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Pre-Operative Fasting Guidelines

Summary of changes/amendments:
Page 2, paragraph 3 - sentence change Page 3, bullet point 3 - additional sentence Newsprint should be visible through a glass of the liquid Page 3, bullet point 8 - additional sentence: Some anaesthetists may allow a 4-hour fasting period for formula milk to reduce the risk of hypoglycaemia in infants Page 5, Maximum fasting times removal of sentence: Maintenance fluids should normally contain dextrose, especially in smaller children, who have an increased risk of becoming hypoglycaemic if fasted. This has been removed in light of recent advice from the National Patient Safety Agency and the Association of Paediatric Anaesthetists that some dextrose-containing fluids should be avoided in children due to the risk of iatrogenic hyponatraemia. Page 8 additional reference (4) Reference numbers revised accordingly throughout the text Minor changes throughout to improve clarity

Written by:

Dr C D Palmer - Consultant Anaesthetist, DRI

With thanks to: The Preoperative Fasting Guidelines Working Group: Dr G Kesseler, Consultant Anaesthetist, Doncaster Royal Infirmary Dr P Smith, Consultant Anaesthetist, Bassetlaw DGH Mr S Gosney, Advanced Anaesthetic Practitioner, Theatres, Doncaster Royal Infirmary Ms. J Ingram, Former Matron for Theatres, Doncaster Royal Infirmary Ms. V. Todorovic, Consultant Dietician in Clinical Nutrition, Bassetlaw DGH Ms. A. Winning, Clinical Effectiveness Information Specialist, Doncaster Royal Infirmary

Approved by:

Clinical Review Group January 2005

Reviewed by: Implementation Date: For Review:

Dr C D Palmer Consultant Anaesthetist, DRI - May 2007

May 2007 May 2009

WARNING: Always ensure that you are using the most up to date policy or procedure document. If you are
unsure, you can check that it is the most up to date version by looking on the Trust Website: www.dbh.nhs.uk under the headings Freedom of Information Information Classes Policies and Procedures

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Pre-Operative Fasting Guidelines

Introduction:
The practice of pre-operative fasting aims to minimise residual gastric volume and acidity prior to surgery or other procedures. This helps to prevent regurgitation, inhalation and aspiration of gastric contents which may otherwise occur during general anaesthesia, regional anaesthesia or intravenous sedation. However, prolonged periods of fasting are unnecessary and may cause distress, dehydration, biochemical imbalance and hypoglycaemia, especially in children. There is also a tendency for gastric volume to increase after a prolonged fast. There is limited evidence based research to support the duration of the preoperative fast required. In 1999, the American Society of Anaesthesiologists produced practice guidelines on this subject1. These were produced after a comprehensive literature review and world-wide survey of anaesthetists; taking into account the opinions of an expert panel. The Association of Anaesthetists of Great Britain and Irelands most recent guidelines are in agreement with their recommendations2. A comprehensive review in the Cochrane Database of Systematic Reviews3 and a detailed guideline by the Royal College of Nursing4 came to very similar conclusions. It would seem prudent to use these guidelines as the basis for our recommendations. In addition to guidelines on minimal fasting periods, we have also included guidelines on maximum fasting periods, in an attempt to reduce prolonged fasting. These guidelines also apply to patients undergoing non-surgical procedures requiring general anaesthesia, regional anaesthesia or sedation. These include endoscopy, radiological procedures, DC cardioversion and electro-convulsive therapy. The term surgery is used throughout this document for conveniences sake but guidelines also apply to non-operative procedures. This document replaces all previous fasting guidelines and is to be used Trust-wide to guide the production of: Patient information materials Integrated Pathways of Care (IPOCs) and other patient management protocols Guidance for all staff carrying out pre-operative assessment Educational materials for nursing, medical and other staff

Existing documentation must be reviewed to ensure that it complies with these guidelines and should be changed accordingly.

