The impact of preoperative carbohydrate loading on patients with type II diabetes in an enhanced recovery after surgery protocol. Preoperative oral fluids: is a five-hour fast justified prior to elective surgery? Throughout these guidelines, the term preoperative should be considered synonymous with preprocedural, as the latter term is often used to describe procedures that are not considered to be operations. Black or white coffee before anaesthesia? 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. NPO Instructions in chronic tobacco chewers are they enough? Ultrasound-guided assessment of gastric residual volume in patients receiving three types of clear fluids: A randomised blinded study. Additional fasting time (e.g., 8 or more hours) may be needed in cases of patient intake of fried foods, fatty foods, or meat. Society for Ambulatory Anesthesia 12th Annual Meeting, Orlando, Florida, 1997. CINeMA: An approach for assessing confidence in the results of a network meta-analysis. Table 7 summarizes the evidence for clinically important outcomes. Preoperative nil per os (NPO) guidelines have been in existence since the recognition of the risk of perioperative aspiration. However, only the findings obtained from formal surveys are reported in the current update. * The interventions listed in the evidence model below were examined to assess their impact on outcomes related to perioperative pulmonary aspiration. Framing the question and deciding on important outcomes. An RCT comparing a light breakfast consumed less than 4 h before a procedure with overnight fasting reports equivocal findings for gastric volume and pH levels for adults (Category A3-E evidence).47 A second RCT reports equivocal findings when a light breakfast is allowed at 4 h compared with 6 h before a cesarean section (Category A3-E evidence), although a significant reduction in maternal and neonatal blood glucose levels was reported when fasting was extended beyond 6 h (Category A3-H evidence).48 Nonrandomized comparative studies for children given nonhuman milk 4 h or less before a procedure versus children fasted for more than 4 h report equivocal findings for gastric volume and pH (Category B1-E evidence).4951 One nonrandomized study indicated that fasting for more than 8 h may be associated with significantly lower blood glucose levels (Category B1-H evidence).51 The literature is insufficient to evaluate the effect of the timing of ingestion of solids and nonhuman milk and the perioperative incidence of pulmonary aspiration or emesis/reflux. For these guidelines, the primary outcomes of interest are pulmonary aspiration and the frequency or severity of adverse consequences associated with aspiration (e.g., pneumonitis). Making multiple, small, incremental improvements across the whole of the perioperative pathway is likely to be the best way of improving outcomes from elective surgery in the developed world. All meta-analyses are conducted by the ASA methodology group. Patients chewing gum had a minimally increased residual gastric volume at anesthesia induction compared with fasting (table 6). Oral carbohydrate administration in patients undergoing cephalomedullary nailing for proximal femur fractures: An analysis of clinical outcomes and patient satisfaction. A randomized controlled trial of preoperative carbohydrate drinks on postoperative walking capacity in elective colorectal surgery. #6. Do not routinely administer preoperative medications that block gastric acid secretion for the purpose of reducing the risk of pulmonary aspiration in patients with no apparent increased risk for pulmonary aspiration. Guidelines to the practice of anesthesia Revised edition 2022. Clear fluids are: Do not swallow gum or hard candy. Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. Carbohydrate-containing liquids may have an impact on blood glucose levels in patients with diabetes, especially patients who skip or reduce their usual hypoglycemics before surgery. 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. Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. 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. No aspiration after carbohydrate-containing clear or noncaloric clear liquids was reported in 17 randomized controlled trials.23,24,26,39,55,57,59,63,74,75,77,78,8084 (strength of evidence not rated due to lack of events). Differences were not detected in regurgitation43,49,55,66,68,69 (very low strength of evidence) or preoperative vomiting39,5052,62 (low strength of evidence). Potential inclusionexclusion discrepancies were also examined with an artificial intelligence tool, a component of the systematic review software. Safe pre-operative fasting times after milk or clear fluid in children. Findings from these RCTs are reported separately as evidence. Screening was performed independently by two methodologists. Almost all adult study participants had an ASA Physical Status I or II (92%). Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Two hundred ninety-eight new citations were identified and reviewed, with 42 new studies meeting the above stated criteria. Literature citations are obtained from healthcare databases, direct internet searches, Task Force members, liaisons with other organizations, and from manual searches of references located in reviewed articles. Oral fluids prior to day surgery. Clinical and metabolic results of fasting abbreviation with carbohydrates in coronary artery bypass graft surgery. A light meal or nonhuman milk may be ingested for up to 6 h before elective procedures requiring general anesthesia, regional anesthesia, or procedural sedation and analgesia.. The literature is insufficient to evaluate the effect of preoperative antiemetics on the perioperative incidence of pulmonary aspiration, gastric volume, or pH.. Finally, there is a need for education of patients, their caregivers, and healthcare providers regarding avoidance of preoperative fasting beyond the recommended durations and the detrimental effects of prolonged fasting. Rigorous comparisons for equivalence or superiority between 1-h versus 2-h fasting durations in pediatric patients are needed. Gastric residual volume in infants and children following a 3-hour fast. Effect of pre-operative oral carbohydrate loading on recovery after day-case cholecystectomy: A randomised controlled trial. 8,827. The guideline topics were approved by the Guidelines Committee and the ESAIC Board after a consultation process within the subcommittees of the ESAIC Scientific Committee. Category A. RCTs report comparative findings between clinical interventions for specified outcomes. The effect of preoperative oral intake of liquid carbohydrate on postoperative stress parameters in patients undergoing laparoscopic cholecystectomy: An experimental study. Cimetidine as a single oral dose for prophylaxis against Mendelsons syndrome. The history, examination, and interview should include assessment of ASA physical status, age, sex, type of surgery, and potential for difficult airway management as well as consideration of gastroesophageal reflux disease, dysphagia symptoms, other gastrointestinal motility and metabolic disorders (e.g., diabetes mellitus) that may increase the risk of regurgitation and pulmonary aspiration. The evidence suggests there is not a clinically meaningful increase in gastric volume after chewing gum. Effect on the risk factors of acid aspiration. Pre-operative oral carbohydrate treatment before coronary artery bypass surgery. Clear liquids may be ingested for up to 2 h before procedures requiring general anesthesia, regional anesthesia, or procedural sedation and analgesia. 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. The carbohydrates may be simple or complex. Benefits, Harms, and Strength of Evidence for 1-h versus 2-h Clear Liquid Fasting in Children. The addition of protein to preoperative carbohydrate-containing clear liquids did not appear to either benefit or harm healthy patients. Randomized clinical trial of the effects of oral preoperative carbohydrates on postoperative nausea and vomiting after laparoscopic cholecystectomy. Interindividual and intraindividual variability of fasted state gastric fluid volume and gastric emptying of water. Menthol chewing gum on preoperative thirst management: Randomized clinical trial. Scientific evidence used in the development of these updated guidelines is based on cumulative findings from literature published in peer-reviewed journals. Clear liquids containing less than 10 gm/ml carbohydrate were not considered carbohydrate-containing. Gastric emptying of clear liquid drinks assessed with gastric ultrasonography: A blinded, randomized pilot study. In addition, practice guidelines developed by the American Society of Anesthesiologists (ASA) are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. Randomised controlled trial comparing preoperative carbohydrate loading with standard fasting in paediatric anaesthesia. 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). Eight hours fasting from enteral feeds is preferred. In this document, only the highest level of evidence is included in the summary report for each intervention-outcome pair, including a directional designation of benefit, harm, or equivocality. The routine administration of preoperative multiple agents is not recommended for patients with no apparent increased risk for pulmonary aspiration. 