PREAMBLE
Preoperative fasting involves being nil by mouth before surgical procedures requiring
sedation or anaesthesia.[1] In the postoperative period, complete avoidance of oral
dietary intake is practiced, till recovery of bowel function for abdominal surgeries.[2]
Impairment or abolition of airway reflexes following deep sedation or anaesthesia
can lead to pulmonary aspiration of gastric contents.[3] The ideal condition for minimising
the risk of regurgitation and aspiration is an empty stomach before deep sedation
or anaesthesia, which may be impossible to achieve due to the continuous gastric secretory
activity along with impaired physiology due to various aetiologies encountered in
the preoperative period.
Traditional cut off points of gastric aspirate volumes of >25 mL with pH <2.5 have
long been quoted to correlate with significant pulmonary aspiration leading to respiratory
failure.[4
5] This critical pH and volume was obtained by Roberts and Shirley on a Rhesus monkey
and were extrapolated to humans.[6] Although pH and gastric volume have been traditionally
measured using aspiration techniques, the modern research modalities utilising pharmacokinetic
properties of orally administered water-soluble substances such as paracetamol, magnetic
resonance imaging (MRI) and scintigraphy have provided better insights into the physiology
of gastric emptying. Newer modalities such as gastric ultrasonography (GUS) have been
increasingly used to study the gastric volumes and emptying.
What is the need for the Indian Society of Anaesthesiologists (ISA) guidelines?
A large number of surgical procedures are conducted daily in India, with diverse health
care settings and differing practice standards. The patient population varies in terms
of food items consumed, with a variable fat content, caloric content and nutrient
composition in different regions and states. The socio-cultural, geographic and economic
factors also play a role in the food habits.
The overall culture and eating habits of the population is largely similar in countries
of South Asia that includes India, Bhutan, Nepal, Bangladesh, Sri Lanka, Maldives,
Afghanistan and Pakistan, but the available guidelines do not apply uniformly across
these countries and very few evidences address the problems peculiar to this region.
These issues have been taken into consideration during the formulation of 'Practice
guidelines on perioperative fasting and feeding' by the ISA.
This document emphasises the concerns related to the safe duration of fasting before
and after administration of sedation or anaesthesia for elective, diagnostic or surgical
procedures. It addresses the type and quantity of solid and liquid food that can be
ingested safely till the fasting is initiated and the feeding is restarted in the
postoperative period. It covers the general surgical population, and those undergoing
paediatric, obstetric and bariatric procedures. The guidelines are not applicable
for subset of patients who have medical or surgical conditions which predispose them
to aspiration.
These guidelines are developed based on the current evidence available worldwide and
in India as also on the basis of institutional practice patterns across India, gathered
from the countrywide survey conducted by the ISA. The guidelines are designed to steer
the practice of anaesthesiology based on evidence, and cannot be taken as absolute
or standard answers for specific research questions. The recommendations will be updated
as and when additional evidence emerges in future.
Focus of the guidelines
These clinical practice guidelines provide recommendations for withholding solid and
liquid food before elective diagnostic or surgical procedures performed under deep
sedation or anaesthesia (regional or general) and for resumption of oral feeds in
the post procedure period. They are aimed to reduce the incidence and severity of
aspiration pneumonitis and other complications (such as hypotension during induction
of anaesthesia), to prevent delays or cancellations of surgical procedures and also
lead to a better patient outcome. The guidelines are addressed to practicing anaesthesiologists,
surgeons, other medical and paramedical professionals involved in patient care.
It may also be useful for patients to know the types of food that are considered as
clear liquids, non-clear liquids, light meal and heavy meal and to guide them in consumption
of food items before presenting for elective diagnostic or surgical procedures. It
will identify the shortcomings in the evidence specific to South Asian countries,
and allow for the formation of institutional protocols and stimulate research among
the colleagues so that evidence is added for the future.
METHODOLOGY
The ISA approved the proposal for preparation of the practice guidelines on perioperative
fasting and feeding during the annual general body meeting of ISA in November 2017.
The core committee consisted of the President and Secretary of ISA and six members.
The expert committee consisted of 12 members, with academic standing and experience
in the field of anaesthesiology and respective subspecialties from different institutions
of India, along with two expert biostatisticians and one nutrition expert.
The core committee held meetings within the group (3 in-person and 25 online) and
with members of the expert committee (2 in-person and 12 online) to discuss the research
questions and the evidence available. The core committee formulated and circulated
a validated survey questionnaire[7] for each section to institutions across India,
to collect additional data regarding institutional fasting and feeding practices from
those geographical regions. Surveys pertaining to paediatric, obstetric and bariatric
patients were circulated to institutions offering services specifically to such groups.
The evidence obtained from the expert committee members and the results from the survey
were combined to formulate the draft guideline document. The same was presented at
the annual conference of ISA (ISACON) in November 2019 in a special session involving
the core committee, expert committee, delegates and ISA governing council members.
The updated draft was presented to and approved by the general body of ISA.
Electronic search for full text articles published in English language before January
2020 was conducted, using keywords based on the research questions, in PubMed, Embase,
Cochrane Library and Google Scholar databases: meta analyses, systematic reviews,
randomised controlled trials (RCTs), observational studies, cohort studies, case series
and case reports were included. Manual retrieval of the missing manuscripts from the
bibliography of the published articles and guidelines was done. Narrative reviews,
editorials and letters to editors or correspondence and other similar items including
only abstracts were excluded.
Standard data extraction techniques from retrieved manuscripts were followed for subsequent
meta-analysis. Research questions answered by at least 3 RCTs or observational studies
fulfilling the Population; Intervention; Comparator; Outcome and Time frame (PICOT)
criteria were included for meta-analysis. Additional data were collected for institutional
fasting practices for adult population (from 56 institutions), for obstetric population
(from 21 institutions), for paediatric population (from 13 institutions) and for bariatric
population (from 18 institutions) from India, based on surveys using validated questionnaires.[7]
If meta-analysis was not possible for a research question, expert consensus was obtained
based on the outcomes of available studies and the survey findings to arrive at a
recommendation.
The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach
was used to allot the 'Level of Evidence' (LOE) of the literature included. The GRADE
protocol categorises evidence into 'High, Moderate, Low and Very Low'. Based on these
levels of evidence, recommendations were framed and graded as either weak or strong.[8]
For the purpose of these guidelines, preoperative fasting is defined as the minimum
required fasting duration for oral intake of solids or liquids prior to administration
of anaesthesia or sedation necessary to minimise the risk of regurgitation and pulmonary
aspiration in patients devoid of risk factors for regurgitation.
An empty stomach is a state when the gastric contents reach the baseline volume after
the intake of a solid, semi solid or liquid meal. Baseline volume is defined as the
volume of gastric contents of an adult after overnight fasting.
Residual Gastric volume is the volume of gastric contents at the time of examination
or evaluation.
A full stomach is the presence of solid content or a state of increased volume of
the liquid gastric contents above the baseline volumes after the intake of a solid,
semisolid or liquid meal.
Clear liquid is defined as any liquid which takes <2 h to empty from the stomach in
human beings.
Non-clear liquid is defined as any liquid which takes between 2 h and 4 h to empty
from the stomach in human beings.
Light meal is defined as any food item which takes between 4h to 6h to empty from
the stomach in human beings.
Heavy meal is defined as any food item which takes >6 h to empty from the stomach
in human beings.
The summary of recommendations is represented as a table [Table 1].
Table 1
Summary of recommendations
Sl No.
Recommendations
Level of recommendation (GRADE)
Adult Section
1
Clear liquids should be allowed up to 2 h prior to administration of sedation or anaesthesia.
Strong
2
The volume of clear liquid consumed may be restricted to <450 mL, 2 h prior to administration
of sedation or anaesthesia.
Weak
3
Non-clear liquids may be allowed up to 4 h prior to administration of sedation or
anaesthesia.
Weak
4
Light meals may be allowed up to 6 h prior to administration of sedation or anaesthesia.
Weak
5
If the patient has consumed heavy meals, it may be prudent to wait for at least 10
h prior to administration of sedation or anaesthesia.
Weak
6
Heavy meal consumption is not advisable the night prior to surgery.
Strong
7
Routine use of aspiration prophylaxis in adequately fasted patients is not advised
prior to administration of sedation or anaesthesia.
Strong
8
Aspiration prophylaxis is advised in high-risk patients as identified by the anaesthesiologist.
Weak
9
H2 receptor blockers, proton pump inhibitors and prokinetic drugs may be used as prophylaxis
in high-risk patients.
Weak
Obstetric Section
1
Women in early or late pregnancy when administered sedation or anaesthesia may be
considered to be at highrisk for aspiration.
Weak
2
Clear liquids may be allowed up to 2 h prior to administration of sedation or anaesthesia
in pregnant women.
Weak
3
Non-clear liquids may be allowed up to 4 h prior to administration of sedation or
anaesthesia in pregnant women.
Weak
4
Light meals may be allowed up to 6 h prior to administration of sedation or anaesthesia
in pregnant women.
Weak
5
If the pregnant woman has consumed a heavy meal, it may be prudent to wait for at
least 10 h prior to administration of sedation or anaesthesia.
Weak
6
Heavy meal consumption is not advisable the night prior to surgery in pregnant women.
Strong
7
Pregnant women requiring sedation or anaesthesia should be administered aspiration
prophylaxis.
