Original Article

Effect of total fasting hours on the overall quality of recovery

after surgery: An observational study
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ABSTRACT
Context: Preoperative fasting is one of the pre‑requisite for patients undergoing a surgery. Despite clear instructions, patients
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 02/22/2024

frequently fast for extended periods before elective surgeries. Longer periods of fasting may cause discomfort, thirst, hunger,
and other physiological problems.
Aims: To assess the quality of postoperative recovery among adult patients having different preoperative fasting hours by
using the postoperative Quality of Recovery40 (QoR40) score.
Settings and Design: This was an observational study that was conducted for adult patients undergoing elective surgery during
four weeks between 19th September and 13th October 2022 at Security Forces Hospital Riyadh, Kingdom of Saudi Arabia.
Methods and Material: We excluded pediatric patients, patients undergoing spine or neurosurgery, emergency cases, or
local anesthesia cases. Non‑probability convenient sampling technique was used in this study. The postoperative quality of
recovery‑40 (QoR‑40) questionnaire was distributed among 200 patients.
Statistical Analysis Used: All analyses were performed with Statistical Package for the Social Sciences software (SPSS)
v25. Descriptive statistics (frequency, percentage, median, and IQR) were used for the questionnaire’s variables. The
difference between the variables was analyzed using Kruskal‑Wallis, and a P value <0.05 was considered statistically
significant.
Results: Out of 200 patients, 172 patients responded but 16 responses were excluded. A total of 156 adult patients’
responses were included in this study. The majority were female (53%), 31% were older than 45 years. More than 50%
of patients reported fasting for more than 6 hours for drinking and more than 8 hours for eating. On the positive scale, the
comfort score was significantly affected by the fasting hours for drinking (P value = 0.045). On the negative scale of the
questionnaire, the emotions were significantly affected by fasting hours for both drinking (P value = 0.027) and eating (P
value = 0.043).
Conclusions: The study results showed better comfort for patients with lesser fasting hours for drinking. Moreover, the
results strongly suggest the need of following the fasting guidelines without prolonging the fasting duration. However, further
studies with larger sample sizes are recommended.

Key words: Anesthesia, fasting hours, pulmonary aspiration, quality of recovery, Saudi Arabia

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How to cite this article: Alsharkh WS, Aljuaid M, Huda AU, Bawazir A,
DOI:
Alharbi A, Alharbi N. Effect of total fasting hours on the overall quality
10.4103/sja.sja_71_23 of recovery after surgery: An observational study. Saudi J Anaesth
2023;17:373-7.

Wejdan S. Alsharkh, Mohammad Aljuaid1, Anwar U. Huda, Atheer Bawazir, Abdullah Alharbi,
Nouf Alharbi1
Department of Anesthesia, Security Forces Hospital, Riyadh, 1Department of Health Administration, College of Business
Administration, King Saud University, Riyadh, Saudi Arabia

Address for correspondence: Ms. Wejdan S. Alsharkh, Department of Anesthesia, Security Forces Hospital, Riyadh, Saudi Arabia.
E‑mail: Wejdan.ksauhs@gmail.com

Submitted: 25‑Jan‑2023, Revised: 21‑Feb‑2023, Accepted: 26‑Feb‑2023, Published: 22-Jun-2023

