Comment on “Relationship Between Preoperative Fasting Duration and Anxiety Levels With Postoperative Pain, Nausea‐Vomiting, and Sleep Quality in Orthopedic Surgical Patients”

We read with interest the study by Kirtil and Aydin examining associations between preoperative fasting duration, anxiety, and early postoperative outcomes in orthopedic surgical patients (Kirtil and Aydin 2025). The authors appropriately foreground anxiety as a clinically relevant correlate of postoperative pain and sleep quality and report statistically significant relationships between anxiety scores, fasting duration, and postoperative symptom burden. However, we suggest that interpreting fasting duration primarily as an individual-level exposure may overlook a central, modifiable, system-level determinant: operating room scheduling and the institutional implementation gap between evidence-based fasting guidance and real-world practice. International guidance consistently supports clear fluids up to 2 h before anesthesia for healthy patients undergoing elective procedures (Apfelbaum 2017; Smith et al. 2011). Yet multiple reports indicate that “real fasting times” often substantially exceed recommendations, driven by conservative routines, fear of aspiration, and, critically, limited flexibility and uncertainty in operating room workflow (de Klerk et al. 2023; Marsman et al. 2023). In this context, prolonged fasting can function less as a patient behavior and more as a proxy for structural inefficiency: delayed start times, list overruns, and communication practices that default to “nil by mouth from midnight.” Such system-driven fasting may also intensify anxiety through uncertainty, discomfort, and perceived loss of control, thereby amplifying downstream pain and sleep disruption. Without measuring these upstream operational factors, it remains difficult to determine whether the reported associations reflect a patient-level psychophysiological pathway or an institutional pathway in which scheduling constraints simultaneously prolong fasting and heighten distress. This distinction matters for intervention. If prolonged fasting largely reflects scheduling-driven delays, then recommending anxiety monitoring alone may yield limited benefit unless accompanied by workflow and communication changes that reduce unnecessary fasting and uncertainty. Contemporary perioperative literature highlights that suboptimal guideline implementation is common and that organizational factors, including operating room scheduling, contribute meaningfully to excessive fasting (de Klerk et al. 2023; Marsman et al. 2023). Accordingly, a systems lens may strengthen the clinical utility of the authors’ findings and align recommended actions with the levers most likely to change patient experience. We propose three immediate, low-burden steps. First, the authors could re-analyze their existing dataset to examine whether fasting duration varies by scheduled case order (first case vs. later cases) or by time of day. A clear gradient would support the interpretation that fasting is operationally determined. Second, future data collection could add two brief contextual items: “What was your scheduled operating time?” and “What time did you enter the operating room?” The difference would quantify delay-related fasting and permit stratified analyses of anxiety and outcomes by scheduling deviation. Third, the authors could pilot a micro-intervention incorporating (a) a standardized “clear fluids until 2 h” protocol consistent with guideline recommendations and (b) a structured preoperative communication script that updates patients about anticipated timing and what to do if delays occur. Practice guidance and perioperative evidence suggest that improving adherence to clear-fluid policies can reduce unnecessary fasting without compromising safety (Frykholm et al. 2025). Incorporating a workflow-and-communication lens would move the study from identifying correlates to clarifying root causes. It would also shift implications from solely patient-focused mitigation (e.g., anxiety surveillance) toward nursing-led quality improvement and advocacy for evidence-based fasting implementation, an especially relevant contribution in high-throughput surgical services. We encourage the authors to explore this accessible, system-level dimension, which may substantially strengthen the translational impact of their important work. Walaa Badawy: conceptualization, investigation, funding acquisition, writing – original draft. Mostafa Shaban: methodology, validation, conceptualization. The authors extend their appreciation to the Deanship of Research and Graduate Studies at King Khalid University for funding this work through the Large Research Project under grant number RGP2/187/46. The authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.