BJA Open, 10 (C): 100282 (2024)

Open doi: 10.1016/j.bjao.2024.100282

Review Article

REVIEW ARTICLE

Preoperative fasting and the risk of pulmonary

aspirationda narrative review of historical concepts,
physiological effects, and new perspectives
Anne Rüggeberg1,*, Patrick Meybohm2 and Eike A. Nickel1
1
Department of Anaesthesiology and Pain Therapy, Helios Klinikum Emil von Behring, Berlin, Germany and 2Department
of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany

*Corresponding author. E-mail: [email protected]

Summary
In the early days of anaesthesia, the fasting period for liquids was kept short. By the mid-20th century ‘nil by mouth after
midnight’ had become routine as the principles of the management of ‘full stomach’ emergencies were extended to
include elective healthy patients. Back then, no distinction was made between the withholding of liquids and solids.
Towards the end of the last century, recommendations of professional anaesthesiology bodies began to reduce the
fasting time of clear liquids to 2 h. This reduction in fasting time was based on the understanding that gastric emptying
of clear liquids is rapid, exponential, and proportional to the current filling state of the stomach. Furthermore, there was
no evidence of a link between drinking clear liquids and the risk of aspiration. Indeed, most instances of aspiration are
caused by failure to identify aspiration risk factors and adjust the anaesthetic technique accordingly. In contrast, long
periods of liquid withdrawal cause discomfort and may also lead to serious postoperative complications. Despite this,
more than two decades after the introduction of the 2 h limit, patients still fast for a median of up to 12 h before
anaesthesia, mainly because of organisational issues. Therefore, some hospitals have decided to allow patients to drink
clear liquids within 2 h of induction of anaesthesia. Well-designed clinical trials should investigate whether these
concepts are safe in patients scheduled for anaesthesia or procedural sedation, focusing on both aspiration risk and
complications of prolonged fasting.

Keywords: 2 h fasting; clear fluid; clear liquid; drink until call; liberal fasting; preoperative fasting; Sip Til Send; unre-
stricted drinking

The Helsinki Declaration on Patient Safety in Anaesthesiology the norm, even for healthy elective patients with no risk
states: ‘Patients have a right to expect to be safe and pro- factors for aspiration.
tected from harm during their medical care and anaesthesi-
ology has a key role to play improving patient safety
perioperatively’.1 Accordingly, the European Society for How it all began
Clinical Nutrition and Metabolism (ESPEN) guideline ‘Clinical When anaesthesia was in its infancy in the mid-19th century,
Nutrition in Surgery’ recommends avoidance of long periods preoperative fasting was recommended to minimise the
of preoperative fasting2 and ‘Choosing Wisely in paediatric discomfort of nausea and vomiting.4 In the case of 15-yr-old
anaesthesia’ demands shorter real fasting times.3 This is Hannah Greener, who died under ether anaesthesia in 1848, it
nothing new. Even in the early days of anaesthesia, it was remained unclear whether an overdose of ether or aspiration
highlighted that preoperative fasting for several hours would of orally administered brandy led to death.5 The first proven
exacerbate existing states of exhaustion. Nevertheless, in the fatal aspiration was published in 1862. As early as 1853, a
decades that followed, ‘nil by mouth after midnight’ became soldier in Burma vomited during surgery for a bullet wound in

Received: 31 October 2023; Accepted: 27 March 2024

© 2024 The Author(s). Published by Elsevier Ltd on behalf of British Journal of Anaesthesia. This is an open access article under the CC BY license (http://
creativecommons.org/licenses/by/4.0/).
For Permissions, please email: [email protected]

1
 2 - Rüggeberg et al.