© 2023 Saudi Journal of Anesthesia | Published by Wolters Kluwer - Medknow 373

 Alsharkh, et al.: Fasting duration affects quality of recovery postoperatively
Introduction
Pulmonary aspiration is a rare and undesirable complication
of anesthesia and is associated with significant mortality
and morbidity postoperatively.[1] Therefore, preoperative
patient assessment and preparation include steps to prevent
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perioperative pulmonary aspiration. There are guidelines
available that mainly focus on preoperative fasting duration.
These guidelines also mention instructions regarding
administering drugs preoperatively to adjust gastric content
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acidity and volume. The main goal of fasting hours is to
prevent the risk of pulmonary aspiration.[2]
The latest update of the American Society of Anesthesiologists
(ASA) and other international anesthesia societies recommends
a fasting period for at least 6 hours for light meals and 2 hours
for clear fluids before any elective surgical procedure.[3] Our
hospital also follows 8 hours fasting for meals and 2 hours for
water and clear fluids. A common practice for implementing this
in many hospitals is to order nil per oral (NPO) from midnight in
elective surgeries.[4] These recommendations are then frequently
enforced even in situations where surgeries are scheduled later in
the day which increases the overall fasting times.[5] Unnecessarily
prolonged fasting hours could lead to thirst, hunger, and also
patient distress, anxiety, and discomfort.[6] Similarly, it can lead
to hypovolemia which causes dehydration and hypoglycemia.
Moreover, it can result in insulin resistance that increases the
level of insulin in the blood leading to the risk of numerous
other postoperative complications as well.[7]
Postoperative quality of recovery has become a significant
indicator in recent years, reflecting the performance of
the surgeon, anesthesiologist, and the institution where
the operation is conducted. It is a multifaceted process of
resuming normalcy based on comparisons to pre‑illness
norms in numerous areas, such as physical, physiological,
psychological, social, and economic variables.[8] In surgery,
evaluating the relative effect of an emergency or elective
operation on the level of postoperative recovery is essential
for improved distribution and planning of healthcare resources
attempting to improve quality of recovery (QoR). According
to Gornall et al.,[9] the quality of recovery‑40 (QoR‑40)
demonstrated sound psychometric properties for evaluating
the quality of postoperative recovery. Our study aimed to
assess the quality of postoperative recovery among adult
patients after having different fasting hours.
Subjects and Methods
This was an observational study that was conducted on adult
patients admitted for elective surgery during 4 weeks between
19 September and 13 October 2022 at Riyadh’s Security
374 Saudi Journal of Anesthesia / Volume 17 / Issue 3 / July-September 2023
Force Hospital Program (SFHP). This study was approved by
the Security Force Hospital’s institutional review boards (IRB)
(code H‑01‑R‑069) IRB Registration Number with KACST. KSA:
H-01-R-069 Date: 14 December 2021. The study population
included adult patients undergoing elective surgery under
general anesthesia. We excluded pediatric patients, patients
who underwent spine or neurosurgery, emergency cases, or
local anesthesia cases. A total of 200 study questionnaire were
distributed to patients. Non‑probability convenient sampling
technique was used. The questionnaire used a validated
scoring system called QoR‑40 to collect data regarding the
postoperative quality of recovery. The QoR‑40 was created and
validated in Australia in 2000 to assess the patient‑reported
outcome, including quality of life.[10] The Arabic version of the
QoR‑40 was also validated in May 2017.[11]
The questionnaire consists of 5 parts. The first part is a cover
letter that contains a consent form. The second part consists
of demographic data like age, sex, education level, region,
etc. The third part consists of surgery related questions such
as type of operation and duration of fasting for liquids and
meals. The fourth part consists of the four domains that are
considered positive domains and include 4, 3, 5, and 6 items,
respectively. The fifth part consists of the four remaining
domains that are considered negative domains and include
8, 6, 1, and 7 items, respectively.
The overall score and subscales of the QoR‑40 are calculated
using a five‑point Likert scale (1 = none of the time, 5 = all
of the time; for negative questions, the scoring was inverted),
and individual scores are added together, with a minimum
score of 40 points and a maximum score of 200 points.[10]
The questionnaire was given to a patient who underwent
elective surgery under general anesthesia after obtaining
informed consent. An iPad was used to view and answer the
questionnaire or to scan the barcode by patients. All data
were entered and analyzed in SPSS version 25. Descriptive
statistics (frequencies, percentages, mean, SD, median,
and IQR) were used for the questionnaire’s variables. The
Kolmogorov–Smirnov test was used to test the normal
distribution. Non‑normally distributed data were analyzed
using Kruskal‑Wallis, and a post hoc analysis with Bonferroni
correction was performed. However, we did not perform the
paired comparison as there with no significant differences
found in the Kruskal‑Wallis test. A P value less than 0.05 was