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. Hypoglycaemia in children before operation: its incidence and prevention. The literature is insufficient to evaluate the effect of timing of the ingestion of infant formula on the perioperative incidence of pulmonary aspiration, gastric volume, pH or emesis/reflux. Titles with abstracts and full-text screening were performed using systematic review software (DistillerSR,9 Evidence Partners, Ottawa, Canada). A preliminary study using real-time ultrasound. Studies enrolled a median of 75 participants (range, 9 to 237). Patient satisfaction31,46 was reported in only two trials, and a difference could not be assessed (low strength of evidence). Important consideration should be given to comorbidities that may affect gastric emptying and/or aspiration risk, regardless of ASA Physical Status. Observational studies indicate that some predisposing patient conditions (e.g., age, sex, ASA physical status, emergency surgery) may be associated with the risk of perioperative aspiration (Category B2-H evidence).15 Observational studies addressing other predisposing conditions (e.g., obesity, diabetes, esophageal reflux, smoking history) report inconsistent findings regarding risk of aspiration (Category B1-E evidence).611. michael emerson first wife; bike steering feels heavy; asa npo guidelines 2020 chewing tobacco Approximately one half (53%) were conducted in low-resource countries (Human Development Index scores less than 0.8). Support was provided by the American Society of Anesthesiologists (Schaumburg, Illinois) and developed under the direction of the Committee on Practice Parameters, Karen B. Domino, M.D., M.P.H. The original guidelines and the previous update in 2011 was developed by means of a seven-step process. Inform patients of fasting requirements and the reasons for them sufficiently in advance of their procedures. (Chair). Does adding milk to tea delay gastric emptying? RCTs report equivocal findings for gastric volume and acidity when histamine-2 receptor antagonists (i.e., cimetidine, ranitidine) are combined with gastrointestinal stimulants (i.e., metoclopramide) compared with either drug alone (Category A2-E evidence).56,5860,105107 RCTs comparing histamine-2 receptor antagonists or metoclopramide with sodium citrate report equivocal findings for gastric volume and acidity (Category A2-E evidence).57,106. A meta-analysis of three trials found a difference of 2.5ml (95% CI, 8.6 to 3.7) in residual gastric volume for protein-containing clear liquids versus fasting.49,68,91. Editorials, letters, and other articles without data were excluded. Anesthesia care during procedures refers to general anesthesia, regional anesthesia, or procedural sedation and analgesia. A comparison of the effects of ranitidine and omeprazole on volume and pH of gastric contents in elective surgical patients. 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. Both the consultants and ASA members disagree that gastrointestinal stimulants should be routinely administered before elective procedures requiring general anesthesia, regional anesthesia, or procedural sedation and analgesia in patients with no apparent increased risk for pulmonary aspiration. Copyright 2023 American Society of Anesthesiologists. Search for other works by this author on: Address correspondence to American Society of Anesthesiologists: 1061 American Lane, Schaumburg, Illinois 60173. A carbohydrate-rich drink shortly before surgery affected IGF-I bioavailability after a total hip replacement. should I observe the same fasting intervals? Effects of preoperative oral carbohydrate loading on preoperative and postoperative comfort in patients planned to undergo elective cholecystectomy: A prospective randomized controlled clinical trial. Actively encouraging clear liquids in healthy children as close to 2h before procedures as possible is important to avoid them. The mean age of participants was 47 yr, 70% were female, and the average body mass index was 23.9kg/m2. Safety and efficacy of oral rehydration therapy until 2h before surgery: a multicenter randomized controlled trial. Evidence was obtained from two principal sources: scientific evidence and opinion-based evidence (appendix 2). 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. According to the American Society of Anesthesiologists (ASA) Preoperative Fasting Guidelines for Healthy Patients of All Ages, it is recommended that all patients abstain from drinking clear liquids 2 hours prior to elective surgery. The effect of a small drink. The purpose of this modular update is to evaluate the current evidence on preoperative fasting, focusing on these interventions. 