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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.