considered statistically significant.
Results
The response rate was 86% as we received a total of
172 responses. However, we included 156 in our study.
 Alsharkh, et al.: Fasting duration affects quality of recovery postoperatively
Sixteen patients were excluded from the study; three did not
meet the inclusion criteria, three refused to answer, and ten
failed to complete the questionnaire. Among 156 patients,
31% were older than 45 years. More than 50% of the
patients were female. Less than half of the patients had an
education at Bachelor level (42.3%), while smaller proportions
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had secondary level (32.7%), elementary level (16.0%),
and intermediate level (9.0%). Most of these patients
belonged to the middle region of Saudi Arabia (76.3%) while
about 16% were from the southern region.
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The highest percentage of patients underwent General
surgery (37.2%) followed by Urology (14.7%), Obstetrics
and gynecology (12.2%), and the rest with other specialties.
More than half of the patients fasted from drinking for more
than 6 hours (55.8%) and about 38.5% patients fasted from
drinking for more than 12 hours, while half of the patients
fasted from eating for more than 8 hours (50.6%) followed
by 43.6% patients who fasted from eating for more than
12 hours.
There was no statistical difference in the total QoR40
scores for patients who had different durations of fasting
from drinking and from eating as shown in Table 1. Also,
there was no significant difference in positive domains of
QoR‑40 score due to the difference in total fasting hours
from drinking (p > 0.05) as shown in Table 2. Although
comfort item was significantly better in the lesser fasting
hour groups (p = 0.045). Post hoc comparisons using the
Bonferroni correction indicated that the mean rank score
for the more than 12 hours fasting (71.1) was significantly
different from the patients having more than 2 hours
fasting (112.9). Also, there was no significant difference
in negative domains of QoR‑40 scores due to total fasting
hours from drinking (p > 0.05) as shown in Table 2.
Although, the emotion item was significantly different in
three groups (p = 0.027). Post hoc comparisons using the
Bonferroni correction indicated that the mean rank score
Table 1: Comparison of total QoR40 score according to the total
fasting hours from drinking and eating before the operation
Total fasting hours from drinking
> 2 hours > 6 hours > 12 hours
n=7 n=87 n=60
Total QoR40 185 (149‑192) 180 (164‑190) 175 (163‑192)
score
Total fasting hours from eating
6‑8 hours > 8 hours > 12 hours
n=9 n=79 n=68
Total QoR40 180 (177‑184) 179 (163‑190) 176 (163‑193)
score
Values represent the median (interquartile range) P value calculated by the
Kruskal‑Wallis test
Saudi Journal of Anesthesia / Volume 17 / Issue 3 / July-September 2023
for the patients with more than 12 hours fasting (68.8) was
significantly different from the patients with more than 6
hours fasting (84.0).
There was no statistically significant difference in positive
and negative domains of QoR‑40 scores due to different
fasting hours from eating (p > 0.05) as shown in Table 3.
However, only the emotions item was found to be statistically
different (p = 0.043). Post hoc comparisons using the
Bonferroni correction indicated that the mean rank score
for the patients having more than 12 hours fasting from
eating (70.2) was significantly different from the patients
having more than 8 hours fasting (86.1).
Discussion
This study assessed the quality of postoperative recovery
among adult patients after having different fasting hours
by using the QoR‑40 score.[10,11] According to the findings,
more than 50% of the patients reported fasting for more than
6 hours from drinking and more than 8 hours from eating.
On the positive scale, the comfort score was significantly
affected by the fasting hours from drinking (p = 0.045).
The median comfort scores in the positive outcome section
were significantly higher in patients with lesser fasting hours
from liquids. Similarly, emotions, physical independence,
and support scores in positive outcome sections were
also higher in patients with lesser fasting hours from
liquid, even though these scores did not achieve statistical
significance. On the negative scale of the questionnaire, the
emotions were significantly affected by fasting hours from
drinking (p = 0.027) and eating (p = 0.043). There was no
statistical difference in scores of comfort, emotions, physical
independence, and support among the three groups with
different fasting times for liquid. However, emotion scores
were significantly better in the group with lesser fasting
times for eating.
A reason for exceeding the recommended fasting time is the
surgery schedule. According to a national survey measuring
anesthesiologists’ knowledge, attitudes, and current practices
of preoperative fasting, only 50% of respondents confirmed
P that the institution adhered to fasting guidelines. Also, they
0.971
found that the main reason is the inability to manage the case
plan in the operating room and the inadequate knowledge
of the ward nurses and surgeons.[12]
P
Scientific literature showed that healthy persons who drink
0.824
water or other clear liquids up to two hours before the
disorientation stage of anesthesia do not experience an
increase in stomach fluid volume or acidity.[13] de Andrade
375
 Alsharkh, et al.: Fasting duration affects quality of recovery postoperatively