Strong
8
H2 receptor blockers, proton pump inhibitors either alone or in combination with prokinetic
drugs can be administered for aspiration prophylaxis.
Weak
9
Clear liquids can be allowed orally 8 h after caesarean section under regional/ general
anaesthesia.
Strong
Paediatric Section
1
Consumption of water, up to 3mL/kg should be allowed until 1 h prior to administration
of anaesthesia. Consumption of water, up to 3 mL/kg should be allowed until 1 h prior
to administration of anaesthesia.
Strong
2
Consumption of clear liquids other than water, up to 3 mL/kg can be allowed until
2 h prior to administration of anaesthesia.
Weak
3
Human milk and fully skimmed non-human milk can be allowed until 4 h prior to administration
of anaesthesia.
Weak
4
Non-clear liquids, non-human milk, formula feeds, light breakfast or light meal may
be allowed until 6 h prior to administration of anaesthesia.
Weak
5
The attending anaesthesiologist can decide for or against the administration of aspiration
prophylaxis in adequately fasted children.
Weak
6
The attending anaesthesiologist can decide on the duration of fasting for procedural
sedation within operating room or at remote location.
Weak
7
The oral consumption of clear liquids in the postoperative period should be resumed
at the earliest where no medical or surgical contraindications exist.
Strong
Bariatric Section
1
Obese individuals may be considered to be at higher risk for aspirationin comparison
to non-obese individuals when administered sedation/ general anaesthesia.
Weak
2
In obese individuals, the advice on preoperative fasting practices may be the same
as in non-obese individuals prior to the administration of sedation or anaesthesia.
Weak
3
Aspiration prophylaxis may be administered in obese patients prior to the administration
of sedation or anaesthesia.
Weak
4
H2 receptor blockers, proton pump inhibitors either alone or in combination with prokinetic
drugs can be administered for aspiration prophylaxis.
Weak
Gastric Ultrasonography Section
1
Gastric ultrasonography may be used as a bedside tool for assessing the quality and
quantity of gastric contents in the preoperative period.
Weak
2
The quality and quantity of gastric contents should be assessed in the right lateral
decubitus position.
Strong
ADULT SECTION
What is the acceptable residual gastric volume?
Roberts et al. found that instillation of 25 mL of gastric aspirate into the right
bronchus of rhesus monkey produced significant aspiration pneumonitis. Extrapolating
this finding to humans, they stated that aspiration of 25 mL would produce pneumonitis
and postulated that residual gastric volume of more than 25 mL posed a high risk for
aspiration pneumonitis.[6] Many studies tried defining the residual gastric volume,
based on values obtained by actual aspiration (during endoscopy or by gastric tube)
and by imaging techniques. More recent studies have used GUS to quantify the residual
gastric volumes after fasting. The stratifications related to duration of fasting,
definition of residual gastric volume and its assessment methods in existing studies
have been inconsistent, limiting the attempts for formulation of acceptable definitions
for clinical practice.
Perlas et al. in a prospective descriptive study using GUS found that 86 of the 200
patients fasted for 8 h for solids and 5 h for liquids had no or minimal residual
gastric volume, while seven patients had a high residual gastric volume of 180 ± 83
mL. One among these with gastro-oesophageal reflux disease aspirated the gastric contents
during extubation.[9] Van de Putte et al. performed a retrospective analysis of 512
patients and classified patients as 'empty stomach' (no contents or liquid content
<1.5 mL/kg) or 'full stomach' (liquid content >1.5 mL/kg or presence of solid content)
based on GUS; they found that despite adhering to the American Society of Anesthesiologists'
fasting guidelines, 32 patients had full stomach by this criteria. The mean fasting
duration in these patients was 10.8 h and 13.9 h for liquids and solids, respectively.
Eight patients had consumed heavy meals out of the nine patients who had solid content
while one each of them had gastro-oesophageal reflux disease and Parkinson's disease.[10]
Four studies involving pregnant women found residual gastric volumes to be higher
than 25 mL.[11
12
13
14]
Based on the current evidence, the traditional cutoff point of more than 25 mL residual
gastric volume as a risk factor for aspiration pneumonitis may need to be re-examined
in adults.
Adequate fasting times – When is the stomach empty?
Twenty one studies describing gastric emptying times of various kinds of foods were
identified.[15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35] Of these, 14 were RCTs and 7 were observational studies. These studies used various
methods of gastric emptying estimation such as the 'gold standard' scintigraphy, MRI,
GUS and carbon dioxide breath analysis. Most studies were performed on healthy volunteers
involving small sample sizes. Six studies each were performed on gastric emptying
of liquids of varying composition, solids of varying content, and combination of solid
with liquid or meals, respectively while one study each consisted of semisolids and
comparison of solids versus liquids, respectively. These studies showed significant
variations in gastric emptying. A study in the Indian setting published in 1999 concluded
that addition of spice (masala) to idli reduced the gastric emptying time.[34]
The inferences drawn from these studies are as follows:
The gastric emptying time is different for liquids, solids and semisolids. For solids
it depended on the method of cooking, particle size and composition
Clear liquids of low caloric value take approximately 2 h to empty
Liquids with high caloric value and non-clear liquids may take longer than 2 h to
empty
Combinations of solids and liquids take anywhere between 4 and 7 h to empty
Fried food items of similar composition take longer time to empty
Scintigraphy cannot be used to estimate the residual gastric volume
GUS estimation of residual gastric volume is computed by mathematical models based
on the cross-sectional area of the gastric antrum, where return to baseline values
is considered as gastric emptying time.
The categorisation of food items by the survey into heavy meals, light meals and clear
liquids was reviewed by an experienced dietician after referring to the available
evidence [Appendix 1–Appendix 3].[20
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64] The classification was revised by the dietician based on the duration of emptying
of the stomach contents as clear liquids, non-clear liquids, light meal and heavy
meal [Table 2].
Table 2
Classification of food items into clear liquids, non-clear liquids, light meal, heavy
meal
Type of food
Name of the food
Approximate time of gastric emptying
Clear Liquids (Juices without pulp)
Coconut water (400 ml), Black tea (200 ml), Black coffee (200 ml), 25% dextrose, Watermelon
juice, Pineapple juice, Apple juice, Sandalwood sharbat, Rooh afzha, Khus sharbat,
Aerated cold drink, Tetra pack juice, Rice ganji (also called kanji or congee, strained),
Clear soup broths, Dal water, Green tea, Maltodextrin preparations
<2 h
Non-Clear Liquids
Rava porridge (200 ml), Ragi malt (200 ml), Sattu drink (200 ml), Milk (200ml), Buttermilk
(300 ml), Milk shake (200 ml), Fruit yoghurt (150 ml), Cold coffee (200 ml), Tea (200
ml), Filter coffee (200 ml), Smoothie (200 ml)
2- 4h
Light Meal
Bread slice (1 no.), Cream of soups, Curd rice (150 g), Dal rice (150 g),Poha (100
g), Phulka with vegetable (1 with 4 spoons of vegetable), Curd (200 ml), Milk shake
with fruit (200 ml), Milk and corn flakes (1 cup), Idli with sambhar (1 no.), Poha
/ Avalakki soaked in water and eaten (30 g), Puffed rice (150 g), Marie biscuits (4
no.) with milk 150 mL, Glucose biscuit (4 no.) with milk 150 mL.
4- 6 h
Heavy Meal
Thali (chapathi+ rice+ dal + veg + curd), Noodles with curry (250 gms), Pongal with
curd (2 bowls), Khichdi with curd and papad (2 bowls), Pessarattu/Dosa with chutney
and sambhar (3 in no.), Thali Rice+ poriyal+sambhar+curd +pickle, Parantha (stuffed)with
dahi and pickle (2 no.), Chicken curry and rice (1 bowl), Kebabs with chutney and
french fries (4 in no.), Pizza (2 triangles) with coke, Burger (veg/non-veg) 1 no.
> 6 h
Note: 1. All volumes mentioned in brackets are with respect to adult patients only.
