Pulmonary Aspiration Research Articles

A Review of Current Literature of Interest to the Office-Based Anesthesiologist.

A Review of Current Literature of Interest to the Office-Based Anesthesiologist.

Using gastric ultrasound to assess gastric content in the pregnant patient

Perioperative pulmonary aspiration of gastric content can lead to prolonged tracheal intubation, hospitalisation, aspiration pneumonitis and pneumonia.1 Unfortunately, the risk of aspiration is often estimated by fasting time, not accounting for comorbidities that affect gastric emptying, such as labour. Bedside point-of-care ultrasound (POCUS) of gastric content is a validated tool that allows the anaesthetist to assess the qualitative and quantitative content of the stomach.2 This technique has been used and validated in pregnant women to define the cut-off values for the risk of aspiration.

709 PL11.05 NOVEL DIGITAL REFLUX SCINTIGRAPHY DETECTS PULMONARY MICROASPIRATION IN SEVERE GASTRO-OESOPHAGEAL AND LARYNGOPHARYNGEAL REFLUX DISEASE

Abstract No gold-standard diagnostic test for laryngopharyngeal reflux (LPR) exists. Symptoms alone are non-diagnostic, and pH-impedance studies have poor sensitivity. Pulmonary micro-aspiration is under-recognised in LPR and gastro-oesophageal reflux disease (GORD). The present study aimed to describe the results of a novel digital technique for scintigraphic reflux studies in two groups with severe reflux: those with typical reflux symptoms and those with laryngopharyngeal manifestations of reflux. Methods A prospective database of severely symptomatic, treatment-resistant reflux patients was grouped based upon predominant symptom profile of typical GORD or LPR. All patients underwent novel reflux scintigraphy. Results were obtained for early scintigraphic reflux contamination of the pharynx and proximal oesophagus, and delayed contamination of the pharynx and lungs after two hours. Results The LPR patients were predominantly female (70.5% vs. 56.1%; p = 0.042) and older than the GORD group (median age 60 years vs. 55.5 years; p = 0.002). Early scintigraphic reflux was seen at the pharynx in 89.2% (GORD 87.7%, LPR 90.4%; p = 0.133), and at the proximal oesophagus in 89.7% (GORD 88.9%, LPR 90.4%; p = 0.147). Delayed contamination of the pharynx was seen in 95.2% (GORD 93.9%, LPR 96.2%; p = 0.468). Delayed pulmonary aspiration was seen in 46% (GORD 36.6%, LPR 53.3%; p = 0.023). Conclusion Reflux scintigraphy demonstrated a high rate of digitally identified reflux pulmonary aspiration. Contamination of the proximal oesophagus and pharynx was observed frequently in both groups of severe disease. The likelihood of pulmonary aspiration and potential pulmonary disease needs to be entertained in severe GORD and LPR.

Ketamine versus propofol for rapid sequence induction in trauma patients: a retrospective study

BackgroundRapid Sequence Induction (RSI) is used for emergency tracheal intubation to minimise the risk of pulmonary aspiration of stomach contents. Ketamine and propofol are two commonly used induction agents for RSI in trauma patients. Yet, no consensus exists on the optimal induction agent for RSI in the trauma population. The aim of this study was to compare 30-day mortality in trauma patients after emergency intubation prehospitally or within 30 min after arrival in the trauma centre using either ketamine or propofol for RSI.MethodsIn this investigator-initiated, retrospective study we included adult trauma patients emergently intubated with ketamine or propofol registered in the local trauma registry at Rigshospitalet, a tertiary university hospital that hosts a level-1 trauma centre. The primary outcome was 30-day mortality. Secondary outcomes included hospital and Intensive Care Unit length of stay as well as duration of mechanical ventilation. We analysed outcomes using multivariable logistic regression models adjusting for age, sex, injury severity score, shock (systolic blood pressure < 90 mmHg) and Glasgow Coma Scale score before intubation and present results as odds ratios (ORs) with 95% confidence intervals.ResultsFrom January 1st, 2015 through December 31st, 2019 we identified a total of 548 eligible patients. A total of 228 and 320 patients received ketamine and propofol, respectively. The 30-day mortality for patients receiving ketamine and propofol was 20.2% and 22.8% (P = 0.46), respectively. Adjusted OR for 30-day mortality was 0.98 [0.58–1.66], P = 0.93. We found no significant association between type of induction agent and hospital length of stay, Intensive Care Unit length of stay or duration of mechanical ventilation.ConclusionsIn this study, trauma patients intubated with ketamine did not have a lower 30-day mortality as compared with propofol.