the leg and died shortly afterwards. The autopsy showed that best of our knowledge, there are no corresponding studies in
the trachea was full of vomitus.4 humans.12
The British surgeon Sir Joseph Lister published simple,
practical guidelines for fasting in 1883, and was the first to
distinguish between solids and clear liquids: ‘While it is
Learning points
desirable that there should be no solid matter in the stomach  Historically, fasting times have been arbitrarily set with the
when chloroform is administered, it will be found very salu- aim of preventing aspiration.
tary to give a cup of tea or beef-tea about two hours before’.4 As  For decades, no differentiation has been made between clear
‘several hours of preoperative fasting aggravate existing states liquids and solids (nothing by mouth after midnight).
of exhaustion’, tea with red wine or cognac up to 45 min before
induction of anaesthesia was recommended at the beginning
of the 20th century, especially for alcoholics.6 Gastric emptying
Gastric emptying of clear liquids is mainly affected by the
Mendelson’s ‘Nil by mouth’ volume of fluid in the stomach and the energy density of the
liquid (Fig. 1). Gastric emptying exponentially increases as
In 1946, the obstetrician Mendelson retrospectively
fluid volume in the stomach increases and is also proportional
described 66 cases of aspiration of gastric contents during
to the rate of filling.14,15,19e22 Drinking clear liquids therefore
anaesthesia in 44 016 pregnant women, an incidence of
speeds up the emptying of the stomach.15,23
0.15%. Two patients died, both from complete airway
Secondly, the higher the energy density of the liquid, the
obstruction by aspirated solid food. There were no deaths
slower the gastric emptying.16,21,23e25 Receptors in the small
among the 40 patients who aspirated liquid stomach con-
intestine regulate gastric emptying to about 200 kcal per hour
tents; they developed asthma-like symptoms that soon
to prevent the intestine from receiving more nutrients than it
subsided. Mendelson showed that hydrochloric acid or non-
can absorb.14,17 Therefore, liquid gastric emptying depends
neutralised liquid human vomit instilled into the lungs of
mainly on the total caloric content.18,26 There were no signif-
anaesthetised rabbits caused immediate cyanosis, respira-
icant differences in liquid gastric emptying after drinking
tory distress, and changes on chest radiographs similar to
equal amounts of either orange juice or milk, as long as both
those seen in patients with liquid aspiration.7 Mendelson
had the same number of calories.18
recommended ‘withholding oral nutrition during delivery to
For high-calorie non-clear liquids, calorie and nutrient
prevent aspiration’ and made no distinction between clear
content affect gastric emptying times.25 The stomach empties
liquids and solids. In the following decades, the fear of
carbohydrates faster than proteins, and fat stays in the
Mendelson’s syndrome led to the concept of ‘nil by mouth
stomach the longest.27 Analysis of the area under the curve of
after midnight’. Unfortunately, this applied not only to
the gastric content volumeetime profile, which may be a more
high-risk patients, but also to healthy patients without risk
sensitive measure of gastric emptying kinetics, shows that the
factors undergoing elective surgery.4
area under the curve is greater for a high-fat drink than for an
isocaloric high-carbohydrate drink.25
Roberts’ threshold for the risk of aspiration
The ‘nil by mouth after midnight’ concept was reinforced 500 ml water
600
when 25 ml in the stomach, present in half of all healthy 600 ml (30 kcal 100 ml−1)
fasting patients, was adopted as a surrogate marker for a high 150 ml (30 kcal 100 ml−1)
risk of aspiration.4 Citing his own unpublished data, Roberts 500 400 ml (50 kcal 100 ml−1)
stated in 1974: ‘Our preliminary work in the rhesus monkey 600 ml (75 kcal 100 ml−1)
Gastric volume (ml)

suggests that 0.4 ml kg
1 body weight is the maximum acid 400
aspirate which does not produce significant changes in the
lungs’.8 In 1980, Roberts described that the gastric acid applied 300
directly to the left lung via a tracheostomy tube in this study
had a pH of 1.26.9 The number of animals used remained un-
200
clear. Roberts went on to write in 1974 that as 0.4 ml kg
1 body
weight ‘is equivalent to about 25 ml in the adult human fe-
male, we have arbitrarily defined the patient at risk as that 100
patient with at least 25 ml of gastric juice with a pH below 2.5
in the stomach’.8 In the following decades, this threshold was 0
referred to as the ‘critical gastric volume in relation to the risk 0 10 20 30 40 50 60 70 80
of aspiration’. Time (min)
However, fasting elective patients very often exceed the
threshold of 0.4 ml kg
1 for gastric residual volume.10,11 Recent
studies have arbitrarily set the threshold for distinguishing Fig 1. Gastric emptying after drinking water and clear carbo-
between an empty and full stomach at 1.5 ml kg
1,11,12 which hydrate liquids with three different calorie contents. The green
corresponds to the 95th to 97th percentile of gastric volume in dashed lines between the diamonds represent repeated fluid
healthy fasting adults. However, the threshold gastric volume intake of 150 ml. The range of normal gastric residual volumes
that could lead to an increased risk of regurgitation is probably is indicated in green (according to data from11,14e18).
much higher, exceeding 8 ml kg
1 in animal studies.13 To the
 Preoperative fasting and the risk of aspiration - 3