Table 2: QoR‑40 scores (Positive and negative domains) according to total fasting hours from drinking before the operation
All n=156 >2 n=7 >6 Hours n=87 >12 Hours P
n=62
Positive Domains Median (IQR)
Comfort 17 (14‑20) 20 (19‑20) 18 (14‑20) 16 (14‑19) 0.045*
Emotions 15 (10‑15) 15 (12‑15) 15 (9‑15) 13 (10.5‑15) 0.56
Physical 23 (18‑25) 25 (21‑25) 23 (18‑25) 23.5 (17‑25) 0.672
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Independence
Support 30 (29‑30) 30 (30‑30) 30 (29‑30) 30 (28.7‑30) 0.229
Negative Domains Median (IQR)
Comfort 36 (32‑39) 38 (33‑39) 37 (32‑39) 34 (28.7‑38.2) 0.167
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Emotions 30 (28‑30) 30 (30‑30) 30 (29‑30) 30 (27‑30) 0.027*

Support 5 (4‑5) 5 (5‑5) 5 (4‑5) 5 (4‑5) 0.511
Pain 30 (27‑32) 30 (29‑33) 30 (27‑32) 29.5 (26‑32.2) 0.588
Values represent the median (interquartile range) P value calculated by the Kruskal‑Wallis test. * at P<0.05

Table 3: QoR‑40 scores (Positive and Negative domains) according to total fasting hours from eating before the operation
All n=156 6‑8 Hours n=9 >8 Hours n=79 >12 Hours n=68 P
Positive Domains Median (IQR)
Comfort 17 (14‑20) 13 (10‑20) 18 (14‑20) 17 (14.3‑19.8) 0.617
Emotions 15 (10‑15) 14 (6‑15) 15 (9‑15) 14.5 (12‑15) 0.711
Physical Independence 23 (18‑25) 23 (17‑24.5) 23 (16‑25) 24 (20.3‑25) 0.607
Support 30 (29‑30) 29 (27.5‑30) 30 (29‑30) 30 (29‑30) 0.276
Negative Domains Median (IQR)
Comfort 36 (32‑39) 34 (32‑38) 37 (32‑39) 35 (29.3‑39) 0.356
Emotions 30 (28‑30) 30 (28.5‑30) 30 (29‑30) 30 (27‑30) 0.043*
Support 5 (4‑5) 5 (4‑5) 5 (4‑5) 5 (4‑5) 0.994
Pain 30 (27‑32) 30 (29.5‑32) 30 (26‑32) 30 (27‑32.8) 0.872
Values represent the median (interquartile range) P value calculated by the Kruskal‑Wallis test

