True Preoperative Liquid Fasting in Romania-A Secondary Analysis of the Thirst Study

Background: The recently published Thirst study showed that prolonged preoperative fasting for liquids remains an unresolved issue across multiple European countries despite clear guideline recommendations. In-depth analyses of national practices could help the development of targeted interventions. The aim of our study was to provide a national overview of fluid fasting in Romania, highlighting institutional factors that could prolong two distinct fasting times: true fluid fasting time and fasting time until the last sips. Methods: This was a secondary analysis of the recently published Thirst study, a prospective, observational, multicenter study. Twenty-one Romanian centers recruited a total of 2185 adult patients undergoing elective procedures between 25 and 29 November 2024. The main outcomes were: the median value of self-reported fasting time to the last sips (SIPS) and true fluid fasting time for larger amounts (NOT SIPS) across centers and procedures; SIPS and NOT SIPS times across hospital level of care and fluid fasting protocols; and the independent predictive value of hospital level of care, fluid fasting protocols and workload for prolonged fasting. The secondary outcomes were the frequency of prolonged fasting (>4 h) and fasting for 2-4 h across centers, procedures, level of care, protocol and afternoon scheduling. The Kruskal-Wallis test with pairwise comparisons was used to compare differences in median times depending on the studied subgroup. Results: The median fluid fasting times for SIPS and true fluid fasting were 8 h [3:30-13:00] and 12 h [10:00-14:55], respectively, and varied significantly across centers, specialties, levels of care and protocol in place (p < 0.001). Prolonged SIPS and true fluid fasting times were observed in 67.3% and 95% of the patients, respectively. Both times varied significantly across the procedure types (p < 0.05), with ophthalmology having the shortest fasting times. Reduced fluid fasting times were independently associated with moderate-competence centers, lower emergency case load and guideline-based fasting protocols. Conclusions: This secondary analysis shows that non-adherence to fluid fasting guidelines is frequent in most Romanian regions and centers. Further research is needed to develop individualized strategies based on institutional and geographical policies as well as on physiologic effects of fluid fasting.