Pro-Con Debate: 1- vs 2-Hour Fast for Clear Liquids Before Anesthesia in Children.

Perioperative fasting guidelines are designed to minimize the risk of pulmonary aspiration of gastrointestinal contents. The current recommendations from the American Society of Anesthesiologists (ASA) and the European Society of Anaesthesiology and Intensive Care (ESAIC) are for a minimum 2-hour fast after ingestion of clear liquids before general anesthesia, regional anesthesia, or procedural sedation and analgesia. Nonetheless, in children, fasting guidelines also have consequences as regards to child and parent satisfaction, hemodynamic stability, the ability to achieve vascular access, and perioperative energy balance. Despite the fact that current guidelines recommend a relatively short fasting time for clear fluids of 2 hours, the actual duration of fasting time can be significantly longer. This may be the result of deficiencies in communication regarding the duration of the ongoing fasting interval as the schedule changes in a busy operating room as well as to poor parent and patient adherence to the 2-hour guidelines. Prolonged fasting can result in children arriving in the operating room for an elective procedure being thirsty, hungry, and generally in an uncomfortable state. Furthermore, prolonged fasting may adversely affect hemodynamic stability and can result in parental dissatisfaction with the perioperative experience. In this PRO and CON presentation, the authors debate the premise that reducing the nominal minimum fasting time from 2 hours to 1 hour can reduce the incidence of prolonged fasting and provide significant benefits to children, with no increased risks.

Gastric emptying time of two different quantities of clear fluids in children: A double-blinded randomized controlled study.

Perioperative pulmonary aspiration risk increases with increased preoperative gastric volume; hence traditionally, healthy children are kept fasted overnight before surgery. Current guidelines recommend 2-h clear fluids fasting prior to anesthesia. However, emerging evidence favors allowing 3ml/kg clear fluids up to 1-h before anesthesia. We compared the gastric volume and gastric emptying time after ingestion of 3ml/kg and 5ml/kg of clear fluids. The present study enrolled 44 children, aged between 6 and 14years. On the day of surgery, baseline gastric volume was estimated using ultrasound and patients were randomly allocated into two groups of equal number, that is, Group 3 and Group 5 (patients received 3ml/kg and 5ml/kg 5% Dextrose respectively). Repeated gastric ultrasound was performed at every 5min until the gastric volume reached baseline levels. The primary objective of the study was to compare gastric emptying time. Secondary objectives included comparison of antral cross-sectional area and gastric volume. The demographic profile, preoperative fasting duration for clear fluids, and baseline gastric volume were comparable between groups. In both groups, compared to baseline the antral cross-sectional area and gastric volume increased significantly following fluid ingestion and then decreased exponentially to reach baseline within 1-h. The median (IQR) (range) gastric emptying time (minutes) [35.0 (28.8, 40.0) (20.0-45.0) in group 3 and 40.0 (28.8, 45.0) (20.0-50.0) in group 5] and emptying half-time (minutes) [17.0 (15.7, 21.5) (14.4-24.0) in group 3 and 18.6 (16.0, 22.0) (15.1-23.8) in group 5] were comparable [median difference -5 (95% CI -7.8 to 2.1) and -1.5 (95% CI -2.3 to 1.0), respectively] (p=.16 and p=.44, respectively). As the gastric volume returned to baseline within 1-h even after ingesting 5ml/kg clear fluids, the preoperative fasting time can be reduced to 1-h and healthy children undergoing elective procedure can be safely allowed to drink up to 5ml/kg clear fluids.

Left paratracheal pressure versus cricoid pressure for successful laryngeal mask airway insertion in adult patients: a randomized, non-inferiority trial.

