Original article 123
Effect of preoperative intravenous carbohydrate loading on
preoperative discomfort in elective surgery patients
Heli Helminena, Hanna Viitanenb and Juha Sajantia
Background and objective We studied the effect of three
different fasting protocols on preoperative discomfort and
glucose and insulin levels.
Methods Two hundred and ten ASA I–III patients
undergoing general or gastrointestinal surgery were
randomly assigned to three groups: overnight intravenous
5% glucose infusion (1000 ml), carbohydrate-rich drink
Downloaded from http://journals.lww.com/ejanaesthesiology by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 11/27/2021
(400 ml) at 6–7 a.m., or overnight fasting. The subjective
feelings of thirst, hunger, mouth dryness, weakness,
tiredness, anxiety, headache and pain of each patient were
questioned preoperatively using a visual analogue scale.
Serum glucose and insulin levels were measured at
predetermined time points preoperatively.
Results During the waiting period before surgery, the
carbohydrate-rich drink group was less hungry than the
fasting group (P U 0.011). No other differences were seen in
visual analogue scale scores among the study groups.
Trend analysis showed increasing thirst, mouth dryness and
anxiety in the intravenous glucose group (P < 0.05). The
carbohydrate-rich drink group experienced decreasing
thirst but increasing hunger and mouth dryness (P < 0.05). In
Introduction
In the last two decades, several studies have shown that
2 hours is enough time for clear fluids to empty from the
stomach in both children and adults [1–3]. Overnight
fasting can cause considerable discomfort in some patients
in the form of hunger, thirst, tiredness and weakness before
surgery [4,5]. In light of these more recent findings, many
national societies have adopted a more tolerant approach to
preoperative fasting guidelines [6].
In response to any injury, and to surgical trauma, the
human body changes its metabolism into a catabolic state.
One of the main features in this catabolic response is the
development of insulin resistance [7,8], which can develop
even after a minor operation [9,10]. The reduction in
insulin sensitivity is most pronounced on the first day after
surgery but it can persist for as long as 3 weeks [11].
Postoperative insulin resistance may contribute to pro-
longed recovery and length of stay in hospital [12].
The aim of preoperative carbohydrate loading is to trigger
an insulin response. Indeed, intake of a carbohydrate-rich
drink (CHD) before elective abdominal surgery or total
0265-0215 ß 2009 Copyright European Society of Anaesthesiology
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
the fasting group, thirst, hunger, mouth dryness, weakness,
tiredness and anxiety increased (P < 0.05). Both intravenous
and oral carbohydrate caused a significant increase in
glucose and insulin levels.
Conclusion Intravenous glucose infusion does not
decrease the sense of thirst and hunger as effectively as a
carbohydrate-rich drink but does alleviate the feelings of
weakness and tiredness compared with fasting. Euro J
Anaesthesiol 26:123–127 Q 2009 European Society of
Anaesthesiology.
European Journal of Anaesthesiology 2009, 26:123–127
Keywords: carbohydrate loading, intravenous glucose infusion, oral
carbohydrate beverage, preoperative fasting
a
Department of Surgery and bDepartment of Anaesthesia, Seinäjoki Central
Hospital, Seinäjoki, Finland
Correspondence to Heli Helminen, Department of Surgery, Seinäjoki Central
Hospital, Hanneksenrinne 7, 60220 Seinäjoki, Finland
Tel: +358 6 4155888; fax: +358 6 4154348; e-mail: heli.helminen@epshp.fi
Accepted 30 June 2008
hip replacement has been shown to improve postopera-
tive insulin sensitivity [13,14]. Furthermore, a CHD has
been shown to reduce preoperative discomfort compared
with placebo or overnight fasting [5]. However, some
patient groups are unable to ingest oral fluids before
surgery because of the high risk of regurgitation or
underlying disease. Infusion of a preoperative glucose
solution has been shown to improve postoperative metab-
olism by reducing the occurrence of insulin resistance
[15]. Whether a glucose infusion before surgery also
reduces preoperative discomfort is not known. There-
fore, our aim was to investigate the effect of a preopera-
tive glucose infusion on preoperative patient discomfort
and glucose and insulin levels. Intravenous (i.v.) glucose
was compared with an oral CHD or overnight fasting.
Methods
The present prospective, randomized study was
approved by the Ethical Committee of Seinäjoki Central
Hospital. Informed and written consent was obtained
from each patient. Inclusion criteria were adult patients
undergoing elective abdominal, anal, thyroid or parathyr-
oid operations and ASA physical status I–III. Patients
DOI:10.1097/EJA.0b013e328319be16
 124 European Journal of Anaesthesiology 2009, Vol 26 No 2
who were pregnant or who had dementia, impairment
of gastrointestinal motility or diabetes mellitus were
excluded from the study.
A total of 240 patients were recruited into the study.
