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Department of Anesthesiology, University of Michigan School of Medicine, Ann Arbor, Michigan
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Abstract |
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Implications: Findings of this national survey conducted among active members of the Society for Ambulatory Anesthesia may encourage anesthesiologists throughout the world to take a more liberal attitude toward allowing clear liquids 2–3 h and a light breakfast 6 h before an elective surgery in healthy patients.
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Introduction |
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As outpatient surgery gained popularity throughout the 1980s, investigators recommended liberalization of preoperative fasting guidelines, specifically regarding clear liquids (5). A number of studies showed that clear liquids ingested 2–3 h before an elective surgery did not increase residual gastric volume nor the risk of pulmonary aspiration (6–7). In 1996, a national survey on practice patterns (8) showed that 68% of practicing anesthesiologists allowed clear liquids 2–4 h before an elective surgery in children, and approximately 41% would allow the same in adults. However, only 28% of the facilities surveyed had actually updated their institutional policies to include this new recommendation.
More recently, in 1996, the American Society of Anesthesiologists (ASA) appointed a task force to recommend a practice guideline for fasting before elective surgery. The recommendations of this task force were accepted by the ASA in October 1998. The resulting report was published in the journal, Anesthesiology, and in a well known textbook (9,10). These recommendations state that a healthy patient may be allowed clear liquids (e.g., water, clear fruit juice etc.) up to 2 h before an elective surgery; human breast milk 4 h before surgery; nonhuman milk 6 h before surgery; a light breakfast (e.g., toast and tea) 6 h before surgery; and solid food 8 h before surgery. Are anesthesiologists in the United States following these recent guidelines, especially about the recommendation to allow a light breakfast 6 h before an elective operation? To answer that question, we conducted a national survey among the active members of the Society for Ambulatory Anesthesia (SAMBA). We hypothesized that anesthesiologists currently practicing elective outpatient anesthesia in the United States would not allow a light breakfast 6 h before surgery.
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Methods |
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Results |
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In regard to whether their institutional policy allowed clear liquids 2–3 h before elective surgery, 62% of the institutions did, 37% did not, and 1% provided no response. However, 79% would not allow coffee or tea with milk or cream 2–3 h before anesthesia and 21% would or might. However, 68% would allow human breast milk 4 h before surgery.
Only 35% of responders had an institutional policy allowing a light breakfast, such as tea and toast, 6 h before an elective surgery under GA; 64% did not allow a light breakfast. Affirmative responses were higher (46% vs 35%) if the patient were to have only monitored anesthesia care or regional anesthesia. However, responses changed when the question was asked differently. That is, when asked, if they discovered that a patient had consumed a light breakfast, such as toast and tea 6 h before the scheduled time of the induction of GA for an elective outpatient surgery, only 3% would cancel, 65% would proceed as planned, and 32% would delay the procedure to later the same day. Of those who said their practice policy about a light breakfast had changed, 84% said they had no reason to regret their decision to allow the patient a light breakfast 6 h before anesthesia. Only 7% said yes to this question and 9% had no response. Of the 7% with regrets, several volunteered that the problems they encountered were related to schedule changes. None reported pulmonary aspiration.
Toast and tea or coffee was by far the most often allowed breakfast. Other acceptable foods included were bread, sugar cookies, soup, crackers, Jell-O, cereal, low-fat milk, and fruit. Many responders noted that the toast should not be buttered or lightly buttered. Foods not allowable were fatty foods, greasy food, any solid meat (sausage, bacon, steak, chicken), whole milk, eggs, cheese, fried foods, or a heavy breakfast.
If the patient had consumed solid food (rather than a light breakfast) 8 h before the scheduled elective surgery, 9% of responders would cancel the surgery, 10% would delay the start time, and 81% would proceed as planned.
Practice patterns did not vary by state for preoperative fasting times. Additionally, there were no consistent common characteristics among nonresponders to explain their reluctance to participate in the survey (e.g., the state of practice, years in practice, or site of primary practice, such as hospital, surgery center or office setting).