Cricoid pressure (CP) is used to prevent pulmonary aspiration of regurgitated gastric contents and gastric insufflation during positive-pressure ventilation. However, CP impedes the successful insertion of laryngeal mask airway (LMA). Left paratracheal pressure (LPP), a maneuver of applying backward digital force at the lower left paratracheal level, was recently introduced as an alternative to CP. We assessed whether LPP is non-inferior to CP in successful LMA insertion on the first attempt in adult patients undergoing general anesthesia. In this non-inferiority randomized controlled trial, 108 patients undergoing general anesthesia were randomly allocated to receive either LPP or CP during LMA insertion. The primary outcome was the success rate of LMA insertion on the first attempt. The margin of non-inferiority was defined as 15%. The success rate of LMA insertion on the first attempt was 68.5% (37/54) in the LPP group and 51.9% (28/54) in the CP group (P=0.077) with between-group difference of 16.7% (two-sided 95% CI, -1.9% to 35.2%). Time for successful device insertion was comparable in the two groups (P=0.355), whereas LMA insertion was easier in the LPP group than in the CP group (P=0.001). There was no significant difference between the two groups for change in antral cross-sectional area measured before and after mask ventilation (P=0.081). No serious complication was evident in any group. This randomized clinical trial demonstrated the non-inferiority of LPP over CP in the success rate of LMA insertion on the first attempt in adult patients undergoing general anesthesia.

Reinforcing the valuable role of gastric ultrasound for volume and content assessment: an observational study

BackgroundPulmonary aspiration is one of the most important complications in anesthesiology. Assessment of gastric content by ultrasound is a good method to quantify gastric volume and to determine the risk of intraoperative pulmonary aspiration. The aim of this study is to determine the accuracy of the gastric ultrasonography in the qualitative analysis of gastric content, mainly in the analysis of small amounts of liquid content. MethodsGastric ultrasound was performed to 36 patients before upper gastrointestinal endoscopy (UGI), making two longitudinal scans at the epigastric level, one in supine position and the other in right lateral decubitus position, measuring two diameters and the area of the gastric antrum and assessing the content characteristics determining whether it was an empty stomach or contained fluid or solid content. Subsequently, the ultrasound findings were compared with UGI findings. ResultsGastric areas were analyzed by the trace and the lengths of the craniocaudal and anteroposterior axes concluding that there are no significant differences between the two methods. No statistically significant difference was found between UGI and US assessment technics. No statistically significant difference was found between the estimated volume by UGI and US. ConclusionsThough our study has some limitations, qualitative analysis of gastric content using ultrasound followed by endoscopy enabled the conclusion that there are no differences in the qualitative assessment regarding these two techniques, supporting the important role of point-of-care gastric ultrasound (POCGUS) in the assessment of pulmonary aspiration risk by the anesthesiologist in the perioperative period.

Comparison of effect of Various Combinations of four drugs i.e IV Ondansetron, Ranitidine, Metoclopramide and Omeprazole, to reduce Gastric Fluid Residual Volume and Gastric Acidity in Elective Laparoscopic-Cholecystectomy patients

Background: Inhaling of gastric contents in lower respiratory tract and larynx results in developing of pulmonary aspiration. The acidity of aspirate contents and its volume determines severity of aspiration and is major cause of post-anesthetic mortality. Objective: To compare the effect of four drugs (ranitidine, IV ondansetron, metoclopramide, omeprazole and metoclopramide) in all possible four combinations, to decrease gastric fluid residual volume and gastric acidity in undergoing laparoscopic-cholecystectomy. Design: It was a clinical randomized trial. Study Settings: Trial was conducted at Department of Anesthesiology and ICU, Sheikh Zayed Hospital, Lahore, for a period of 6 months from 01-07-2019 to 31-12-2019. Patients and Methods: A total of 308 patients from both the genders undergoing laparoscopic cholecystectomy were included in this study. Four equal groups were made by random division of patients. Group A: ranitidine &amp; ondansetron, group B: ranitidine &amp; metoclopramide, group C: omeprazole &amp; ondansetron and group D: omeprazole &amp; metoclopramide. Pre-anesthetic medicine was given to all the patients two hours before surgery. For assessing volume of gastric fluid and its pH, an oro-gastric tube was passed. An informed written informed consent was taken from all the patients. Results: Mean age in this study was 36.40±9.15, 33.23±9.13, 36.82±9.37 and 36.57±9.49 years respectively for Group A,B,C and D. Aspirate had mean quantity of 12.56±5.60 ml/kg, 12.65±5.39 ml / kg, 13.68±5.76 ml/kg and 14.34±6.85 ml/kg and he aspirate mean pH was 2.56±0.55, 2.47±0.58, 2.51±0.57 and 2.45±0.58 respectively for group A,B,C and D. Among both the trial groups, this different was insignificant (p-value &gt; 0.05) for both outcomes. Conclusion: All the drug combinations had no significant difference. However, comparatively less pH and volume of gastric fluid was shown by combination of ranitidine plus ondansetron. Therefore, this combination is recommended before general anesthesia for reducing gastric fluid aspirate in patients undergoing surgery. Keywords: Laparoscopic cholecystectomy, Omeprazole, Ranitidine, Metoclopramide, Ondansetron, gastric fluid acidity, pH, gastric fluid volume

