Will one hour less make any difference?

Editor, The Editorial by Disma et al.1 on clear fluids fasting for elective paediatric anaesthesia rightly emphasises the need to harmonise guidelines. Some clinical societies have put forward new recommendations to reduce the fasting time for clear fluids from 2 to 1 h.2 The 2 h time limit guideline for oral clear fluids pre-operatively has been in place for at least 20 years now.3 Yet, patients continue to fast for far too long unnecessarily. Audits in our institution showed that the mean fasting time for fluids had only come down from 8 h in 2008 to 7 h in 2018. A recent study showed that even with targeted approaches such as patient education and improved communication, the mean fasting time for fluids could only come down to 5 h with a range up to 10 h!4 Although it could be argued that the lack of awareness of benefits of encouraging fluid intake and/or unfounded fears of pulmonary aspiration could be the reasons, two decades is a very long time for this not to be set right. In our institution, letters to patients explicitly mention a time up to which they could take specified clear fluids (this time is 2 h before the start of their estimated operation time). Hence, lack of patient information is not a factor. Members of the anaesthesia, surgical and nursing team are also aware of the guidelines. The failure to reduce unnecessary fasting times is not due to the 2 h limit. It is due to the practicalities of implementing this time frame. Despite pre-operative information, patients are anxious about taking fluids. The nursing staff have difficulty monitoring the 2 h time frame due to other commitments and they err on the side of not giving oral fluids. One option is for the anaesthetist to prescribe oral fluids with a specific time, quantity and nature of fluid. Although this works well, most anaesthetists do not pro-actively prescribe oral fluids. For these reasons, reducing the guideline time to 1 h is unlikely to make a huge difference since the basic issues relating to practicalities will remain unaddressed. There have been multiple recent large-scale studies in different countries which show the safety of allowing water until patients are called for surgery.5,6 This 0-2-6 approach for all except infants (‘0’ for water, ‘2’ for other clear fluids and ‘6’ for solids) will work best as it takes out the complexities of watching the clock or monitoring (at least for water). In our institution, we have implemented a ‘THINK DRINK’ campaign in which, on the day of arrival, surgical patients get a ‘welcome drink’ of water on admission and are allowed unlimited sips of water until being called. This increased staff and patient satisfaction significantly. An audit within 5 months of the change showed a reduction of ‘mean’ fasting time for fluids to 2 h. The figure included patients who had declined water. Considering the time it takes for a revised guideline to be published, the specialist societies need to consider a change to the 0-2-6 approach now rather than potentially wait another decade to find out that patients are not benefitting from the 1 h time limit. Acknowledgements relating to this article Assistance with the letter: I would like to thank Dr Christopher Horner and Dr Ahmed Gilani for their help with the audit. Financial support and sponsorship: none. Conflicts of interest: none.