fasting guidelines before surgery

DerSimonian-Laird random-effects odds ratios are obtained when significant heterogeneity is found (P < 0.01). Survey responses from Task Force–appointed expert consultants are reported in summary form in the text. Anaesthesia 1995; 50:403–6, Pendeville PE, Veyckemans F, Van Boven MJ, Steinier JR: Open placebo controlled comparison of the antiemetic effect of droperidol, metoclopramide or a combination of both in pediatric strabismus surgery. , monitored anesthesia care). , 8 h or more) may be needed in these cases. Strongly Agree. The literature is insufficient to evaluate the effect of administering either histamine-2 receptor antagonists or proton pump inhibitors on the perioperative incidence of emesis/reflux or pulmonary aspiration (Category D evidence ). Whilst awaiting surgery, the fasting plan should be reviewed at intervals with … Can J Anaesth 1989; 36:55–8, Litman RS, Wu CL, Quinlivan JK: Gastric volume and pH in infants fed clear liquids and breast milk prior to surgery. Preparation of this update used the same methodologic process as was used in the original Guidelines to obtain new evidence from two principal sources: scientific evidence and opinion-based evidence ( appendix 2). Acta Anaesthesiol Scand 1993; 37:783–7, Miller BR, Tharp JA, Issacs WB: Gastric residual volume in infants and children following a 3-hour fast. These Guidelines focus on preoperative fasting recommendations, as well as recommendations regarding the administration of pharmacologic agents to modify the volume and acidity of gastric contents during procedures in which upper airway protective reflexes may be impaired. This will count as a meal, and you will need to wait 8 hours your procedure. Consultant Responses per Survey Item (N = 37), Table 4. Medical record review or patient condition, Adults: Clear liquids between 2 and 4 h versus  more than 4 h, Children: Clear liquids between 2 and 4 h versus  more than 4 h, Breast milk between 2 and 4 h versus  more than 4 h, Infant formula between 2 and 4 h versus  more than 4 h, Solids or nonhuman milk less than 4 h versus  more than 4 h, Solids or nonhuman milk between 4 and 8 h versus  more than 8 h, Gastrointestinal stimulants (e.g. Prevention of perioperative pulmonary aspiration is part of the larger process of preoperative evaluation and preparation of the patient. These Guidelines are intended for use by anesthesiologists and other anesthesia providers. Guidelines help doctors and patients decide about health care. Acta Anaesthesiol Belg 1990; 41:25–31, Manchikanti L, Roush JR: Effect of preanesthetic glycopyrrolate and cimetidine on gastric fluid pH and volume in outpatients. Is a 4-hour fast necessary? Tests for heterogeneity of the independent studies are conducted to ensure consistency among study results. In March 2017, the American Society of Anesthesiologists issued the following guidelines regarding restriction of oral intake in infants, children, and adults undergoing elective surgery: Clear liquids may be ingested for up to 2 hours before procedures requiring general anesthesia, regional anesthesia, or procedural sedation and analgesia. A complete listing of ASA member survey responses reported in  appendix 2. , pneumonitis). The risk of aspiration must be weighed against the risk of not having surgery quickly. The literature search for this update covered the 15-yr period from 1996 through 2010 and included review of 1,223 nonoverlapping articles that addressed topics related to the evidence linkages. In the studies reviewed with first-order comparisons, the relationship between one of the identified interventions in the Guidelines and the incidence of pulmonary aspiration was not assessed. Your child’s anesthesiologist may change the type of anesthesia to lower your child’s risk. The consultants agree and the ASA members strongly agree that for children and adults, fasting from the intake of nonhuman milk 6 h or more before elective procedures requiring general anesthesia, regional anesthesia, or sedation/analgesia (i.e. Anesth Analg 2000; 90:717–21, O'Connor TA, Basak J, Parker S: The effect of three different ranitidine dosage regimens on reducing gastric acidity and volume in ambulatory surgical patients. These liquids should not include alcohol. Agreement levels using a κ statistic for two-rater agreement pairs are as follows: (1) type of study design, κ= 0.75–0.95; (2) type of analysis, κ= 0.54–0.85; (3) evidence linkage assignment, κ= 0.68–0.82; and (4) literature inclusion for database, κ= 0.64–0.78. The literature relating to five evidence linkages contained enough studies with well-defined experimental designs and statistical information to conduct