Document Title: PRE-OPERATIVE FASTING POLICY FOR ADULTS AND

CHILDREN

Document Reference/Register no: 15020 Version Number: 2.0

Document type: (Policy/ Guideline/ Guideline To be followed All relevant clinical

SOP) by: (Target Staff) staff

Ratification Issue Date: 31st January 2019 Review Date: 30th January 2022
(Date document is uploaded onto
the intranet)

Developed in response to: Clinical Need

Contributes to HSC Act 2008 (Regulated Activities) Regulations

2014(Part 3); and CQC Regulations 2009 (Part 4)
CQC Fundamental Standards of Quality and Safety: 9,11
Issuing Division/Directorate: Anaesthetics

Author/Contact: (Asset Agnes Watson, Anaesthetic Consultant and College Tutor for
Administrator) Burns and Plastics Anaesthesia

Hospital Sites:  MEHT

(tick appropriate box/es to indicate □ BTUH
status of policy review i.e. joint/ □ SUH
independent)
Consultation: (Refer to page 2)

Approval Group / Committee(s): n/a Date: n/a

Professionally Approved by: Dr Carol Mc Cartney, Anaesthetic Date: 10th January 2019
(Asset Owner) Consultant

Ratification Group(s): Document Ratification Group Date: 31st January 2019

Executive and Clinical Directors Date: February 2019 Distribution Intranet & website
(Communication of minutes from Method:
Document Ratification Group
 Preoperative Fasting Policy For Adults And Children/15020/ 2.0

Consulted With: Post/ Approval Committee/ Group: Date:

Ben Maddison Consultant Anaesthetist, Pre-assessment Lead 07th January 2019
Joseph Hussey Consultant Anaesthetist, Paediatric Anaesthesia
Lead
Samantha Brayshaw Consultant Anaesthetist, Obstetric Anaesthesia
Lead
Pete Berry Consultant Anaesthetist, Burns ITU Lead
Linda Wise Lead Nurse Anaesthetic Assessment Unit
Dawn Little Lead Nurse DSU

Related Trust Policies (to be read in 13032 Pre-operative Preparation Policy

conjunction with) 15016 Reducing Fasting Times for Adults and Children
Requiring General Anaesthetic or Sedation in Burns ITU

Document Review History:

Version Authored/Reviewer: Summary of amendments/ Issue Date:
No: Record documents superseded by:
1.0 Dr Sofia Huddart November 2015
1.1 Dr Peter Thomas Updated paragraphs 3.2, 5.5, 5.9, 5.10, 7.2, October 2017
8.2
1.2 Dr Agnes Watson Preoperative paediatric fluid fasting changed 14 November 2017
to 1 hour. Updated paragraph 5.3 and new
Appendix 1
2.0 Dr Agnes Watson Full Review 31st January 2019

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INDEX

1. Purpose

2. Equality Impact Assessment

3. Scope

4. Staffing and Training

5. Fasting Guideline

6. Breach Reporting

7. Audit

8. References

9. Appendices

Appendix 1- Pre-operative Fluid Fasting for Children

Appendix 2 – Equality Impact Assessment Form

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1 Purpose

1.1 To define the preoperative fasting protocol for adult and paediatric patients
undergoing procedures under general anaesthesia, regional anaesthesia and
sedation i.e. monitored anaesthesia care based on current recommendations.

1.2 Preoperative fasting is intended to reduce the risk of pulmonary aspiration of gastric
contents the complications of which are aspiration pneumonia, respiratory disability
and related morbidity and mortality.

2 Equality Impact Assessment

2.1 The Trust is committed to the provision of a service that is fair, accessible and meets
the needs of all individuals.
(Refer to Appendix 2)

3 Scope
3.1 This document applies to all adult and paediatric patients undergoing monitored
anaesthesia care in the Trust.

3.2 These guidelines are based on the most recent recommendations of the American
Society of Anaesthesiologists (ASA) 2017 guideline and the European Society of
Anaesthesiology (ESA) 2011 guideline

4 Staffing and Training

4.1 This guideline is intended for use by all healthcare workers involved in the care of
patients undergoing monitored anaesthesia care.

