The PAAD is published and distributed through the Substack app which amongst its many impressive features provides us with stats on how many people open each individual post. Of all of the PAADs sent out since Ron Litman’s untimely death, the topic of preoperative fasting has been the most viewed. Thus, whenever I see an article on this topic it goes to the top of the PAAD list. Many of you will be disappointed with the new ASA guidelines and I would urge all of you who either agree or disagree with them to send me your thoughts which I will post in a reader response. Myron Yaster MD
Original Article
Joshi GP, Abdelmalak BB, Weigel WA, Harbell MW, Kuo CI, Soriano SG, Stricker PA, Tipton T, Grant MD, Marbella AM, Agarkar M, Blanck JF, Domino KB. Update of 2023 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting: Carbohydrate-containing Clear Liquids with or without Protein, Chewing Gum, and Pediatric Fasting Duration-A Modular the 2017 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting. Anesthesiology. 2023 Feb 1;138(2):132-151.. PMID: 36629465.
In the February issue of Anesthesiology, a multi-specialty ASA task force published a practice guideline for perioperative fasting, which is characterized as a “modular” update because it focuses narrowly on the issues of carbohydrate containing clear liquids with or without protein, chewing gum, with specific attention to the issue of pediatric clear liquid fasting duration. The guideline is an update of the guideline adopted by the ASA in 2016 and published in 2017. (1) No consideration was given to fasting intervals for non-clear liquids or solid foods for adult or pediatric patients. As with previous practice guidelines, these apply to healthy patients who do not have conditions which increase the risk of vomiting and aspiration.
The literature review encompassed articles focusing on carbohydrate containing clear liquids with or without protein published since 2000 and those evaluating chewing gum and pediatric 1-hr fasting for clear liquids since 1990.
For adults, the task force concluded
1) that the prior recommendation of 2 hour fasting time for clear liquids continues to be appropriate but specifies that the clear liquid should contain carbohydrates, which reduce not only thirst but hunger.
2) There was “insufficient evidence to recommend protein-containing clear liquids preferentially over other clear liquids before elective procedures requiring general anesthesia, regional anesthesia, or procedural sedation.”
3) They “suggest not delaying elective procedures requiring general anesthesia, regional anesthesia, or procedural sedation in healthy adults who are chewing gum (although the gum should be spit out prior to the induction of anesthesia)
For pediatric patients, the issues of gum and protein-containing clear liquids were not addressed. The task force focused on whether to recommend drinking clear liquids until 1-hr vs 2-hr prior to procedures requiring general anesthesia, regional anesthesia, or procedural sedation. Contrary to the conclusions of the European Society of Anesthesiology and Intensive Care (ESAIC) published as a guideline in 2022,(2) and discussed in the PAAD published one year ago (Jan 5, 2022), the ASA task force concluded that “there is insufficient evidence concerning benefits and harms to recommend” a 1-hr fasting time for clear liquids in pediatric patients.
Because actual fasting times commonly far exceed the limits distributed to patients, (3) the task force highlights the fact that what is more important that an institution’s fasting guidelines is that all individuals involved in preparing patients for anesthesia and surgery should be knowledgeable about the guidelines and that information distributed to patients in all locations should conform to the adopted guidelines. It should be emphasized to all healthy, low-risk patients, adults, but especially children, to drink carbohydrate-containing clear liquids until as close to 2 hours prior to procedures as possible.
Because children frequently arrive to the hospital in excess of 2 hours after the last drink of clear liquids, many pediatric institutions will allow and even encourage such children (and especially infants) to drink on arrival in the preoperative unit, if the OR schedule permits. This is more easily accomplished if the institution allows drinking until 1 hour rather than 2 hours prior to anesthesia start.
Despite the conclusions of the ASA task force, many pediatric institutions have adopted the 1-hr interval for clear liquids (Children’s Hospital of Philadelphia, Texas Children’s Hospital, Children’s Healthcare of Atlanta, St. Jude Children’s Research Hospital, etc.) without an observed increase in aspiration events.
Has your institution changed the interval for clear liquids? What do you think? Send your responses to Myron (myasterster@gmail.com) and we will post them in a reader response.
References:
1. 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 Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiology. 2017 Mar;126(3):376-393.
2. Frykholm P, Disma N, Andersson H, Beck C, Bouvet L, Cercueil E, Elliott E, Hofmann J, Isserman R, Kaucane A, Kuhn F, de Queiroz Siqueira M, Rosen D, Rudolph D, Schmidt AR, Schmitz A, Stocki D, Sumpelmann R, Stricker PA, Thomas M, Veyckemans F, Afshari A. Preoperative fasting in children: guideline from the European Society of Anaesthesiology and Intensive Care. Eur J Anaesthesiol 2022; 39:4–25.
3. Disma N, Frykholm P, Cook-Sather SD, Lerman J. Pro-con debate: 1- vs. 2-hour fast for clear liquids before anesthesia in children. Anesth Anal 2021; 133:581-91.