A drink before surgery? Patients may be fasting longer than needed

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Two Sydney hospitals have become the first in Australia to relax rules for fasting before surgery, as growing evidence shows patients can safely drink water, juice and even black coffee while waiting for a procedure.

Since July, patients having elective surgery at Prince of Wales Hospital in Randwick and Sydney Eye Hospital have been allowed to drink “clear” liquids – those without milk or pulp – right up to going into the operating theatre.

Dr Louisa Lowes says fasting rules for surgery were causing unnecessary discomfort. Credit: Wolter Peeters

Patients are asked to fast from food and drink as a precaution to reduce the risk of vomiting or asphyxiating during surgery.

However, growing evidence about how quickly the stomach empties suggests there is little risk from patients having water, refined juice or black coffee and tea before going under anaesthetic.

The two hospitals join a growing group of more than 170 facilities worldwide which have switched to a “sip ’til send” model popularised in the UK. In South Australia, Royal Adelaide Hospital has also adopted the policy.

Anaesthetist Dr Louisa Lowes, Prince of Wales’ director of perioperative medicine and one of three clinicians at the hospital who led the change, said there had been no increase in adverse events since the change in July.

“Our big concern is that patients waiting for theatre can get quite uncomfortable when they can’t have anything to drink at all,” she said.

The previous fasting regime also presented a problem when procedures were delayed, Lowes said.

“Staff will be hesitant to give someone a drink because they don’t know if they will need to be sent in the next two hours, and as a result people have been fasting longer than they need to.”

Patients may sip on 200 millilitres of a drink, or a small cup, each hour before surgery. Previously, they needed to fast from two hours before surgery. Rules for eating – banned from six hours before surgery – remain unchanged.

The Australia and New Zealand College of Anaesthetists rewrote its elective surgery fasting guidelines in 2022, reducing the recommended fasting time from clear liquids from six hours to two.

Professor Joanna Sutherland, chair of the college’s safety and quality committee, said evidence was increasingly showing that the old rule of “fasting from midnight” from liquids before a procedure did more harm than good.

She said liquids not only did not pose the same risk of vomiting or choking – through airway blockage or inflammation of the lungs from acidic material – as solids, but likely even helped reduce it.

“We now understand the longer a normal stomach is kept empty of clear fluids, the more likely the acidic environment in the stomach could cause damage to the lung,” she said.

“If you give a small amount of fluid it will not only dilute the acid but will also encourage the stomach to empty.”

She said it was possible further changes to the college’s fasting guidelines for clear liquids could occur. However, she said anaesthetists were “very risk averse”, and there was a need to not over-complicate the message to patients.

Sutherland said it was important for patients to take their fasting instructions from their own surgical team, noting a variety of medications – including opioids and appetite suppressant drugs, such as Ozempic – impact the speed at which the stomach empties.

In private hospitals, fasting directions are usually determined by individual surgeons.

Dr Michelle Atkinson, a private orthopaedic surgeon in Sydney and president of the Royal Australasian College of Surgeons, said some surgeons – including herself – already allowed patients to drink until surgery, noting papers on its safety had been published since the early 1990s.

Lowes said she was hopeful more public hospitals would also make the change.

“The ball is now rolling: there are a lot of other hospitals that are interested in this, and I think we will see more change their own guidelines and policies moving forwards,” she said.

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