Sealed envelopes were made using a random number
allocation and were opened the day prior to surgery by a
researcher independent of the clinical team. The patients
were randomly assigned to one of three treatment groups:
overnight i.v. glucose infusion (i.v. group), CHD in the
morning (CHD group) or fasting from midnight (fasting
group). Patients in the i.v. group were given 1000 ml of
i.v. 5% glucose solution (¼200 kcal) (Normosteril; Baxter,
Finland) between midnight and 6 a.m. and nothing by
mouth after midnight. Patients in the CHD group were
given nothing after midnight and a 12.5% CHD (Nutricia
Preop; Numici, The Netherlands), that is 400 ml
(¼200 kcal), between 6 and 7 a.m. Patients in the fasting
group were given nothing by mouth after midnight.
There were no food or drink restrictions before midnight
in any of the groups.
Hospital admission was scheduled for all patients 1 day
before the surgical procedure. All comorbidity factors
were recorded for each patient. No intestinal washout
treatment or enemas were used. To study the effects of
the different treatment groups on glucose and insulin
levels, a serum glucose test was taken in the evening
(10 p.m.) before operation, in the morning (6 a.m. and
7.30 a.m.) and at the induction of anaesthesia. A serum
insulin sample was taken from the first 64 patients at the
same time points as the glucose samples. The sample
times in the morning were chosen in order to obtain blood
glucose and insulin levels before and after the morning
drink.
The patients scored their subjective sense of discomfort
with a visual analogue scale (VAS 0–10) repeatedly
during the study. Eight different variables were evalu-
ated: thirst, hunger, dryness of mouth, weakness, tired-
ness, anxiety, headache and pain. The variables were
evaluated in the evening (10 p.m.) before operation, in
the morning at 6 a.m. and just before going to the
operating theatre.
Patients were premedicated and anaesthetized according
to the normal practice of our hospital. Oral premedication
of hydroxyzine hydrochloride (Atarax; UCB, Belgium)
25–50 mg with a small amount of water was given at 7
a.m. in the morning. Anaesthesia for the first operation
was scheduled to start at 8 a.m.
There are no specific methods for power analysis of
ordinal data such as VAS values. A sample size of 40–
80 in each of the three study groups has yielded signifi-
cant differences in previous studies [5,16,17]. Results are
presented as mean
SD or medians and percentiles. As
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
the distributions in most of the groups were found to be
skewed, statistical analysis was carried out using the
Kruskal–Wallis test and the Mann–Whitney U-test.
Friedman’s test and the Wilcoxon signed-rank test were
used for intragroup trend analysis of the VAS measure-
ments. Differences in categorical data were compared
with the x2 test and the Fisher’s exact test, wherever
appropriate. A P value of less than 0.05 was considered
significant. The statistical analysis was conducted with
SPSS 12.0.1 statistical software (SPSS Inc, Chicago,
Illinois, USA).
Results
Two hundred and forty patients were originally recruited
into the study. Thirty patients were excluded from the
final analysis because of incomplete data. The data were
gathered over a period of 10 months.
The groups were comparable for sex ratio, age, ASA
physical status and BMI (Table 1). There were no cases
of apparent or suspected pulmonary aspiration periopera-
tively in any patient group. There were no differences
among groups in the number of patients receiving seda-
tives in the evening before surgery (185) or premedica-
tion before anaesthesia (206). The mean
SD time
period from 6 a.m. to the induction of anaesthesia (wait-
ing period) was 4.1
1.9 h in the i.v. group, 3.8
1.7 h in
the CHD group and 4.3
1.8 h in the fasting group (not
significant). Twenty-nine patients in the i.v. group, 27
patients in the CHD group and 38 patients in the fasting
group had a waiting period of over 4 h, that is, their
surgery was not scheduled to be first in the morning.
The highest median VAS scores were seen for thirst,
tiredness and anxiety (Table 2). The VAS scores (median,
25th–75th percentiles) for headache and pain were low
(0, 0–2 and 0, 0–3, respectively) and not significantly
affected in the preoperative time period.
In the i.v. group, trend analysis showed increasing
preoperative discomfort over time in three out of eight
VAS variables (Table 2). Specifically, preoperative thirst
(P < 0.001), mouth dryness (P < 0.01) and anxiety
(P < 0.01) (Table 2) increased during the time period
from the preoperative evening to induction of anaesthe-
sia. There was no consistent trend for hunger, weakness
or tiredness.
Table 1 Patients’ characteristics (mean W SD or number of
patients)
i.v. group CHD group Fasting group
(n ¼ 67) (n ¼ 70) (n ¼ 73)
Gender (male/female) 25/42 26/44 22/51
Age (years) 61
16 60
15 58
4
BMI (kg/m2) 26
4 27
5 27
5
ASA 1/2–3 56/11 53/17 55/18
CHD, carbohydrate-rich drink; i.v., intravenous glucose.
 Preoperative i.v. carbohydrate loading Helminen et al. 125