In comparison to energy density, osmolality has less of an  The amount and type of solid food consumed must be
effect on gastric emptying. Replacing glucose monomers with considered when determining a suitable fasting period.
polymers may increase the rate of gastric emptying, but this
osmolality effect is more pronounced at high carbohydrate
concentrations.17
Importantly, the gastric emptying rate of liquids shows a Risk factors for pulmonary aspiration
high inter-subject variability of about 30%, while the intra-
Recent studies have defined the normal gastric fluid volume as
subject variability is <10%.14 The high variability of gastric
up to 1.5 ml kg
1.11 But 1.5 ml kg
1 gastric fluid volume rep-
emptying after liquid intake is also explained by the fact that
resents the upper end of normal baseline gastric secretions.
the stomach emptying is episodic. Consequently, measuring
Therefore, with this definition up to 6e13% of patients who
gastric volumes will result in different data depending on the
have formally fasted will have an increased gastric fluid vol-
time points just before or just after episodic emptying.
ume.11,43e46 Cho and colleagues47 found a fasting gastric vol-
Clear liquids quickly leave the stomach. There is a func-
ume >1.5 ml kg
1 in 31% of gynaecological patients and Zhou
tional tunnel along the small curvature of the stomach which
and colleagues48 in 48% of patients with diabetes. However,
allows liquids to pass directly into the duodenum within 10
the incidence of perioperative aspiration is only 0.02e0.04% in
min, bypassing the greater part of the stomach.28 When vol-
retrospective studies49,50 and 0.02e0.07% in elective adults and
unteers drink 500 ml of water, more than half of the water has
children in prospective studies.51e53 Therefore, gastric volume
left the stomach after 10 min, and the stomach is empty after
does not appear to be a suitable surrogate marker for the risk
20 min.18 If a subject drinks 600 ml of a carbohydrate drink (30
of pulmonary aspiration and, in particular, for the risk of
g L
1 glucose), half of the liquid will have left the stomach after
pneumonia.
15 min and the stomach will be empty after 30 min. If subjects
Sonographic evidence of fluid in the stomach is not asso-
drink 600 ml of the carbohydrate drink first and then continue
ciated with a higher risk of aspiration. Drinking clear liquids
drinking 150 ml every 20 min, they will have ingested a total fills the stomach but also increases the compliance of the
volume of 900 ml in less than an hour, consumed the energy of
gastric fundus while intragastric pressure is stable until the
a small breakfast, and still have an empty stomach.14,15 The gastric volume is 1 L or less.19,24 But if the pressure in the
gastric emptying time after drinking tea or coffee with milk (up
stomach increases, the tone of the lower oesophageal
to about one-fifth of the total volume) is comparable to that of
sphincter also increases, so that the barrier pressure between
water or pure tea.29e32 Trauma, such as fractures of the radius
the stomach and oesophagus is maintained.54,55
or hip, does not delay gastric emptying of clear liquids,33,34 nor
does obesity35 or diabetes mellitus.36 Gastric emptying is in-
dependent of age37 and is not affected by carbonated
Pre-existing conditions
liquids.38,39
In addition to oral liquid intake, 2.5 L of saliva and gastric Comorbidities are not independent risk factors for pulmonary
juice pass through the stomach each day.40 Their secretion can aspiration.50 Laryngeal incompetence, for example in neuro-
increase up to 600 ml h
1 in the cephalic secretion phase muscular diseases, leads to dysphagia. In this case, the risk of
(triggered, for example, by thoughts of food). Therefore, fasting aspiration is increased only during the swallowing process.
does not guarantee an empty stomach. Liquids pass through the oesophagus within 1 s when the
body is in an upright position. Even in severe swallowing dis-
orders such as achalasia, gastric emptying is not affected.
Gastric emptying of solid food Reflux disease is a disorder of motility and function of the
Differentiating between gastric emptying of solids and liquids oesophagus or cardia that does not affect gastric emptying.
is very important. In addition to the digestion and breakdown Conditions that may be associated with delayed gastric
of food, the stomach also has a reservoir function.19 This emptying are often cited as reasons for the need for a 2-h
function does not apply to water and clear liquids with low liquid fast. But it is often the case that no distinction is made
energy densities, which pass through the stomach quickly, between the gastric emptying of solids and liquids. This
proportionally to the rate of filling. distinction is crucial, and is important to understand. Aspi-
According to European guidelines, breastfeeding should be ration of clear liquids is rarely of clinical significance, whereas
encouraged up to 3 h before anaesthesia, milk and light solid aspiration of solids often leads to serious complications.56
foods up to 4 h and solid foods up to 6 h before induction of However, gastric emptying is usually delayed only for solids.
anaesthesia for children.41 In adults, solid food should be Gastric ultrasound in patients with risk factors for gastro-
prohibited for 6 h before elective surgery.32 But American paresis revealed the presence of solid food in the stomach in
guidelines explicitly point out that both the amount and type 12.5% of fasted patients.57
of foods ingested have to be considered when determining an In patients with gastroparesis, gastric emptying of clear
appropriate fasting period for solids. A longer fasting time (e.g. liquids is usually unaffected, and sometimes even accelerated.
8 h or more) may be needed after fried foods, fatty foods, or One example is diabetic gastroparesis, which primarily affects
meat and for patients with coexisting diseases or conditions solids.58e60 Gastric emptying after carbohydrate drinks is even
that can affect gastric emptying (see below).42 faster in patients with type 2 diabetes than in those without
diabetes.61 Similarly, vagotomy results in rapid fluid and
delayed solid emptying.58 Some drugs, such as semaglutide,
delay gastric emptying for solids.62 Perioperative semaglutide
Learning points
use was associated with increased residual gastric volume, but
 Clear liquids leave the stomach very quickly, with a half-life in 85.2% of 33 patients, solid content was observed.62 Only four
of 10e15 min for clear liquids that have no calories or low patients met the study criteria for an increased gastric fluid
calorie content. volume of >0.8 ml kg
1, but this is a normal fluid level.
 4 - Rüggeberg et al.

