Preoperative Fasting and Drinking Compliance Under the ERAS Framework: Current Status, Barriers, and Optimization Strategies — A Cross-Sectional Study

Background Optimizing preoperative fasting and drinking practices is an essential component of Enhanced Recovery After Surgery (ERAS). However, substantial discrepancies persist between guideline recommendations and actual patient behavior. This study aimed to evaluate compliance with preoperative fasting and drinking guidelines among elective surgical patients, identify influencing factors, and explore potential strategies to improve individualized perioperative dietary management. Methods This cross-sectional study was conducted from June 2024 to March 2025 in the anesthesiology and operating room setting of a tertiary care institution. A total of 398 elective surgical patients were recruited through convenience sampling. Data were collected using a structured questionnaire capturing demographic characteristics, preoperative education, fasting and drinking behavior, and perceived barriers. According to ERAS recommendations, patients were categorized into four groups: fully compliant, under-compliant, over-fasting, and dual violations. Statistical analyses included t tests, chi-square tests, and multinomial logistic regression, with a significance level of α=0.05. Results Among the 398 valid responses, 39.4% were fully compliant, 11.3% under-compliant, 45.0% over-fasting, and 4.3% presented dual violations. Patients in the over-fasting group had prolonged fasting durations (solid food: 13.7 ± 3.0 hours; clear liquids: 10.0 ± 3.1 hours), exceeding ERAS recommendations (P<0.001). Multivariable logistic regression identified lower education level (OR=3.64, 95% CI 1.10–8.19, P=0.002) and diabetes (OR=5.86, 95% CI 1.74–19.73, P=0.004) as independent risk factors for poor compliance, while receiving multimodal preoperative education (OR=0.18, 95% CI 0.08–0.39, P<0.001) and understanding the purpose of fasting (OR=0.39, 95% CI 0.24–0.64, P<0.001) were protective factors. Preoperative discomfort was common, with thirst (37.4%), hunger (33.4%), and anxiety (26.9%) being the most frequently reported symptoms; these were significantly more prevalent in the over-fasting group (P<0.001). Conclusions Suboptimal and excessive fasting remain widespread under ERAS-based perioperative care. Inadequate patient understanding, inconsistent education, and procedural inertia contribute to poor compliance. Extended fasting times confer no additional safety benefit and are associated with increased discomfort and metabolic risk. Strengthening multimodal education, improving workflow consistency, and integrating digital decision-support tools may enhance adherence and support individualized fasting management. These findings provide evidence to inform quality improvement in ERAS implementation. Clinical trial number: not applicable.