CHHS17/240

Canberra Hospital and Health ServicesClinical Guideline Fasting Guidelines for Patients Undergoing Procedures Requiring Sedation or AnaesthesiaContents

Contents...................................................................................................................................1

Guideline Statement................................................................................................................2

Scope........................................................................................................................................3

Section 1 – Definition of Clear Fluids........................................................................................3

Section 2 – Recommended Fasting Duration for Adults...........................................................3

Section 3 – Recommended Fasting Duration for Children........................................................4

Section 4 – Fasting and Bowel Preparation for Endoscopy......................................................5

Section 5 – Pre-Operative Carbohydrate Drinks.......................................................................5

Section 6 – Chewing Gum.........................................................................................................5

Implementation........................................................................................................................6

Related Policies, Procedures, Guidelines and Legislation.........................................................6

References................................................................................................................................6

Search Terms............................................................................................................................7

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Guideline Statement

BackgroundPatients should be fasted prior to any procedure where there is potential for a loss of protective airway reflexes. This includes sedation, general anaesthesia and planned conscious procedures where there may be an unanticipated need for sedation or general anaesthesia.

The aim of fasting is to reduce the risk of peri-operative regurgitation. Regurgitation in a patient with impaired airway reflexes may be associated with aspiration of gastric contents and life threatening complications including airway obstruction, chemical pneumonitis and bacterial pneumonia.

Conversely, an unnecessarily long duration of fasting is not without harm. Prolonged food fasting contributes to patient discomfort and a catabolic state associated with loss of protein and lean mass as well as impaired insulin resistance1.

Unnecessarily prolonged abstinence from fluids contributes to patient thirst, discomfort, dehydration and modestly increased gastric volumes on anaesthetic induction2.

Patients should be encouraged to minimise the duration of their solid and fluid fasting to the recommendation durations in this guideline.

The recommended fasting durations are general in nature. Conditions associated with increased aspiration risk that may require individualised recommendations include women beyond the 1st trimester of pregnancy, emergency or trauma cases, obese patients, patients with severe gastro-oesophageal reflux or upper gastrointestinal motility disorders, and patients who have undergone bariatric surgery (including adjustable gastric banding).

Key ObjectiveThis guideline provides advice to staff and patients scheduled to undergo procedures with a potential need for sedation or anaesthesia as to the required duration of fasting to optimise patient safety while minimising patient discomfort.

AlertMorning fasting does not require automatic withholding of morning medications. Most medications can be consumed with a small sip of water and patients should be provided with specific advice as to which medications to consume and which to withhold.

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Scope

This guideline applies to all staff involved in the management and care of patients planned for procedures where there is potential need for anaesthesia or sedation.

This document applies to the following Canberra Hospital Health Services (CHHS) staff working within their scope of practice: Medical Officers Registered Nurses and Midwives Student Nurses and Midwives working under supervision

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Section 1 – Definition of Clear Fluids

The following table provides examples for what are to be considered ‘clear fluids’ for the purpose of the following recommendations.

Clear Fluids Not Considered Clear Fluids Water Clear cordial Black tea or black coffee Fruit juices not containing pulp (e.g.

apple juice)

Drinks containing milk Cloudy fruit juices and juices containing

pulp (e.g. some orange juice) Alcohol

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Section 2 – Recommended Fasting Duration for Adults

Recommended Fasting Duration for AdultsSolids/ Non-Clear Fluids/ Nasogastric Feeds

Withhold for 6 hoursFor a case booked on a morning list: No food after 0200For cases booked on an afternoon list: An early breakfast may be consumed, but no food to be taken after 0700

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Recommended Fasting Duration for AdultsClear Fluids

Withhold for 2 hours Clear fluid consumption should be limited to 200ml/hrFor a case booked on a morning list Finish drinking by 0600 Finish drinking by 0500 if scheduled for cardiac surgeryFor a case booked on an afternoon list Finish drinking by 1100

Longer periods of fasting should be avoided without a specific reason

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Section 3 – Recommended Fasting Duration for Children

Parents should be encouraged to consider feeding their child shortly prior to commencement of formal fasting, to minimise an unnecessarily prolonged duration.