Sufficient gastric content volume

Delayed or inadequate gastric emptying time

Impaired function of the lower oesophageal sphincter

Residual gastric content is regurgitated

Sufficient amount of regurgitated

gastric content gets into the bronchi

Regurgitated gastric content

can damage the lungs

Aspiration pneumonia

Fig 2. Factors that must coincide for patients to develop aspiration pneumonia.

Aspiration pneumonia adaptation of anaesthetic techniques can prevent aspiration.

Particular attention should be paid to the indication and cor-
Based on the aforementioned findings, pulmonary aspiration
rect performance of a rapid sequence induction. In an online
in elective patients is the result of the coincidence of several
survey, 1921 members of the European Society of Anaes-
factors (Fig. 2):
thesiology from 56 countries were asked about their clinical
o A sufficient volume of gastric content must be present. practice of rapid sequence induction.65 The majority (61.7%) of
o Delayed or inadequate gastric emptying time. the respondents preoxygenated patients with O2 100% for 3
o The function of the lower oesophageal sphincter must be min and 65.9% administered opioids during rapid sequence
impaired or unable to withstand the applied pressure (e.g. induction. In all patients where rapid sequence induction was
reflex reactions of the patient during tracheal intubation indicated, the Sellick manoeuvre was used by 38.5% and was
under insufficiently deep anaesthesia). never used by 37.4% of the respondents. The remaining re-
o The residual gastric content must be regurgitated. spondents only performed the Sellick manoeuvre in certain
o Sufficient regurgitated gastric content must reach the patient groups. First-line medications for haemodynamically
bronchi. stable adult patients were propofol (90.6%) and sux-
o The regurgitated gastric content must be harmful to the amethonium (56.0%). Manual ventilation (inspiratory pressure
lungs. <12 cm H2O) was used by 35.5% of the respondents.
An international survey of 10 003 anaesthetists from 141
The presence or occurrence of individual factors does not
countries demonstrated that preferences for positioning
lead to aspiration pneumonia.
(head-up or head-down), nasogastric tube use, and cricoid
force application during rapid sequence intubation vary sub-
stantially, but were routinely performed for a hypothetical
Prevention of aspiration patient with intestinal obstruction.66 When anaesthetists
Most aspiration events are as a result of failure to recognise were asked to identify the most important learning point from
the risk factors for aspiration (see Table 1) and to adjust the their experience with aspiration, their response was to
anaesthetic technique accordingly.63,64 Therefore, good pre- address gastric decompression before anaesthesia. This in-
operative patient assessment and staff training with cludes placing a nasogastric tube if not already present,
 Preoperative fasting and the risk of aspiration - 5