Pre-operative fasting times for clear liquids at a tertiary children's hospital; what can be improved?

BackgroundThe goal of preoperative fasting is to prevent pulmonary aspiration during general anesthesia. Fasting times are often prolonged leading to patient discomfort and risk for adverse events. This retrospective quality improvement survey evaluated effective nil-per-os (NPO) times and causes for prolonged NPO times with the aim to suggest improvement strategies by a newly founded fasting task force.MethodsData from all electronic anesthesia records from 2019 at our institution were reviewed for fasting times. Our NPO instructions follow American Society of Anesthesiology guidelines and are calculated based on the patient’s arrival time (90 min before operating room [OR] time). Primary outcome was the effective NPO time for clear liquids, secondary outcomes were incidence of delays and the parental compliance with the NPO instructions. Data are presented as median (interquartile range).ResultsIn total 9,625 cases were included in the analysis. NPO time was documented in 72.1% with a median effective NPO time of 7:13 h (7:36). OR in room times were documented in 72.8%, 2,075 (29.5%; median time 0:10 h [0:21]) were earlier and 4,939 (70.5%; median time 0:29 h [0:54]) were later than scheduled. Parental NPO compliance showed a median deviation for clear liquid intake of 0:55 h (8:30).ConclusionsThis study revealed that effective NPO times were longer than current ASA guidelines. Contributing causes include case delays and parental non-compliance to NPO instructions. Thus, task force recommendations include change NPO instruction calculations to scheduled OR time versus arrival time, and encourage parents to give their child clear liquids at the instructed time.

Preoperative Fasting Time and Its Association with Hypoglycemia during Anesthesia in Pediatric Patients Undergoing Elective Procedures at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia.

Background Preoperative fasting is important to reduce the risk of pulmonary aspiration during anesthesia. The influence of prolonged fasting time on glucose levels during anesthesia in children remains uncertain. Therefore, this study is aimed at assessing preoperative fasting time and its association with hypoglycemia during anesthesia in pediatric patients undergoing elective procedures at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. The research hypothesis of the study is as follows: there is a prolonged preoperative fasting time, and it influences the glucose levels during anesthesia among pediatric patients undergoing elective procedures at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. Methods Institutional based cross-sectional study was conducted among 258 pediatric patients who had undergone elective procedures in a tertiary care center. A systematic sampling method was used to select study participants. The data were collected through face-to-face interviews and medical record reviews. Binary logistic regression was used to identify associated factors of hypoglycemia during anesthesia among pediatric patients undergoing elective procedures. All explanatory variables with a p value of ≤0.25 from the bivariable logistic regression model were fitted into the multivariable logistic regression model to control the possible effect of confounders, and finally, the variables which had an independent association with hypoglycemia were identified based on adjusted odds ratio with 95% confidence interval, and a p value less than 0.05 was significant. Results The mean (standard deviation) fasting hours from breast milk, solid foods, and clear fluids were 7.75 (2.89), 13.25 (3.14), and 12.31 (3.22), respectively. The majority (89.9%, 57.9%, and 100%) of participants had fasted from solid, breast milk, and clear fluids for more than 8, 6, and 4 hours, respectively. More than one-fourth (26.2%) of participants were hypoglycemic immediately after induction. Residence, order of nothing per mouth, source of patient, and duration of fasting from solid foods had a significant association with hypoglycemia during anesthesia in children. Conclusion Children undergoing elective procedures were exposed to unnecessarily long fasting times which were associated with hypoglycemia during anesthesia.