5 Fasting Guidelines
5.1 Adults:
 6 hours before anaesthesia for solid food or enteral feed
 2 hours before anaesthesia for clear fluid

5.2 Infants (age less than 1 year)

 6 hours before anaesthesia for infant formula, cow's milk, solids or enteral feed
 4 hours before anaesthesia for breast milk
 2 hours before anaesthesia for clear fluids

5.3 Children (age between 1 and 16 years)

 6 hours before anaesthesia for formula, cow's milk, solids or enteral feed
 4 hours before anaesthesia for breast milk
 Wizard Ward: 1 hour before anaesthesia for clear fluids (see attached appendix 1
guideline.)
 Phoenix Ward – On Phoenix ward the 3 groups of children are:

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Elective Cleft surgery and Orthopaedic surgery– they have standard admission
times as per Wizard Ward and can have measured drink on admission (i.e. at 7.30
or 11.30/ 12.00) (refer to appendix 1 guideline). Max fax and Plastic trauma
children – nurses will liaise with anaesthetist but can have measured drink up to 1
hour before surgery (refer to appendix 1 guideline)
Emergency Orthopaedic and general surgery - no change in fluid fasting advice
(i.e. 2 hours). Some of these children may be nil by mouth.
 Children’s Burn Ward , anaesthetist to liaise with nursing staff preferably night
before about fluid fasting times, those with normal gastric emptying can have
measured drink up to 1 hour before surgery (refer to appendix 1 guideline)

5.4 Obstetric Patients

 As for adults for elective procedures
 Clear fluids should be encouraged in labour

5.5 Plastic Surgery Hand Trauma Patients & Elective Hand Patients
 For operations planned as regional anaesthesia only
 Clear fluids allowed up until patient leaves ward for theatre

5.6 For the purposes of these guidelines clear fluids constitutes fluid through which print
can be read and does not contain alcohol or milk. It includes black tea and coffee,
pulp free fruit juices, fizzy/carbonated drinks and carbohydrate-rich drinks.

5.7 Chewing gum and boiled sweets are allowed up to 2 hours before anaesthesia. After
this point they should be removed to prevent oral retention on induction of
anaesthesia.

5.8 However, patients should not be postponed or delayed solely because they have
been chewing gum or sucking boiled sweets immediately prior to the induction of
anaesthesia.

5.9 Infants and children are defined as per the Practice guidelines for preoperative fasting
of the American Society of Anaesthesiologists Committee 2017.

5.10 Patients should be encouraged to drink clear fluids up to 2 hours prior to surgery and
at least within 4 hours of surgery. In the case of hand surgery where the planned
anaesthetic technique is regional anaesthesia alone, patients should be allowed to
drink clear fluids until they leave the ward for theatre.

5.11 The anaesthetist has final say for the fasting policy in each individual patient in their
care and may request alternative fasting times for particular patients or procedures.
These should be clearly documented in the medical notes.

5.12 In the case of non-elective procedures where the patient is not fully fasted the risk of
aspiration must be balanced against the urgency and the risks of the procedure.

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6 Breach Reporting
6.1 A Datix web should be completed for non-compliance with this guideline in the case of
elective procedures.

6.2 In the case of emergency procedures the reasons for not waiting for full fasting should
be clearly documented in the medical notes.

7 Audit
7.1 The use of these guidelines will be reviewed by yearly audits by the anaesthetic
department.

7.2 The standard for fasting times for non-emergency procedures are 100% of patients to
have been offered a drink of clear fluid between 2-4 hours before anaesthesia. In the
case of hand surgery where the planned anaesthetic technique is regional
anaesthesia alone, patients should be allowed to drink clear fluids until they leave the
ward for theatre.

8 References
Smith I et al. Perioperative Fasting in Adults and Children: Guidelines from the
European Society of Anaesthesiology. Euro J Anaesthesiology 2011;28(8):556– 569
https://www.aagbi.org/sites/default/files/Perioperative_fasting_in_adults_and_children
__.4.pdf

American Society of Anaesthesiologists. 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: an updated report by
the American Society of Anaesthesiologists Committee on Standards and Practice
Parameters. Anaesthesiology 2017; 126:376-93

www.rcoa.ac.uk/system/files/CSQ-ARB-2012-O.pdf
anesthesiology.pubs.asahq.org/article-aspx?articleid=2396245

JR Colvin, CJ Peden. Raising the Standards: a compendium of audit recipes for

continuous quality improvement in anaesthesia. Royal College of Anaesthetists, 3 rd
Edition (2012)

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Appendix 1: Pre-operative Fluid Fasting Guideline for Children

This should be read in conjunction with Clinical Guideline 15020, Preoperative Fasting Policy for
Adults and Children.
Policy
Policy for pre-operative fasting for children day case surgery and inpatient elective surgical
admissions are:

 6 hours for solid food

 4 hours for breast milk
 1 hour for clear fluids
(Clear fluids are defined as fluid through which print can be read. This is water, diluted squash or
juice or ready diluted drinks such as Fruit Shoot or Ribena)
This is based on current evidence that 1 hour fasting for clear fluids does not lead to increased
stomach volume, decreased pH or adverse outcome. (This policy is based on the GOSH pre-
operative fasting policy for Woodpecker Ward implemented 2015.)
Parental Information
Morning admissions: Parents will be advised at pre-assessment for morning admissions to give fluids
up until 06.30 then stop. At 07.30 on admission a drink will be given to the child by nursing staff on
arrival. This is to minimise unregulated large volumes of fluid intake prior to admission
Afternoon admission: Parents will be advised at pre-assessment for afternoon admissions to give
fluids up until 11.30 then stop. Admission at 12.00. At 12 - 12.30 a drink will be given to the child by
nursing staff. This is to minimise unregulated large volumes of fluid intake, prior to admission.
On Arrival to ward
A clear fluid drink will be provided on arrival at times above of 5ml/kg. If the weight of the child is not
known an age dependent volume will be given to minimise delays.