Table 2 Visual analogue scale data for preoperative discomfort variables [median (interquartile range)]
VAS variable Treatment group Preoperative evening Morning at 6.00 a.m. Before anaesthesia Friedman’s test

Thirst i.v. 0 (0–2) 1 (0–3.5) i 2 (0–4) i P ¼ 0.000

CHD 1 (0–2) 2 (0–4) i 1 (0–4.5) d P ¼ 0.007
Fasting 0 (0–2.5) 3 (0–4.5) i 3 (0–5) i P ¼ 0.000
Hunger i.v. 0 (0–3.5) 0 (0–2) 0 (0–4) P ¼ 0.3
CHD 0 (0–1) 0 (0–2) 0 (0–2) i P ¼ 0.001
Fasting 0 (0–2.5) 0 (0–2) 2 (0–5) iM P ¼ 0.001
Mouth dryness i.v. 1 (0–4) 2 (0–4) i 2 (0–5) P ¼ 0.001
CHD 1 (0–4) 2 (0–5) i 2 (0–5) P ¼ 0.000
Fasting 1 (0–2.5) 2 (0– –4) i 2 (1–5) P ¼ 0.000
Weakness i.v. 0 (0–1) 0 (0–2) 0 (0–3) P ¼ 0.2
CHD 0 (0–0.5) 0 (0–1) 0 (0–1.5) P ¼ 0.6
Fasting 0 (0–0) 0 (0–0) 0 (0–1) i P ¼ 0.001
Tiredness i.v. 1 (0–4) 2 (0–4) 2 (0–5) P ¼ 0.8
CHD 2 (0–6) 2 (0–4) 2 (0–5) P ¼ 0.09
Fasting 2 (0–3.5) 2 (0–3.5) 3 (0–5) i P ¼ 0.01
Anxiety i.v. 2 (0–5) 3 (1–6) i 3 (0.5–6) P ¼ 0.005
CHD 2 (0–5) 2 (0–5) 2 (1–5) P ¼ 0.1
Fasting 2 (0–4) 3 (1–5) i 3 (1–5) P ¼ 0.02

CHD, carbohydrate-rich drink; i.v., intravenous glucose; VAS, visual analogue scale. VAS: 0 ¼ ‘none at all’; 10 ¼ ‘the worst I can imagine’. i ¼ increasing trend (P < 0.05) and
d ¼ decreasing trend (P < 0.05) according to Wilcoxon’s paired rank test (comparison with values at previous time point). M P ¼ 0.011 CHD group vs. fasting group.