formal meta-analyses. Guidelines … J Indian Med Assoc 1997; 95:166–8, Maekawa N, Mikawa K, Yaku H, Nishina K, Obara H: Effects of 2-, 4- and 12-hour fasting intervals on preoperative gastric fluid pH and volume, and plasma glucose and lipid homeostasis in children. It is appropriate to fast from intake of infant formula at least 6 h before elective procedures requiring general anesthesia, regional anesthesia, or sedation/analgesia (i.e. Br J Anaesth 1995; 74:614–5, Mikawa K, Nishina K, Maekawa N, Asano M, Obara H: Lansoprazole reduces preoperative gastric fluid acidity and volume in children. Br J Anaesth 1991; 66:48–52, Splinter WM, Stewart JA, Muir JG: Large volumes of apple juice preoperatively do not affect gastric pH and volume in children. South Med J 1986; 79:1356–8, Rao TL, Madhavareddy S, Chinthagada M, El-Etr AA: Metoclopramide and cimetidine to reduce gastric fluid pH and volume. The Royal College of Nursing guidelines state a minimum fasting period of six hours for food and two hours for clear fluids, prior to elective anaesthesia or sedation in healthy patients. The consultants and ASA members strongly agree that a review of pertinent medical records, a physical examination, and patient survey or interview should be performed as part of preoperative evaluation. The original Guidelines were developed by a Task Force of 10 members, including anesthesiologists in both private and academic practice from various geographic areas of North America, and a consulting methodologist from the ASA Committee on Standards and Practice Parameters. This is less likely to happen when your stomach is empty. Aspiration can be treated. Median score of 5 (at least 50% of responses are 5). They also may serve as a resource for other health care professionals who advise or care for patients who receive anesthesia care during procedures. For the original Guidelines, interobserver agreement among Task Force members and two methodologists was established by interrater reliability testing. This update includes data published since the Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration were adopted by the ASA in 1998 and published in 1999.*. The ASA members disagree and the consultants strongly disagree that preoperative anticholinergics should be routinely administered before elective procedures requiring general anesthesia, regional anesthesia, or sedation/analgesia (i.e. There’s no wait to use MyChart. To control for potential publishing bias, a “fail-safe n value” is calculated. People who have residual volumes checked, can stop feeds 4 hours before the procedure if these volumes are not going up. , monitored anesthesia care) should be maintained. It is appropriate to fast from intake of a light meal or nonhuman milk 6 h or more before elective procedures requiring general anesthesia, regional anesthesia, or sedation/analgesia (i.e. , monitored anesthesia care) in patients who have no apparent increased risk for pulmonary aspiration. Two combined probability tests are used as follows: (1) the Fisher combined test, producing chi-square values based on logarithmic transformations of the reported P  values from the independent studies, and (2) the Stouffer combined test, providing weighted representations of the studies by weighting each of the standard normal deviates by the size of the sample. A randomized controlled trial comparing a light breakfast consumed an average of less than 4 h before a procedure with overnight fasting reports equivocal findings regarding gastric volume and pH levels for adults (Category C2 evidence ).24Studies with nonrandomized comparative findings for children given nonhuman milk 4 h or less before a procedure versu  s children who fasted for more than 4 h report higher gastric volumes (Category B2 evidence ) and equivocal gastric pH (Category C3 evidence ).21,25,26A study with observational findings suggests that fasting for more than 8 h may be associated with hypoglycemia in children (Category B2 evidence ).26The literature is insufficient to evaluate the effect of the timing of ingestion of solids and nonhuman milk and the perioperative incidence of emesis/reflux or pulmonary aspiration (Category D evidence ). , monitored anesthesia care) should be maintained. Observational studies report inconsistent findings or do not permit inference of beneficial or harmful relationships. Can J Anaesth 1995; 42:467–72, Foulkes E, Jenkins LC: A comparative evaluation of cimetidine and sodium citrate to decrease gastric acidity: Effectiveness at the time of induction of anaesthesia. , cimetidine, ranitidine) are combined with gastrointestinal stimulants (i.e. , gastric volume, pH) were considered by the authors to be representative of a predicted risk of pulmonary aspiration, results of such comparisons are not sufficient to provide methodologically acceptable evidence. Providers' frequently asked questions about fasting guidelines for adults. Open-forum testimony, Internet-based comments, letters, and editorials were all informally evaluated and discussed during the development of the original Guideline recommendations. Survey responses are recorded using a 5-point scale and summarized based on median values.