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GENERAL PRINCIPLES for ELECTIVE SURGERY

Minimum Fast for Clear Fluids: Clear fluids include: Water, diluting juice, black tea and black coffee. Milk (non-human) and milk-containing drinks curdle (become semi-solid) in the stomach and should be considered as solids. Previous guidelines have allowed a dash of milk in tea or coffee as well-diluted milk does not tend to curdle in the stomach. We feel that this is open to misinterpretation by patients and staff and have therefore removed this allowance from these guidelines. If milk is added to tea or coffee inadvertently, it is up to the discretion of the anaesthetist whether surgery should proceed. Non-clear fresh fruit juices containing pulp (e.g. fresh orange juice) should be avoided within 6 hours of surgery. Newsprint should be visible through a glass of the liquid. Clear jellies without fruit pieces leave no residue in the stomach and may be considered as clear fluids. These may be of particular use in paediatric practice. Fizzy drinks are probably as safe as still drinks as long as they contain no pulp. Some published guidelines advise against treating them as clear fluids but this is not supported by the clinical evidence. Patients may drink clear fluids up to 2 hours prior to the start of the list. Furthermore, all patients should be encouraged to take a drink of clear fluid 2 hours before the list begins, unless there is a surgical contra-indication. Alcohol containing drinks should not be consumed within the 24 hours prior to surgery as this may increase gastric emptying time. Breast fed infants should have their last feed 4 hours prior to surgery. Formula milk should usually be treated as non-human milk and the fasting period after a formula feed should be 6 hours. Some anaesthetists may allow a 4-hour fasting period for formula milk to reduce the risk of hypoglycaemia in infants.

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Minimum Fast for Solids: Solids and milk-containing drinks should not be consumed within 6 hours of the beginning of the operating list. Patients should eat normally on the day before surgery and avoid large or fatty meals. Fat and dietary fibre tend to remain in the stomach for longer than other foods. Chewing gum does not increase gastric volume significantly but should be avoided as it may be swallowed inadvertently. This also applies to boiled sweets. Patients for a morning list should eat nothing for six hours before surgery. Realistically, most patients will not usually eat after midnight and this is a convenient cut-off point. Children often do not eat after 6pm and a light snack at bedtime should be advised. Patients for an afternoon list should have a light breakfast (for example see below) at least 6 hours prior to the start of the list. Patients with diabetes mellitus should observe usual dietary guidelines prior to fasting.

Light Breakfast - example A small bowl of cereals (Rice Krispies or Corn Flakes) with skimmed or semiskimmed milk. No high fibre cereals such as Weetabix, muesli, bran etc. OR A slice of white toast with honey, jam, syrup, or marmite but no butter.

Prescribed Medications and Premedication: Prescribed medications, especially pre-medication can be taken within the 2 hours prior to surgery with a small drink of water (<30 ml). Some medications may be omitted prior to surgery as a result of other protocols e.g. ACE inhibitors, warfarin and oral hypoglycaemic agents. Analgesic drugs should not normally be omitted due to fasting as pain may prolong gastric emptying times.

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Exceptions: The management of patients with diabetes mellitus presenting for surgery within this trust is covered by established regimes for fasting, administration of fluids and insulin, and blood sugar monitoring. Guidelines for fasting times are similar and patients should adhere to their usual diet outside the period of the peri-operative fast, whenever possible. It should be borne in mind that some patients with diabetes mellitus may have prolonged gastric emptying times due to autonomic neuropathy. Diabetic patients presenting for surgery or other non-operative procedures requiring an anaesthetic should be given advice on fasting and consequent management of their diabetes in accordance with trust guidelines. These are laid out in the trust document "Surgery and Diabetes - Guidelines on Glycaemic control" (HMR7 Order code: WPR 4110R.1). In some cases, a longer fast may be necessary e.g. bowel preparation for gastro-intestinal surgery. Great care should be taken to ensure that adequate fluid replacement be given orally or intravenously to prevent dehydration.

Maximum fasting times: All patients should be encouraged to drink clear fluids up to 2 hours prior to the start of the list (i.e. 7 a.m. for morning lists and 12 mid-day for afternoon lists) unless this is contraindicated due to the type of surgery. If a patient has been fasted for fluids for more than six hours, ward staff should contact theatres or the anaesthetist to ask if it would be acceptable for the patient to have a drink. If not, consideration should be given to starting maintenance intravenous fluids on the ward.

