Review

Preoperative fasting
O. Ljungqvist1 and E. Søreide2
1
Centre of Gastrointestinal Disease, Ersta Hospital and Department of Surgery, Huddinge University Hospital, Karolinska Institute, Stockholm, Sweden
and 2 Department 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: olle.ljungqvist@ersta.se)

Downloaded from https://academic.oup.com/bjs/article/90/4/400/6143199 by guest on 24 May 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
mouth’ from midnight of the day before operation has been
to ensure an empty stomach at the time of anaesthesia. It
is well documented that general anaesthesia attenuates
the protective laryngeal reflexes and increases the risk of
pulmonary aspiration in all kinds of surgical patient1 – 4 .
The clinical picture following aspiration varies with
the volume and constitution of the aspirated content3 .
If larger chunks of food enter the tracheobronchial tree,
airway obstruction, sudden asphyxia and death may result1 ;
aspiration of gastric fluids may cause bronchoconstriction
and a chemical inflammation in the lower airways
(pneumonitis), referred to as aspiration pneumonitis or
Mendelson’s syndrome3,5 . With increasing severity of the
pulmonary reaction, the symptoms range from transient
wheezing and coughing to severe hypoxia, dyspnoea and
fulminant respiratory failure1,6 – 9 .
Even in the early days of the anaesthetic era it was under-
stood by most that intake of solids should be avoided in the
immediate preoperative period. On the other hand, preop-
erative oral intake of calorie-containing fluids (e.g. beef tea)
was actually recommended by some surgical authorities10 .
Later studies documented anaesthesia-related aspiration
pneumonitis in many surgical settings1 – 3,11 , resulting in
tical purposes, patients were informed not to eat or drink
anything – nil by mouth – after midnight of the day before
operation. No distinction was made between intake of
solids and fluids.
Over the past two decades, several authors have
questioned the scientific merit of such rigid fasting
routines. A series of studies has addressed this issue and
shown that less strict guidelines can be used without
placing the patient at risk11 – 13 . Several national anaesthesia
societies now recommend more liberal fasting rules in
respect of clear fluids (water, clear juices, coffee, tea)14 – 16 .
Recent studies also indicate that feeding patients with
a specially designed high-carbohydrate beverage in the
immediate preoperative period is not only safe, but may
also reduce the catabolic stress response to surgery and so
enhance postoperative recovery17,18 . All this constitutes a
major change to well established clinical practice.
Methods
Over the past 10 years or so, several national societies of
anaesthetists have revised their guidelines on preoperative
fasting. These countries include, but are not limited to,
Norway and Sweden14,15 , the USA16 , 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

UK20 . The literature forming the basis for these changes
was reviewed and summarized. Data assembled by one of
the authors (E.S.) while working on task forces for the
national anaesthesiology societies in both Norway15 and
the USA16 on this matter are also included. These processes
included a search of Medline using appropriate search
words, as well as accessing old references and textbooks to
broaden the search for original references.
Pulmonary aspiration and preoperative fasting:
fact and fiction
When the scientific basis of rigid fasting rules started
to be questioned in the 1980s, it was already known
that gastric emptying of water and other inert, non-
caloric fluids followed an extremely fast exponential curve
in volunteers21,22 (Fig. 1). However, concern had been
raised about the extent to which these results could be
applied in the immediate preoperative period with its
increased anxiety and stress5 . However, neither anxiolytic
medication nor the degree of preoperative anxiolysis affects
gastric emptying of clear fluids or gastric fluid volume and
acidity in preoperative patients23,24 . It seems that clinically
significant delayed gastric emptying is not present in the
immediate preoperative period.
For passive regurgitation and pulmonary aspiration to
occur during anaesthesia, a certain gastric volume must
be present; a minimum of 200 ml is probably a fair
estimate25 – 27 . This contrasts with the gastric volumes
generally found in otherwise healthy elective patients.
Numerous studies have reported a mean gastric fluid
volume in the range of 10–30 ml, with 120 ml rarely
exceeded irrespective of intake of clear fluids12,13,28 – 30 .
Outliers probably represent patients with an undetected
gastric disorder such as functional dyspepsia, in which a
fasting gastric volume of up to 200 ml can be found31,32 .