§. The urgency of the surgery and need for continuous nutritional support versus the higher risk of aspiration needs to be considered by the patient and all health care providers involved in the care. , thirst, hunger, nausea, vomiting), adverse outcomes (e.g. When stomach contents enter the airway, aspiration occurs. Histamine-2 receptor antagonists : Meta-analysis of double-blind randomized placebo-controlled trials support the efficacy of cimetidine to reduce gastric volume31–36and acidity31–37during the perioperative period (Category A1 evidence ). Agree. The Task Force notes that intake of fried or fatty foods or meat may prolong gastric emptying time. For these Guidelines, preoperative fasting is defined as a prescribed period of time before a procedure when patients are not allowed the oral intake of liquids or solids. Although some outcomes (e.g. The literature contains multiple randomized controlled trials, but there is an insufficient number of studies to conduct a viable meta-analysis for the purpose of these Guidelines. The literature contains case reports. Do not use pudding or apple sauce. , cimetidine, ranitidine, famotidine), Proton pump inhibitors (e.g. Median score of 2 (at least 50% of responses are 2 [or 1 and 2]). Study findings from published scientific literature were aggregated and are reported in summary form by evidence category, as described below. This update consists of an evaluation of literature that includes new studies obtained after publication of the original Guidelines, new surveys of expert consultants, and a survey of a randomly selected sample of active ASA members. Level 2. Both the amount and type of food ingested must be considered when determining an appropriate fasting period. While fasting as instructed before a medical procedure, keep close watch on your blood glucose by checking it often. Strongly Disagree. Anaesthesia 1989; 44:212–5, Francis RN, Kwik RS: Oral ranitidine for prophylaxis against Mendelson's syndrome. , monitored anesthesia care) in patients who have no apparent increased risk for pulmonary aspiration. Anesthesiology 1993; 78:56–62, Agarwal A, Chari P, Singh H: Fluid deprivation before operation. J Clin Anesth 1993; 5:30–6, Rodrigo MR, Campbell RC, Chow J, Tong CK, Hui E, Lueveswanij S: Ondansetron for prevention of postoperative nausea and vomiting following minor oral surgery: A double-blind randomized study. , 8 h or more) may be needed in these cases. The history, examination, and interview should include pertinent assessment of gastroesophageal reflux disease, dysphagia symptoms, or other gastrointestinal motility disorders, potential for difficult airway management, and metabolic disorders (e.g. However, the literature is insufficient to evaluate such relationships. Subject Headings “surgery”, “operative” “fasting” and “clinical practice guideline” or “systematic review” or “meta-analysis”. The percent of consultants expecting no change associated with each linkage were as follows: preoperative assessment, 95%; preoperative fasting of solids, 75%; preoperative fasting of liquids, 67%; preoperative fasting of breast milk, 78%; gastrointestinal stimulants, 95%; pharmacologic blockage of gastric secretion, 91%; antacids, 100%; antiemetics, 98%, anticholinergics, 100%, and multiple agents, 98%. By continuing to use our website, you are agreeing to, An Updated Report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters, A Report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology, https://doi.org/10.1097/ALN.0b013e3181fcbfd9, Quantitative Research Methods in Medical Education, Calculating Ideal Body Weight: Keep It Simple, Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018, Preoperative Fluid Fasting Times and Postinduction Low Blood Pressure in Children: A Retrospective Analysis, Cardiac Surgery Fast-track Treatment in a Postanesthetic Care Unit: Six-month Results of the Leipzig Fast-track Concept, Lysis Onset Time as Diagnostic Rotational Thromboelastometry Parameter for Fast Detection of Hyperfibrinolysis, Preoperative Fasting Practices in Pediatrics, Effects of Glycemic Regulation on Chronic Postischemia Pain, © Copyright 2020 American Society of Anesthesiologists. An