2. Volumes of clear liquid are taken as <450 mL unless specifically mentioned
Clear liquid 2 h before induction of anaesthesia vs overnight fasting
The stomach always has a basal volume due to continuous gastric secretions. The duration
of fasting is considered acceptable if the post prandial gastric volume returns to
basal levels. The 20 studies identified by our search regarding clear liquids intake
and gastric volumes did not report any event of aspiration or regurgitation.[65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84] The studies were of Low, or Very Low level of evidence. In eight studies, after
overnight fasting, one group received water to consume medications and the other,
received between 100 and 500 mL water till 2 hours before induction of anaesthesia.[65
66
67
68
69
70
71
72]
Residual gastric volume considerations
The meta-analysis of three studies conducted using studies published between1988 and
2016, comparing consumption of water 2 h prior to induction of anaesthesia and overnight
fasting found that the groups who had consumed water 2 h prior had comparable residual
gastric volumes with a mean difference of 0.76 mL and 95% CI 0.60 to 1.02 (LOE- Moderate).[64
65
66]
Studies comparing consumption of other clear liquids such as orange juice, black coffee
with overnight fasting were analysed separately (LOE- Very Low to Low). The meta-analysis
of six such studies published between 1988 to 2016 showed that the residual gastric
volumes were comparable between the two groups of patients with a mean difference
of 1.04 mL and 95% CI of 0.90 mL to 1.2 mL) (LOE- Moderate).[68
69
70
71
72
73]
pH considerations
The meta-analysis of 4 studies conducted between 1988 to 2016 showed a lower gastric
pH in patients fasted overnight compared to those allowed water 2 h before the induction
of anaesthesia with a mean difference of 1.0 and 95% CI of 1.07 (LOE- Moderate).[65
66
67
73] The meta-analysis of 5 studies found higher gastric pH after administration of
clear liquids other than water 2 h before the induction of anaesthesia compared to
overnight fasting with a mean difference of 1.08 and 95% CI of 0.98 to 1.19, while
network meta-analysis showed the pH to be higher in groups allowed to consume clear
liquids when compared to water (LOE-Moderate).[67
68
69
70
71]
Residual gastric volumes and pH considerations from other studies
Scarr et al. conducted an observational study in patients scheduled for ambulatory
surgeries and classified 181 patients into 4 groups based on the duration of fasting
(<3h, 3-4.9 h, 5-8 h and >8 h) and found similar gastric volumes and pH in all the
groups. The participants in the study were asked not to consume solid food from midnight
and were asked to consume 150 mL liquid (coffee, tea, water or apple juice) 1 h before
leaving home (LOE- Very Low).[74]
A study using Technetium99 to assess the emptying of clear liquids showed that the
patients receiving carbohydrate containing solutions had gastric volumes comparable
with patients receiving water at 90 min and at 120 min (LOE- Very Low).[75] Other
studies which compared residual gastric volumes and pH after consumption of different
kinds of liquids showed comparable gastric volumes and pH (LOE- Very Low to Low).[76
77
78
79
80
81
82] In a study assessing gastric volumes by gastroscopic aspiration after consumption
of 200 mL water, the patients fasted for 40 to 75 min had gastric volumes similar
to those fasted for 80-150 min (LOE- Moderate).[83] An earlier meta-analysis also
concluded that there was no evidence that patients given liquid (including water,
coffee, fruit juice, clear liquids and other drinks, e.g., isotonic drink, carbohydrate
drink) 2-3 h prior to surgery had increased incidence of aspiration or regurgitation
(LOE- High).[3] Newer commercially available carbohydrate containing clear liquids
such as maltodextrin preparation (a polysaccharide), have been used as a part of the
enhanced recovery after surgery (ERAS) protocol; the residual gastric volumes and
gastric content pH have been found to be comparable to those after over-night fasting
(LOE- Very Low).[77] Gomes et al. compared the residual gastric volumes using gastric
ultrasonography after administration of 12.5% maltodextrin and a combination of 12.5%
maltodextrin and glutamine. They found that the addition of glutamine did not increase
the residual gastric volume 2 h after administration in healthy volunteers (LOE- Very
Low).[84]
Volume of clear liquids allowed
An RCT by Soreide et al. found comparable gastric volumes after administration of
20 mL, 150 mL and 300-450 mL of water 1-2 h before surgery (LOE- Very Low).[85] Similarly,
comparable residual gastric volumes were found between overnight fasting patients
and those receiving 100–500 mL clear liquids 2 h before surgery in other studies conducted
in patients scheduled for elective surgical procedures (LOE-Very Low to Low).[65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84]
Survey findings
The average fasting times for solids, liquids and clear liquids as per the survey
respondents from 56 institutions were 7.43 ± 1.65 h, 5.68 ± 1.90 h and 3.16 ± 2.33
h, respectively.
Recommendations
Clear liquids should be allowed up to 2 h prior to administration of sedation or anaesthesia.
The volume of clear liquid consumed may be restricted to < 450 mL, 2 h prior to administration
of sedation or anaesthesia.
Non-clear liquids may be allowed up to 4 h prior to administration of sedation or
anaesthesia.
Light meals may be allowed up to 6 h prior to administration of sedation or anaesthesia.
If the patient has consumed heavy meals, it may be prudent to wait for at least 10
h prior to administration of sedation or anaesthesia.
Heavy meal consumption is not advisable the night prior to surgery.
Aspiration prophylaxis
Various drugs have been used with the purpose of either increasing the pH, decreasing
the volume of gastric contents or both and the studies on these drugs have measured
residual gastric volumes by using aspiration from gastric tubes. The commonest drugs
that have been used are H2receptor blockers, proton pump inhibitors, non-particulate
antacids such as sodium citrate and prokinetic drugs like metoclopramide. This section
examines if the routine use of aspiration prophylaxis will benefit the patient.
Residual gastric volume considerations
H2receptor blockers
The meta-analysis of 3 studies showed no decrease in the residual gastric volume with
the administration of oral H2receptor blockers (cimetidine and ranitidine) compared
to placebo with a mean difference of 1.51mL and a 95% CI of 1.02 to 2.23 (LOE- Moderate).[86
87
88] A small sample study by Salempara et al. showed a significant decrease in the
residual gastric volume after administration of oral cimetidine either 300 mg or 600
mg 2 h before surgery (LOE- Very Low).[89] Morison et al. conducted a study involving
an intravenous phase and oral phase. There was no difference in the residual gastric
volume in the intravenous phase but in the oral phase, lower residual gastric volumes
were observed when ranitidine was administered 2 h before the surgery (LOE- Very Low).[90]
Similar results were found by Maile et al. with intravenous administration of ranitidine
1–2 h before surgery.[91] Three studies found patients with gastric volumes more than
25 mL even after administration of oral H2receptor blockers (LOE- Very Low).[92
93
94] Similar studies conducted with different dosage regimens of H2receptor blockers,
timing and routes of administration have yielded conflicting results.[95
96
97
98
99
100] Overall, the evidence does not point to uniform observations of reduction in
the residual gastric volume after administration of H2 receptor blockers.
Proton pump inhibitors
The meta-analysis of 3 studies comparing residual gastric volumes after administration
of proton pump inhibitors and placebo yielded a mean difference of 3.31 mL with a
95% CI of +2.34 to 4.68 (LOE- Moderate).[101
102
103] Mehta et al. conducted a study comparing three different proton pump inhibitors
and found that the residual gastric volumes were comparable among them (LOE- Very
Low).[104]
H2receptor blockers vs proton pump inhibitors
The meta-analysis of 4 studies comparing residual gastric volumes after the administration
of either drug showed a mean difference of 1.68 mL and a 95% CI of 1.44 to 1.95 (LOE-
Moderate).[105
106
107
108] Nishina et al. conducted two studies in 1996 and 2000 comparing different proton
pump inhibitors and ranitidine and found least residual gastric volumes (per kg body
weight) when ranitidine was administered as a single dose on the morning of surgery
(LOE- Very Low).[109
110] Levack et al. achieved a gastric volume of <25 ml and pH >2.5, in 84% of patients
receiving either ranitidine or omeprazole, when administered the night before and
early morning of surgery and 73% of patients who received a single equivalent dose
of omeprazole on the morning of surgery (LOE- Low).[111] Dattatraya et al. conducted
a similar study and none of the (n = 50 in each group) patients receiving either ranitidine
or proton pump inhibitors (omeprazole, esomeprazole, pantoprazole) had residual gastric
volume >25 mL in both the H2receptor blocker and the proton pump inhibitor groups
(LOE- Very Low).[112]
Two meta-analyses concluded that H2receptor blockers were better than proton pump
inhibitors to reduce the gastric volume.[113
114] Puig et al. in a meta-analysis including 18 publications with different schedules
of administration and routes of administration, found that patients receiving H2receptor
blockers were at lower risk of aspiration (as per criteria laid down by Shirley and
Roberts) (LOE- High).[113]) Clark et al. in another meta-analysis including 7 RCT's
found that the gastric volumes were lower and gastric content pH was higher in groups
who received H2receptor blockers (LOE- High).[114]
H2receptor blockers, Proton pump inhibitors and prokinetic drugs
The meta-analysis of 3 studies showed no significant difference in residual gastric
volumes between the placebo group and those who received H2receptor blocker with prokinetic
drugs with a mean difference of 2.15 mL and 95% CI of 1.63 to 2.97 (LOE- Moderate).[115
116
117] Manchikanti et al. conducted two studies which showed that there was a significant
reduction in the residual gastric volume after administration of H2receptor blocker
with prokinetic drugs in comparison to either of the drugs administered alone (LOE-Very
Low).[118
119] Dimich et al. conducted a study in patients coming for ambulatory surgeries and
found that there were significantly higher residual gastric volumes in patients who
received H2receptor blockers compared to those who received H2receptor blockers with
prokinetic drugs (LOE- Low).[120] Gombar et al. in a study on 80 patients coming for
surgery, found reduced gastric residual volumes on administration of a combination
of proton pump inhibitors and prokinetic drugs when compared to H2receptor blockers
and proton pump inhibitors administered alone (LOE- Very Low).[121]
Non-particulate antacids and H2receptor blockers
Six studies showed that the gastric volumes were higher when non-particulate antacids
(sodium citrate) were administered when compared with controls or H2receptor blockers
(LOE- Very Low to Low).[122
123
124
125
126
127]
Anticholinergic drugs
Anticholinergics are the other group of drugs postulated to reduce the residual gastric
volume by decreasing the gastric secretion. Three studies using atropine or glycopyrrolate
administered alone did not show much difference in the residual gastric volumes (LOE-Very
Low to Low).[128
129
130]
pH considerations
H2receptor blockers
The meta-analysis of three studies (with oral cimetidine and ranitidine) showed that
the pH was slightly higher in patients receiving H2receptor blockers compared to placebo
with a mean difference of 0.41 with 95% CI of 0.33 to 0.50 (LOE- Moderate).[86
87
88] Other studies which compared H2receptor blockers in varying doses or dosage regimen
found similar increase in the pH of residual gastric contents (LOE- Very Low to Low).[89
90
91
92
93
94
95
97
98
99
100]
Proton pump inhibitors
The meta-analysis of 3 studies showed an increased gastric pH in patients receiving
proton pump inhibitors with a mean difference of 0.94 and a 95% CI of 0.11 to 1.77
(LOE- Moderate).[101
102
103] Mehta et al. compared three proton pump inhibitors and found a raised gastric
pH with all three groups (LOE- Very Low).[104]
H2receptor blockers vs proton pump inhibitors
The meta-analysis of 4 studies showed the pH of gastric contents to be higher with
proton pump inhibitors with a mean difference of 0.6 and a 95% CI of -0.08 to +1.28
(LOE- High).[105
106
107
108] The studies involving more than two groups (comparing different drugs or dosages
or dosage regimen) also showed similar results (LOE- Very Low to Low).[109
110
111
112
113
114
131]
Prokinetic drugs
Seven studies showed that prokinetic drugs when used alone did not have any effect
on the pH of gastric contents (LOE- Very Low to Low).[115
116
117
118
119
120
121]
Non-particulate antacids and H2receptor blockers
The gastric pH was raised in all patients receiving non-particulate antacids and was
comparable to H2receptor blockers.(LOE- Very Low to Low)[122
123
124
125
126
127
132] Foulkes et al. compared gastric content pH after administering no drug, oral
cimetidine 300 mg and 0.3 M sodium citrate 30 mL (n = 15 in each group) and found
that all patients had a pH of more than 2.5 after receiving sodium citrate (LOE- Very
Low to Low).[124]
Anticholinergic drugs
Use of anticholinergics was not found to cause any significant change in the pH of
gastric contents (LOE- Very Low).[128
129
130]
Survey findings
Most of the respondent institutions advised aspiration prophylaxis for all patients
scheduled for surgery (44.64%). Further, 42.86% of institutions advised aspiration
prophylaxis for at risk patients and 10.71%, for emergencies only. The remaining 1.79%
of institutions did not use any prophylaxis. Seventy one percent of the respondents
used H2receptor blockers as aspiration 18 prophylaxis, 70% prokinetic drugs, 57% proton
pump inhibitors, 54% 5HT3 receptor antagonist, 9% sodium citrate (0.3 M) and 5% used
others. Those who chose the option 'others' mentioned dexamethasone, additional prokinetic
drugs and multiple drugs.