100
Gastric content volume (%)
50
10
(10 min) 1 2
Time (h)
Fig. 1Gastric emptying of solids and clear fluids in healthy
volunteers. Adapted from data in references 21 (n = 180) and 22
(n = 4)
Copyright  2003 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd
O. Ljungqvist and E. Søreide ž Preoperative fasting 401
If gastric fluid volumes that are able to induce passive
regurgitation are extremely rare in otherwise healthy
elective patients, why has the matter received so much
attention? One reason is that airway management problems
frequently precipitate pulmonary aspiration6,8,9,33 . Air
blown into the stomach, bucking and coughing may
all cause episodes of gastro-oesophageal reflux. Hence,
pulmonary aspiration may happen even in patients with
a low gastric fluid volume. Still, the incidence of
perioperative pulmonary aspiration is extremely low and
overall carries a good prognosis in elective patients6 – 9,33 .
Downloaded from https://academic.oup.com/bjs/article/90/4/400/6143199 by guest on 24 May 2021
From prolonged preoperative fasting to liberal
fasting rules for clear fluids
Several randomized controlled studies11,12,28 – 30 and meta-
analyses13,16 in otherwise healthy adults scheduled for
elective surgery have documented that oral intake of
water and other clear fluids (tea, coffee, soda water, apple
and pulp-free orange juice) up to 2 h before induction of
anaesthesia does not increase gastric fluid volume or acidity.
Thus, the risk of aspiration pneumonitis should vomiting
or regurgitation occur is not increased compared with the
situation in totally fasted patients. For obvious reasons,
these findings do not apply to patients with peritonitis
and gastrointestinal stasis. Diabetes and other medical
conditions affect gastric emptying, but much more so for
solids than for fluids34,35 .
Preoperative fluid intake is associated with an increased
feeling of well-being, a reduced thirst and dryness of
the mouth and, in some studies, less anxiety11,12,30,36,37 .
Allowing habitual coffee drinkers their morning coffee
may also reduce postoperative headache due to caffeine
withdrawal38 .
Fasting guidelines and solids
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
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,
particulate matter was found 4 h after the light breakfast
in one of their patients and the number of patients studied
3
was small. In an ultrasonographic study of gastric emptying
after a light breakfast (one slice of white bread with
butter and jam, with one cup of coffee and one cup
of pulp-free orange juice) in healthy women volunteers,
Søreide et al.40 showed that 4 h of fasting was needed
www.bjs.co.uk British Journal of Surgery 2003; 90: 400–406
402 Preoperative fasting ž O. Ljungqvist and E. Søreide
to guarantee complete emptying of solid particles. Quite
different from clear fluids, solids empty according to a
linear curve (Fig. 1). Factors such as smoking, functional
dyspepsia, psychological stress and female hormones may
further prolong gastric emptying times for solids34,35,41,42 .
So, to provide a sufficient margin of safety, the fasting
period after intake of solids should probably be not less
than 6 h15,16,43,44 .
Modern recommendations for preoperative
fasting
Based on all the new data available, several editorials10,43,44
and national anaesthesia society guidelines14 – 16,19,20
recommend no more than a 2-h fast for clear fluids
(water, tea, coffee, pulp-free fruit juices) in elective patients
(Table 1). Importantly, this does not apply to milk or any
other fat-containing fluid. No complications associated
with new and more liberal fasting guidelines were reported
in a follow-up study 3 years after implementation of the
national guidelines in Norway45 .
New preoperative fasting guidelines and
premedication
The use of premedication deserves a special mention
because some of the drugs commonly used may affect
gastric emptying. Intake of water together with oral
benzodiazepines as premedication up to 1 h before
induction of anaesthesia does not increase gastric fluid
volume30 . Up to 150 ml water to swallow tablets has
been recommended in adults15 . Larger quantities of water
Table 1Overview of current recommendations for elective surgery and anaesthesia given in fasting guidelines from different countries
where revised recommendations have been made during the past 10 years14 – 16,19,20
Fasting time before
anaesthesia (h)
Country Clear fluids Solids
UK 3 6
Canada 2 6–8
Norway 2 6
Sweden 2–3 Fast from midnight for
solids, 4 h for yoghurt or
clear soup
USA 2 6 (‘light meal’)
Clear fluids are often defined as non-particulate fluids without fat. Non-human milk is often defined as a solid.
Copyright  2003 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd
ingested this close to anaesthesia and operation may in
some patients induce an unwanted water diuresis and
problems with a full urinary bladder30 . Based on the well
documented prolonged gastric emptying encountered with
the use of opiates, it seems reasonable to stop fluid intake
at least 1 h before the use of opiate premedication28 .
