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Winnipeg Regional Health Authority

Surgery and Anesthesia Programs

Evidence Informed

Guideline

Guideline Name:

Preoperative Fasting

(Adult)

Page

1 of 7

Date:

Supercedes:

1. Introduction:

Preoperative fasting instructions for healthy adults should be based on current evidence. The

Winnipeg Regional Health Authority (WRHA) Anesthesia Program and the Anesthesia

Program Council have reviewed the current literature and the varied preoperative fasting

practices within the WRHA with the intent of standardizing the practice of preoperative

fasting to align with guidelines from the Canadian Anesthesiologist Society (Merchant et al.,

2013) and American Society of Anesthesiologists (Apfelbaum, 2011). In collaboration with

the WRHA Surgery and Women’s Health Programs, this evidence informed guideline has

been developed to facilitate the communication and implementation of preoperative fasting

requirements for adult patients across the WRHA.

2. Purpose:

2.1 To balance the adverse effects of preoperative fasting with the risk of pulmonary

aspiration of gastric contents under anesthesia

2.2 To standardize the preoperative fasting requirements for adult surgical patients across the

Winnipeg Regional Health Authority.

Final, Sept.30, 2013

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3. Scope:

This guideline applies to adult surgical patients undergoing elective and ambulatory

emergency surgeries where an anesthesiologist or designate is present, regardless of the

type of anesthetic that may be administered. This guideline also includes women

undergoing elective Cesarean section. This guideline does not include surgical procedures

where an anesthesiologist or designate is not present such as endoscopy and other minor

procedures where the physician/ surgeon directs the administration of sedation and minor

surgical procedures where no sedation is given and local anesthetic is administered by the

surgeon.

4. Definitions:

4.1 Preoperative fasting: a prescribed period of time before a procedure when patients are

not permitted oral intake of liquids or solids.

4.2 Adult surgical patients: individuals undergoing surgery within WRHA facilities with

the exception of Children’s Hospital and dental surgeries at Misericordia Health Center.

4.3 Elective surgery patients: individuals scheduled to undergo non-urgent surgery.

4.4 Ambulatory emergency surgery patients: individuals awaiting unscheduled, minor

urgent surgeries (typically minor maxillofacial, plastic, or orthopedic surgery) and who

have been discharged from hospital. These patients are re-admitted when operating

room time becomes available for their procedure.

4.5 Clear fluids: water, apple juice, cranberry juice (no orange juice), clear tea or black

coffee (no milk, cream, powdered creamer, sugar, or sweetener), clear broth (no

noodles, vegetables, meat, or solids of any kind). Sports and carbonated drinks are not

acceptable.

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5. Background:

Because regurgitation and pulmonary aspiration in the perioperative period is associated with

increased mortality and morbidity, emphasis should be placed on informing patients of the

appropriate fasting requirement prior to elective procedures requiring general anesthesia,

regional anesthesia, sedation, or analgesia (Fischer, Bader & Sweitzer, 2009). An adequate

review of a patient’s pertinent medical records, physical examination, and a patient interview or

survey should be performed as a part of a thorough preoperative assessment (Fischer et al.,

2009). Conditions that might predispose the patient for an increased risk of regurgitation and

pulmonary aspiration can be elicited from the perioperative assessment. Examples of patient-

related factors and conditions that can increase the risk of perioperative aspiration can include

gastro-esophageal reflux, raised intra-abdominal pressure (e.g. obesity, pregnancy), metabolic

disorders (e.g. diabetes mellitus), known or potential difficult airway management, and

dysphagia (Fischer et al., 2009).

Recent practice guidelines published by the Canadian Anesthesiologists’ Society (Merchant et

al., 2013) and the American Society of Anesthesiologists (Apfelbaum, 2011) have reviewed the

evidence and provide rationale for the adult preoperative fasting recommendations presented in

this clinical practice guideline. Research suggests that a more liberal approach to restricted fluid

intake prior to surgery is safe (Brady, Kinn, Stuart & Ness, 2010). Meta-analysis of randomized

controlled trials comparing 2 – 4 hour fasting times for clear liquids with greater than 4 hours

provides evidence that gastric pH is increased and gastric volumes are decreased with the 2 – 4

hour fast. (Apfelbaum, 2011; Merchant et al., 2013). Although the literature (Smith et al., 2011)

suggests that fasting 6 hours from the intake of a light meal is sufficient in the preoperative

period, the definition of what constitutes a light meal makes the implementation of a 6 hour

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fasting guideline problematic. Therefore, fasting for 8 hours from the time of ingestion of a meal

that contains fatty foods, fried foods, and dairy and meat products is recommended prior to

procedures requiring general anesthesia, regional anesthesia, sedation, or analgesia (Apfelbaum,

2011; Merchant et al., 2013).