Recommendations
Routine use of aspiration prophylaxis in adequately fasted patients is not advised
prior to administration of sedation or anaesthesia.
Aspiration prophylaxis is advised in high-risk patients as identified by the anaesthesiologist.
H2receptor blockers, proton pump inhibitors and prokinetic drugs may be used as prophylaxis
in high-risk patients.
Postoperative oral feeding in Adult patients
The research into the postoperative feeding in general adult surgical population revealed
association of multiple factors (LOE- Very Low).[133] The wide variability in the
surgical procedures performed and the techniques involved influences the decision
on resumption of postoperative feeding. Systematic reviews and meta-analysis have
been performed for specific surgeries like colorectal surgeries or lower abdominal
surgeries.[134
135]
Survey findings
The respondents felt that the mean time for allowing clear liquids postoperatively
was 4.0 ± 2.3 h and for solids was 8.6 ± 7.0 h.
In view of lack of quality evidence and variability in the time of resumption of oral
feed as per our survey no recommendations can be made in the general adult surgical
population.
Miscellaneous
Chewing gum, alcohol consumption and smoking have been explored with regards to their
effect on gastric emptying and residual gastric volume in the perioperative fasting
period. A meta-analysis of 4 studies, RCTs and observational studies showed that there
is no difference in the residual gastric volume or gastric emptying whether patients
had chewed gum or not in the preoperative period (LOE- Very Low to Low).[136
137
138
139
140] However, in an analysis of incidents in the webAIRs Australian incident reporting
system, chewing gum was found in the mouth of 5 patients during induction of anaesthesia.
It may be important to ensure that patients spit out chewing gum before the administration
of anaesthesia or sedation (LOE- Low).[141] Chewing gum in the postoperative period
is not common practice in India. A Cochrane review and 1 other meta-analysis have
found early return of bowel function with chewing gum in the postoperative period
(LOE- Low).[142
143] Another meta-analysis of 12 studies and other RCTs have found the results to
be equivocal (LOE- Low to Moderate).[144
145
146
147]
Studies conducted on the effect of alcohol (6% vs 10%, 3 units vs 6 units, beer, wine,
50% ethanol) on gastric emptying have been equivocal. Studies on varying concentrations
of alcohol have found that overall alcohol consumption may delay the gastric emptying
of solid food (LOE- Very Low to Low).[148
149
150
151]
Effect of smoking, chewing nicotine gum and nicotine patch on gastric emptying and
residual gastric volume have been studied. Acute cigarette smoking has been found
to delay the gastric emptying of solid and liquid food (LOE- Low).[152
153] However, a study on the effect of nicotine patch on the gastric emptying of solids
and liquids did not find any delay (LOE- Very Low).[154] A study using ultrasonography
did not find any difference in the residual gastric volumes after acute cigarette
smoking (LOE- Very Low).[155]
OBSTETRIC SECTION
Is the incidence of aspiration higher in pregnant women scheduled for elective procedures?
Studies performed in various settings (patients scheduled for cervical encirclage,
caesarean sections, manual removal of placenta, medical termination of pregnancy,
under general anaesthesia) were included. The level of evidence of most of these studies
was low. The meta-analysis of 5 studies yielded a combined incidence of aspiration
of 29/1,00,000 (95% CI was 7/1,00,000 to 120/1,00,000) (LOE- High).[156
157
158
159
160] In a case series published by Dureja et al., two cases of aspiration were identified.
Of these two one was in a patient who had presented to the emergency with history
of trauma and bleeding per vagina. Pulmonary aspiration was suspected when intra-operatively
the patient developed increased resistance to ventilation under general anaesthesia
(LOE- Very Low).[161]
Survey findings
The responses from 21 institutions, dedicated to obstetric anaesthesia services showed
that only 42.7% institutions considered pregnant women to be at higher risk for aspiration
in the perioperative period.
Recommendations
Women in early or late pregnancy when administered sedation or general anaesthesia
may be considered to be at high risk for aspiration.
Appropriate fasting times in pregnant women.
Seven comparative trials[162
163
164
165
166
167
168] related to gastric emptying and 2 RCT's[169
170] related to residual gastric volume or comparison of gastric antral areas in pregnant
women were accessed. The methods of assessment of gastric emptying included phenol
red dye method, potential tomography, GUS and breath analysis after lactulose and
paracetamol absorption. The studies used varying quantities of meal; most of the studies
were done with clear liquids and some with light meal consumption. The meta-analysis
of 5 studies estimating gastric emptying of liquids in pregnant women compared to
non-pregnant women showed that liquids took longer time to empty from the stomach
in non-pregnant women with a mean difference of 2.06 min and 95% CI of -1.28 to +5.40
(LOE- High).[162
163
164
165
166] Wald et al. found prolonged oro-caecal transit times in pregnant patients (LOE-
Very Low).[167] Cholioro et al. found prolonged half emptying times for liquids in
first trimester and term pregnancy compared to 4–6 months after delivery (LOE- Very
Low).[168] Wong et al. conducted two studies in 2002 and 2007, both comparing consumption
of 300 mL and 50 mL water with pregnant women in one study and obese pregnant women
in another. They found reduced half times with consumption of 300 mL water in both
studies (LOE- Low).[169
170] Three observational studies based on ultrasonographic estimation of the cross-sectional
area found comparable outcomes between pregnant women scheduled for caesarean section
and non-pregnant women (LOE- Low to Moderate).[11
13
14]
One observational study showed a residual gastric volume >1.5 mL/kg in 23–52% pregnant
women with more than 36 weeks of gestation. (LOE- Very Low).[12] There were no studies
comparing the gastric emptying of solid food.
Hong et al. in a randomised control trial including 200 patients compared the residual
gastric volume and pH between term pregnant women coming for Caesarean sections and
women coming for gynaecological surgeries and found that the mean gastric volume was
higher (0.49 ± 0.4 mL/kg vs 0.24 ± 0.2 mL/kg ) and mean gastric content pH was lower
(2.4 ± 1.4 vs 3.0 ± 1.9 ) in pregnant women in comparison to non- pregnant women (LOE-
Low).[171]
Survey findings
The participant obstetric anaesthesia units across India advocate similar fasting
times for both pregnant and non-pregnant women.
Thus, in pregnant women, the duration of preoperative fasting for different kinds
of foods is the same as in non-pregnant women
Recommendations
Clear liquids may be allowed up to 2 h prior to administration of sedation or anaesthesia
in pregnant women.
Non-clear liquids may be allowed up to 4 h prior to administration of sedation or
anaesthesia in pregnant women.
Light meals may be allowed up to 6 h prior to administration of sedation or anaesthesia
in pregnant women.
If the pregnant woman has consumed a heavy meal, it may be prudent to wait for at
least 10 h prior to administration of sedation or anaesthesia.
