Southern African Journal of Anaesthesia and Analgesia 2020; 26(2)(Supplement 1):S1-75 SVI Foreword to the 2020-2025 edition of the SASA Guidelines for the safe use of procedural sedation and analgesia for diagnostic and therapeutic procedures in adults Writing guidelines on procedural sedation and analgesia is a formidable and challenging task. Effects of a preoperative carbohydrate-rich drink before ambulatory surgery: A randomized controlled, double-blinded study. Nonrandomized comparative studies assessing the impact of ingesting breast milk before a procedure are equivocal for gastric volume or pH when compared with the ingestion or clear liquids or infant formula (Category B1-E evidence).4446. This is a modular update of the Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures. Association of nausea and length of stay with carbohydrate loading prior to total joint arthroplasty. A carbohydrate-rich beverage prior to surgery prevents surgery-induced immunodepression: a randomized, controlled, clinical trial. Sugarless gum chewing before surgery does not increase gastric fluid volume or acidity. Outcomes: adverse effects of fasting (preoperative hunger, thirst, and nausea) and pulmonary aspiration. That's a GOOD thing. Fasting and Pharmacologic Recommendations. Oral fluids prior to day surgery. The body of evidence included 139 studies (adult surgical: 99 randomized controlled trials,2334,3664,6886,91,118157 7 nonrandomized trials,65,66,87,152,158160 3 prospective cohort studies,90,161,162 2 retrospective cohort studies,163,164 1 case-control study,165 and 2 beforeafter studies67,166; adult nonsurgical: 1 randomized controlled trial,167 9 crossover,168176 and 2 nonrandomized trials177,178; pediatric surgical: 9 randomized controlled trials,100,113,179185 1 prospective cohort186; and pediatric nonsurgical: 2 randomized controlled trial,102,104 1 crossover,35 and 1 prospective cohort103) comparing carbohydrate-containing clear liquids (simple, complex) with water, placebo, or fasting. Effects of preoperative oral carbohydrate supplementation on postoperative metabolic stress response of patients undergoing elective abdominal surgery. Airway management techniques that are intended to reduce the occurrence of pulmonary aspiration are not the focus of these guidelines. The Task Force notes that intake of fried or fatty foods or meat may prolong gastric emptying time. asa npo guidelines 2020 chewing tobacco asa npo guidelines 2020 chewing tobacco vo 9 Thng Su, 2022 vo 9 Thng Su, 2022 Braz J Anesthesiol (English Edition). The consultants agree and the ASA members strongly agree that for otherwise healthy neonates (< 44 gestational weeks) and infants, fasting from the intake of breast milk for 4 or more hours before elective procedures requiring general anesthesia, regional anesthesia, or procedural sedation and analgesia should be maintained. To avoid prolonged fasting in children, efforts should be made to allow clear liquids in children at low risk of aspiration as close to 2h before procedures as possible. For the first time, the 2020 data include information on the flavors of the companies' smokeless tobacco products. Supplemental digital content is available for this article. Survey responses from Task Forceappointed expert consultants are reported in summary form in the text, with a complete listing of consultant survey responses reported in appendix 2 (table 3). Only studies containing original findings from peer-reviewed journals were acceptable. The term gastroesophageal reflux disease refers to positional reflux and its consequent symptomology, rather than food intolerances (e.g., tomatoes do not agree with me). Effects of preoperative fasting abbreviation with carbohydrate and protein solution on postoperative symptoms of gynecological surgeries: Double-blind randomized controlled clinical trial. Population: patients undergoing general anesthesia, regional anesthesia, or procedural sedation for elective procedures, Interventions: drinking carbohydrate-containing clear liquids (simple or complex) until 2h before general anesthesia, regional anesthesia, or procedural sedation for elective procedures; drinking protein-containing clear liquids (all studied included carbohydrates) until 2h before general anesthesia, regional anesthesia, or procedural sedation for elective procedures; gum chewing before surgery/procedure; and a shortened duration for clear liquid fasting in children of 