TAM (Treatments and Medicines) NHS Highland
Responsibilities and organisational arrangements
Directors/ Assistant Directors /General Managers/ Lead Nurses for the Health and Social Care Partnerships (or equivalent) are responsible for the distribution of this protocol to staff within their area/directorate/business unit; ensuring information given to patients is consistent with this change in policy.
Senior Clinical Nurses are responsible for ensuring this protocol is implemented within their area and to monitor compliance.
All clinical staff are responsible for their own compliance with the guidance contained within this protocol, identifying their own training needs and attending appropriate training when provided.
Background
The requirement for all adult surgical patients undergoing general anaesthesia to be in the fasted state has been considered one of the fundamental cornerstones for safe peri‐operative care, (Fawcett & Thomas 2018). This has been challenged, and many now accept that the morbidity caused by prolonged fluid fasting is no longer acceptable and offers no safety benefit (Morrison et al 2020).
Pre-operative fasting is the time during which a patient is “nil by mouth” before a planned procedure or emergency surgery, and continues until the patient regains consciousness post operatively and is able to take fluids orally (RCN 2005). The aim is to have an empty stomach so as to avoid the event of the patient aspirating (stomach contents entering the lungs) whilst under general anaesthesia or deep sedation.
Evidence has demonstrated that some patients are at greater risk from prolonged fasting, specifically those who are diabetic, pregnant women, those that have peptic ulcer, gastric reflux, stress, pain, or who habitually take narcotics or alcohol (AAGBI, 2010, Robinson & Davidson (2014)
It was historical practice to fast patients from food for for 6–8 h and from fluids for 2 hours prior to anaesthesia to reduce this risk of aspiration, but there is little evidence for these cut-offs (Morrison et al 2020, Maltby 2006).
Given the unpredictable nature of operating room scheduling and inevitable delays, patients are waiting and fasting much longer (NHST Survey Pre-op fluid fasting May 2021, NHSH Survey Pre-op fluid fasting in trauma, Feb 2022) than expected, which is a common cause of patient morbidity and anxiety.
Prolonged fluid fasting is an inappropriate way to prepare for the stresses of surgery and can be detrimental to patients, (BADS 2013; Lambert & Carey 2015). Not only can prolonged fasting result in significant discomfort for patients including increased feelings of thirst and hunger (Crenshaw 2011, Pimenta & Aguilar-Nascimento 2013, Lambert & Carey 2015), but can also lead to hypotension on induction of anaesthesia, and evidence of a catabolic state (Fawcett & Thomas 2018) and is associated with an increased incidence of postoperative nausea and vomiting, (Thomas & Engelhardt 2017).
In 1999, The American Society of Anesthesiology took the first step towards liberalising pre-operative fluid fasting guidelines and both randomised control trials and reviews in the past decade have shown that there is little or no evidence that the volume or pH of gastric contents differed significantly whether patients were permitted a shortened pre-operative fluid fast or had a standard fast from fluids.
In 2005 the RCN endorsed clinical practice guidelines demonstrating that free clear fluids could be safely administered until 2 h before surgery in adults (RCN 2005) and it was envisaged that this would have had patient benefits including; increased wellbeing, reduced side effects like headache, dry mouth, sore throat, and nausea (Smith et al. 2011, Chon et al. 2017).
Unfortunately, local audits have shown that the 2 hr fluid fast has failed to reduce median fluid fasting times which often significantly exceed 6 hours.
The NHS Highland anaesthetic department implemented a policy for reduced fasting times among a cohort of patients awaiting surgery for neck of femur fracture repair. Patients were highlighted on admission and provided with a 170ml cup with a jug of water by their bed-space. Patients were allowed to sip clear fluid up until the point of being summoned for their procedure. This policy was termed ‘Sip Til Send’. These patients exhibited a much reduced fluid fasting time with no increased incidence of complications eg aspirations.
Results from the subsequent audit were presented at a local departmental meeting of anaesthetists at NHS Highland with support for extending this protocol to wider emergency and elective patients awaiting surgery.
Elective surgery patients have fewer variables regarding pathology, physiology, timing, risk and mode of anaesthesia and are often on an enhanced recovery pathway. Patients undergoing elective surgery may gain from improved recovery consequent to this policy change. Sip Til Send will be the default for the National Treatment Centre.
NHS Tayside having adopted the Sip Til Send policy in December 2021 for all surgical areas across all sites. now have a cohort of over 2000 cases with no adverse events such as aspiration.