 Age 1-5 years- 60mls (White cup- bottom laminated line)

 Age 6-11 years- 140mls (White cup- top laminated line)
 Age 12 and above- A full white cup- 200mls

Following confirmation of list order further repeat drinks of similar volume to above can be given at
hourly intervals to a cut off time following discussion with the anaesthetist looking after the child.
Exclusions
Children having emergency surgery (except urgent plastic and maxillofacial trauma – to be discussed
with anaesthetist for list)
Children with delayed gastric emptying , GORD on treatment (ranitidine, domperidone, omeprazole )
or under investigation.

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Children with other conditions that may affect gastric emptying, renal failure, enteropathies,
oesophageal strictures, achalasia, diabetes mellitus
Late comers should be excluded from the drink on arrival until list order and timing has been
confirmed by the anaesthetist looking after the child.
Implementation and Regulation
This policy will be audited on implementation to ensure any negative impact on the service, such as
delays, are noted or any complications occur.
If any concerns please contact Dr Agnes Watson, Consultant Anaesthetist Bleep #6400 596 or
Victoria Bird, Sister in Charge, Wizard Ward.
References
Background evidence for new starvation times Excessive fasting can cause a great amount of
distress for children and their carers. The AAGBI1 (Association of Anaesthetists Great Britain and
Ireland) states that recommended fasting times are, six hours for food, four hours for breast milk, two
hours for clear fluids.
The recent literature challenges the traditional fasting times. A recent study of 10,000 children, over
a 6 year period, drinking free fluids up until the time of surgery does not increase their risk of
aspiration2. This is supported by Schmidt et al3 , who showed there was no change in gastric pH or
volume after 1 or 2 hours fasting. There is also ample evidence from radio-nucleotide studies that
the time taken for more than 80% of clear fluid to exit the stomach is less than 1 hour4. Furthermore,
if glucose is included in children’s clear fluid then gastric emptying is significantly quicker 5.
1. AAGBI safety guideline: Pre-operative Assessment and Patient Preparation – The role of the
Anaesthetist (2010). The Association of Anaesthetists of Great Britain and Ireland.
http://www.aagbi.org/sites/default/files/preop2010.pdf
2. Andersson H, Zaren B, Frykholm P. Low incidence of pulmonary aspiration in children
allowed intake of clear fluids until called to the operating suite. Pediatric Anesthesia 2015; 25
(8) 770-777.
3. Schmidt A, Buehler P, Seglios L et al. Gastic pH and residual volume after 1 and 2 h fasting
time for clear fluids in children. British Journal of Anaesthesia 2015;114 (3): 477-82
4. Malmud, LS, Fisher RS, Knight LC et al. scintigraphic evaluation of gastric empyting. Semin
Nucl Med. 1982; 12: 116-125.
5. Schmitz A, Kellenberger C, Lochbuehier N et al. Effect of different quantities of a
sugaredclear fluid on gastric empyting and residual voume in children: a crossover study
using magnetic resonance imaging. British Journal of Anaesthesia 2012: 108: 644-7.
6. Kelly C, Walker R. Perioperative pulmonary aspiration is infrequent and low risk in pediatric
anaesthetic practice. Pediatric Anesthesia. 2015 25: 36-43

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Appendix 2: Preliminary Equality Analysis

This assessment relates to: 15020 Pre-Operative Fasting for Adults and Children

A change in a service to patients A change to an existing policy X A change to the way staff work

A new policy Something else

(please give details)
Questions Answers

1. What are you proposing to change? Full policy review

2. Why are you making this change? 3 year review

(What will the change achieve?)

3. Who benefits from this change and how? Clinicians & patients

4. Is anyone likely to suffer any negative No

impact as a result of this change? If no,
please record reasons here and sign and date
this assessment. If yes, please complete a
full EIA.

5. a) Will you be undertaking any Yes

consultation as part of this change? Refer to pages 1 & 2
b) If so, with whom?
Preliminary analysis completed by:

Name Agnes Watson Job Title Consultant Anaesthetist Date December 2018