1 h, Comparators: fasting or drinking noncaloric clear liquids (e.g., water, placebo, broth, black tea, black coffee); no gum chewing; and clear liquid fasting duration of 2h in pediatric patients. rdr2 special miracle tonic pamphlet location; scholastic scope finding and using text evidence answer key; prayer to bless bread and wine for communion buick lacrosse for sale under $10,000. Tobacco's calories (if there's any) is insignificant to interrupt weight loss. Home glucometer readings may help guide the patients choice of a carbohydrate or a noncaloric clear liquid. Although the relationship between gastric volume and gastric emptying time with aspiration risk has not been demonstrated in adequately powered studies,7 most published studies have used these measures as intermediate outcomes. Small study effects and the potential for publication bias were evaluated using funnel plots and regression-based tests.12 Analyses were conducted in R (R Foundation for Statistical Computing, Vienna, Austria).1315 (See the methods supplement for further details, https://links.lww.com/ALN/C962.). Furthermore, it would be necessary to update related policies, printed literature, and wall posters/charts to ensure that patients are receiving consistent messages and instructions from all medical personnel. Comparison of the effects of famotidine and ranitidine on gastric secretion in patients undergoing elective surgery. The effect of preoperative oral carbohydrate administration on insulin resistance and comfort level in patients undergoing surgery. should I observe the same fasting intervals? Third, expert consultants were asked to: (1) participate in opinion surveys on the effectiveness of various preoperative fasting strategies and pharmacologic agents and (2) review and comment on a draft of the guidelines developed by the Task Force. scented chewing tobacco (tobacco with added flavours) naswar, nas, niswar (tobacco with slaked lime, indigo, cardamom, oil, menthol, water) chillam (heated tobacco) paan (tobacco, areca. Aspiration of gastric contents is associated with increased perioperative morbidity and mortality [ 1-3 ], with highest risk associated with high volume, acidic, or particulate aspiration. Reduction of the risk of acid pulmonary aspiration in anaesthetized patients after cimetidine premedication. A randomized trial. Aspiration pneumonitis and aspiration pneumonia. Safety and efficacy of oral rehydration therapy until 2h before surgery: A multicenter randomized controlled trial. 1 Clear liquids include water, tea, black coffee, pulp-free juice, and carbohydrate-rich drinks. There was no incidence of aspiration in any group. There is insufficient evidence to recommend protein-containing clear liquids preferentially over other clear liquids 2h before elective procedures requiring general anesthesia, regional anesthesia, or procedural sedation (no recommendation). Effects of oral rehydration therapy on gastric volume and pH in patients with preanesthetic H2 antagonist. Accepted for publication October 26, 2016. Level 2: The literature contains multiple RCTs, but the number of RCTs is not sufficient to conduct a viable meta-analysis for the purpose of these updated guidelines. The categories of recommendations in the Grading of Recommendations, Assessment, Development, and Evaluation approach include strong in favor, conditional in favor, conditional against, and strong against an intervention. The role of H2 receptor antagonist premedication in pregnant day care patients. Gastric emptying of three liquid oral preoperative metabolic preconditioning regimens measured by magnetic resonance imaging in healthy adult volunteers: A randomised double-blind, crossover study. Assessment of gastric emptying of maltodextrin, coffee with milk and orange juice during labour at term using point of care ultrasound: A non-inferiority randomised clinical trial. Safety of oral glutamine in the abbreviation of preoperative fasting: A double-blind, controlled, randomized clinical trial. CINeMA: An approach for assessing confidence in the results of a network meta-analysis. The percent of consultants expecting no change associated with each linkage were as follows: preoperative assessment 95%; preoperative fasting of solids 75%; preoperative fasting of liquids 67%; preoperative fasting of breast milk 78%; gastrointestinal stimulants 95%; pharmacologic blockage of gastric secretion 91%; antacids 100%; antiemetics 