Recommended Fasting Duration for ChildrenSolids, including Lollies and Nasogastric Feeds

Withhold for 6 hoursFor a case booked on a morning list: No food after 0200For cases booked on an afternoon list: An early breakfast may be consumed, but no food to be taken after 0700

Formula/ Non-Breast MilkChildren Under 6 Months of Age Children Over 6 Months Old

Withhold for 4 hoursFor a case booked on a morning list Finish last feed by 0400For a case booked on an afternoon list Finish last feed by 0900

Withhold for 6 hoursFor a case booked on a morning list Finish last feed by 0200For a case booked on an afternoon list Finish last feed by 0700

Breast MilkChildren Under 6 Months Old Children Over 6 Months Old

Withhold for 3 hoursFor a case booked on a morning list Finish last feed by 0500For a case booked on an afternoon list

Withhold for 6 hoursFor a case booked on a morning list Finish last feed by 0200For a case booked on an afternoon list

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Recommended Fasting Duration for Children Finish last feed by 1000 Finish last feed by 0700

Recommended Fasting Duration for ChildrenClear Fluids

Withhold for 2 hoursFor a case booked on a morning list: Finish drinking clear fluid by 0600For a case booked on an afternoon list: Finish drinking clear fluid by 1100

Clear fluid fasting time may be shortened to 1 hour at the discretion of the case anaesthetist

Avoid extending fasting times beyond the recommended duration

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Section 4 – Fasting and Bowel Preparation for Endoscopy

Patients undergoing colonoscopy may be prescribed a split-dose bowel preparation including 500ml of ColonLytely on the morning of the procedure.

Consumption of 500ml ColonLytely dose must be complete a minimum of 2 hours prior to scheduled procedure time (i.e. 0600 for a morning list, or 1100 for an afternoon list).

Patients may continue to consume up to 200ml/hr of water up until 2 hours before their procedure.

Gastric residual volume in these patients has been shown to be equivalent to those completing bowel preparation the evening before the procedure3.

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Section 5 – Pre-Operative Carbohydrate Drinks

The role of pre-operative carbohydrate drinks are supported by Enhanced Recovery After Surgery programs1 and may be prescribed for selected patients at the time of pre-operative consultation.

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Section 6 – Chewing Gum

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Chewing gum poses a potential risk as a foreign body in the airway. It may be chewed before surgery, but must be confirmed as discarded a minimum of 2 hours before surgery.

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Implementation

These guidelines will be communicated, with agreement sought, through the Surgical Service Taskforce, Surgical Services Executive, SAOH Nursing 3, 4, 5, Unit meetings.

All staff involved in the preparation and facilitation of patients for proposed surgery or procedural sedation will be fully informed regarding the implementation of Fasting Guidelines.

Posters of the new fasting guidelines will be created and displayed in all areas identifying the change of process, and consumer advice leaflets will be updated with the new information.

Communication messages will also be placed on the HUB for all staff.

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Related Policies, Procedures, Guidelines and Legislation

Policies Health Directorate Nursing and Midwifery Continuing Competence Policy Consent and Treatment

Procedures CHHS Patient Identification and Procedure Matching Policy

Legislation Health Records (Privacy and Access) Act 1997 Human Rights Act 2004

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References

1. Scott, M. J. et al. Enhanced Recovery after Surgery (ERAS) for gastrointestinal surgery, part 1: Pathophysiological considerations. Acta Anaesthesiol. Scand. 59, 1212–1231 (2015).

2. Brady, M., Kinn, S. & Stuart, P. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst. Rev. CD004423 (2003). doi:10.1007/BF03077179

3. Agrawal, D., Elsbernd, B., Singal, A. G. & Rockey, D. Gastric residual volume after split-

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dose compared with evening-before polyethylene glycol bowel preparation. Gastrointest. Endosc. 83, 574–580 (2016).

4. Smith, I. et al. Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology. Eur. J. Anaesthesiol. 28, 556–569 (2011).

5. Guidelines on Pre-Anaesthesia Consultation and Patient Preparation - Appendix 1: Fasting Guidelines. ANZCA Professional Document PS07 at www.anzca.edu.au

6. Brady, M. et al. Preoperative fasting for preventing perioperative complications in children. Cochrane Database Syst. Rev. CD005285 (2009). doi:10.1002/14651858.CD005285.pub2

7. American Society of Anesthesiologists Committee on standards and practice parameters. 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 Com. Anesthesiology 114, 495–511 (2011).

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Search Terms

Fasting, Elective Surgery, Surgery, Procedural Sedation, Sedation, Food, Drink, NBM, Nil By Mouth, Pre-Operative

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Disclaimer: This document has been developed by Health Directorate, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

(to be completed by the HCID Policy Team)Date Amended Section Amended Approved ByEg: 17 August 2014 Section 1 ED/CHHSPC Chair

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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register