Exceptions to liberal fasting guidelines
While the new guidelines can be used safely for most
patients about to undergo elective anaesthesia and surgery,
Downloaded from https://academic.oup.com/bjs/article/90/4/400/6143199 by guest on 24 May 2021
it is important to emphasize that strict preoperative fasting
is still recommended for all those having emergency
operations. Other situations in which the traditional fasting
rule should still be used include gastrointestinal obstruction
of any form, or cancer in the upper gastrointestinal
tract. Patients with hiatus hernia have a greater risk of
regurgitation, but there is no clear evidence to show
that this group has slower gastric emptying or greater
residual gastric volume than other patients. Because of
this increased risk of aspiration it may be wise to use a
rapid-sequence induction method5 to secure endotracheal
intubation in those with hiatus hernia. Some societies,
for example in Sweden, advise that these patients may
need modification of the rules, while others make no
special exception.
Metabolic aspects of preoperative fasting
versus oral nutrition
The metabolic implications have only recently been
emphasized when discussing preoperative fasting routines.
Patients for
Exclusions whom individual
from guidelines modifications
(i.e. fast) are needed
Emergency operation, –
gastrointestinal disease or intake
of drugs likely to slow gastric
emptying
Emergency operation Known delay in gastric emptying
Emergency operation Reflux, regurgitation, full stomach,
slow gastric motility, difficult
airway
Women in labour, emergency Conditions affecting gastric
operation emptying and patients with airway
problems
www.bjs.co.uk British Journal of Surgery 2003; 90: 400–406

The old rule of fasting from midnight means that
the patient prepares for surgery – a major stress – with
a substantial omission of food. While this has been
considered the normal way to prepare for operation, a
16–18-h fast before any other kind of stress, such as a
mountain hike or marathon run, would be considered an
unnatural way to prepare the body. The fasted state at the
time of operation has recently been shown to represent an
additional stress17 .
Several animal models of severe stress have shown
that the fasted rodent (6–24-h fast) has substantially less
capacity to cope with haemorrhage or endotoxaemia17 . The
fed animal responds to trauma with a less marked endocrine
stress response, handles glucose metabolism in a more
anabolic way, displays better muscle strength for several
days after the insult and shows less bacterial translocation
compared with the animal subjected to identical stress in
the fasted state. These findings led to studies in adults
having elective operations. The animal studies indicated
that the availability of carbohydrates and the metabolic
setting of the fed state were the crucial factors for recorded
improvements. Thus, when transferring these findings into
the clinical setting, the first studies hypothesized that
the carbohydrate-fed state might result in an improved
metabolic situation after operation. Following open upper
abdominal surgery, patients treated with a high-dose
glucose infusion (5 mg per kg per min) overnight had
a reduction in postoperative insulin resistance of 50 per
cent compared with that in patients fasted overnight46 .
20
Change in insulin resistance (%)
10
−10
−20
−30
∗
−40
−50
−60
Cholecystectomy46 Colorectal surgery48
Fig. 2Relative change in insulin resistance following different elective surgical procedures in control patients (fasted overnight before
operation or treated with a placebo beverage) and patients given preoperative carbohydrate to alter metabolism (either as an infusion of
30 per cent glucose with or without insulin, or as a carbohydrate-rich beverage)46 – 49 . There were six to eight patients in each group.
Measurements were performed before surgery (100 per cent insulin sensitivity) and within 24 h after operation using the
hyperinsulinaemic normoglycaemic clamp technique. *P < 0·05 versus control46 – 49
Copyright  2003 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd
O. Ljungqvist and E. Søreide ž Preoperative fasting 403
Intravenous insulin and glucose given a few hours before
elective arthroplasty had a similar effect47 , as did a beverage
containing a large amount of carbohydrate (12·5 per cent)
before colorectal surgery48 and elective hip replacement49 .
These data are summarized in Fig. 2.
Why should insulin resistance be considered a factor
of clinical importance in the postoperative patient? This
deserves some elaboration because not all surgeons are
familiar with this particular aspect of metabolism50 . Insulin
resistance is a transient phenomenon that lasts for about
3 weeks after uncomplicated elective open abdominal
Downloaded from https://academic.oup.com/bjs/article/90/4/400/6143199 by guest on 24 May 2021
operations51 . The degree of insulin resistance is an
independent factor predicting the length of hospital stay50 .