98%, anticholinergics 100%, and multiple agents 98%. Simple carbohydrates included clear fruit juices or water with glucose or fructose added. Retrospective comparative studies (e.g., case-control). Insulin sensitivity and beta-cell function after carbohydrate oral loading in hip replacement surgery: A double-blind, randomised controlled clinical trial. colonel frank o'sullivan interview; beverly hills high school football The guidelines may not apply to or may need to be modified for patients with coexisting diseases or conditions that can affect gastric emptying or fluid volume (e.g., pregnancy, obesity, diabetes, hiatal hernia, gastroesophageal reflux disease, ileus or bowel obstruction, emergency care, or enteral tube feeding) and patients in whom airway management might be difficult. Preoperative carbohydrate loading in gynecological patients undergoing combined spinal and epidural anesthesia. The consultants agree and the ASA members strongly agree that for children and adults, fasting from the intake of nonhuman milk for 6 or more hours before elective procedures requiring general anesthesia, regional anesthesia, or procedural sedation and analgesia should be maintained. Effect of preoperative intravenous carbohydrate loading on preoperative discomfort in elective surgery patients. According to the American Lung Association, chewing tobacco contains at least 28 chemicals that can lead to various illnesses, including mouth, esophageal, and pancreatic cancers, gum disease, and tooth decay and loss. Smokeless tobacco causes cancer of the mouth, esophagus, and pancreas. A carbohydrate-rich drink reduces preoperative discomfort in elective surgery patients. Preparation of these guidelines followed a rigorous methodological process. Comparative trial of the effect of ranitidine and cimetidine on gastric secretion in fasting patients at induction of anaesthesia. The characteristics of randomized trials supporting recommendations for adult surgical patients included a median of 46 participants (range, 20 to 150). Aspiration can occur during any type of anesthesia, as a result of . General variance-based effect-size estimates or combined probability tests were obtained for continuous outcome measures, and Mantel-Haenszel odds ratios were obtained for dichotomous outcome measures. Technical Guideline for Sample Handling of Smokeless Tobacco and Smokeless Tobacco Products Status: Valid Note: This document will be periodically reviewed by CORESTA Document history: Date of Review Information September 2019 Version 1 May 2020 Version 2 - Major update and total revision. The influence of oral carbohydrate solution intake on stress response before total hip replacement surgery during epidural and general anaesthesia. Meta-analysis of RCTs comparing fasting times of 2 to 4 h versus more than 4 h report equivocal findings for gastric volume and gastric pH values in adult patients given clear liquids 2 to 4 h before a procedure (Category A1-E evidence).1221 RCTs reported less thirst and hunger for fasting times of 2 to 4 h versus more than 4 h (Category A2-B evidence).12,13,19,2224 Similarly, RCTs comparing nutritional or carbohydrate drinks at 2 to 4 h versus more than 4 h of fasting report equivocal findings for gastric volume, gastric pH, blood glucose values, hunger, and thirst (Category A2-E evidence).15,21,2432 A meta-analysis of RCTs reports a lower risk of aspiration (i.e., gastric volume < 25mL and pH > 2.5) when clear liquids are given 2 to 4 h before a procedure (Category A1-B evidence).12,13,16,17,19,20, Meta-analysis of RCTs report higher gastric pH values (Category A1-B evidence) and equivocal findings regarding differences in gastric volume (Category A1-E evidence) for children given clear liquids 2 to 4 h versus fasting for more than 4 h before a procedure.3342 Ingested volumes of clear liquids in the above studies range from 100ml to unrestricted amounts for adults, and 2ml/kg to unrestricted amounts for children. Both the consultants and ASA members agree that for infants, fasting from the intake of nonhuman milk for 6 or more hours before elective procedures requiring general anesthesia, regional anesthesia, or procedural sedation and analgesia should be maintained. Level 1: The literature contains a sufficient number of RCTs to conduct meta-analysis, and meta-analytic findings from these aggregated studies are reported as evidence. Inconsistent results were reported for residual