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Discussion |
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As the results of a similar national survey (8) conducted in 1993 show, institutional policy change always lags behind the practice patterns of physicians. On the question of light breakfast, we find the same lag in our survey. Whereas only 35% of the respondents said an institutional policy about light breakfast before elective operation was already in place at their respective facilities, 97% would not cancel the case if their patient had actually consumed a light breakfast six hours before the scheduled elective surgery. This is a major shift from the known practice patterns of 10 to 15 years ago. At that time, any patient discovered to have deviated from the strict traditional "nothing by mouth after midnight" rule would have been automatically canceled.
It was assumed for years that the incidence of regurgitation of stomach content and pulmonary aspiration are related directly to the residual gastric volume. However, a close scrutiny of the existing data by the ASA task force could not establish that link (9). Ranging from a study by Beaumont (3) as early as 1834, to a more recent one by Minami and McCallum (4) in 1984, investigators have demonstrated that liquids and solids behave differently after being ingested. Thus, there should be little controversy regarding consumption of clear liquids two to three hours before an operation. However, the variability of gastric emptying is more pronounced after solid food. Factors that influence the gastric emptying time for solid food include type of food (i.e., proportion of carbohydrate, protein, and fat), body posture after food intake, exercise, meal weight, caloric density, size of the food particles swallowed, and total amount of food (11,11a).
Compared with the large number of studies addressing the implications of allowing clear liquids two to three hours before surgery, only a few address the question of allowing solid food before surgery. The absence of an easy and readily available method of assessing gastric contents after solid food in the perioperative period may be the reason for this paucity of interest. Miller et al. (12) gave patients a light breakfast consisting of a slice of buttered toast, and a cup of tea or coffee with milk two to four hours before surgery and measured gastric contents after the induction of anesthesia by inserting a gastric tube. They concluded there was no significant difference in gastric volume or pH between the control group (fasting) and the study group. Soreide et al. (13) gave healthy female volunteers a standard hospital breakfast consisting of one slice of white bread with butter and jam, one cup (150 mL) of coffee without milk or sugar, and one glass (150 mL) of pulp-free orange juice. Gastric contents were measured by repeated ultrasonography and paracetamol absorption techniques. No solid food could be detected in the stomach in any subject 240 minutes after ingestion of breakfast. They concluded that at least four hours is needed for solid food to empty from the stomach before an operation. In light of these known facts about the physiology of gastric emptying, duration of fasting and types of food for light breakfast allowed by the respondents in this survey appear sensible.
Although we surveyed only members of SAMBA, our conclusions should apply to all elective surgeries. Almost 80% of all elective surgeries today are either ambulatory or same-day admittance. A total of 64% of survey responders are primarily hospital based. Policies and practices regarding the preanesthetic preparation, such as fasting guidelines, for all elective surgery including ambulatory surgery are the same.
We conclude that the majority of the active members of the SAMBA are already following the practice guidelines proposed by the ASA task force on preoperative fasting. 
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Acknowledgments |
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Footnotes |
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Address correspondence and reprint requests to Sujit K. Pandit, MD, Department of Anesthesiology, University of Michigan Health System, 1G323 University Hospital, Box 0048, 1500 E. Medical Center Dr., Ann Arbor, MI 48109-0048. Address e-mail to psujit@umich.edu.
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This article has been cited by other articles:
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  R. E. Wachtel and F. Dexter A Simple Method for Deciding When Patients Should Be Ready on the Day of Surgery Without Procedure-Specific Data Anesth. Analg., July 1, 2007; 105(1): 127 - 140. [Abstract] [Full Text] [PDF]
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M. B. Sosis, S. K. Pandit, K. W. Loberg, and U. A. Pandit Coffee Is Not a Clear Liquid Response Anesth. Analg., October 1, 2000; 91(5): 1308 - 1309. [Full Text] [PDF]
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