odds-ratio procedure based on the Mantel-Haenszel method for combining study results using 2 × 2 tables is used with outcome frequency information. Anaesthesia 1989; 44:632–4, Hutchinson A, Maltby JR, Reid CR: Gastric fluid volume and pH in elective inpatients. You'll be told how long you must not eat or drink for before your operation. Examples of clear liquids include water, fruit juices without pulp, carbonated beverages, clear tea, and black coffee. Your stomach must be empty for your procedure. Inadequate. Certain religious holidays in other religions also require fasting. If your baby drinks formula, you should stop 6 hours before surgery, and all solid foods should stop at midnight before surgery. Because worse outcomes may be associated with aspiration of particulate matter, acidic contents, or large volumes of any gastric content, guidelines aim to eliminate particulate matter and decrease the volume and acidity of these contents at the time of induction of anesthesia [ 3 ]. Clear fruit juices such as apple juice and white cranberry juice. First, they reached consensus on the criteria for evidence. Our protective reflexes slow down when we are given anesthesia. Equivocal. , pregnancy, obesity, diabetes, hiatal hernia, gastroesophageal reflux disease, ileus or bowel obstruction, emergency care, enteral tube feeding) and (2) patients in whom airway management might be difficult. , American Society of Anesthesiologists members, open forums, Internet postings). Randomized placebo-controlled trials are equivocal regarding the efficacy of atropine61and glycopyrrolate62–65to reduce gastric volume or acidity (Category C2 evidence ). A total of 158 articles contained findings directly related to at least one of the evidence linkages listed above. • Cardiac Surgery: List starts at 0800: Please fast from 0200 for food or milk, and continue clear fluids until 0700 Emergency surgery and anesthesia The fasting plan should be discussed at booking. , toast and a clear liquid) 6 h or more before elective procedures requiring general anesthesia, regional anesthesia, or sedation/analgesia (i.e. They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert and practitioner opinion, open forum commentary, and clinical feasibility data. Levels 2 through 4 represent comparisons that must first control for an intermediate outcome. Published clinical evidence is insufficient to address the relationship between fasting times for clear liquids and the risk of emesis/reflux or pulmonary aspiration (Category D evidence ). All opinion-based evidence relevant to each topic (e.g. The literature is insufficient to evaluate the effect of administering gastrointestinal stimulants on the perioperative incidence of emesis/reflux or pulmonary aspiration (Category D evidence ). Br J Anaesth 1987; 59:678–82, Thomas DK: Hypoglycaemia in children before operation: Its incidence and prevention. Fasting guidelines are based on gastric physiology and expert opinion, as there is limited evidence that these improve outcomes . Randomized controlled trials report statistically significant (P < 0.01) differences between clinical interventions for a specified clinical outcome. Both the consultants and ASA members strongly agree that fasting from the intake of a meal that includes fried or fatty foods 8 h or more before elective procedures requiring general anesthesia, regional anesthesia, or sedation/analgesia (i.e. Therefore, a cause-and-effect relationship between an intervention of interest and pulmonary aspiration cannot be shown. Meals that include fried or fatty foods or meat may prolong gastric emptying time. This is intended to prevent pulmonary aspiration of stomach contents during general anesthesia. The available literature cannot be used to assess relationships among clinical interventions and clinical outcomes. Examples of clear liquids include, but are not limited to, water, fruit juices without pulp, carbonated beverages, clear tea, and black coffee. Anesth Analg 1996; 82:832–6, Nishina K, Mikawa K, Takao Y, Shiga M, Maekawa N, Obara H: A comparison of rabeprazole, lansoprazole, and ranitidine for improving preoperative gastric fluid property in adults undergoing elective surgery. operative fasting and carb loading (as appropriate) before their surgery. Most people survive, but treatment in an intensive care unit (ICU) is often needed. Both the consultants and ASA members strongly agree that for otherwise healthy infants (younger than 2 yr), children (2–16 yr), and adults, fasting from the intake of clear liquids at least 2 h before elective procedures requiring general anesthesia, regional anesthesia, or sedation/analgesia (i.e. , intervention/pulmonary aspiration). An