gastric volume. The effect of preoperative oral carbohydrate or oral rehydration solution on postoperative quality of recovery: A randomized, controlled clinical trial. First, the Task Force reached consensus on the criteria for evidence. Preoperative oral feeding reduces stress response after laparoscopic cholecystectomy. Effects of oral carbohydrate with amino acid solution on the metabolic status of patients in the preoperative period: A randomized, prospective clinical trial. Effect of gum chewing on gastric volume and emptying: A prospective randomized crossover study. There is insufficient evidence concerning benefits and harms to recommend pediatric patients drink clear liquids until 1h versus 2h before procedures with general anesthesia, regional anesthesia, or procedural sedation (no recommendation). Randomized clinical trial comparing an oral carbohydrate beverage with placebo before laparoscopic cholecystectomy. GRADE guidelines: 15. Survey responses from expert and membership sources are recorded using a 5-point scale and summarized based on median values. The updated searches covered a 6.5-yr period from January 1, 2010, through May 31, 2016. Bugsnet: An R package to facilitate the conduct and reporting of Bayesian network meta-analyses. 5. This was my first step in dramatically reducing my alcohol intake. Comfort, safety and quality of upper gastrointestinal endoscopy after 2 hours fasting: A randomized controlled trial. Several pediatric anesthesia practices in the United States now utilize the 1-h fasting duration for clear liquids. The effects of carbohydrate-rich drink on perioperative discomfort, insulin response and arterial pressure in spinal aesthesia. Consider both the amount and type of foods ingested when determining an appropriate fasting period. Gastric emptying of clear liquid drinks assessed with gastric ultrasonography: A blinded, randomized pilot study. A Tool to Screen Patients for Obstructive Sleep Apnea, ACE (Anesthesiology Continuing Education), One-hour Clear Liquid Fasting in Pediatric Patients, Appendix: Study and Patient Characteristics, https://doi.org/10.1097/ALN.0000000000004381, https://CRAN.R-project.org/package=netmeta, https://CRAN.R-project.org/package=metasens, https://gdt.gradepro.org/app/handbook/handbook.html, 2023 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting: Carbohydrate-containing Clear Liquids with or without Protein, Chewing Gum, and Pediatric Fasting DurationA Modular Update of the 2017 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting, 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: A Report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade, 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway, Add Chewing Gum to 6-Hour Fasting Guidelines. The use of gastrozepin as a prophylaxis against pulmonary acid aspiration: a new muscarinic receptor antagonist. Copyright 2017, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. Anesthesiology 2017; 126:376393 doi: https://doi.org/10.1097/ALN.0000000000001452. The overall assessment of aspiration risk may not rely on ASA Physical Status alone, as many of the comorbidities that qualify patients for a higher ASA Physical Status score may be unrelated to delayed gastric emptying or aspiration risk (for example, poorly controlled hypertension). Select options. Effects of preoperative oral carbohydrate on cirrhotic patients under endoscopic therapy with anesthesia: A randomized controlled trial. The outcomes of interest for this update include the adverse consequences of fasting (hunger, thirst, and preoperative nausea and vomiting) and pulmonary aspiration. Observational (e.g., correlational or descriptive statistics). Patient satisfaction46,80 was reported in two trials, with higher satisfaction in patients drinking carbohydrate-containing clear liquids (low strength of evidence). Going from evidence to recommendationsThe significance and presentation of recommendations. Although differences were not detected in thirst, preoperative nausea, or patient satisfaction, the body of evidence is consistent with lower patient ratings of hunger with carbohydrate-containing clear liquids over noncaloric ones. : A randomised crossover trial. Editorials, letters, and other articles without data were excluded. Category A: Expert Opinion. The American Society of Anesthesiologists (ASA) recommends patients to fast from fatty food or meats eight (8) hours prior to