In the CHD group, trend analysis showed increasing VAS Before intake of the morning drink at 6.00 a.m., glucose
scores for thirst between the evening before surgery and concentrations but not insulin levels were higher in the
the morning at 6 a.m. (P < 0.01), after which the VAS i.v. group than in the CHD and fasting groups (P < 0.01)
scores decreased before induction of anaesthesia (Table 3). Ninety minutes after the morning drink, both
(P < 0.01) (Table 2). Two other variables, namely hunger glucose and insulin concentrations were increased in the
(P < 0.001) and mouth dryness (P < 0.001), increased CHD group compared with the other two groups
over time (Table 2). No consistent trends for the other (P < 0.001). At the induction of anaesthesia, glucose
VAS variables were seen. concentrations were higher in the i.v. group than in
the fasting group (P < 0.01), but insulin concentrations
In the fasting group, trend analysis showed increasing did not differ among the groups (Table 3).
discomfort over time in six out of eight variables. Patients
in this group became more thirsty (P < 0.001), more
hungry (P < 0.001), more tired (P < 0.01) and more Discussion
anxious (P < 0.05) and experienced more weakness The present study shows that administration of i.v.
(P < 0.001) and mouth dryness (P < 0.001) before surgery glucose had some effects on preoperative discomfort.
(Table 2). In contrast to the fasting group, hunger, weakness and
tiredness were not increased during the waiting period
In the evening before surgery, there were no differences before surgery. On the contrary, preparation with an oral
among the treatment groups in any of the VAS variables carbohydrate drink not only reduced preoperative thirst
(Table 2). Before intake of the morning drink (6.00 a.m.), effectively but it also alleviated preoperative hunger
patients in the fasting group were thirstier than those in better than i.v. glucose.
the i.v. group but this did not reach statistical significance
(P ¼ 0.07). Before induction of anaesthesia, patients in We used the VAS to measure the patients’ subjective
the CHD group were less hungry (P ¼ 0.011) than those feelings preoperatively because of its general acceptance
in the fasting group. No other differences in discomfort and ease of administration. The variables in the VAS
variables were seen among the study groups during the questionnaire were the same as those used in several
waiting period. previous studies [5,16,17]. High test–retest reproduci-
Table 3 Preoperative serum glucose and insulin concentrations (mean W SD)
Treatment group (n) Preoperative evening Morning at 6.00 a.m. Morning at 7.30 a.m. Before induction
1
Glucose (mmol l ) i.v. (67) 5.5
1.3 6.4
2.1 M
5.5
1.7 5.5
1.4y
CHD (70) 5.6
0.9 5.3
1.1 6.8
2.6MM 5.3
1.6
Fasting (73) 5.5
1.1 5.2
0.8 5.3
1.0 4.9
1.2
Insulin (mU l1) i.v. (19) 7.4
6.8 12.6
9.6 18.47
43.9 8.2
10.8
CHD (22) 10.3
7.2 19.4
22.9 36.9
32.0ô 8.6
7.5
Fasting (23) 10.4
9.7 6.5
4.0 6.2
3.5 5.5
3.3

CHD, carbohydrate-rich drink; i.v., intravenous glucose. M P < 0.01 i.v. group vs. CHD and fasting group. MM P < 0.001 CHD group vs. i.v. and fasting groups. y P < 0.05 i.v.
group vs. fasting group. ô P < 0.001 CHD group vs. i.v. and fasting group.

Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.