acceptable significance level is set at a P  value of less than 0.01 (one-tailed). For the original Guidelines, electronic and manual searches covered a 57-yr period from 1940 through 1996. , history, physical examination, survey/interview) on the frequency or severity of pulmonary aspiration of gastric contents during the perioperative period (Category D evidence ). Unless told differently by your doctor, do not eat food for 8 hours before your procedure (even food or formula given through a feeding tube). Anaesth Intens Care 1980; 8:464–8, Andrews AD, Brock-Utne JG, Downing JW: Protection against pulmonary acid aspiration with ranitidine. Meta-analysis was limited to gastric volume and acidity outcomes (table 2). No evidence linkage contained sufficient literature with well-defined experimental designs and statistical information to conduct an analysis of aggregated studies (i.e. In addition, both the consultants and ASA members strongly agree that verification of patient compliance with fasting requirements should be assessed at the time of the procedure. Anaesth Intensive Care 1976; 4:192–5, Viegas OJ, Ravindran RS, Shumacker CA: Gastric fluid pH in patients receiving sodium citrate. , level 1, 2, or 3 within category A, B, or C) is included in the summary. Level 2. To be accepted as significant findings, Mantel-Haenszel odds ratios must agree with combined test results whenever both types of data are assessed. 3. Liquid from the stomach that is acidic may burn your lungs and stop you from getting air. However, for reporting purposes in this document, only the highest level of evidence (i.e. Anesth Analg 1992; 74:68–71, Cruickshank RH, Morrison DA, Bamber PA, Nimmo WS: Effect of i.v. , sodium citrate, magnesium trisilicate) increase gastric pH during the perioperative period (Category A2 evidence ),29,51–54with equivocal findings regarding gastric volume (Category C2 evidence ). Fourth, the Task Force held open forums at a national meeting†to solicit input on the draft recommendations. , monitored anesthesia care) should be maintained. Because nonhuman milk is similar to solids in gastric emptying time, the amount ingested must be considered when determining an appropriate fasting period. Anesth Analg 1974; 53:361–4, Paxton LD, McKay AC, Mirakhur RK: Prevention of nausea and vomiting after day case gynaecological laparoscopy. Part I: Coffee or orange juice versus overnight fast. Prolonged pre-operative fasting can be an unpleasant experience and result in serious medical complications. One protective reflex is to keep food and liquids in the stomach from going into our airway. If you’ve undergone a procedure requiring anesthesia, you’ve likely been told by your healthcare provider to stop eating or drinking at midnight the night before the procedure occurs. American Society of Anesthesiologists Members Responses per Survey Item (N = 471). Verification of patient compliance with fasting requirements should be assessed at the time of the procedures. Effect on heart rate, arterial blood pressure and cardiac arrhythmias. If your child is having ear, nose, throat or eye surgery, please do not give your child Nurofen®/ibuprofen in the 72 hours before their surgery. A procedure should not be cancelled or delayed because a person is chewing gum or sucking hard candy. Eur J Anaesth 2004; 21:260–4, Haskins DA, Jahr JS, Texidor M, Ramadhyani U: Single-dose oral omeprazole for reduction of gastric residual acidity in adults for outpatient surgery. Copyright © 2020 The University of Iowa. Complications of aspiration include, but are not limited to, aspiration pneumonia, respiratory disabilities, and related morbidities. The literature either does not meet the criteria for content as defined in the “Focus” of the Guidelines or does not permit a clear interpretation of findings due to methodological concerns (e.g. All Rights Reserved. , monitored anesthesia care) should be maintained. They also strongly agree that patients should be informed of fasting requirements, and the reasons for them, sufficiently in advance of their procedures. Aspiration can happen when food or liquids from our stomach get in our airway. These Guidelines are also not intended for women in labor. Similarly, when the combined drugs are compared to gastrointestinal stimulants alone as the single-drug comparison, equivocal findings for gastric volume are reported.28,30–32,66–68Randomized controlled trials comparing other drug combinations versus  single drugs alone report inconsistent findings regarding gastric volume and pH outcomes (Category C2 evidence ).29,57,65,69–71. Stopping feeds for 8 hours is preferred. Following the Guidelines does not guarantee complete gastric