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 PRACTICE guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. High-risk residual gastric content in fasted patients undergoing gastrointestinal endoscopy: a prospective cohort study of prevalence and predictors. Decision-making is complicated by emerging data suggesting that some of the conditions traditionally considered to have an impact on gastric emptying may have little or no effect on gastric emptying. Eligible studies included randomized and nonrandomized trials, quasiexperimental, cohort (prospective and retrospective), and case-control designs. Randomized clinical trial to compare the effects of preoperative oral carbohydrate loading. Industry support was reported in 16 trials, and author conflict of interest was reported in 12 (10%) studies. Unless otherwise specified, outcomes for the listed interventions refer to the occurrence of pulmonary aspiration complications associated with aspiration, gastric contents, or nausea/vomiting. Reaction score. All studied protein-containing clear liquids also contained carbohydrates. GRADE guidelines: 14. Comparators of interest include, Carbohydrate- and protein-containing clear liquids alone and in combination. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints and are not intended to replace local institutional policies. Level 1: The literature contains observational comparisons (e.g., cohort, case-control research designs) with comparative statistics between clinical interventions for a specified clinical outcome. Advise patients at every office visit to avoid exposure to environmental tobacco smoke at home, work, and in public places. chewing tobacco npo guidelines. A light meal or nonhuman milk may be ingested for up to 6 h before elective procedures requiring general anesthesia, regional anesthesia, or procedural sedation and analgesia.. There was no incidence of aspiration in any group. These guidelines aim at reducing the risk for gastric content aspiration to the lowest possible, to avoid associated morbidity, unplanned hospital and/or an intensive care admission. NPO Guidelines NPO Guidelines Guidelines for Adults and Teenagers Adults and teenagers over the age of 12 may have solid foods and dairy products until 8 hours before their scheduled arrival time at the hospital or surgery center. Effects of preoperative carbohydrate drinks on postoperative outcome after colorectal surgery. Guidance regarding the cigarette tax rate increase was provided in the Virginia Cigarette Tax Rate Increase . Individuals can improve their health and reduce their risk of contracting these and other diseases by quitting chewing tobacco. A comparative evaluation of cimetidine and sodium citrate to decrease gastric acidity: effectiveness at the time of induction of anaesthesia. Conditional recommendations are those where most, but not all, would choose the action or approach.20,21 When the task force judged the body of evidence inappropriate to rate the strength of evidence but judged a recommendation important, a best practice statement was considered.22. The administration of an oral carbohydrate-containing fluid prior to major elective upper-gastrointestinal surgery preserves skeletal muscle mass postoperativelyA randomised clinical trial. 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). Comfort, safety and quality of upper gastrointestinal endoscopy after 2 hours fasting: A randomized controlled trial. An acceptable significance level was set at P< 0.01 (one-tailed). For the previous update, consensus was obtained from multiple sources, including: (1) survey opinion from consultants who were selected based on their knowledge or expertise in preoperative fasting and prevention of pulmonary aspiration, (2) survey opinions solicited from active members of the ASA membership, (3) testimony from attendees of a publicly-held open forum for the original guidelines held at a national anesthesia meeting, (4) Internet commentary, and (5) Task Force opinion and interpretation. Gastric pH and residual volume after 1 and 2h fasting time for clear fluids in children. Preoperative oral carbohydrate loading in laparoscopic gynecologic surgery: A randomized controlled trial. Lansoprazole in the prophylaxis of acid aspiration during elective surgery. In addition, practice guidelines developed by the American Society of Anesthesiologists (ASA) are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. Total hip arthroplasty and perioperative oral carbohydrate treatment: A randomised, double-blind, controlled trial. Effect of oral liquids and ranitidine on gastric fluid volume and pH in children undergoing outpatient surgery. Preoperative cimetidineeffects on gastric fluid. Gastric emptying time of two different quantities of clear fluids in children: A double-blinded randomized controlled study. The effects of intravenous cimetidine and metoclopramide on gastric volume and pH. Do not routinely administer preoperative antacids for the purpose of reducing the risk of pulmonary aspiration in patients with no apparent increased risk for pulmonary aspiration. Girish P. Joshi, M.B.B.S., M.D., Dallas, Texas; Basem