Table 1 Predisposing factors for pulmonary aspiration. Data from.50,63,67e70

Full stomach Recent eating

Ileus (paralytic, non-paralytic)
Pregnancy
Delayed gastric emptying (traumatised patients, pyloric spasm)
Gastric hypersecretion (pain, stress)
Advanced chronic disease resulting in gastroparesis (diabetes mellitus/chronic kidney disease/neuromuscular
disorders)
Oesophageal Severe reflux disease
sphincter
Oesophageal disorders: Zenker’s diverticulum, strictures
Previous oesophageal-gastric surgery
Morbid obesity
Laryngeal Inadequate depth of anaesthesia
reflexes
Traumatic brain injury, cerebral infarction
Neuromuscular disorders
Others Emergency surgery
Difficult airway
Inadequate use of first generation supraglottic airway devices

applying suction through it, administering a small amount of Prolonged liquid fasting
saline to unblock a potentially obstructed tube, and changing
International guidelines have recommended 2-h clear liquid
the patient position on the operating table to facilitate gastric
fasting before induction of anaesthesia in adults.32,42,67,78,79 In
emptying. For more details on rapid sequence induction, see
clinical practice, however, adult patients fast for a median of
the review by Collins and O’Sullivan.71
9e12 h.11,80e84 Prolonged liquid deprivation not only causes
However, there is a lack of evidence from randomised
discomfort such as thirst, anxiety, fatigue, and postoperative
controlled trials for many of the interventions that constitute
nausea,80,82,85e100 but can also lead to serious postoperative
rapid sequence induction.65,72 In particular, cricoid pressure is
complications. The duration of preoperative liquid fasting is a
controversial, but a large, controlled, randomised trial from
modifiable precipitating factor of delirium in the post-
France found no advantage in terms of pneumonia and mor-
anaesthesia recovery room (odds ratio 2.69) and on the ward
tality in the cricoid pressure group, but a significantly higher
(odds ratio 10.57).101 Preoperative dehydration quadruples the
rate of more difficult laryngoscopy.73 Contrary to Sellick’s
number of postoperative complications after hip fracture,
assumption,74 more recent sonographic studies have shown
especially neurological, cardiovascular, renal, or respiratory
that the oesophagus is displaced laterally rather than dorsally
problems.102 Dehydrated tumour nephrectomy patients have
to the cervical spine when cricoid pressure is applied.75 How-
an increased risk of postoperative renal failure.103 Preopera-
ever, prophylactic strategies to prevent aspiration also carry
tive oral rehydration solution supplementation significantly
potential risks of side-effects (e.g. rapid sequence induction
reduced post-spinal transient ischaemic electrocardiographic
with unexpected difficult intubation); therefore a critical
changes in older patients.104
appraisal of the risk factors is needed.76
In adults, prolonged fasting resulted in perioperative
There is no evidence of a link between drinking clear liq-
hyperglycaemia, insulin resistance, increased interleukin-6
uids and the risk of aspiration in elective patients.12 Of course,
levels, urinary ketone excretion, impaired cardiac output,
emergency patients with an indication for rapid sequence in-
and psychosomatic status, and decreased muscle strength
duction must remain fasting from the time of diagnosis, even
compared with drinking carbohydrate drinks 2 h before in-
for clear liquids. In cases of doubt, gastric ultrasound can be
duction of anaesthesia.91,93,95,98,105e114 Perioperative hyper-
used as a ‘point-of-care’ procedure when considering whether
glycaemia is associated with an increased risk of infection,
to place a gastric tube before induction of anaesthesia and
reoperation, and mortality in patients undergoing visceral
perform a controlled ‘rapid sequence induction’. A scientific
surgery.115 Patients who drink coffee regularly have an
evaluation of this topic is expected in the recommendations of
increased risk of postoperative caffeine withdrawal
new guidelines on perioperative fasting. The usefulness of
headache.116
ultrasound in assessing gastric contents and the associated
During long periods of fasting, children also experience
risk of aspiration is one of the main topics of this upcoming
thirst, hunger, anxiety, vomiting, and pain.117e119 Prolonged
guideline.77 Where possible, performing surgery with regional
preoperative fasting may be a risk factor for postoperative
anaesthesia may be an alternative.
emergence delirium in children.120,121 Optimised preoperative
fasting management reduces fasting time, decreases ketone
body concentration, and helps to stabilise mean arterial blood
Learning points pressure during induction of anaesthesia in children.122,123
 Most cases of aspirations are associated with failure to Up to 13% of patients deliberately ignore fasting recom-
recognise risk factors for aspiration and failure to adjust the mendations for eating or drinking in order to avoid fasting for
anaesthetic technique accordingly. several hours.124e128 Some patients would lie about how long
 Gastroparesis mainly delays the gastric emptying of solids, they had fasted if they were told that their operation would be
but not liquids. delayed or cancelled because they had eaten or drunk
 6 - Rüggeberg et al.

