: “Coronary procedures require the use of intravenous contrast which can precipitate the acute renal impairment. Keeping patients nil-by-mouth, particularly those with pre-existing renal impairment or the elderly could, arguably, precipitate acute kidney injury leading to a prolonged hospital stay and associated health and economic implications.” They add that if patients are kept hydrated (ie. not nil-by-mouth), the “risk of contrast-induced nephropathy will be reduced.
Concluding their study, they say that a “a prospective randomised trial may be required to convince the majority of cardiologists to abandon the traditional stringent nil-by-mouth protocols they currently adopt for their coronary procedures.”