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Practice Guidelines for Preoperative Fasting and the Use ...

Practice PARAMETERS. 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 An Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration*. P RACTICE Guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recom- these Guidelines , the term Preoperative should be consid- ered synonymous with preprocedural, as the latter term is often used to describe procedures that are not considered to mendations may be adopted, modified, or rejected accord- be operations.

observational studies with associative statis-tics (e.g., relative risk, correlation, sensitivity and specificity). Level 3:The literature contains noncomparative observational studies with descriptive statis-tics (e.g., frequencies, percentages). Level 4: A preoperative assessment includes a review of medical The literature contains case reports.

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1 Practice PARAMETERS. 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 An Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration*. P RACTICE Guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recom- these Guidelines , the term Preoperative should be consid- ered synonymous with preprocedural, as the latter term is often used to describe procedures that are not considered to mendations may be adopted, modified, or rejected accord- be operations.

2 Anesthesia care during procedures refers to ing to clinical needs and constraints, and are not intended general anesthesia, regional anesthesia, or procedural seda- to replace local institutional policies. In addition, Practice tion and analgesia. Guidelines developed by the American Society of Anesthe- siologists (ASA) are not intended as standards or absolute Purposes of the Guidelines requirements, and their use cannot guarantee any specific The purposes of these Guidelines are to provide direction for outcome. Practice Guidelines are subject to revision as war- clinical Practice related to Preoperative Fasting and the use of ranted by the evolution of medical knowledge, technology, pharmacologic agents to reduce the risk of pulmonary aspi- and Practice .

3 They provide basic recommendations that are ration and to reduce the severity of complications related supported by a synthesis and analysis of the current litera- to perioperative pulmonary aspiration. Clinical Practice ture, expert and practitioner opinion, open forum commen- includes, but is not limited to, withholding of liquids and tary, and clinical feasibility data. solids for specified time periods before surgery and prescrib- This document updates the Practice Guidelines for ing pharmacologic agents to reduce gastric volume and acid- Preoperative Fasting and the Use of Pharmacologic Agents ity. Enhancements in the quality and efficiency of anesthesia to Reduce the Risk of Pulmonary Aspiration: An Updated care include, but are not limited to, the utilization of peri- Report adopted by the ASA in 2010 and published in 2011.

4 Operative preventive medication, increased patient satisfac- tion, avoidance of delays and cancellations, decreased risk of Methodology dehydration or hypoglycemia from prolonged Fasting , and the minimization of perioperative morbidity. Complications Definition of Preoperative Fasting and Pulmonary of aspiration include, but are not limited to, aspiration pneu- Aspiration monia, respiratory compromise, and related morbidities. For these Guidelines , Preoperative Fasting is defined as a pre- scribed period of time before a procedure when patients are Focus not allowed the oral intake of liquids or solids. Perioperative Prevention of perioperative pulmonary aspiration is part of pulmonary aspiration is defined as aspiration of gastric con- the process of Preoperative evaluation and preparation of the tents occurring after induction of anesthesia, during a proce- patient.

5 The Guidelines specifically focus on Preoperative fast- dure, or in the immediate postoperative period. Throughout ing recommendations, as well as recommendations regarding This article is featured in This Month in Anesthesiology, page 1A. Supplemental digital content is available for this article. Direct URL. citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal's Web site ( ). A complete bibliography used to develop these updated Guidelines , arranged alphabetically by author, is available as Supplemental Digital Content 1, Submitted for publication October 26, 2016. Accepted for publication October 26, 2016.

6 Approved by the ASA House of Delegates on October 26, 2016. * Updated by the American Society of Anesthesiologists Committee on Standards and Practice Parameters: Jeffrey L. Apfelbaum, (Chair), Chicago, Illinois; Madhulika Agarkar, , Schaumburg, Illinois; Richard T. Connis, , Woodinville, Washington; Charles J. Cot , , Boston, Massachusetts; David G. Nickinovich, , Bellevue, Washington; and Mark A. Warner, , Rochester, Minnesota. American Society of Anesthesiologists: Practice Guidelines for Preoperative Fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: An updated report. ANESTHESIOLOGY 2011; 114:495 511. Copyright 2017, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved.

7 Anesthesiology 2017; 126:376 93. Anesthesiology, V 126 No 3 376 March 2017. Copyright 2017, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. <zdoi; >. Downloaded From: Unauthorized reproduction of this article is prohibited. by ASA, Vicki Tedeschi on 06/26/2017. Practice PARAMETER. the administration of pharmacologic agents to modify the and pharmacologic agents and (2) review and comment on a volume and acidity of gastric contents during procedures in draft of the Guidelines developed by the Task Force. Fourth, which upper airway protective reflexes may be impaired. opinions about the guideline recommendations were solic- Airway management techniques that are intended to ited from a random sample of active members of the ASA.

8 Reduce the occurrence of pulmonary aspiration are not the Fifth, the Task Force held an open forum at a major national focus of these Guidelines . For example, a rapid-sequence meeting to solicit input on its draft recommendations. induction/endotracheal intubation technique or awake endo- Sixth, the consultants were surveyed to assess their opinions tracheal intubation technique may be useful to prevent this on the feasibility of implementing the updated Guidelines . problem during the delivery of anesthesia care. The guide- Seventh, all available information was used to build consen- lines do not address the selection of anesthetic technique, nor sus within the Task Force to finalize the updated Guidelines . do they address enhanced recovery protocols not designed to reduce the perioperative risk of pulmonary aspiration.

9 Availability and Strength of Evidence The intended patient population is limited to healthy Preparation of these Guidelines followed a rigorous methodologi- patients of all ages undergoing elective procedures. The cal process. Evidence was obtained from two principal sources: Guidelines do not apply to patients who undergo procedures scientific evidence and opinion-based evidence (appendix 2). with no anesthesia or only local anesthesia when upper air- Scientific Evidence. Scientific evidence used in the devel- way protective reflexes are not impaired and when no risk opment of these updated Guidelines is based on cumulative factors for pulmonary aspiration are apparent. findings from literature published in peer-reviewed journals. The Guidelines may not apply to or may need to be modi- Literature citations are obtained from healthcare databases, fied for patients with coexisting diseases or conditions that can direct internet searches, Task Force members, liaisons with affect gastric emptying or fluid volume ( , pregnancy, obesity, other organizations, and from manual searches of references diabetes, hiatal hernia, gastroesophageal reflux disease, ileus or located in reviewed articles.)

10 Bowel obstruction, emergency care, or enteral tube feeding) Findings from the aggregated literature are reported in and patients in whom airway management might be diffi- the text of the Guidelines by evidence category, level, and cult. Anesthesiologists and other anesthesia providers should direction and in appendix 2 (table 2). Evidence categories recognize that these conditions can increase the likelihood of refer specifically to the strength and quality of the research regurgitation and pulmonary aspiration, and that additional or design of the studies. Category A evidence represents results alternative preventive strategies may be appropriate. obtained from randomized controlled trials (RCTs) and Cat- egory B evidence represents observational results obtained Application from nonrandomized study designs or RCTs without per- These Guidelines are intended for use by anesthesiologists and tinent comparison groups.


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