something.125,127,128 Approximately 2e3% of patients do not stopped.56 Close communication between the operating
adhere to the fasting rules for solids, putting themselves at theatre and ward would be necessary but is often limited
serious risk. Although pulmonary aspiration of clear liquids is because of the workload, staff shortages, and surgeons’ con-
rarely of clinical significance, aspiration of solid food often cerns that the anaesthesia department may refuse to anaes-
leads to serious complications.56 thetise the patient if the liquid fasting time was too short.56,134
Giving i.v. fluids does not seem to be a solution. Oral liquid
withdrawal in patients who receive i.v. fluids while waiting for
Reasons for prolonged liquid fasting surgery is almost twice as long as in patients who do not
The main reasons for prolonged liquid fasting are summarised receive i.v. fluid replacement (12.5 vs 6.5 h), and they experi-
in the Ishikawa diagram in Figure 3. Systemic reasons ence significantly more thirst and thirst-related distress.138
focussed on problems in the organisational implementation of However, infusions should be given if they are needed
guidelines. Human reasons are based on concerns about because of pre-existing conditions or other medical reasons.
aspiration if the 2 h limit is not met. To better understand the
latter, knowledge of the risk factors for aspiration in elective
patients and knowledge of gastric emptyingdpathophysiol-
Learning points
ogy and clinical studiesdare required (see above).  Prolonged liquid fasting reduces patient comfort and may
Quality improvement measures to implement the 2 h liquid lead to serious postoperative complications.
fasting have not yet resulted in liquid withdrawal times in the  The main reasons for the failure to implement the recom-
range recommended by guidelines.129e133 In a survey of Indian mendation of 2 h are the variable timing of surgical pro-
anaesthetists, only 20% reported following the ASA guide- cedures and the (historical) fear of aspiration.
line.134 In an international survey, only about half of the
anaesthetists recommended that patients continue to drink
clear liquids up to 2 h before surgery.135 The main reasons
given for these discrepancies were uncertainty of scheduling
And today
of the surgical procedures and failure to implement the Current guidelines recommend 2 h of liquid fasting,32,42,78,79
guideline.134,135 In an operating theatre the exact time to start which translates into median fasting times of up to 12 h in
anaesthesia is often unpredictable and affected by short-term clinical practice.80,83,129 Because many anaesthetists refuse to
re-scheduling.56 Up to 12e16% of operations have been induce anaesthesia in patients who have liquid fasting for <2
cancelled on the day that they were scheduled, mainly h, mostly for medico-legal reasons, significant reductions in
because other operations took longer than planned, emer- prolonged fasting times have not yet been achieved. The lack
gency cases overwhelmed theatre capacity, or operations were of implementation of guidelines puts patients at risk in several
cancelled because of limited personal or material resources or ways. Reduced wellbeing increases the perioperative stress
patient reasons.136,137 In fact, neither patients nor hospital response, dehydration increases the incidence of severe
staff know exactly what time intake of clear liquid should be postoperative complications, and lack of energy intake leads

Cause
Guideline Anaesthetist Surgeon

Concern about aspiration

Prohibits drinking
within 2 h Requirement to act
Cancellation if
before induction within the standard
fasting times are
of anaesthesia practice and follow
not adequate
guidelines Effect
Extended
fasting times
Lack of clear Adaptability to list for clear liquids
Concern about order and last
information
aspiration minute changes in
theatre schedule
Usual practice :
staff shortage preventing close coordination
‘Nothing per mouth
between theatres and wards to adjust
from midnight’
fasting times with theatre schedule

Patient Ward staff System

Fig 3. Ishikawa diagram summarising the main reasons for prolonged liquid fasting.
 Preoperative fasting and the risk of aspiration - 7