 126 European Journal of Anaesthesiology 2009, Vol 26 No 2
bility and a high level of patient compliance have been
found using this scoring method [5].
In this study, the highest median scores were seen for
thirst, tiredness and anxiety, all of which were observed
in the fasting group. The feeling of thirst increased in all
study groups during the waiting period before 6 a.m.
There was a trend towards a reduced sense of thirst in the
i.v. group compared with the fasting group at this time
point (P ¼ 0.07). After the morning drink, patients in
the CHD group reported a significant reduction in thirst,
whereas thirst continued to increase in patients in the
other two groups. Our results are in accordance with
previous investigations in which clear fluids (placebo or
CHD) efficiently reduced preoperative thirst compared
with fasting [5,18].
Interestingly, both the CHD and fasting groups showed
an increase in hunger VAS after the morning drink.
However, the fasting group had significantly higher
VAS scores than the CHD group at induction of anaes-
thesia. There was no consistent trend in the i.v. group. In
a randomized study by Hausel et al. [5] in ASA I–II
patients undergoing abdominal surgery, CHD reduced
the sense of hunger and improved the sense of anxiety
compared with placebo or fasting. The effect on hunger
was thought to be directly related to the intake of energy
and could in part explain why no increase in hunger was
observed in the i.v. group in our study. However, contrary
to the findings of Hausel et al., hunger did not decrease in
the CHD group during the time period after the morning
drink and beginning of anaesthesia. This may partly be
explained by our different study design. First, in the
study by Hausel et al. [5], the intake of drink (water or
carbohydrate beverage) was in the preoperative evening
(800 ml) and in the morning (400 ml) approximately
215 min before induction of anaesthesia. It may be
possible that the evening drink offered some extra
benefit in terms of reduced sense of hunger during the
waiting period. Second, in the Hausel et al. study, the
last measurement of VAS values were made 90 min after
the morning drink, whereas in our study it was just before
the induction of anaesthesia, approximately 4 h after the
morning drink. This point, we believe, reflects the peak
values of discomfort. It may be possible that the carbo-
hydrate drink dilates the stomach momentarily and so
decreases the sense of hunger. However, this effect may
be over after 4 h. Further studies may be indicated to
determine the optimal time of ingestion of an oral carbo-
hydrate drink.
Although the VAS scores did not differ among the groups
with regard to weakness and tiredness, only the fasting
group showed an increase over time in these variables. In
the study by Hausel et al. [5], oral carbohydrate loading
reduced the feeling of unfitness and anxiety preopera-
tively, which they attributed to the secondary effects
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
from the intake of energy. Our study did not show any
consistent change in anxiety after either carbohydrate
treatment regimen. It is possible that the premedication
administered approximately 1 h after the morning drink
confounded the results of our study. In addition, pre-
operative anxiety has been shown to be multidimensional
and can vary significantly according to certain patient
characteristics and demographics [19].
The main objective of preoperative carbohydrate treat-
ment is to produce the change in metabolism that nor-
mally takes place when breakfast is eaten [6]. This elicits
an endogenous release of insulin that turns off the over-
night fasting state of the metabolism [6]. Preoperative
carbohydrate loading with an overnight glucose infusion
or CHD 2 h before the operation has been shown to
reduce postoperative insulin resistance [13–15,20]. In
our study, i.v. glucose (200 kcal) given during the night
before surgery caused an elevation in serum glucose but
not insulin concentrations in the morning at 6 a.m. In this
group of patients, the level of glucose was maintained and
was significantly higher than in the fasting group at the
induction of anaesthesia. The lower glucose levels of the
patients in the fasting group may have resulted in nega-
tive effects of preoperative well being in this group. The
carbohydrate drink increased serum glucose and insulin
levels significantly, but the effect was over before the
induction of anaesthesia. This is comparable with the
findings of Svanfeldt et al. [21] in healthy volunteers, in
whom oral carbohydrate loading in the morning increased
both glucose and insulin levels attaining maximum values
30 min after ingestion. Glucose concentrations returned
to baseline within 90 min, whereas insulin concentrations
decreased somewhat more slowly [21].
All perioperative care and treatment was performed
according to our standard protocols and we did not make
any age or ASA class restrictions. Of note is that there
were no problems relating to gastric regurgitation in any
patients, even in those with, for example, gastric cancer.
However, we did not attempt to evaluate the safety of
preoperative drinking before induction of anaesthesia in
our study per se. Therefore, we cannot state that this
regimen should be regarded as safe in patients regardless
of concomitant disease.
In conclusion, preoperative i.v. glucose infusion offered
certain benefits over fasting, namely better preservation
of glucose levels and no increased sense of weakness,
tiredness or hunger during the waiting period. On the
contrary, the oral CHD reduced preoperative thirst effi-
ciently and patients in this study group were significantly
less hungry than those in the fasting group. As thirst has
been suggested to be the main determinant of preopera-
tive discomfort [22] and oral administration of carbo-
hydrate is more simple to carry out, it would appear that
using the oral route for carbohydrate loading whenever
 Preoperative i.v. carbohydrate loading Helminen et al. 127

possible should be recommended. In patients unable to

ingest oral fluids, however, preoperative i.v. glucose is
a viable alternative especially if the waiting period is
prolonged.