This Month in Anesthesiology

This Month in Anesthesiology

Perioperative management of post-COVID-19 surgical patients: Indian Society of Anaesthesiologists (ISA National) Advisory and Position Statement.

Perioperative management of post-COVID-19 surgical patients: Indian Society of Anaesthesiologists (ISA National) Advisory and Position Statement.

Evaluation of cases of kerosene poisoning: A 3-year prospective study at Menoufia University Hospitals

Background: kerosene is a common cause of childhood poisoning specially in low and middleincome countries. Complications are primarily related to pulmonary aspiration which is a significant contributor to Intensive Care Unit (ICU) admission. Objectives: To study the clinical profile of kerosene poisoning in children presented to Menoufia Poison Control Centre and to identify patients who need ICU admission. Methods: a prospective study including children presented to Menoufia Poison Control Center with acute kerosene poisoning during the period of three years from 2018 to 2020. Results: During the study period, a total number of 154 children were admitted. Male children were 56.5% and females represent 43.5%. More than half of cases (52.6%) were less than 3 years. The majority of cases were from rural areas (76.6%). All cases were exposed to kerosene orally and 24.9% had combined oral and dermal exposure. ICU admitted cases had longer period of hospitalization and presented mainly by tachypnea, hypoxemia and chest retractions. Conclusion: Respiratory system is mainly affected in kerosene poisoning. Patients presenting with respiratory distress, moderate or severe grades of PSS, hypoxemia on presentation should be admitted to the ICU. Community education is necessary to reduce this preventable poisoning in children.

Efficacy of Baska mask as an alternative airway device to endotracheal tube in patients undergoing laparoscopic surgeries under controlled ventilation.

Background and Aims:Newer supraglottic devices with an additional gastric channel offer greater protection from aspiration and avoidance of laryngoscopy for their insertion would result in attenuated hemodynamic responses.The primary objective was to assess hemodynamic responses to insertion of Baska mask as compared to tracheal intubation. The time and attempts taken to secure airway and evidence of regurgitation and pulmonary aspiration of gastric contents were also assessed.Material and Methods:This prospective, randomized study was conducted in 80 patients undergoing laparoscopic cholecystectomy. All patients received standardized anaesthesia protocol. Baska mask was used to secure airway in Group B, while tracheal intubation was done in group T. Methylene blue was injected through Ryle's tube into stomach in both groups. At end of surgery, fibreoptic bronchoscopy was performed to detect bluish staining of trachea and/or main bronchi as evidence of aspiration of gastric contents and bluish staining in oropharynx as evidence of regurgitation. Chi-square test and Independent sample t-test were applied.Results:The time taken to secure airway was significantly longer in Group B as compared to Group T (45.3 ± 12.6 vs. 24.3 ± 9.1 sec) Percentage of patients who had oropharyngeal blue stain was comparable in both groups. No patient in both groups had tracheal blue stain. Group T had significantly higher HR and MAP after intubation till 10 min later.Conclusion:Baska mask insertion was associated with attenuated hemodynamic responses, though more time and attempts were required for securing the airway. It could be considered as an alternative to tracheal intubation during laparoscopic surgeries.

A rare case of sepsis from Citrobacter koseri in adults

We describe the case of a 53-year-old man, recently diagnosed with decompensated type II diabetes mellitus, admitted to our Department for fever, asthenia, and detection of multiple lung abscesses and pulmonary embolism at chest tomography.His clinical history revealed just a recent orthopedic surgery of osteosynthesis on the left wrist with normal clinical and instrumental post-surgical evolution. Empirical antibiotic therapy with piperacillin/tazobactam and clindamycin was initiated. During hospital stay, swelling and functional impotence in the right knee occurred. They were investigated by arthrocentesis and magnetic resonance, and diagnosed as septic arthritis.Blood culture performed at admission tested positive for Citrobacter koseri on several samples where meropenem was added according to antibiogram. On the other hand, the cultures of bronchoaspirate, pulmonary fine needle aspiration, and arthrocentesis were negative.Antibiotic therapy was administered up to two weeks after discharge and radiological and physical features progressively improved.

Upper Gastrointestinal Disorders in Adult Patients with Intellectual and Developmental Disabilities.

