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Preoperative Fasting Guidelines Author: Marianna Crowley, MD Section Preoperative fasting guidelines Author: Marianna Crowley, MD Section Editor: Natalie F Holt, MD, MPH Deputy Editor: Nancy A Nussmeier, MD, FAHA Contributor Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Mar 2017. | This topic last updated: Jan 13, 2017. INTRODUCTION — Pulmonary aspiration of gastric or oropharyngeal contents during anesthesia is a rare event, but one with significant morbidity and mortality [1]. Fasting guidelines for patients having anesthesia attempt to reduce the risk of aspiration and the severity of the pulmonary effects should aspiration occur. Fasting guidelines are based on gastric physiology and expert opinion, as there is limited evidence that these improve outcomes [2]. Because worse outcomes may be associated with aspiration of particulate matter, of acidic contents, and of large volumes of gastric contents, guidelines aim to eliminate particulate matter and decrease the volume and acidity of gastric contents at the time of induction of anesthesia [3]. Preanesthesia fasting guidelines apply to patients having elective surgery and are intended for procedures performed under general anesthesia, regional anesthesia, and monitored anesthesia care. Aspiration may occur during all types of anesthesia in non-fasted patients, because anesthetic and sedative medications reduce or eliminate airway protective reflexes that normally prevent regurgitated gastric contents from entering the lungs [4]. The rationale and recommendations for preoperative fasting are reviewed here. Anesthetic strategies for avoidance of aspiration, the management of patients who have not fasted, and the fasting duration of patients having urgent or emergent procedures are discussed separately. (See "Rapid sequence induction and intubation (RSII) for anesthesia" and "General anesthesia: Induction".) FASTING RECOMMENDATIONS — Recommendations that oral intake of liquids and solids be restricted for varying times prior to anesthesia aim to minimize gastric volume at the time of surgery. Various types of material empty from the stomach at different rates. While experts believe that restricting oral intake will decrease aspiration, gastric volume is a surrogate endpoint used in clinical studies because the incidence of aspiration is low. We suggest that the following fasting intervals should be followed before induction of anesthesia: ●Clear liquids – Two hours (see 'Clear liquids' below) ●Breast milk – Four hours (see 'Other liquids' below) ●Nonhuman milk, formula, light meal – Six hours (see 'Other liquids' below and 'Solids' below) ●Fried or fatty food, or meat – Eight hours (see 'Solids' below) Clear liquids — We require patients to consume no liquids within two hours of surgery. Patients may drink clear liquids until two hours before elective procedures requiring anesthesia or sedation. Clear liquids include water, juices without pulp, coffee or tea without milk, and carbohydrate drinks, and should not include alcohol. Protein-containing carbohydrate drinks that are administered to enhance surgical recovery should not be consumed within three hours of surgery. Clear liquids and gastric secretions move rapidly out of the stomach; the 50 percent emptying time of water is approximately 12 minutes [5]. Glucose-containing fluids initially leave the stomach more slowly, but after 90 minutes the stomach is empty of clear liquids regardless of type [6]. Gastric residual volume averages about 25 mL in patients fasted overnight prior to surgery [7]. This is unchanged in patients who drink clear liquids, water, clear juices, coffee, tea, or carbohydrate drinks up to two hours before surgery [6,8-12]. Values for pH are also unchanged in patients drinking clear liquids. Enhanced recovery protocols for surgery may include the administration of 300 to 400 mL of a carbohydrate drink up to two hours prior to anesthesia, which in some cases contains protein and/or lipids. One trial found gastric emptying to be unchanged when protein or lipid were added to the carbohydrate drink [13]. However, in another trial the addition of protein to the preoperative carbohydrate drink increased the time to return to baseline gastric volume from two to three hours [14]. (See "Enhanced recovery after colorectal surgery", section on 'Carbohydrate rich drink'.) There is no evidence that restriction of the volume of clear liquids is beneficial [15]. Patients who drink carbohydrate-rich clear liquids until two hours prior to anesthesia may have less thirst, hunger, and anxiety [16], although the effect on thirst may only last 60 minutes after a drink [6]. Other liquids — Patients may not drink non-clear liquids within six hours of elective procedures requiring anesthesia or sedation. Undiluted milk is considered a solid for the purposes of preoperative fasting guidelines because it may act as a solid if it curdles in the stomach and because it contains variable amounts of protein and fat. Non-clear liquids are felt to empty more slowly from the stomach and may leave residual particulate matter. Studies