Gagheggi Ravanini et al.[14] demonstrated that shortened
fasting while ingesting a carbohydrate and protein solution
does not increase the risk of pulmonary complications related
to bronco‑pulmonary aspiration. Faria et al.[15] randomly
assigned adult women undergoing elective laparoscopic
cholecystectomy to 200 mL of a carbohydrate beverage
containing 12.5% maltodextrin 2 or a brief drink 8 hours prior
to surgery. They demonstrated that decreasing preoperative
fasting reduced insulin resistance and the body’s natural
response to trauma.
Similarly, Çakar et al. showed that consuming 400 ml of oral
[16]
carbohydrates 2 hours preoperatively can decrease tiredness,
headache, nausea, and vomiting. However, Lee et al.[17] found
that patients receiving preoperative carbohydrate loading
did not significantly improve their preoperative wellbeing
or recovery when compared to the control group. Our study
found that patients with lesser fasting hours from liquids
intake report a better level of comfort regarding breathing
and general physical comfort.
Our results showed no statistically significant relationship
between the prolonged fasting hours from eating and the
negative section of comfort (nausea, vomiting, feeling cold,
and dizzy). Although, it was proven in a previous study that
patients fasting more than 8 hours complained of nausea
and vomiting.[18] Also, it has been reported that longer than
recommended preoperative fasting hours are inessential
and are have no relationship with improved safety of
general anesthesia (GA). Hunger and thirst make patients
uncomfortable and increase surgical stress, and excessive
hunger may be related to increased postoperative nausea
and vomiting.[19]
A better emotional outcome in a positive section of the
questionnaire could not be found in our study. This could
be due to the inability to assess all the domains in the
preoperative period as the questionnaire was only introduced
to the patients postoperatively. Therefore, the domains of
comfort, emotions, physical independence, and support
were not assessed preoperatively. Also, we did not follow up
with the patients after an immediate postoperative period.
Another limitation of the study was that a new electronic
documentation system was started in the hospital setting
during the data collection period that led to a smaller
number of operation room bookings. Thus, fewer number
of patients were included in the study. Also, the short time
for data collection resulted in lower sample collection. Lastly,

376 Saudi Journal of Anesthesia / Volume 17 / Issue 3 / July-September 2023

 Alsharkh, et al.: Fasting duration affects quality of recovery postoperatively

some patients were discharged before we could reach them
to fill out the questionnaire. Although, as a strong point,
7.
this is the first study conducted in Saudi Arabia to link the
QoR‑40 scores with the fasting hours before anesthesia. In
conclusion, our study found better comfort for patients with
8.
lesser fasting hours from drinking. However, we could not
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preoperative fasting and early postoperative feeding are safe? Arq Bras
Cir Dig 2013;26:54‑8.
Kukliński J, Steckiewicz KP, Sekuła B, Aszkiełowicz A, Owczuk R.
The influence of fasting and carbohydrate‑enriched drink administration
on body water amount and distribution: A volunteer randomized study.
Perioper Med (Lond) 2021;10:27. doi: 10.1186/s13741‑021‑00198‑0.
Megari K. Quality of life in chronic disease patients. Health Psychol
Res 2013;1:e27. doi: 10.4081/hpr. 2013.e27.

prove that the lesser fasting hours from eating improves the
quality of recovery. Our results strongly suggest that following
the guidelines is highly recommended without prolonging
the fasting duration before the surgery.
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 02/22/2024
9. Gornall BF, Myles PS, Smith CL, Burke JA, Leslie K, Pereira MJ, et al.
Measurement of quality of recovery using the QoR‑40: A quantitative
systematic review. Br J Anaesth 2013;111:161‑9.
10. Myles PS, Weitkamp B, Jones K, Melick J, Hensen S. Validity and
reliability of a postoperative quality of recovery score: The QoR‑40.

Acknowledgement
Mr. Abdullah Alghamdi for his administrative support for
data collection.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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