Preoperative fasting guidelines…yet again
Lynne G. Maxwell MD
Preoperative fasting guidelines continue to be a focus of intense interest in the worldwide pediatric anesthesia community and we have repeatedly highlighted publications documenting changes in NPO practices recommended by many international pediatric anesthesia societies. We last presented a summary of the review of these recommendations by Zhang et al1 in December 2023 (https://ronlitman.substack.com/p/preoperative-fasting-guidelinesagain-8ae?utm_source=publication-search).
As we commented in the above cited PAAD, “from many personal discussions and public responses to previous PAADs, it’s pretty clear to us that many institutions and practitioners have changed and reduced their clear liquids fasting guidelines from two to one hour. Indeed, some have changed their policies to encourage clear liquids when patients arrive to the preoperative staging area”, continuing to offer clear fluids (CF) until 1 hour prior to the now better known surgical time, especially if the start time is delayed.
In light of the recent recommendations from multiple international pediatric anesthesia societies to reduce fasting time for clear liquids from 2 hours to 1 hour for healthy children having elective surgery, the Society for Pediatric Anesthesia Quality and Safety Committee (SPA-QS) established a task force to explore this issue, reviewing current publications from institutions who have made this change as well as the recommendations from the societies. The task force recommended an Institutional Review Board (IRB) survey of PALC members to assess the current state of fasting guidelines among the 88 institutions represented in the PALC. The Pediatric Anesthesia Leadership Council is comprised of pediatric anesthesia chairs and division chiefs across the US, conducted a survey of PALC members to assess the current state of fasting guidelines at pediatric institutions in the US, the reasons for changing allowed clear liquid intake from 2 hours to 1 hours, concerns that have deterred institutions from making this change, and the institutional experience in terms of adverse events if 1 hour clear liquid intake was adopted, as well as the number of cases done in each institutions.2 This article was accompanied by an editorial by Deutsch and Nasr.3
Original Article
Dalal PG, Malviya S, Cravero J, Fehr J; Society for Pediatric Anesthesia, Quality and Safety Committee “Nil per Os” Task Force. Reviewing "Nil Per Os" Guidance for Clear Fluids in Children Before Anesthesia: Survey of the Pediatric Anesthesia Leadership Council. Anesth Analg. 2025 Mar 1;140(3):507-514. doi: 10.1213/ANE.0000000000007219. Epub 2024 Nov 19. PMID: 39773771.
Deutsch N, Nasr VG. Encouraging Clear Fluids Up to 1 Hour Before Anesthesia. Anesth Analg. 2025 Mar 1;140(3):504-506. doi: 10.1213/ANE.0000000000007324. Epub 2025 Feb 14. PMID: 39976616.
Survey responses were screened to eliminate duplicate responses from the same institution, resulting in 75 institutions responding (85.2%). At the time of the survey in 2023, 8 of 75 institutions had implemented 1 hour CF fasting guidelines, with 7 others in the process of moving from 2 hours to 1 hour. In the 8 institutions adopting the 1 hour guideline, 653,000 cases were performed with no increase in the incidence of aspiration (although this reporting depended on the awareness of the respondent of these adverse events). Regardless of their institutional policy, 87.5% of respondents supported the 1 hour CF cutoff.
Despite the recommendations from multiple societies (see table in previous PAAD 12/28/23), the ASA’s recent modular update pointedly rejected a change from the prior recommendation of 2 hours for pediatric patients, citing insufficient evidence for the safety of this change.
Regardless of the institutional recommendations, parents commonly fail to continue to offer CF up until the recommended time limit, resulting in children being fasted excessively and arrive famished and on occasion even dehydrated. Parents informed to feed clears up to 2 hours before surgery often fast their children for far longer times. “This has both psycho-social and physiological consequences for the child, as well as being potentially distressing for both the child and parents.”4
As Deutsch and Nasr comment “despite high support to move to a 1 hour fasting protocol, many institutions may still be reluctant to do so for medicolegal reasons in lights of the recent practice guidelines published by the ASA”. They continue “settling this debate by performance of randomized controlled trial to compare a 2 and 1 hour CF cutoff is near impossible, especially in a setting of low incidence of adverse events. An appropriately powered study would require tens of thousands of patients to demonstrate a difference. Furthermore, the actual NPO times for most patients far exceed 1 or 2 hours, making the data even more difficult to interpret. With the significant amount of pediatric experience of a 1 hour cutoff in other countries (and in US institutions that have adopted this practice), and no evidence of a significant increase in aspiration risk, pediatric anesthesiologists should feel assured that this is a safe practice.”3
As Deutsch and Nasr point out, the liberalized CF guideline should apply to healthy children scheduled for elective surgery, who are not at increased risk of aspiration. Individualized preoperative fasting times should be recommended for patients with GE reflux disease, hiatal hernia, gastroparesis or intraabdominal processes. Both Dalal et al and Deutsch and Nasr raise the issue of POC gastric ultrasound in decision-making about induction and airway management.
Has your institution changed its practice, or has it been considered and rejected? Send your thoughts to Myron who will post them in a Friday Reader response.
References
1. Zhang E, Hauser N, Sommerfield A, Sommerfield D, von Ungern-Sternberg BS. A review of pediatric fasting guidelines and strategies to help children manage preoperative fasting. Paediatr Anaesth. 2023 Dec;33(12):1012-1019. doi: 10.1111/pan.14738. Epub 2023 Aug 2. PMID: 37533337.
2. Dalal PG, Malviya S, Cravero J, Fehr J; Society for Pediatric Anesthesia, Quality and Safety Committee “Nil per Os” Task Force. Reviewing "Nil Per Os" Guidance for Clear Fluids in Children Before Anesthesia: Survey of the Pediatric Anesthesia Leadership Council. Anesth Analg. 2025 Mar 1;140(3):507-514. doi: 10.1213/ANE.0000000000007219. Epub 2024 Nov 19. PMID: 39773771.
3. Deutsch N, Nasr VG. Encouraging Clear Fluids Up to 1 Hour Before Anesthesia. Anesth Analg. 2025 Mar 1;140(3):504-506. doi: 10.1213/ANE.0000000000007324. Epub 2025 Feb 14. PMID: 39976616.
4. Singla K, Bala I, Jain D, Bharti N, Samujh R. Parents' perception and factors affecting compliance with preoperative fasting instructions in children undergoing day care surgery: A prospective observational study. Indian J Anaesth. 2020 Mar;64(3):210-215. doi: 10.4103/ija.IJA_794_19. Epub 2020 Mar 11. PMID: 32346168.