to insulin resistance and, thus, muscle breakdown. Patients compared with clinics with a 6/4/1 regimen (2.5 h, n¼7163) or a
put themselves at risk by deliberately breaking the fasting 6/4/2 regimen (3.7 h, n¼742.)145 The Uppsala working group,
recommendations for solids. which has been practising ‘no limitations on clear liquid
Strict adherence to the recommendation of at least 2 h of intake until called to theatre’ in children for >20 yr, reported a
liquid withdrawal is therefore incompatible with the recom- median fasting time of 1 h.49,146 Allowing children to drink
mendation that patients should not fast for >2 h because of the clear liquids until premedication significantly reduces the
risk of postoperative complications. Fulfilling both re- actual fasting time from 3.9 h to 48 min.147 In none of the
quirements of the guidelinesdat least 2 h, but not >2 studies was a shorter fasting time an independent risk factor
hdappears to be practically impossible, especially for hospi- for aspiration.49,144,145,147
tals providing emergency care. To decide which of the two
guideline requirements is considered more important,
anaesthetists are increasingly carrying out a risk assessment For adults
between these two options: To find out what approaches individual centres have taken to
- adherence to the 2-h limit, which in practice usually results reduce fasting times in adults, we conducted a literature
in excessively prolonged liquid fasting times or search (PubMed) to identify relevant articles. The search terms
- allowing shorter liquid fasting times even shorter than 2 h to were: fasting and anaesthesia, language English and date limit
reduce perioperative complications. was set from year 2020 onwards. We identified 425 articles to
assess for relevance. Of these, 148 articles were relevant to
The current adult guidelines only consider studies that preoperative liquid fasting and 14 reported approaches to
investigated liquid fasting times between 2 and 4 h vs >4 h, or reduce liquid fasting times. From the secondary literature, we
conclude that drinking up to 2 h before induction of anaes- added another study published in 2018.
thesia has no effect on, or even reduces, gastric residual vol-
ume.32,42 There is neither evidence nor any theoretical
pathophysiological explanation for harm after clear liquid Intensive training to implement the 2 h limit
fasting for <2 h. Therefore, a recent international multidisci-
Intensive training can reduce liquid fasting time to some
plinary consensus statement recommends that all patients
extent. In two recent studies, liquid fasting time before surgery
with no or low risk of aspiration should receive unrestricted
was significantly reduced by education/training interventions.
clear liquids before procedural sedation.139
However, the fasting times achieved were still significantly
This is why more and more anaesthetists consider con-
longer than those recommended by the guidelines, at >5
cepts such as ‘Sip Til Send’, ‘drink until called’ or ‘unrestricted
h.129,130 The introduction of a fasting guideline reminder via a
drinking before surgery’.42,52,83,85,140e142
mobile phone SMS by Zia and colleagues131 in addition to a
written hospital policy reduced median liquid fasting times by
Learning points 3 h, but only 13.6% of patients fasted appropriately. Komatsu
and colleagues132 reported a reduction in liquid fasting time
 To date, there is no system that makes it possible to comply
from 243 to 180 min through multidisciplinary interventions in
with both recommendations of the guidelinesdat least 2 h,
a perioperative management centre. However, only 8% of pa-
but not much more than 2 h.
tients consumed >200 ml of clear liquid at baseline and at the
 As a result, an increasing number of hospitals are weighing
end of the study.
up the pros and cons of prolonged liquid fasting or of going
below the recommendation of 2 h.
Different approaches to implement ‘Sip Til Send’
In 2021, Sands and colleagues141 submitted freedom of infor-
What approaches have individual centres
mation requests to all acute National Health Service England
implemented to shorten liquid fasting times? Hospital Trusts. The results revealed that 21 out of 100 Trusts
In paediatric anaesthesia, liberal fasting regimens are much now have preoperative intake guidelines that allow water after
more common than in adult anaesthesia, where there are only the 2-h cut-off recommended by current national guidance
a few published approaches to the implementation of shorter and 15 Trusts allow water to be sipped up to the point of
fasting times. sending for the patient for theatre. None of these Trusts are
reporting increased rates of adverse events in the current
literature or safety publications.141
For children
In some centres, only drinking water is allowed. In the UK,
For children, the recommendation for clear liquid fasting was Kannan140 started a ‘THINK DRINK’ campaign in which, on the
reduced to 1 h in 2022.41 The extent to which liberalisation of day of arrival, surgical patients get a ‘welcome drink’ of water
the preoperative liquid fasting time to the new recommen- on admission and are allowed unlimited sips of water until
dation of 1 h41 will be translated into clinical reality remains to being called. Patients showed a reduction in the mean fasting
be seen. In a quality management project involving around 16 time for liquids to 2 h. Daly and colleagues100 allowed one glass
000 children, the introduction of the 1 h limit only reduced the of water (160 ml) per hour for women undergoing elective
median liquid fasting time from 9 to 6 h.143 Implementation of Caesarean delivery under spinal anaesthesia. Liquid fasting
the 1-h fasting instruction reduced the median effective fast- time was reduced from almost 8 h to 55 min with significant
ing time for clear fluids to 2.6 h in a prospective, observational, reductions in thirst, nausea, discomfort, light-headedness,
multi-institutional cohort study of 22 766 paediatric anaes- and anxiety. However, in a study by Bouvet and colleagues148
thetics.144 In the NIKs study, clinics with a ‘drink until call’ allowing only limited water consumption does not ensure
regimen had the shortest liquid fasting times of 1.8 h (n¼4188) high patient satisfaction, at least during delivery. The authors
 8 - Rüggeberg et al.