have demonstrated increased emptying times when fat is added to liquids [17,18]. The impact of suspended solid particles in liquids is less certain. A small number of trials of non-clear juices or liquids with small amounts of milk have not demonstrated delayed emptying. For example, drinking orange juice two to three hours before surgery resulted in similar gastric volumes to drinking coffee or not drinking [11]. Similarly, the addition of 50 mL of milk to 250 mL of tea did not change gastric emptying time [19]. Large amounts of milk curdle in the stomach and behave as a solid, but when diluted may behave in a manner similar to clear liquids. Expert opinion is divided on whether the addition of milk to coffee or tea precludes their identification as clear liquids [20,21]. Solids — Patients may not eat solid food (or drink milk) beginning six hours before elective procedures requiring anesthesia or sedation; the fasting interval should be increased to at least eight hours following a large or fatty meal. Solid food takes longer than liquids to empty from the stomach. It begins emptying after a delay of about an hour, then empties in a linear fashion, with half of the solid food passing into the duodenum in about two hours [22]. However, emptying times are quite variable and depend on the volume and nutrient content of the meal. Gastric emptying is slowed by increased food weight, caloric density, and addition of fat, and is slower in females and older adults [23-27]. In one study, the median time for the disappearance of solid particles was 210 minutes after a light breakfast of toast, coffee without milk, and pulp-free juice [28]. Gastric emptying time is longer with larger meal weight, higher calorie content, and higher fat content [26]. For example, in one study, increasing meal size from 300 to 1700 grams increased the half-emptying time from 77 to 277 minutes [23]. Despite a lack of evidence for a specific interval, most patients accept and tolerate restriction of solid food, especially when liquids are allowed. Enteral tube feeds — Patients without a cuffed endotracheal or tracheostomy tube in place should have gastric tube feeds stopped eight hours before elective procedures requiring anesthesia or sedation. In some circumstances, patients with surgically-placed post-pyloric tube feeds may have feeds continued to the time of non-abdominal surgery. Enteral formulas often contain carbohydrates, protein, and fat, so we consider tube feeds to be a fatty meal [29]. Thus we stop gastric tube feeds eight hours prior to anesthesia for patients without either a cuffed endotracheal tube or tracheostomy tube to protect from aspiration. It is less clear whether the patient who has the lungs protected by a cuffed endotracheal tube or tracheostomy needs to be fasted at all prior to surgery. Prolonged restriction of tube feeds may result in a catabolic state in severely ill patients. However, this must be weighed against the risk of aspiration around the endotracheal tube cuff, which occurs more frequently when these patients are placed supine, as is often required for surgery [30,31]. The surgeon, the anesthesiologist, and the primary team caring for the patient should decide whether to stop tube feeds on an individual basis, taking into account the patient’s nutritional status and other risks for aspiration. Ideally surgery should be scheduled to minimize unnecessary fasting. The patient should be transported and positioned for surgery in a head- up position, if possible. The main advantage of post-pyloric feeding is that it may reduce the risk of gastroesophageal reflux and pneumonia [32]. We do not require that surgically-placed duodenal or jejunal tube feeds be stopped for non-abdominal surgery. Nasally-placed enteral feeding tubes lead to less certainty as to the location of the tip, and thus are treated as gastric tubes. If the patient is presenting for abdominal surgery, we also stop enteral feeding through any tube eight hours prior to surgery. (See "Enteral feeding: Gastric versus post- pyloric", section on 'Post-pyloric feeding'.) Chewing gum — Chewing gum generates saliva and stimulates gastric secretion, so it may be considered equivalent to clear liquids. We instruct patient to stop chewing gum two hours prior to anesthesia. However, we do not delay surgery in patients who chew gum up to the time of surgery, as studies have shown either no effect on gastric volume and pH, or a small effect [33-35]. If the patient has swallowed a piece of chewing gum, we treat it as solid intake and thus delay the procedure for six hours. Medications — Patients should take routine medications on the morning of surgery with water or a clear liquid, ideally several hours prior to the scheduled surgery. Essential medications that must be taken within two hours of surgery may include inadvertently omitted medications (eg, beta blockers, aspirin), medications on a critical schedule (eg, anti- seizure medications), or medications given as part of the anesthetic plan (eg, acetaminophen, gabapentin); these should be taken with a sip of water.
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