B. Abdelmalak, M.D., Cleveland, Ohio; Wade A. Weigel, M.D., Seattle, Washington; Monica W. Harbell, M.D., Phoenix, Arizona; Catherine I. Kuo, M.D., Downers Grove, Illinois; Sulpicio G. Soriano, M.D., Boston, Massachusetts; Paul A. Stricker, M.D., Philadelphia, Pennsylvania; Tommie Tipton, B.S.N., R.N., C.N.O.R., Dallas, Texas; Mark D. Grant, M.D., Ph.D., Schaumburg, Illinois; Anne M. Marbella, M.S., Schaumburg, Illinois; Madhulika Agarkar, M.P.H., Schaumburg, Illinois; Jaime Friel Blanck, M.L.I.S., M.P.A., Baltimore, Maryland; Karen B. Domino, M.D., M.P.H., Seattle, Washington. The 2017 guideline also did not address chewing gum or whether a shorter duration of fasting from clear liquids would be more beneficial than the current recommendation of 2h of fasting for pediatric patients. Single-dose oral omeprazole for reduction of gastric residual acidity in adults for outpatient surgery. The effects of preoperative carbohydrate loading on the metabolic response to surgery in a low resource setting. Oral ranitidine for prophylaxis against Mendelsons syndrome. Aspiration can occur during any type of anesthesia, as a result of . Effect of preanesthetic glycopyrrolate and cimetidine on gastric fluid pH and volume in outpatients. Procedures in which upper airway protective reflexes may be impaired. None of the studies received industry support, and 1 study noted author conflict of interest. Surgical fasting guidelines in children: Are we putting them into practice? Anesthesiologists and other anesthesia providers should recognize that these conditions can increase the likelihood of regurgitation and pulmonary aspiration, and that additional or alternative preventive strategies may be appropriate. No smoking for at least 12 hours before surgery. (Chair). Cimetidine for prophylaxis of aspiration pneumonitis: comparison of intramuscular and oral dosage schedules. Because gum chewing and 1-h fasting in pediatric patients were new in this guideline, studies published beginning in January 1990 were eligible. The authors declare no competing interests. 8,061. netmeta: Network meta-analysis using frequentist methods. Tolerance of, and metabolic effects of, preoperative oral carbohydrate administration in childrenA preliminary report. The effect of a new preoperative fasting regime on the subjective perception, postoperative recovery, postoperative complications, and satisfaction in pediatric patients. asa npo guidelines 2020 chewing tobacco Call us today! 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 Com. 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. In this framework, randomized control trials start as high strength of evidence, and nonrandomized studies start as low. The effect of pre-operative intake of oral water and ranitidine on gastric fluid volume and pH in children undergoing elective surgery. Accepted for publication October 26, 2016. Effects of 2-, 4- and 12-hour fasting intervals on preoperative gastric fluid pH and volume, and plasma glucose and lipid homeostasis in children. Effect of preoperative consumption of high carbohydrate drink (pre-op) on postoperative metabolic stress reaction in patients undergoing radical prostatectomy. 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). asa npo guidelines 2020 chewing tobacconewtonian telescope 275mm f/5,3. The administration of preoperative anticholinergics to reduce the risk of pulmonary aspiration is not recommended. Airway management techniques that are intended to reduce the occurrence of pulmonary aspiration are not the focus of these guidelines. Chewing Gum: A Hazard That Warrants Delaying the Case? Anesthesiology 2013; 118:291307. Meta-analysis of placebo-controlled RCTs indicate that metoclopramide is effective in reducing gastric volume and pH during the perioperative period (Category A1-B evidence).5560 The literature is insufficient to evaluate the effect of metoclopramide on the perioperative incidence of pulmonary aspiration.***. For example, a rapid-sequence induction/endotracheal intubation technique or awake endotracheal intubation technique may be useful to prevent this problem during the delivery of anesthesia care. In the meantime, the task force wishes to remind clinicians to exercise clinical judgment in minimizing feeding interruptions in critically ill patients whose airways are protected with endotracheal or tracheostomy tubes with properly inflated cuffs undergoing procedures that do not include reintubation or airway manipulations. Girish P. Joshi, Basem B. Abdelmalak, Wade A. Weigel, Monica W. Harbell, Catherine I. Kuo, Sulpicio G. Soriano, Paul A. Stricker, Tommie Tipton, Mark D. Grant, Anne M. Marbella, Madhulika Agarkar, Jaime F. Blanck, Karen B. Domino; 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.

Winter Wedding Venues California, Articles A