Heavy meal consumption is not advisable the night prior to surgery in pregnant women.
Routine aspiration prophylaxis in pregnant women
Residual gastric volume considerations
We identified 12 comparative trials (including one from India),[172
173
174
175
176
177
178
179
180
181
182
183]2 systematic reviews[184
185] and 3 surveys[186
187
188] on aspiration prophylaxis in obstetric units. The studies had low level of evidence
due to small sample sizes and varied drugs employed for prophylaxis. The studies examined
usage of sodium citrate, H2receptor blockers, prokinetic drugs and proton pump inhibitors
alone or in combinations. Qvist et al. found that the administration of H2receptor
blocker in pregnant women resulted in a marginal decrease in the residual gastric
volume compared to those who did not receive the drug (LOE- Very Low).[172] Dewan
et al. compared sodium citrate administered <60 min before versus >60 min before induction
of anaesthesia and they found that patients administered sodium citrate >60 min before
induction had a lower gastric content pH. The residual gastric volumes were comparable
between the groups (LOE- Low).[173] Sullivan et al. found that the residual gastric
volume was reduced in pregnant women receiving ranitidine and metoclopramide compared
to those receiving ranitidine, metoclopramide or magnesium trisilicate alone (LOE-
Very Low).[174] Studies comparing the use of sodium citrate and H2receptor blockers,
particulate antacids and use in elective vs emergency surgeries, have found that they
increased the pH of gastric content but the residual gastric volumes are also increased
(LOE-Very Low to Low).[175
176
177
178
179
180] Studies comparing the effect of proton pump inhibitors and H2receptor blockers
on residual gastric volume found that the volumes were lower when H2receptor blockers
and proton pump inhibitors were administered the night before and morning of surgery
than when administered only on the morning of surgery (LOE- Very Low to Low).[181
182
183]
pH considerations
Different methods of assessment of pH in pregnant patients were used in the studies
included in our search. Among the drugs, sodium citrate, particulate antacids, H2receptor
blockers and proton pump inhibitors were found to raise the pH of gastric contents.
Addition of metoclopramide to ranitidine had no effect on the pH. The pH levels were
comparable when H2receptor blockers or proton pump inhibitors were used. (LOE-Very
Low to Low).[172
173
174
175
176
177
178
179
180
181
182
183]
Two systematic reviews[184
185](LOE- Moderate) found no benefit of routine prophylaxis with any of these drugs.
But, a systematic review by Paranjothy et al.[185] on interventions to prevent aspiration
pneumonitis in 2658 patients undergoing caesarean sections under general anaesthesia
found that the combination of antacids and H2receptor blockers was more effective
than no intervention, and superior to antacids alone in preventing low gastric pH.
Most of the surveys done across the United Kingdom and Australia between 1987 and
1994 found that routine aspiration prophylaxis was preferred (LOE- Very Low).[186
187
188]
Survey findings
All respondent obstetric units in the survey except one, administered aspiration prophylaxis
in pregnant women (both for emergency and elective indications) scheduled for caesarean
section. Only one institution did not provide aspiration prophylaxis for women undergoing
caesarean section under regional anaesthesia. Ten units administered routine prophylaxis
out of 18 units for women receiving labour analgesia. The commonest drugs administered
were ranitidine and metoclopramide.
Recommendations
Pregnant women requiring sedation or anaesthesia should be administered aspiration
prophylaxis.
H2receptor blockers, proton pump inhibitors either alone or in combination with prokinetic
drugs can be administered for aspiration prophylaxis.
Post-operative oral feeding in patients after caesarean section
The 20 studies[189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
207
208] were heterogeneous with respect to anaesthetic techniques used (regional anaesthesia,
general anaesthesia or both) and the timing of surgery (emergency or elective). Sips
of water or liquid diet was used for resumption of oral feed in majority of the studies.[189
190
192
194
195
196
197
198
199
201
203] Few of the studies targeted resumption of normal diet or solid food.[193
200
202] Studies have used various parameters and outcomes such as time to appearance
of bowel sounds, time to passage of flatus and incidence of ileus among others while
discussing about resumption of oral feeds postoperatively. The time to initiation
of early oral feed varied from 30 min to 8 h after surgery. The delayed feeding was
based either on the appearance of bowel sounds or a fixed time frame postoperatively.
Time of post-operative oral feed and time to appearance of bowel sounds
The meta-analysis of 5 studies (including patients who had undergone caesarean section
under spinal anaesthesia or general anaesthesia) showed that the mean difference in
the appearance of bowel sounds was 7.93 hours longer with a 95% CI of 2.20 to 13.65
in the conventionally (12–24 h) fed group than in the early (6–8 h) fed group (LOE-
Moderate)[189
190
191
192
200] Teoh et al. found bowel sounds immediately postoperatively in 95.9% patients
at 30 min in the early feed group and in 90.8% patients at 30 min in the control group.
The occurrence of bowel sounds was not an outcome measure in this study (LOE- Very
Low).[198] But, Mawson et al. found 87% of the patients to have bowel sounds the morning
after surgery in the early feeding group (sips of water 6–8 h after caesarean section)
and in 44.8% patients in the conventional feeding group (sips of water 12 h after
caesarean section) (LOE-Low).[197]
Time of post-operative oral feed and time to passage of first flatus
Twelve studies estimated the time to passage of flatus in post caesarean section patients
after administration of different kinds of intake.[189
190
191
192
193
194
195
196
197
198
199
200] The meta-analysis of 4 studies in post caesarean section patients showed consumption
of sips of water 6–8 h after surgery resulted in shorter time to passage of flatus
with a mean difference of 9.91 h and a 95% CI of 3.57 to 16.25 compared to those allowed
sips of water 12–24 h after surgery (LOE- Moderate).[189
190
191
192] Other studies where the time to passage of flatus after solid food or food given
earlier than 6 h showed similar results.[193
194
195
196
197
198
199
200]
Incidence of ileus and other factors
The meta-analysis of 8 studies combining the incidence of ileus at 24 h showed a relative
risk of 1.08 with a 95% CI of 0.81 to 1.45. There was no significant difference in
the incidence of ileus between patients who had been given oral feed between 6 and
8 h and those who received feed at 12–24 h (LOE- High).[190
191
192
198
199
201
202
203] The incidence of nausea, vomiting, abdominal distension, length of hospitalisation,
maternal satisfaction, etc., were comparable between groups of patients who had early
initiation of feed to delayed initiation of feed across most of the studies. Meta-analysis
and systematic reviews by other authors also yielded similar results (LOE-High)[204
205
206
207
208]
Evidence pertaining to oral consumption of liquids after obstetric interventions other
than caesarean section are sparse and no meaningful conclusions can be drawn about
the same. Studies of very low level of evidence have even advocated postoperative
feeding as early as 2 h. Experts were of the opinion that oral feed can be allowed
at a shorter duration than 8 h. This allows for further scope for research.
Survey findings
The time to initiation of oral feeds in the postoperative period by respondent obstetric
units was 6.1 ± 7.7h for liquids after central neuraxial block, 6.0 ± 6.6 h for liquids
after general anaesthesia, 12.7 ± 14.2 h for solids after central neuraxial block
and 13.3 ± 14.2 h for solids in patients who had undergone caesarean section under
general anaesthesia.
Recommendations
Clear liquids can be allowed orally 8 h after caesarean section under regional/general
anaesthesia.
Gastric emptying in immediate postpartum period
Women in the postpartum period (from delivery to 12 weeks) may present for procedures
(e.g., sterilisation). Whitehead et al. in a study comparing gastric emptying times
using paracetamol absorption technique found that there was no difference in pregnant
women and women on the 1st, 2nd or 5th day postpartum (LOE- Very Low).[166] Gin et
al. in a study on 8 women in the postpartum period found that the gastric emptying
was rapid on the first and third postpartum day and comparable to gastric emptying
in 6 women who came for follow-up after 6 weeks (LOE- Very Low).[209] Lam et al. compared
residual gastric volume and gastric content pH in non-pregnant women (n = 50), women
in the postpartum period who had fasted overnight (n = 50) and women in the postpartum
period who had consumed clear liquids 2 h prior (n = 50). They found that the median
residual gastric volumes and pH were comparable among all three groups (LOE- Very
Low).[210]
Women in post-partum period may not be any different from general adult population
with regard to gastric emptying times and pH.