surgery, non-human milk or light meal for six (6) hours prior, breast milk for four (4) hours prior, and clear liquids including water, pulp-free juice, and tea or coffee without milk for two (2) hours prior to the A carbohydrate-rich beverage prior to surgery prevents surgery-induced immunodepression: A randomized, controlled, clinical trial. A comparative evaluation of cimetidine and sodium citrate to decrease gastric acidity: effectiveness at the time of induction of anaesthesia. Healthcare database searches included PubMed, Web of Science, Google Books, and the Cochrane Central Register of Controlled Trials. The consultants agree and the ASA members strongly agree that fasting from the intake of a light meal ( e.g ., toast and a clear liquid) of 6 or more hours before elective procedures requiring general anesthesia, regional anesthesia, or procedural sedation and analgesia should be maintained. A randomized crossover study of the effects of glutamine and lipid on the gastric emptying time of a preoperative carbohydrate drink. metasens: Statistical methods for sensitivity analysis in meta-analysis. Two hundred ninety-eight new citations were identified and reviewed, with 42 new studies meeting the above stated criteria. Evaluation of effects of a preoperative 2-hour fast with glutamine and carbohydrate rich drink on insulin resistance in maxillofacial surgery. Findings from these RCTs are reported separately as evidence. Studies with multicomponent interventions (for example, enhanced recovery after surgery protocols) were excluded if the effect of fasting on outcomes could not be independently ascertained. Clinical practice includes, but is not limited to, withholding of liquids and solids for specified time periods before surgery and prescribing pharmacologic agents to reduce gastric volume and acidity. Reducing the duration of the preoperative fast for clear fluids may be one way to cheaply and easily improve postoperative outcomes, particularly for the older and multi-morbid patients who make up an . Three (30%) studies enrolled patients rated with ASA Physical Status I or II, and 1 (10%) study included ASA Physical Status I to III (6 [60%] studies did not report ASA Physical Status). Does preoperative oral carbohydrate reduce hospital stay? Actively encouraging clear liquids in healthy children as close to 2h before procedures as possible is important to avoid them. Benefits, Harms, and Strength of Evidence for 1-h versus 2-h Clear Liquid Fasting in Children. The body of evidence was first described according to study characteristics and treatment arms. An acceptable significance level was set at P< 0.01 (one-tailed). Investigation of preoperative fasting times in children. Individuals can improve their health and reduce their risk of contracting these and other diseases by quitting chewing tobacco. Evaluating ranitidine, pantoprazole and placebo on gastric pH in elective surgery. Oral preoperative antioxidants in pancreatic surgery: A double-blind, randomized, clinical trial. However, if a patient chews gum for personal comfort or preference, we recommend not delaying the scheduled elective procedure, due to inconclusive evidence of harm. Guidelines to the practice of anesthesia Revised edition 2022. Differences were not detected in vomiting99,100 or gastric pH99 between children fasted 1h versus 2h (low and very low strength of evidence, respectively). Category A. RCTs report comparative findings between clinical interventions for specified outcomes. Preoperative carbohydrate loading and intraoperative goal-directed fluid therapy for elderly patients undergoing open gastrointestinal surgery: A prospective randomized controlled trial. Evaluation of the effects of a preoperative 2-hour fast with maltodextrine and glutamine on insulin resistance, acute-phase response, nitrogen balance, and serum glutathione after laparoscopic cholecystectomy: A controlled randomized trial. Shrinking preoperative fast time with maltodextrin and protein hydrolysate in gastrointestinal resections due to cancer. Both the systematic literature review and opinion data are based on evidence linkages, or statements regarding potential relationships between preoperative fasting interventions and pulmonary aspiration or associated complications. Simple or complex carbohydratecontaining clear liquids appear to reduce hunger compared with noncaloric clear liquids.
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