This is probably explained by the fact that postoperative
insulin resistance in many of its central aspects resembles
a state of untreated type II diabetes mellitus50,52 . In short,
glucose uptake is reduced, in part due to a lesser response by
specific glucose transporters to insulin stimulation. Inside
the cell it is mainly the pathway to glycogen formation
that is disturbed. At the same time, endogenous glucose
production is enhanced. A recent study of a large number of
patients in intensive care (most after thoracic or abdominal
surgery) showed that, if their insulin resistance was treated
using intensive insulin therapy to normalize glucose levels
(as opposed to giving intermittent insulin to maintain
glucose below 12 mmol/l), both morbidity and mortality
rates were reduced, the latter by over 40 per cent53 . With
this in mind, it seems reasonable to suspect that the less
‘diabetic’ the patient, the better he or she will fare.
Carbohydrate
Control
∗
∗
∗
Arthroplasty47 Arthroplasty49
www.bjs.co.uk British Journal of Surgery 2003; 90: 400–406
404 Preoperative fasting ž O. Ljungqvist and E. Søreide
Clinical effect of preoperative carbohydrate
The main objective of preoperative carbohydrate treatment
is to produce the change in metabolism that normally takes
place when breakfast is eaten. This elicits an endogenous
release of insulin that turns off the overnight fasting
state of the metabolism. The easiest way to accomplish
this change is to give carbohydrate. In the preoperative
situation, this can be effectively achieved either by giving a
high-dose glucose infusion (5 mg per kg per min or more)
or by providing a sufficiently concentrated carbohydrate-
containing beverage24,54 . Thus, a carbohydrate-rich (12·5
per cent) clear beverage was prepared to suit the
preoperative situation, in that it contained mainly polymers
of carbohydrates to minimize the osmotic load and so
reduce gastric emptying time24 .
Before being used in clinical studies, the gastric emptying
of the beverage was tested in healthy volunteers and
in preoperative patients using isotopic studies of gastric
emptying. It was shown to pass through the stomach
in doses of 400 ml within 90 min. As the effect remains
for about 4 h, it has also been tested in patients taking
400 ml up to 2 h before intake of morphine-containing
premedication. Follow-up studies in more than 250
patients showed that the median residual gastric volume
was about 20 ml, which is almost exactly the same as that
found after intake of water or after an overnight fast55 .
The same mixture of carbohydrates has also been
preliminarily reported in patients about to undergo
gastroscopy56 . Again, the mean volume was the same in
three groups of patients: overnight fasted, after intake of
400 ml water, and after 400 ml carbohydrate solution 2 h
before the investigation. In this study of some 80 patients
in each group, there was a total of five patients (all taking
a beverage) with a gastric volume of more than 120 ml, the
highest with 200 ml. In a follow-up study of 60 patients,
200 ml was given twice, with the later intake 2 h before
gastroscopy. This time, the highest volume found was
120 ml and the mean was about 35 ml, regardless of intake
of water or carbohydrate. To date, more than 600 patients
have been included in various clinical studies and there
has been no complication reported following intake of the
carbohydrate-rich beverage.
Further evaluation of this carbohydrate-rich preoper-
ative beverage has revealed that it improves subjective
well-being compared with placebo (water). While both
drinks reduce preoperative thirst, the addition of carbohy-
drate also reduces hunger and anxiety, and improves overall
well-being (as measured by 12 variables including pain,
fatigue and fitness)55 . In addition, postoperative subjective
well-being has also been scored in patients undergoing col-
orectal surgery, and preliminary results presented57 . Again,
Copyright  2003 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd
carbohydrate was most beneficial, followed by placebo
(water); overnight-fasted patients scored lowest. In an
assembly of three small prospective studies containing a
total of 52 patients, length of hospital stay was analysed
retrospectively using a meta-analytic technique52 . Patients
undergoing open cholecystectomy, colorectal surgery or
elective hip replacement, who were treated with preoper-
ative carbohydrate, were discharged from hospital about
20 per cent earlier than those fasted overnight. The value
of preoperative carbohydrate is being evaluated further
in ongoing trials. A preliminary report from a prospec-
Downloaded from https://academic.oup.com/bjs/article/90/4/400/6143199 by guest on 24 May 2021
tive double-blind placebo-controlled randomized trial of
89 patients undergoing major abdominal surgery noted a
trend in the same direction58 .