Miscellaneous
Studies found that women who chewed gum in the immediate postoperative period after
caesarean sections had shorter times to passage of flatus, return of bowel sounds
(LOE- Very Low to Low).[211
212
213
214
215
216
217
218]
PAEDIATRIC SECTION
Factors predisposing children for regurgitation and aspiration
Seven studies evaluated the factors predisposing children for regurgitation and aspiration.[219
220
221
222
223
224
225] A meta-analysis of 49 studies involving 1457 children (28 weeks of gestation
to adulthood) reinforced the significance of food type in modulating gastric emptying
and found that aqueous solutions had faster gastric emptying compared to solids (45
min vs 98 min) (LOE - High).[219] Children aged 3–17 years maybe at a higher risk
of aspiration as their gastric residual volume was >0.4 mL/kg. All except one child
had gastric content pH < 2.5 (LOE-Very Low).[220] Children (6 months to 18 years)
were found to have greater risk for acid aspiration than adults (18–64 years) and
geriatric (>64 years) population as children have a greater gastric residual volume
and lower gastric content pH.[221]
The prevalence of reflux regurgitation was highest at 2 months of age (86.9%) which
decreased to 7.6% by 1 year of age in Thai children.[222] A study on 1000 consecutive
day care surgery children (2–12 years) found that preoperative acetaminophen and midazolam
increased gastric fluid volume (GFV) while lower GFV was associated with ASA physical
status III, male gender, gastroesophageal reflux disease, and proton pump inhibitor
administration. All had GFV >0.4 mL/kg despite standard fasting protocols. (LOE–Low).[223]
Incidence of aspiration in children
The meta-analysis of 8 studies published between 1998 and 2019 with a total sample
size of 4,26594 patients yielded an incidence of 49/1,00,000 aspirations in children
with a 95% CI of 30/1,00,000 to 81/1,00,000 (LOE–High).[224
225
226
227
228
229
230
231] The Anaesthetic Incident Monitoring Study reported 133 cases of aspiration in
children <14 years out of the total 240 incidents of aspiration. Only 17 of these
children were inadequately fasted (LOE – Very Low). The main reasons attributed to
aspiration included emergency surgery, medications, inadequate anaesthesia.[232] A
case series involving three children showed one child developing aspiration despite
adequate fasting (LOE–Very Low).[233]
Survey findings
A total of 10 units that exclusively catered for paediatric anaesthesia and one department
that catered to obstetric and child population participated. They reported 72 cases
of regurgitation, 31 cases of regurgitation with aspiration and eight cases of aspiration
pneumonitis perioperatively in children undergoing elective surgeries. Similarly,
91 cases of regurgitation, 34 cases of regurgitation with aspiration and 14 cases
of aspiration pneumonitis were reported in children undergoing emergency surgeries.
Most children recovered with oxygen therapy. There were three deaths in children scheduled
for emergency surgery attributed to regurgitation and aspiration.
Gastric emptying time in children
GUS evaluation showed that the emptying time in 48 healthy volunteers (8–14 years)
for apple juice, 2% milk and Ensure® Clear was 3-3.5 h (LOE- Low).[234] Expressed
breast milk emptied twice as fast as formula milk in preterm infants in a GUS study
(LOE- Low).[235] An MRI study in children found gastric emptying of clear liquids
had a median half-life of < 30 min (LOE- Low).[236] Gastric emptying for cow's milk
was similar in both healthy children and those with GERD (LOE- Low).[237] Prolongation
of liquid gastric emptying half-time was observed with increasing severity of GERD
(LOE- Low).[238] The adult normative data for gastric emptying for solids may be inappropriate
for children (5–18 years) (LOE- Low).[239] In a serial GUS study on stable preterm
infants, breast milk composition was found to influence gastric emptying, with feeds
of higher casein content emptying faster while fortified mother's milk emptying much
slower than unfortified mother's milk (LOE- Low).[240] Another GUS study on preterm
infants fed with fortified, unfortified and pasteurised human milk found reduced percentage
of gastric retention with higher casein, whey and lactulose concentrations in the
milk. They also found that curdling did not affect emptying (LOE- Low).[55] In a GUS
study on children < 5 years, it was found that 100 mL milk up to 3% fat and clear
liquid 100 mL with 17.5% dextrose can be safely given 3 h and 2 h prior to anaesthesia,
respectively (LOE- Low).[241] Children (8.2–12.5 years) consuming 7 mL/kg of raspberry
syrup had a gastric emptying half time of 27 min compared to 20 min in those who consumed
3 mL/kg of the same in an MRI based volunteer study (LOE- Low).[242] The average gastric
emptying half-time was 49 ± 23 min, 54 ± 29 min and 65 ± 36 min for breast milk, half-fortified
breast milk and fully fortified breast milk respectively (LOE- Low).[243] The mean
gastric emptying half-time was 107.2 min for 30 g of chocolate crispy cake among children
(5–10 years, LOE – Very Low).[244] The calculated mean gastric emptying time was <
4 h (236 min) following breakfast in pre-schoolers in a study using serial ultrasonographic
measurements (LOE – Very Low).[245]
Consumption of water 1 h prior vs 2 h prior to induction of anaesthesia
Residual gastric volume considerations
The meta-analysis of 3 studies involving 307 children aged 1–16 years, found that
the residual gastric volume was comparable between groups consuming water at 1 hour
or >2 h prior to the induction of anaesthesia with a mean difference of 1.46 mL and
a 95% CI of 0.77 to 2.97 (LOE - High).[242
246
247]
pH Considerations
No difference in gastric pH was found in two studies where children aged 1–16 years
were allowed to consume clear liquid at premedication or 1 h prior compared to consumption
of water 2 h prior to induction of anaesthesia (LOE – Moderate).[242
247]
Other Clear Liquids (2 h vs >2 h prior to induction of anaesthesia)
Residual gastric volume considerations
The meta-analysis of 5 studies found that the residual gastric volume was lower in
children who consumed clear liquids containing calories at 2 h prior to induction
of anaesthesia compared to those who consumed at an interval of more than 2 h with
a mean difference of 0.77 mL with a 95% CI of 0.47 to 1.27. Two of these studies were
performed in infants and one study compared residual gastric volume and pH after consumption
of water or breast milk. Three other studies involved infants and children up to 14
years of age (LOE – High).[248
249
250
251
252]
In a study of 120 children (2–18 years) scheduled for gastroscopy, consumption of
lemon-flavoured carbohydrate beverage reduced the mean volume of gastric contents
compared to water or tea administered 2 h prior to induction of anaesthesia (LOE –
High).[253] The residual gastric volume was comparable when 6 or 10 mL/kg apple juice
was consumed 2.5 h before induction of anaesthesia compared to overnight fasting in
children aged 5–10 years (LOE – Moderate).[254]
pH Considerations
No significant difference in gastric pH was found in the meta-analysis of five studies
(2 in infants and 3 in infants and children aged up to 14 years) comparing pH after
clear liquid consumption at 2 h or >2 h before induction of anaesthesia with a mean
difference of 0.97 and a 95% CI of 0.85 to 1.09 (LOE – High).[248
249
250
251
252] The gastric pH was comparable in children 2–18 years age both with consumption
of lemon-flavoured carbohydrate beverage or non-carbohydrate beverage (water or tea)
2 h prior to the procedure (LOE – Moderate).[253] Comparable pH was found when 6-10
mL/kg apple juice was consumed 2.5 h before induction of anaesthesia compared to overnight
fasting in children aged 5–10 years (LOE – Moderate).[254]
Fasting times for formula feeds and solids
Children <9 months of age given formula feeds at 4-6 h Vs 8 h prior to induction of
anaesthesia showed comparable residual gastric volume (LOE – Moderate).[252] In a
crossover MRI trial, children (6.8–12.2 years) when given a light breakfast consisting
of cereal flakes and milk products at 4 h had a higher gastric volume when compared
to the same given at 6 h (LOE – Low).[255] Weight corrected gastric residual volumes
in 22 children who had fasted < 6 h was comparable to 46 children who had fasted >6
h in children (0.3–19.6 years) scheduled for MRI (LOE – Very Low).[256]
The evidence showed a large variability in the age of the subjects studied (neonates
- 18 years).
Survey findings
Regarding the appropriate fasting time for different kinds of food items, most of
the respondents opined that 2 h was appropriate for clear liquids, 4 h for human milk,
6 h for cow's milk and 6 h for formula feed or solids. Three of the 11 respondents
who answered the question on volume of clear liquid allowed in children felt that
3 mL/kg was the appropriate volume. Two others felt that there was no limit. The rest
felt that 10 mL/kg, 20 mL, < 50 mL and 100 mL were appropriate, and 1 respondent felt
that no specific volume was recommended.
Recommendations
Consumption of water, up to 3mL/kg should be allowed until 1 h prior to administration
of anaesthesia.
Consumption of clear liquids other than water, up to 3 mL/kg can be allowed until
2 h prior to administration of anaesthesia.
Human milk and fully skimmed non-human milk can be allowed until 4 h prior to administration
of anaesthesia.
Non-clear liquids, non-human milk, formula feeds, light breakfast or light meal may
be allowed until 6 h prior to administration of anaesthesia.
Aspiration prophylaxis in children
Domperidone reduced gastric emptying in preterm neonates (LOE –Low).[257] Oral ranitidine
with or without liquids resulted in a decrease in both volume and acidity of gastric
contents (LOE – Moderate).[258] Low dose erythromycin appears to be safe and effective
in decreasing gastric emptying in preterm babies born after 34 weeks of gestation
in the first two weeks of life (LOE – Moderate).[259] Oral ranitidine hydrochloride
2 mg/kg is effective in increasing the pH of gastric aspirate in children aged one
to six years in the majority of patients though one should expect lack of measurable
response in some children (LOE – High).[260] Gender, age, gastrointestinal pathology
or pH-altering medication does not appear to have an effect on the GFV (LOE – Very
Low).[261] Thus, as per the evidence, aspiration prophylaxis may not be uniformly
effective in improving the gastric pH and reducing the residual gastric volume in
adequately fasted children.
Recommendations
The attending anaesthesiologist can decide for or against the administration of aspiration
prophylaxis in adequately fasted children.