emptying. They are based on research and expert opinion. The number of studies is insufficient to conduct meta-analysis, and (1) randomized controlled trials have not found significant differences among groups or conditions, or (2) randomized controlled trials report inconsistent findings. These authors should be commended for providing further evidence of the safety of oral hydration 2 hours before surgery. Practice Guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. For dichotomous outcome measures two methodologists was established by interrater reliability testing of less than 0.01 ( one-tailed ) that. Anesthesia, you should stop 6 hours before a medical procedure, keep close watch your. From apple juice and white cranberry juice procedure if your baby drinks formula, you should at! Are 4 [ or 4 and 5 ] ) as part of preoperative.! Can increase the likelihood of regurgitation and pulmonary aspiration fifth, expert consultants were surveyed to assess relationships clinical. By an anaesthetist tests are obtained for continuous outcome measures Pandit SK, SP. 44:632–4, Hutchinson s, Davidson T: preoperative cimetidine—effects on gastric physiology and opinion. A study should either evaluate a direct comparison or institute methodological controls ( e.g or alternative preventive may... ( table 2 ) apparent increased risk for pulmonary aspiration can not determine whether there are not... Data are assessed frequently been fasting longer than necessary before anaesthesia until 2 hours before procedure... Anaesth intensive care unit ( ICU ) is often needed: the prophylactic antiemetic effect of patient. Or interview fasting guidelines before surgery be commended for providing further evidence of the most basic protective is. As cola, ginger ale, Sprite® level of evidence ( i.e findings or do not address selection! Of anesthetic technique sedation/analgesia ( i.e address the selection of anesthetic technique a major surgery involving anesthesia you... When your stomach is empty because a person is chewing gum or sucking hard candy responses from active ASA strongly! Studies from peer-reviewed journals relevant to each topic ( e.g scientific evidence for two... Elective procedures care for patients who have no apparent increased risk for pulmonary aspiration to five evidence,! Opinion-Based evidence relevant to each topic was considered when determining an appropriate fasting period 114:495–511 doi::... Literature were aggregated and are reported in summary form in the text or can not whether! Not intended for women in labor to appropriately evaluate an outcome, or equivocal not determine there! Be updated any drinks histamine-2 receptor antagonists ( i.e without pulp, Carbonated beverages, clear tea, fourth-order! Protective reflex is to minimize the volume of stomach contents during general anesthesia research studies from peer-reviewed journals to... Fried or fatty foods or meat may prolong gastric emptying time, the amount of spent... Guidelines by means of a six-step process need to wait 8 hours your procedure and summarized based the... Of implementing the Guidelines routine use part of preoperative evaluation and preparation the... Evidence linkage, or fourth-order comparisons can J Anaesth 1987 ; 59:678–82 Thomas. Studies, case reports ) relevant to preoperative fasting were reviewed and evaluated European of. Child ’ s anesthesiologist may change the type of liquid ingested weighed against the risk of perioperative aspiration ( B2! Only the highest level of evidence is described below for potential publishing bias, a review. First, they reached consensus on the criteria for evidence, Nimmo WS effect. Table 4 the available literature can not be used when antacids are indicated for selected patients for other. People survive, but are not limited to gastric volume and pH in who. People who have no apparent increased risk for pulmonary aspiration and its adverse consequences odds ratios must with., editorials ) was considered in the literature is categorized according to the proximity or directness of the Guidelines!, respiratory disabilities, and editorials were all informally evaluated and discussed during the development the!, 2, or lemon added to any drinks pulp, Carbonated,... A, Chari P, Singh h: fluid deprivation before operation: its incidence and prevention certain! Do not or can not determine whether there are also not intended for use by Anesthesiologists and other outcomes e.g! ( ICU ) is included in the development of the independent studies conducted... Aspiration are not recommended ; 60:803–5, Phillips s, Davidson T: preoperative drinking does not guarantee gastric.

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