Conclusions
Free intake of clear fluids up to 2 h before anaesthesia
for elective operation is safe and improves subjective well-
being, primarily by reducing thirst. More recent research
indicates that oral carbohydrate intake on the morning of
operation can improve the perioperative metabolic milieu
and reduce the surgical stress response. Evolution of ideas
may bring us back to the Holmes’ System of Surgery
recommendation from 188310 , in which the wisdom of
keeping the stomach free from solids was pointed out, but
the oral intake of carbohydrate, energy-containing fluids
before operation was encouraged.
Competing interests statement
Olle Ljungqvist is the owner of a patent for a
carbohydrate-containing beverage from which the pre-
operative beverage mentioned in the article has been
produced. Part of the research reported in this article
has been funded by grants from Royal Numico, NL, a
commercial company that holds the licence for this patent.
References
1 Mendelson CL. The aspiration of stomach contents into the
lungs during obstetric anaesthesia. Am J Obstet Gynecol 1946;
52: 191–205.
2 Edwards G, Morton HJV, Pask EA, Wylie WD. Deaths
associated with anaesthesia. A report on 1000 cases.
Anaesthesia 1956; 11: 194–220.
3 Bannister WK, Sattilaro AJ. Vomiting and aspiration during
anesthesia. Anesthesiology 1962; 23: 251–264.
4 Marshall BM, Gordon RA. Vomiting, regurgitation, and
aspiration in anaesthesia, II. Can Anaesth Soc J 1958; 5:
439–447.
www.bjs.co.uk British Journal of Surgery 2003; 90: 400–406

5 Gibbs CP, Modell JH. Aspiration pneumonitis. In Anesthesia
(2nd edn), Miller RD (ed.), vol. 3. Churchill Livingstone:
New York, 1986; 2023–2050.
6 Olsson GL, Hallen B, Hambraeus-Jonzon K. Aspiration
during anaesthesia: computer-aided study of 185 358
anaesthetics. Acta Anaesthesiol Scand 1986; 30: 84–92.
7 Pedersen T, Johansen SH. Serious morbidity attributable to
anaesthesia. Considerations for prevention. Anaesthesia 1989;
44: 504–508.
8 Warner MA, Warner ME, Weber JG. Clinical significance
of pulmonary aspiration in the perioperative period.
Anesthesiology 1993; 78: 56–62.
9 Kluger MT, Short TG. Aspiration during anaesthesia: a
review of 133 cases from the Australian Anaesthesia Incident
Monitoring Study (AIMS). Anaesthesia 1999; 54: 19–26.
10 Strunin L. How long should patient fast before surgery?
Time for new guidelines. Br J Anaesth 1993; 70: 1–3.
11 Maltby JR, Sutherland AD, Sale JP, Shaffer EA. Preoperative
oral fluids: is a five-hour fast justified prior to elective
surgery? Anesth Analg 1986; 65: 1112–1116.
12 Phillips S, Hutchinson S, Davidson T. Preoperative drinking
does not affect gastric contents. Br J Anaesth 1993; 70: 6–9.
13 Søreide E, Strømskag KE, Steen PA. Statistical aspects in
studies of preoperative fluid intake and gastric content. Acta
Anaesthesiol Scand 1995; 39: 738–743.
14 Erikson LI, Sandin R. Fasting guidelines in different
countries. Acta Anaesthesiol Scand 1996; 40: 971–974.
15 Søreide E, Fasting S, Ræder J. New preoperative fasting
guidelines in Norway. Acta Anaesthesiol Scand 1997; 41: 799.
16 American Society of Anaesthesiologists Task Force on
Preoperative Fasting. 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: a report by the American
Society of Anaesthesiologists Task Force on Preoperative
Fasting. Anesthesiology 1999; 90: 896–905.
17 Ljungqvist O, Nygren J, Hausel J, Thorell A. Preoperative
nutrition therapy – novel developments. Scand J Nutr 2000;
44: 3–7.
18 Ljungqvist O, Nygren J, Thorell A. Insulin resistance and
elective surgery. Surgery 2000; 128: 757–760.
19 Canadian Anesthesiologists’ Society. Guidelines to the Practice
of Anesthesia (rev edn). Canadian Anesthesiologists’ Society:
Toronto, 2002; http://www.cas.ca/guidelines/practice.asp [18
November 2002].