References
1 Splinter WM, Schaefer JD. Unlimited clear fluid ingestion two hours before
surgery in children does not affect volume or pH of stomach contents.
Anaesth Intensive Care 1990; 18:522–526.
2 Read MS, Vaughan RS. Allowing preoperative patients to drink: effects on
patients’ safety and comfort of unlimited oral water until 2 h before
anaesthesia. Acta Anaesthesiol Scand 1991; 35:591–595.
3 Nygren J, Thorell A, Jacobsson H, et al. Preoperative gastric emptying.
Effects of anxiety and oral carbohydrate administration. Ann Surg 1995;
222:728–734.
4 Phillips S, Hutchinson S, Davidson T. Preoperative drinking does not affect
gastric contents. Br J Anaesth 1993; 70:6–9.
5 Hausel J, Nygren J, Lagerkranser M, et al. A carbohydrate-rich drink reduces
preoperative discomfort in elective surgery patients. Anesth Analg 2001;
93:1344–1350.
6 Ljungqvist O, Soreide E. Preoperative fasting. Br J Surg 2003; 90:400–
406.
7 Black P, Brooks D, Bessey B, et al. Mechanisms of insulin resistance
following injury. Ann Surg 1982; 196:420–435.
8 Henderson A, Frayn K, Galasko C, Little R. Dose-response relationships for
the effects of insulin on glucose and fat metabolism in injured patients and
control subjects. Clin Sci 1991; 80:25–32.
9 Thorell A, Efendic S, Gutniak M, et al. Development of postoperative insulin
resistance is associated with the magnitude of operation. Eur J Surg 1993;
159:593–599.
10 Thorell A, Nygren J, Essen P, et al. The metabolic response to
cholecystectomy: insulin resistance after open compared with
laparoscopic operation. Eur J Surg 1996; 162:187–191.
11 Thorell A, Efendic S, Gutniak M, et al. Insulin resistance after abdominal
surgery. Br J Surg 1994; 81:59–63.
12 Thorell A, Nygren J, Ljungqvist O. Insulin resistance: a marker of surgical
stress. Curr Opin Clin Nutr Metab Care 1999; 2:69–78.
13 Nygren J, Soop A, Thorell A, et al. Preoperative oral carbohydrate
administration reduces postoperative insulin resistance. Clin Nutr 1998;
17:65–71.
14 Soop M, Nygren J, Myrenfors P, et al. Preoperative oral carbohydrate
attenuates immediate postoperative insulin resistance. Am J Physiol
Endocrinol Metab 2001; 280:E576–E583.
15 Ljungqvist O, Thorell A, Gutniak M, et al. Glucose infusion instead of
preoperative fasting reduces postoperative insulin resistance. J Am Coll
Surg 1994; 178:329–336.
16 Bisgaard T, Kristiansen V, Hjortso N, et al. Randomized clinical trial
comparing an oral carbohydrate beverage with placebo before
laparoscopic cholecystectomy. Br J Surg 2004; 91:151–158.
17 Hausel J, Nygren J, Thorell A, et al. Randomized clinical trial of the effects of
oral preoperative carbohydrates on postoperative nausea and vomiting
after laparoscopic cholecystectomy. Br J Surg 2005; 92:415–421.
18 Breuer J-P, von Dossow V, von Heymann C, et al. Preoperative oral
carbohydrate administration to ASA III-IV patients undergoing elective
cardiac surgery. Anesth Analg 2006; 103:1099–1108.
19 Kindler CH, Harms C, Amsler F, et al. The visual analog scale allows
effective measurement of preoperative anxiety and detection of patients’
anesthetic concerns. Anesth Analg 2000; 90:706–712.
20 Nygren J, Soop M, Thorell A, et al. Preoperative oral carbohydrates and
postoperative insulin resistance. Clin Nutr 1999; 18:117–120.
21 Svanfeldt M, Thorell A, Hausel J, et al. Effect of ‘preoperative’ oral
carbohydrate treatment on insulin action – a randomised cross-over
unblinded study in healthy subjects. Clin Nutr 2005; 24:815–821.
22 Madsen M, Brosnan J, Nagy V. Perioperative thirst: a patient perspective.
J Perianesth Nurs 1998; 13:225–228.

Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.