concluded that fresh clear liquids, unrestricted amounts of with regurgitation (n¼146) had a mean liquid fasting duration
liquids and sweet liquids could improve patient comfort. of 2.52 h compared with patients without regurgitation (n¼76
In one British study and one Dutch study, all clear liquids 305) with a liquid fasting duration of 2.36 h.
were allowed; however, the amount that could be consumed
was limited. The ‘Sip Til Send’ policy implemented by
Checketts,142 allowing one 170 ml glass of clear liquid per hour What is coming next?
until patients are sent for their procedure, reduced liquid  With the new upcoming guideline ‘Perioperative Fasting in
fasting times from 6 h to 17 min. They did not observe an in- Adults’, a systematic literature review from 2010 onwards
crease in reported adverse events in >12 000 patients through on the impact of preoperative fasting on perioperative out-
ongoing governance monitoring. The Dutch study by Marsman comes is expected, together with a revision of the
and colleagues52 reduced the median fasting time to 74 min by recommendations.77
allowing clear liquids to be consumed until arrival in the  Eurofast, a large multicentre study, will monitor the inci-
operating theatre, with a maximum of 1 glass per hour and an dence of pulmonary aspiration in 180 000 paediatric patients
additional glass with premedication (see below for more in relation to liquid fasting time. The study is expected to be
details). completed by the end of June 2024.152
In two studies, patients were allowed to drink all clear  A multicentre randomised controlled study on ‘Preoperative
liquids without restrictions on the amount. In the UK, Fasting Versus Not Fasting in Critically Ill Patients’.153
McCracken and Montgomery85 allowed >4700 day case pa-  An ongoing systematic review on ‘Abbreviation of preoper-
tients unrestricted clear oral fluids before operation until ative fasting in surgical patients’ is analysing articles pub-
transfer to the theatre. They demonstrated a significant lished in the last 10 yr and is expected to be completed by the
reduction in nausea without adverse events of pulmonary end of February 2024.154
aspiration of gastric contents requiring hospital admission. A
German quality improvement study used fasting cards to
implement unrestricted drinking of clear liquids until called to Learning points
the theatre. Using this approach, they reduced the median
liquid fasting time from 12 to 2.1 h.83 Patients who were  Adequately powered studies demonstrating the safety of
allowed unrestricted drinking before surgery drank wisely and liberal liquid fasting regimes in patients, particularly
according to their needs.149 Neither sonographically nor gas- regarding the risk of aspiration, are lacking.
troscopically did the ‘Sip Til Send’ regimen result in a clinically
relevant increase in residual gastric volume.150,151
Conclusion
Learning points Attempts to reduce fasting times through quality improve-
ment measures have failed so far. Concepts such as ‘Sip Til
 In children, liberal liquid fasting regimens even below the Send’ have achieved significant reductions in fasting times
recommended 1 h are much more common than in adults. and improvements in patient well-being. However, these
 In adults, quality improvement measures have not yet concepts need to be further investigated in well-designed,
resulted in liquid fasting times in the range of the recom- large clinical trials to assess patient safety, focusing on both
mendation of 2 h. the risk of aspiration and the complications of prolonged
 When drinking was allowed within 2 h before induction of fasting.
anaesthesia, there was a significant reduction in fasting
times for liquids.
Authors’ contributions
Conception and interpretation of this work: all authors
Perspectives Drafting of the manuscript: AR
However, no adequately powered studies have demonstrated Critical revisions of the manuscript: PM, EN
the safety of short liquid fasting times in patients, particularly Approved the final version of the manuscript: all authors
with regard to the risk of aspiration. The authors of the Accountable for all aspects of the work: all authors
updated American guideline have calculated that, with a
baseline incidence of 1.1/10 000 cases of aspiration in elective
patients, 214 000 participants per study arm would be required Declarations of interest
in a two-arm study to demonstrate a two-fold increase (power, The authors declare that they have no conflicts of interest.
80%; a, 0.05).79 So far, no study has met this requirement for
the number of cases. However, the data from Marsman and
colleagues52 are a first step. Acknowledgements
In 2023, Marsman and colleagues52 achieved a median
The authors would like to thank Susan Hinkson, Ib Jammer,
liquid fasting time of 74 min in 16 815 patients with a liberal
and Alexander Nagrebetsky for proofreading the manuscript.
liquid fasting policy (for details see above), with no significant
increase in the incidence of regurgitation or aspiration
compared with 59 636 control patients who followed standard
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Handling editor: Phil Hopkins