20 Smith A. Preoperative fasting in adults. In Raising the
Standard, Lack JA, White LA, Thomas GM, Rollin A-M
(eds). Royal College of Anaesthetists: London, 2000;
http://www.rcoa.ac.uk/standards [9 December 2002].
21 Erskine L, Hunt JN. The gastric emptying of small volumes
given in quick succession. J Physiol 1981; 313: 335–341.
22 Brener W, Hendrix TR, McHugh PR. Regulation of the
gastric emptying of glucose. Gastroenterology 1983; 85:
76–82.
Copyright  2003 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd
O. Ljungqvist and E. Søreide ž Preoperative fasting 405
23 Haavik P, Søreide E, Hofstad P, Steen PA. Does
preoperative anxiety influence gastric fluid volume and
acidity? Anesth Analg 1992; 75: 91–94.
24 Nygren J, Thorell A, Jacobsson H, Larsson S, Schnell PO,
Hylen L et al. Preoperative gastric emptying. Effects of
anxiety and carbohydrate administration. Ann Surg 1995;
222: 728–734.
25 Tryba M, Zenz M, Mlasowsky B, Huchzermeyer H. Does a
stomach tube enhance regurgitation during general
anaesthesia? Anaesthesist 1983; 32: 407–409.
26 Plourde G, Hardy JF. Aspiration pneumonia: assessing the
risk of regurgitation in the cat. Can Anesth Soc J 1986; 33:
Downloaded from https://academic.oup.com/bjs/article/90/4/400/6143199 by guest on 24 May 2021
345–348.
27 O’Mullane EJ. Vomiting and regurgitation during
anaesthesia. Lancet 1954; i: 1209–1212.
28 Maltby JR, Koehli N, Ewen A, Shaffer EA. Gastric fluid
volume, pH, and gastric emptying in elective inpatients.
Influences of narcotic–atropine premedication, oral fluid,
and ranitidine. Can J Anaesth 1988; 35: 562–566.
29 Maltby JR, Lewis P, Martin A, Sutherland LR. Gastric fluid
volume and pH in elective patients following unrestricted
oral fluid until three hours before surgery. Can J Anaesth
1991; 38: 425–429.
30 Søreide E, Holst Larsen H, Reite K, Mikkelsen H,
Søreide JA, Steen PA. Effects of giving water 25–450 ml with
oral diazepam premedication 1–2 h before operation. Br J
Anaesth 1993; 71: 503–506.
31 Brock-Utne JG, Moshal MG, Downing JW, Spitaels JM,
Stiebel R. Fasting volume and acidity of stomach contents
associated with gastrointestinal symptoms. Anaesthesia 1977;
32: 749–752.
32 Hveem K, Hausken T, Berstad A. Ultrasonographic
assessment of fasting liquid content in the human stomach.
Scand J Gastroenterol 1994; 29: 786–789.
33 Søreide E, Bjørnestad E, Steen PA. An audit of aspiration
pneumonitis in gynaecological and obstetric patients. Acta
Anaesthesiol Scand 1996; 40: 14–19.
34 Minami H, McCallum RW. The physiology and
pathophysiology of gastric emptying in humans.
Gastroenterology 1984; 86: 1592–1610.
35 Petring OU, Blake DW. Gastric emptying in adults: an
overview related to anaesthesia. Anaesth Intensive Care 1993;
21: 774–781.
36 Agarwal A, Chari P, Singh H. Fluid deprivation before
operation. The effect of a small drink. Anaesthesia 1989; 44:
632–634.
37 Read MS, Vaughan RS. Allowing pre-operative patients to
drink: effects on patients’ safety and comfort of unlimited
oral water until 2 hours before anaesthesia. Acta Anaesthesiol
Scand 1991; 35: 591–595.
38 Fennelly M, Galletly DC, Purdie GI. Is caffeine withdrawal
the mechanism of postoperative headache? Anesth Analg
1991; 72: 449–453.
39 Miller M, Wishart HY, Nimmo WS. Gastric content at
induction of anaesthesia. Is a 4-hour fast necessary? Br J
Anaesth 1983; 55: 1185–1188.
www.bjs.co.uk British Journal of Surgery 2003; 90: 400–406
406 Preoperative fasting ž O. Ljungqvist and E. Søreide
40 Søreide E, Hausken T, Søreide JA, Steen PA. Gastric
emptying of a light hospital breakfast. A study using real time
ultrasonography. Acta Anaesthesiol Scand 1996; 40:
549–553.