Prolonged fasting is not without discomfort or risk for the preoperative population. Adverse

effects from a fasting state include thirst, hunger, irritability, dehydration, nausea and vomiting,

confusion, electrolyte imbalance, insulin resistance, post-operative hypoglycemia, muscle

wasting and a weakened immune system (Crenshaw, 2011; McAuthur, 2011; Stuart, 2006).

Some have argued a period of prolonged restricted fluid intake may result in altered organ

function and surgical outcomes (Lobo, Macafee, & Allison, 2006). Research, however, clearly

supports a change to the strict practice of protracted fasting prior to elective surgery in the adult

population.

6. Recommendations:

For elective surgical patients: clear fluids (as previously defined) permitted up to 2 hours

prior to advised arrival time to hospital on the day of surgery

For ambulatory emergency patients awaiting call back to hospital: clear fluids (as

previously defined) until call received from facility to come in for procedure

No solid food or alcohol after midnight, the night before your surgery

No chewing gum or chewing tobacco after midnight, the night before your surgery

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7. Contributing Authors

Dr. Fahd Al Gurashi; Site Medical Manager Obstetrical Anesthesia, Women’s Hospital

Lisa Anthony; Quality Process Improvement Officer, Orthopedics – WRHA Surgery Program

Dr. Don Duerksen; Gastroenterologist/ Medical Director

Barbara Ginter-Boyce; Unit Manager, PAC and Surgery Misericordia Health Centre

Bruce Knoll; Anesthesia/Surgery Program Manager

Dr. Stephen Kowalski; Anesthetist/ Anesthesia site leader Health Sciences Centre

Dr. Trevor Lee; Anesthesia Associate Head WRHA/U of M

Michele Lepp; Quality/Process Improvement Officer –WRHA Surgery Program

Barbara Lewthwaite; Clinical Nurse Specialist, St Boniface Hospital

Dr. Jack McPherson; Medical Director WRHA Surgery Program

Graciana Medeiros; Perioperative / MDR Nurse Educator – WRHA Surgery Program

Dr. Tamara Miller; Section Head Obstetrical Anesthesia, St. Boniface Hospital

Dr. Carol Schneider; Chair, WRHA Women’s Health Program Standards Committee

Lanette Siragusa; Program Director, WRHA Surgery Program

Tanya Welch; Clinical Nurse Educator, Surgery, Health Sciences Centre

Jing Zuo; Clinical Dietitian (Surgery) Health Sciences Centre

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8. References:

8.1 Apfelbaum, J. L. (2011). Practice guidelines for perioperative fasting and the use of

pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy

patients undergoing elective procedures. American Society of Anesthesiologists

Committee on Standards and Practice Parameters. Anesthesiology 2011, 114, 495-511.

8.2 Brady, M. C., Kinn, S., Stuart, P, & Ness, V. (2010). Preoperative fasting for adults to

prevent perioperative complications. Cochrane Database of Systematic Reviews, Issue

5. Art. No.: CD004423. DOI: 10.1002/14651858.CD004423.

8.3 Crenshaw, J.T. (2011). Preoperative fasting: Will the evidence ever be put into

practice? American Journal of Nursing, 111(10), 38-43.

8.4 Fischer, S. P., Bader, A. M., & Sweitzer, B. (2009). Preoperative Evaluation. Miller’s

Anesthesia (7th

ed.). Philadelphia: Churchill Livingstone, 1062.

8.5 Lobo, D. N., Macafee, D. A. L., & Allison, S. P. (2006). How perioperative fluid

balance influences postoperative outcomes. Best Practice & Research Clinical

Anaesthesiology, 20 (3), 439-455.

8.6 McArthur, A. (2011). Preoperative fasting: Clinician information. JBI Clinical

Information Service Evidence, released October 3, 2011.

8.7 Merchant, R., Chartrand, D., Dain, S., Dobson, G., Kurrek, M., Lagacé, A., et al.

(2013). Guidelines to the practice of anesthesia. Canadian Journal of Anesthesia, 60,

60-84. DOI 10.1007/s12630-012-9820-7.

8.8 Smith, I., Kranke, P., Muart, I., Smith, A., O’Sullivan, G., Søreide, E., et al. (2011).

Perioperative fasting in adults and children: Guidelines from the European Society of

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Anaesthesiology. European Journal of Anaesthesiology, 28(8), 556-569.

DOI:10.1097/EJA.Ob013e3283495ba1.

8.9 Stuart, P. (2006). The evidence base behind modern fasting guidelines. Best Practice &

Research Clinical Anaesthesiology, 20(3), 457 – 469.