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Preoperative Fasting Review Preoperative fasting O. Ljungqvist1 and E. Søreide2 1Centre of Gastrointestinal Disease, Ersta Hospital and Department of Surgery, Huddinge University Hospital, Karolinska Institute, Stockholm, Sweden and 2Department of Anaesthesia and Intensive Care Medicine, Rogaland Central and University Hospital, Stavanger, Norway Correspondence to: Dr O. Ljungqvist, Centre of Gastrointestinal Disease, Ersta Hospital, PO Box 4622, SE-116 91 Stockholm, Sweden (e-mail: [email protected]) Downloaded from https://academic.oup.com/bjs/article/90/4/400/6143199 by guest on 27 September 2021 Background and methods: To avoid pulmonary aspiration, fasting after midnight has become standard in elective surgery, but recent studies have found no scientific support for this practice. Several anaesthesia societies now recommend a 2-h preoperative fast for clear fluids and a 6-h fast for solids in most elective patients. The literature supporting such fasting recommendations was reviewed. Results: The recommendations are safe and improve well-being before operation, mainly by reducing thirst. A carbohydrate-rich beverage given before anaesthesia and surgery alters metabolism from the overnight fasted to the fed state. This reduces the catabolic response (insulin resistance) after operation, which may have implications for postoperative recovery. Conclusion: Most patients having elective operations can be allowed a free intake of clear fluids up to 2 h before anaesthesia. Preoperative carbohydrates reduce postoperative insulin resistance. Paper accepted 22 October 2002 Published online 29 January 2003 in Wiley InterScience (www.bjs.co.uk). DOI: 10.1002/bjs.4066 Introduction increasingly stricter preoperative fasting rules5. For prac- The main reason for the traditional strict rule of ‘nil by tical purposes, patients were informed not to eat or drink mouth’ from midnight of the day before operation has been anything – nil by mouth – after midnight of the day before to ensure an empty stomach at the time of anaesthesia. It operation. No distinction was made between intake of is well documented that general anaesthesia attenuates solids and fluids. the protective laryngeal reflexes and increases the risk of Over the past two decades, several authors have pulmonary aspiration in all kinds of surgical patient1–4. questioned the scientific merit of such rigid fasting The clinical picture following aspiration varies with routines. A series of studies has addressed this issue and the volume and constitution of the aspirated content3. shown that less strict guidelines can be used without 11–13 If larger chunks of food enter the tracheobronchial tree, placing the patient at risk . Several national anaesthesia airway obstruction, sudden asphyxia and death may result1; societies now recommend more liberal fasting rules in 14–16 aspiration of gastric fluids may cause bronchoconstriction respect of clear fluids (water, clear juices, coffee, tea) . and a chemical inflammation in the lower airways Recent studies also indicate that feeding patients with (pneumonitis), referred to as aspiration pneumonitis or a specially designed high-carbohydrate beverage in the Mendelson’s syndrome3,5. With increasing severity of the immediate preoperative period is not only safe, but may pulmonary reaction, the symptoms range from transient also reduce the catabolic stress response to surgery and so 17,18 wheezing and coughing to severe hypoxia, dyspnoea and enhance postoperative recovery . All this constitutes a fulminant respiratory failure1,6–9. major change to well established clinical practice. Even in the early days of the anaesthetic era it was under- stood by most that intake of solids should be avoided in the Methods immediate preoperative period. On the other hand, preop- erative oral intake of calorie-containing fluids (e.g. beef tea) Over the past 10 years or so, several national societies of was actually recommended by some surgical authorities10. anaesthetists have revised their guidelines on preoperative Later studies documented anaesthesia-related aspiration fasting. These countries include, but are not limited to, pneumonitis in many surgical settings1–3,11, resulting in Norway and Sweden14,15,theUSA16, Canada19 and the Copyright 2003 British Journal of Surgery Society Ltd British Journal of Surgery 2003; 90: 400–406 Published by John Wiley & Sons Ltd O. Ljungqvist and E. Søreide ž Preoperative fasting 401 UK20. The literature forming the basis for these changes If gastric fluid volumes that are able to induce passive was reviewed and summarized. Data assembled by one of regurgitation are extremely rare in otherwise healthy the authors (E.S.) while working on task forces for the elective patients, why has the matter received so much national anaesthesiology