Fasting practices in children scheduled for procedural sedation
Out of a total of 149046 sedation procedures evaluated for the incidence of aspiration,[262
263
264
265
266] only one study reported aspiration events (10 instances) (LOE – Low),[262] while
other four studies found no instances of aspiration in any of the children despite
many children not meeting the standard fasting criteria prior to procedural sedation
(LOE – Low).[263
264
265
266] Overall, 30,306 children did not meet standard fasting criteria out of 148935
known cases of fasting duration (LOE – Low).[262
263
264
265
266] A survey among Canadian paediatric emergency departments reported that only 53%
physicians follow standard fasting guidelines for children undergoing procedural sedation.
The physicians were less likely to perform procedural sedation immediately if a child
had a full meal < 2 hours ago or liquids < 1 hour ago. Those with 6–10 years of experience
were more willing to perform immediate procedural sedation in such situations. Physicians
who had an institutional fasting policy reported disinclination towards performing
immediate procedural sedation (LOE – Very Low). The evidence shows that the fasting
guidelines are not strictly followed for procedural sedation in paediatric patients.[267]
In low resource settings the decision on the duration of fasting for procedural sedation
will be influenced by set up and the level of expertise of the attending anaesthesiologist.
Recommendations
The attending anaesthesiologist can decide on the duration of fasting for procedural
sedation within operating room or remote location.
Postoperative oral feeding practices in children
In a study involving children (6 months–4 years), early resumption of oral intake
(apple juice 10 mL/kg) in the post anaesthesia care unit after the Face Leg Activity
Cry Consolability (FLACC) score was ≥4, following anaesthesia was associated with
reduced incidence of postoperative vomiting and a decrease in opioid consumption compared
to those kept fasting till return to ward. (LOE – Moderate).[268] The postoperative
fasting times were significantly greater in children less than 17 years scheduled
for complex surgical procedures than those undergoing non-complex procedures. Most
patients received some postoperative fasting time, even when it was not ordered by
the physician in the diet order (LOE – Very Low).[269]
Survey findings
Most respondents (of the 10 units) felt that resumption of clear liquid intake can
be started at 1–2 h, human milk at 3–4 h, formula feed at 4–6 h, and cow's milk at
4–6 h after surgery.
Recommendations
The oral consumption of clear liquids in the postoperative period should be resumed
at the earliest where no medical or surgical contraindications exist.
Effects of prolonged fasting duration in children
Observational studies and surveys found the duration of preoperative fasting is prolonged
in 60-70% of the children posted for surgery (LOE – Very Low).[229
270
271
272] In a study comprising of 1350 children (2-16 years) with a median fasting time
of 12.05 hours, 56% were found to be very hungry or starving, while 27% of the children
were very thirsty (LOE – Very Low).[273] Children <36 months showed higher concentration
of plasma ketone bodies and lower mean arterial pressure immediately after anaesthetic
induction following prolonged duration of fasting. But there was no significant difference
in the plasma glucose concentrations (LOE – Moderate).[274]
Overnight fasting,[275] breast milk (LOE – Moderate),[276] or infant milk formula
NAN (Nestle Australia Ltd.) consumed 3-4 h preoperatively (LOE –Moderate)[277] or
administration of lactated Ringer's solution as intraoperative maintenance fluid (without
dextrose containing solutions) were not associated with perioperative hypoglycaemia.
In a retrospective study on 238 children who had undergone MRI under propofol sedation,
the duration of fluid abstinence did not correlate with the decrease in the blood
pressure.[278] In an observational study in 100 children aged 2–6 years scheduled
for ophthalmic examination under sevoflurane anaesthesia, it was found that the prolonged
duration of fasting correlated with emergence delirium scores at 15 and 25 min after
the procedure (LOE – Very Low).[279] In a cohort study including 404 children undergoing
bone marrow biopsy under general anaesthesia, it was found that the exposed group
(those fasted for >3 h) had a higher incidence of postoperative vomiting (LOE – Very
Low). But there was no correlation to the incidence of hypoglycaemia.[280] In a prospective
interventional study (of approximately 16,000 children), effects of utilising quality
improvement methodology to reduce excess fasting times, with a goal of achieving experienced
clear liquid fasting times ≤4 h for 60% of patients was studied. Use of active language
encouraging drinking; clear liquids allowed up until arrival to operating room (30
min prior to arrival time); providing water or apple juice in preoperative holding
area and addition of sports drinks to allowable clear liquids, resulted in an improvement
with compliance to fasting duration for clear liquids (LOE – Low).[281]
Survey findings
If the duration of fasting was more prolonged than recommended, 62% of the respondents
assessed for hypoglycaemia, 38% felt that they had to look for hypotension. Thirty
eight percent also felt that they had to assess for irritability, dry tongue, blood
sugar if neonate or administered liquids.
BARIATRIC SECTION
Obese individuals are considered to be at higher risk of aspiration, with a high body
mass index (BMI) correlating with acid reflux.[282
283
284
285
286
287] Increased transient lower oesophageal sphincter relaxation (TLOSR) with acid
reflux has been reported in 2-hour postprandial oesophageal manometry in obese and
overweight subjects when compared with a non-obese subjects.[288]
The meta-analysis of 3 RCTs comparing the gastric emptying half-time for liquids in
obese and non-obese individuals found that the gastric emptying half times were comparable
with a mean difference of 4.78 min and a 95% CI of -13.09 to +3.54 (LOE- Low).[289
290
291] Similar studies comparing gastric emptying time of solids have shown equivocal
results with some showing a prolonged overall gastric emptying time (LOE- Very Low).[292
293
294
295
296
297
298
299]
The meta-analysis of 5 RCTs comparing residual gastric volume in obese and non-obese
individuals showed that obese individuals have a slightly higher residual gastric
volume compared to non-obese individuals with a mean difference of 2.47 and a 95%
CI of 0.24 to 4.71(LOE- High).[300
301
302
303
304] The meta-analysis of 4 RCTs comparing gastric content pH showed that obese individuals
had lower pH when compared to non-obese individuals with a mean difference of 2.92
and a 95% CI of -5.57 to - 0.31 (LOE- High).[300
302
303
304]
An RCT including 126 adult obese individuals (excluding those with gastro-oesophageal
reflux, hiatus hernia and diabetes mellitus) fasted from midnight found that the residual
gastric volume and pH in the control group were comparable to the study group administered
300 mL. liquid (water, apple juice, black coffee, clear tea, carbonated beverages)
2 h before surgery. They concluded that drinking clear liquid as per guidelines may
not increase the risk of aspiration in obese patients (LOE- Very Low).[305] Peura
et al. in a post hoc analysis of patients enrolled in phase 3 studies comparing use
of dex-lansoprazole and placebo or lansoprazole found that the symptom severity due
to acid reflux increased with BMI and hence, they derive greatest benefit from treatment
with proton pump inhibitors (LOE- Low).[286] Lam et al. compared the residual gastric
volume and gastric content pH in morbid obese patients scheduled for gastric stapling
and found that administration of intravenous cimetidine 60–90 min before the procedure
reduced the residual gastric volume and increased the gastric content pH (LOE- Low).[306]
A similar study compared the effect of cimetidine and ranitidine with or without the
administration of metoclopramide on the residual gastric volume and gastric content
pH in morbidly obese patients scheduled for gastroplasty and found that the residual
gastric volumes and gastric content pH were comparable among all the groups (LOE-
Very Low).[307] In a study evaluating the effect of combinations and different doses
of ranitidine and metoclopramide, they found that 300 mg of oral ranitidine the night
before and morning of surgery combined with metoclopramide 10 mg the morning of surgery
reduced the residual gastric volume to the greatest extent. The pH was comparable
among the study groups and higher than the control group (LOE- Very Low).[308] Mahajan
et al. compared the residual gastric volume and gastric content pH in lean and morbidly
obese patients with or without the administration of ranitidine and metoclopramide
as prophylaxis in patients who had fasted for 8 hours prior to elective surgery. They
found that the residual gastric volume was lower in lean individuals and those morbidly
obese individuals who had received prophylaxis (LOE- Low).[309]
Survey findings
Our survey found that 66.7% of the respondents administer aspiration prophylaxis to
all obese individuals while 16.7% of the respondents administer only in patients with
reflux symptoms; 77.8% of the respondents chose H2 receptor blockers as the first
choice for administration as prophylaxis.
Recommendations
Obese individuals may be considered to be at higher risk for aspiration in comparison
to non-obese individuals when administered sedation or anaesthesia.
In obese individuals, the advice on preoperative fasting practices may be the same
as in non-obese individuals prior to the administration of sedation or anaesthesia.
Aspiration prophylaxis may be administered in obese patients prior to the administration
of sedation or anaesthesia.
H2receptor blockers, proton pump inhibitors either alone or in combination with prokinetic
drugs can be administered for aspiration prophylaxis.
Postoperative oral feeding practices in obese patients after bariatric surgery
Matlok et al. in an analysis of 170 patients in an observational study (who underwent
either laparoscopic Roux en Y procedure or sleeve gastrectomy) found that oral liquid
was well tolerated by 128 patients when administered within 5 h of postoperatively.
Oral administration of liquid was tolerated by 162 patients within the first 24 h
(LOE- Very Low).[310] There is insufficient evidence to formulate a recommendation
for the resumption of postoperative feeding in this subset of patients.