Timing of lists and all-day lists: Whenever possible, children should be scheduled at the start of lists and in age order (i.e. youngest first) as they are less able to tolerate prolonged fasting times. Some lists may have scheduled early or late starts e.g. before 9 a.m. - this should be taken into consideration when giving information to patients. All-day lists often present timing problems. If it is possible to predict which patients are to be operated on in the afternoon, they may be given a light early breakfast. All patients should be encouraged to drink clear fluids up to 2 hours prior to the start of the list.

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Patients at increased risk of gastro-oesophageal reflux: Patients with a history of symptomatic gastro-oesophageal reflux, hiatus hernia and morbid obesity (Body Mass Index greater than 40) may be at increased risk of regurgitation and aspiration of gastric contents under general anaesthesia or intravenous sedation. In these cases, steps should be taken to increase gastric pH and reduce gastric volume preoperatively using antacids, H2 antagonists or proton-pump inhibitors. Patients scheduled for Regional Anaesthesia alone require similar precautions due to the possible requirement for conversion to general anaesthesia during surgery. Ranitidine can be prescribed preoperatively by pre-operative assessment nurse practitioners to these patients under a Patient Group Direction6. Under these guidelines, Ranitidine 150 mg is prescribed on the night before surgery and on the morning of surgery.

Patients requiring Regional Anaesthesia only: Fasting guidelines apply as for General Anaesthesia. There is a higher than average likelihood that these cases may need to be converted to general anaesthesia or require intravenous sedation.

Procedures requiring Local Anaesthesia only: No fasting required patients should eat a normal diet. This is in line with current protocols for ophthalmic surgery.

Use of Intravenous Sedatives: Patients requiring intravenous sedation need to be fasted preoperatively. Oral sedation e.g. temazepam given prior to the procedure usually does not necessitate preoperative fasting if general or regional anaesthesia are not planned. Use of inhaled sedation e.g. Entonox does not usually warrant fasting unless there are other risk factors.

Non-surgical procedures requiring anaesthesia: Some non-surgical procedures require general/regional anaesthesia or intravenous sedation. Examples include radiological procedures, endoscopic procedures, endovascular procedures, DC cardioversion and ECT. Fasting guidelines apply as for surgical procedures.

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EMERGENCY SURGERY
Fasting guidelines may need to be overridden in order to expedite surgery in urgent or emergency cases. Anaesthetists are able to take further steps to prevent regurgitation/aspiration e.g. rapid sequence induction of anaesthesia, use of antacids and pro-kinetic agents. If it is possible to delay surgery, the same guidelines should be followed i.e. 6 hours for solids, two hours for clear fluids. However, it should be borne in mind that trauma; pain, fear and alcohol intoxication may greatly prolong gastric emptying. Prolonged periods without fluid administration should be avoided. Maintenance intravenous fluids containing glucose should be administered to all patients not receiving fluids for more than 6 hours Many emergency cases will have received intravenous fluid resuscitation prior to surgery.

WOMEN IN LABOUR
This is covered in a separate protocol - Diet and Fluid in Labour (MSG 23) which is available on the central delivery suite at DRI.

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REFERENCES:
1. Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures Anesthesiology 1999; 90:896-905 2. Pre-operative assessment, the role of the anaesthetist. Association of Anaesthetists of Great Britain and Ireland November 2001 3. Preoperative fasting for adults to prevent perioperative complications. The Cochrane Database of Systematic Reviews 2003, Issue 4 4. Perioperative fasting in adults and children an RCN guideline for the multidisciplinary team. RCN publications November 2005. http://www.rcn.org.uk/publications/pdf/guidelines/perioperative_fasting_adults_children _full.pdf 5. Patient Group Direction for the Supply of Ranitidine by Pre-Operative Assessment Nurse Practitioners to Patients with Gastro-oesophageal Reflux and Morbid Obesity. Doncaster and Bassetlaw NHS Foundation Trust. PGD Ref : 3 6. Surgery and Diabetes - Guidelines on Glycaemic control. Trust Document HMR7. Order code: WPR 4110R.1.