societies in both Norway15 and attention? One reason is that airway management problems the USA16 on this matter are also included. These processes frequently precipitate pulmonary aspiration6,8,9,33.Air included a search of Medline using appropriate search blown into the stomach, bucking and coughing may words, as well as accessing old references and textbooks to all cause episodes of gastro-oesophageal reflux. Hence, broaden the search for original references. pulmonary aspiration may happen even in patients with a low gastric fluid volume. Still, the incidence of Pulmonary aspiration and preoperative fasting: perioperative pulmonary aspiration is extremely low and Downloaded from https://academic.oup.com/bjs/article/90/4/400/6143199 by guest on 27 September 2021 fact and fiction overall carries a good prognosis in elective patients6–9,33. When the scientific basis of rigid fasting rules started to be questioned in the 1980s, it was already known From prolonged preoperative fasting to liberal fasting rules for clear fluids that gastric emptying of water and other inert, non- caloric fluids followed an extremely fast exponential curve Several randomized controlled studies11,12,28–30 and meta- in volunteers21,22 (Fig. 1). However, concern had been analyses13,16 in otherwise healthy adults scheduled for raised about the extent to which these results could be elective surgery have documented that oral intake of applied in the immediate preoperative period with its water and other clear fluids (tea, coffee, soda water, apple increased anxiety and stress5. However, neither anxiolytic and pulp-free orange juice) up to 2 h before induction of medication nor the degree of preoperative anxiolysis affects anaesthesia does not increase gastric fluid volume or acidity. gastric emptying of clear fluids or gastric fluid volume and Thus, the risk of aspiration pneumonitis should vomiting acidity in preoperative patients23,24. It seems that clinically or regurgitation occur is not increased compared with the significant delayed gastric emptying is not present in the situation in totally fasted patients. For obvious reasons, immediate preoperative period. these findings do not apply to patients with peritonitis For passive regurgitation and pulmonary aspiration to and gastrointestinal stasis. Diabetes and other medical occur during anaesthesia, a certain gastric volume must conditions affect gastric emptying, but much more so for be present; a minimum of 200 ml is probably a fair solids than for fluids34,35. estimate25–27. This contrasts with the gastric volumes Preoperative fluid intake is associated with an increased generally found in otherwise healthy elective patients. feeling of well-being, a reduced thirst and dryness of Numerous studies have reported a mean gastric fluid the mouth and, in some studies, less anxiety11,12,30,36,37. volume in the range of 10–30 ml, with 120 ml rarely Allowing habitual coffee drinkers their morning coffee exceeded irrespective of intake of clear fluids12,13,28–30. may also reduce postoperative headache due to caffeine Outliers probably represent patients with an undetected withdrawal38. gastric disorder such as functional dyspepsia, in which a fasting gastric volume of up to 200 ml can be found31,32. Fasting guidelines and solids 100 Solids Clear fluids Some authors have also considered whether preoperative fasting times for solids can be safely reduced to 2–3 h. Miller et al.39 concluded that it was appropriate to allow a light breakfast, consisting of two slices of toasted bread 50 with butter and jam, and one cup of tea, 2–3 h before anaesthesia; this was based on their finding that this regimen had no effect on gastric fluid volume. However, 10 particulate matter was found 4 h after the light breakfast Gastric content volume (%) Gastric content volume in one of their patients and the number of patients studied (10 min) 1 2 3 was small. In an ultrasonographic study of gastric emptying Time (h) after a light breakfast (one slice of white bread with Fig. 1 Gastric emptying of solids and clear fluids in healthy butter and jam, with one cup of coffee and one cup volunteers. Adapted from data in references 21 (n = 180) and 22 of pulp-free orange juice) in healthy women volunteers, (n = 4) Søreide et al.40 showed that 4 h of fasting was needed Copyright 2003 British Journal of Surgery Society Ltd www.bjs.co.uk British Journal of Surgery 2003; 90: 400–406 Published by John Wiley & Sons Ltd 402 Preoperative fasting ž O. Ljungqvist and E. Søreide to guarantee complete emptying of solid particles. Quite ingested this close to anaesthesia and operation may in different from clear fluids, solids empty according to a some patients induce an unwanted water diuresis and linear curve (Fig. 1). Factors such as smoking,
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