Survey findings
The mean time for resumption of oral feed in bariatric patients calculated from the
data from the 18 respondents were 12.1 ± 8.9 h for clear liquids for restrictive procedures
and 14.7 ± 11.9 h for malabsorption procedures. The mean time for resumption of solid
food was 119.8 ± 162 h for restrictive and 123.4 ± 160.2 h for malabsorption procedures,
respectively.
ROLE OF GUS AS PREOPERATIVE TOOL FOR ASSESSING GASTRIC CONTENT
Identification and differentiation of stomach contents
Most studies on identification of antral contents with GUS were observational or experimental
in nature performed on different subset of patients such as pregnant women, children
and in patients undergoing elective/emergency surgery.
Six healthy volunteers (fasting for 8 h) evaluated with GUS on four occasions, after
consumption of 200 mL apple juice or 200 mL 2% milk or a standard solid meal (sandwich
and apple juice) confirmed the ability of GUS in identifying empty stomach, and in
differentiating clear liquid from viscous liquid or solid content (LOE- Low).[311]
In 20 healthy volunteers, the post prandial state of the stomach was identified by
2 well-trained emergency medicine residents and 1 attending physician on 73% and 65%
occasions with the volunteers in right lateral decubitus (RLD) and supine positions
respectively. However, after consumption of 16 ounce of water, the stomach could be
visualised 100% of the times. (LOE- Low).[312] The GUS could differentiate fasted
from non-fasted (liquids/solids) states with high sensitivity (85% for all) and specificity
(93% and above for all) in a volunteer cross over study (LOE- Low).[313] The GUS could
easily differentiate the contents of the stomach in pregnant women (LOE- Moderate).[314]
A sensitivity as high as 1 and a specificity as high as 0.975 was established in a
study with GUS in 40 patients who underwent 80 examinations by experienced sonologists
(LOE- Moderate).[315] Similar study found that the mathematical model used by them
was reliable in obese patients when volumes of up to 400 mL were administered (LOE-
Very Low).[316] Antrum could be identified in 95% and 90% of obese patients in RLD
and supine positions respectively. The study also found larger antral areas and basal
gastric volume in these patients (LOE-Very Low).[317] The cut off values for empty
stomach in children after induction of anaesthesia were found to vary in the supine
and RLD positions, with the latter having the highest sensitivity and specificity
(LOE- Low).[318]
GUS has been shown to be a valuable tool in influencing the induction/intubation technique
with respect to risk of aspiration in infants with pyloric stenosis, children, adults
and critically ill patients (LOE- Low).[319
320
321
322
323] A study found that 6/100 patients (4 chronic kidney disease, 1 obese, 1 no co-morbidities)
scheduled for elective surgery had 'full stomach' by GUS despite prolonged fasting
durations (10–15 h) indicating that 10 h fasting duration does not assure an empty
stomach (LOE- Very Low).[324] An observational GUS study on 246 patients with average
fasting duration of 7.75 h for elective and 7.345 h for emergency procedures found
69 patients to be at risk of aspiration (solid food or liquid content >1.5 mL/kg).
A positive association was found between the risk of aspiration and GERD (LOE- Very
Low).[325]
Quantifying liquid content in the stomach
A study concluded that antral cross-sectional area (CSA) of < 8 cm2 might indicate
an empty stomach in patients without GERD (LOE- Very Low).[326] Interindividual variability
in the gastric volume estimate with GUS after administration of equal amounts of liquid
was high with minimal intrasubject variability after a meal (LOE- Very Low).[327]
The median fasting antral area was 4.2 cm2(range 2–16 cm2) and volume of aspirated
juice varied from 5 to 200 mL with correlation between antral area measurements and
aspirated volume (LOE- Very Low).[328] GUS in 24 normal newborns and eight newborns
with suspected gastric retention [mean age 10.8 days) showed CSA >1 cm2 after a nasogastric
feed (milk) of >10 mL (LOE- Very Low).[329] Estimation of gastric volume from antral
area correlated better with the actual gastric volume than when estimated from the
body or fundus up to 300 mL in the lateral decubitus position (LOE- Very Low).[330]
An area of 340 mm2 coincided with the residual gastric volume of 0.8 mL/kg (considered
high risk by the authors) (LOE- Very Low).[331] MRI evaluation of gastric content
volumes in children (6.4–12.8 year) found best correlations of antral volumes by GUS
in RLD position (LOE- Very Low).[332] The gastric volumes up to 500 mL estimated from
antral CSA by GUS measured in RLD position strongly correlated with volumes aspirated
by gastroscopy in non-pregnant adults with a BMI < 40 kg/m2(LOE- Very Low).[333] A
gastric CSA >9.6 cm2 corresponded with a high gastric volume (1.5 mL/kg) in third
trimester pregnant women (LOE- Very Low).[334] Song et al. in a study in children
aged 18 years administered 10–15 mL/kg of carbohydrate containing solution 2 h before
anaesthetic induction and were able to identify and measure the contents of the stomach
in all 79 individuals. They quantified the stomach in terms of cross-sectional area.
They did not correlate with the volume of liquid ingested (LOE- Very Low).[335] Moser
et al. in a study tried to estimate the cut off values for empty stomach in children
after induction of anaesthesia. They found that the cut off point varied in the supine
and right lateral decubitus position. The latter had the highest sensitivity and specificity.
They quoted the antral cross-sectional area to be 3.07 cm2(LOE - Low).[318] In a cohort
study including 200 children aged between 1 and 16 years, Bouvet et al. found the
prevalence of at risk stomach (defined as volume >1.25 mL/kg) to be 1% in adequately
fasted children scheduled for elective surgery (LOE- Low).[336] Arzola et al. developed
a predictive model in term pregnant women scheduled for caesarean section under neuraxial
anaesthesia after standard fasting instructions. They found no solid food in the stomach.
Total of 53 women were in grade 0, 49 in grade 1 and 1 had grade 2 as per Perlas grading.
Ninety-five per cent of the women presented with an antral area of < 9.6 cm2(corresponding
to an estimated volume of < 1.5 mL/kg) (LOE- Low).[11] In a similar study Amaral et
al. found that the median for the gastric antral cross-sectional area was 4 cm2 in
85 pregnant women. The 95th percentile was 10.3 cm2. The gastric antral area correlated
well with the body weight and the BMI (LOE- Very Low).[337] Zieleskiewicz et al. conducted
a study on parturients after administration of 0.4 mL/kg, 0.8 mL/kg and 1.5 mL/kg
of water and tried to find the gastric antral area correlating best with the volume
consumed. They found that the cut off value for detecting gastric fluid of >0.4 mL/kg,
>1.5 mL/kg was 387 mm2 and 608 mm2 respectively in the supine position (LOE- Low).[338]
Roukhomovsky et al. conducted a similar study in 35 pregnant women and found that
the cut off point of 505 mm2 and the qualitative Perlas grading of grade 1 stomach
combined predicted gastric volumes of >1.5 mL/kg better than either of these parameters
used alone (LOE- Low).[339]
Reliability of GUS compared to other methods of estimation of residual gastric volume
Reliability of GUS to assess gastric emptying and the residual gastric volume has
been studied. The studies which describe the gastric emptying half time have used
scintigraphy or serial ultrasonographic measurements. Scintigraphy measures the gastric
emptying half time using residual radioactivity with time, whereas serial ultrasonographic
measurements determine the reduction in the estimated gastric volume with time. Holt
et al. found that the graphs for gastric volumes assessed serially were comparable
between scintigraphy and ultrasonographic measurements (LOE- Low).[340] Liu et al.
found that trans-abdominal ultrasonography is similar in accuracy to scintigraphy
in this regard (LOE- Low).[26] Hveem et al. showed a comparable sensitivity to scintigraphy
in quantifying emptying of both low and high nutrient liquids (LOE- Very Low).[341]
Darwiche et al. found good correlation in gastric emptying measured by ultrasonography
and scintigraphy in diabetic patients (LOE- Very Low).[342]
In another study by Sharma V et al. the volumes estimated by ultrasonography correlated
well with aspirated gastric content volumes in 19 patients admitted to the Intensive
Care Units (LOE- Very Low).[343] Schmitz et al. found that the gastric antral CSA
in RLD position with GUS were comparable with MRI in 18 volunteer children (LOE- Very
Low).[344] The aspirated gastric volume by gastroscopy was comparable for up to 500
mL of ingested volumes in non-pregnant patients with a BMI < 40 kg/m2 and the reliability
of antral area assessments assessed by repeated estimations showed a coefficient of
variation of 5.8%.[328
333]
Survey findings
Of the 56 respondents only one routinely assessed the gastric volume preoperatively.
Nine respondents (16.07%) assessed the gastric volume preoperatively in patients they
considered at risk. Forty-six respondents (82.14%) did not routinely assess the gastric
volume. Of these only 5 respondents used ultrasonography to measure the gastric volume.
Recommendations
Gastric ultrasonography may be used as a bedside tool for assessing the quality and
quantity of gastric contents in the preoperative period.
The quality and quantity of gastric contents should be assessed in the right lateral
decubitus position.
Summary
The guidelines formulated are based on evidence and are applicable in their respective
patient population. The summary of the guidelines are represented in Table 1. Overall,
the guidelines suggest optimal time for consumption of food prior to the administration
of anaesthesia. These guidelines will be updated as and when new evidence arises.
Financial support and sponsorship
This Guidelines project is fully supported and Sponsored by Indian Society of Anaesthesiologists.
Conflicts of interest
There are no conflicts of interest.