41 Scott AM, Kellow JEK, Shuter B, Nolan JM, Hoschl R,
Jones MP. Effects of cigarette smoking on solid and liquid
intragastric distribution and gastric emptying.
Gastroenterology 1993; 104: 410–416.
42 Hutson WR, Roehrkasse RL, Wald A. Influence of gender
and menopause on gastric emptying and motility.
Gastroenterology 1989; 96: 11–17.
43 Brock-Utne JG. Clear fluids, not breakfast, before surgery.
Acta Anaesthesiol Scand 1996; 40: 507–508.
44 Simini B. Preoperative fasting. Lancet 1999; 353: 862.
45 Fasting S, Søreide E, Ræder JC. Changing preoperative
fasting policies. Impact of a national consensus? Acta
Anaesthesiol Scand 1998; 42: 1188–1192.
46 Ljungqvist O, Thorell A, Gutniak M, Häggmark T,
Efendic S. Glucose infusion instead of preoperative fasting
reduces postoperative insulin resistance. J Am Coll Surg 1994;
178: 329–336.
47 Nygren JO, Thorell A, Soop M, Efendic S, Brismar K,
Karpe F et al. Perioperative insulin and glucose infusion
maintains normal insulin sensitivity after surgery. Am J
Physiol 1998; 275: E140–E148.
48 Nygren J, Soop M, Thorell A, Efendic S, Nair KS,
Ljungqvist O. Preoperative oral carbohydrate administration
reduces postoperative insulin resistance. Clin Nutr 1998; 17:
65–71.
49 Soop M, Nygren J, Myrenfors P, Thorell A, Ljungqvist O.
Preoperative oral carbohydrate treatment attenuates
immediate postoperative insulin resistance. Am J Physiol
Endocrinol Metab 2001; 280: E576–E583.
Copyright  2003 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd
50 Thorell A, Nygren J, Ljungqvist O. Insulin resistance: a
marker of surgical stress. Curr Opin Clin Nutr Metab Care
1999; 1: 69–78.
51 Thorell A, Guntiak M, Efendic S, Häggmark T,
Ljungqvist O. Insulin resistance after abdominal surgery. Br
J Surg 1994; 81: 59–63.
52 Ljungqvist O, Nygren J, Thorell A, Brodin U, Efendic S.
Preoperative nutrition – elective surgery in the fed or the
overnight fasted state. Clin Nutr 2001; 20(Suppl 1):
167–171.
53 van der Berghe G, Wouters P, Weekers F, Verwaest C,
Bruyninckx F, Schetz M et al. Intensive insulin therapy in the
Downloaded from https://academic.oup.com/bjs/article/90/4/400/6143199 by guest on 24 May 2021
surgical intensive care unit. N Engl J Med 2001; 345:
1359–1367.
54 Thorell A, Alston Smith J, Ljungqvist O. The effect of
preoperative carbohydrate loading on hormonal changes,
hepatic glycogen and glucoregulatory hormones during
abdominal surgery. Nutrition 1996; 12: 690–695.
55 Hausel J, Nygren J, Lagerkranser M, Hellström PM,
Hammarqvist F, Lindh A et al. A carbohydrate-rich drink
reduces preoperative discomfort in elective surgery patients.
Anesth Analg 2001; 93: 1344–1350.
56 Hausel J, Thorell A, Nygren J, Farago I, Bergholm L,
Andersson AS et al. Preoperative beverages in patients with
upper gastrointestinal symptoms. Clin Nutr 2000; 19(Suppl
1): 132 (Abstract).
57 Hausel J, Nygren J, Almström C, Thorell A, Ljungqvist O.
Preoperative oral carbohydrates improves well being after
elective colorectal surgery. Clin Nutr 1999; 18(Suppl 2): 80
(Abstract).
58 Hofman Z, Van Drunen J, Yuill K, Richardson R,
Davidson I, Cecil T et al. Tolerance and efficacy of
immediate pre-operative carbohydrate feeding in
uncomplicated elective surgical patients. Clin Nutr 2001;
20(Suppl 3): 32 (Abstract).
www.bjs.co.uk British Journal of Surgery 2003; 90: 400–406