The purpose of this literature review is to address the diagnosis and treatment of upper gastrointestinal (GI) disorders in patients with intellectual and developmental disabilities (IDD). Manifestations of upper GI dysmotility and disorders include dysphagia, pulmonary aspiration, malnutrition, gastroesophageal reflux, and gastritis, all of which can impact a person’s quality of life and lead to chronic, life-threatening conditions. This article will explore the existing diagnostic methods and treatments for gastrointestinal disorders as they relate to patients with IDD.

Prediction of gastric fluid volume by ultrasonography in infants undergoing general anaesthesia

BackgroundPoint-of-care ultrasonography can estimate gastric contents and volume to assess the risk of pulmonary aspiration; however, its use in infants has not been well validated. We aimed to develop a predictive model for estimating gastric fluid volume using ultrasonography in infants. MethodsThis prospective observational study enrolled 200 infants (≤12 months) undergoing general anaesthesia. After anaesthetic induction, while preserving spontaneous respiration, we measured gastric antral cross-sectional area using ultrasonography in both the supine and right lateral decubitus positions. We then suctioned the gastric content and measured its volume. The primary outcome was development of a gastric fluid volume prediction model with multiple regression analysis. Agreement between the predicted volume and the suctioned volume was evaluated using a Bland–Altman plot. ResultsOverall, 192 infants were included in the final analysis. Pearson correlation analysis showed that the gastric antral cross-sectional area in the supine (P<0.001; correlation coefficient: 0.667) and right lateral decubitus (P<0.001; correlation coefficient: 0.845) positions and qualitative antral grade (P<0.001; correlation coefficient: 0.581) correlated with suctioned volume. We developed a predictive model: predicted volume (ml)=–3.7+6.5 × (right lateral decubitus cross-sectional area [cm2])–3.9 (supine cross-sectional area [cm2])+1.7 × grade (P<0.01). When comparing the predicted volume and suctioned volume, the mean bias was 0.01 ml kg−1 and the limit of agreement was –0.58 to 0.62 ml kg−1. ConclusionsGastric fluid volume can be estimated using a predictive model based on ultrasonography data in infants. Clinical trial registrationNCT03155776.

Perioperative pulmonary aspiration and regurgitation without aspiration in adults: a retrospective observational study of 166,491 anesthesia records.

Pulmonary aspiration (PA) of gastric contents is a rare but serious perioperative complication. Recent studies focused on pediatric patients, but over a decade has passed since the latest incidence and outcome in adult population have been reported. Patients who experienced regurgitation without aspiration were rarely mentioned. Besides, our department proposed a modified rapid sequence induction (RSI) protocol in 2018 and its preventive effect remained to be examined. A total of 166,491 anesthesia records from March 2015-October 2020 were reviewed. Outcomes from regurgitation events were classified as PA or regurgitation without aspiration following strict criteria. Available information including demographics, anesthetic managements, surgical procedures, and other medical records were reviewed for analysis. Among the 166,491 anesthesia records, 20 patients had PA (1:8,325), and 20 had regurgitation without aspiration (1:8,325). The morbidity of PA was 1:16,649, and the mortality was 1:55,497. During anesthesia induction, 76.0% of regurgitation events developed aspiration, and the remaining 24.0% had regurgitation without aspiration. But prior to anesthesia induction, only 10.0% regurgitation events developed aspiration. Emergency procedures were associated with serious risks of PA (OR: 27.1, 95% CI: 10.8-68.0) and regurgitation without aspiration (OR: 83.0, 95% CI: 24.3-283.1) compared with elective procedures. The highest incidence of pulmonary aspiration was observed in bronchoscopy procedures (2/1,747). The modified RSI reduced the incidence of regurgitation events during induction in emergency procedures but did not show significant advantages over classic protocol (0:1,055 versus 12:4,469, P=0.139) possibly due to insufficient sample size. The sample size required for future study was estimated based on the current data. The incidence of pulmonary aspiration and regurgitation without aspiration was low, especially in elective cases. Regurgitation during anesthesia induction had mostly developed aspiration. Further evaluation of the effect of modified RSI protocol needs a large sample size.

AB224. SOH21AS261. Preoperative fasting period among elective surgical patients at a tertiary level hospital, University Hospital Limerick (UHL)

Background: Preoperative fasting period is the prescribed time when oral intake of liquids or solids are restricted prior to surgical procedures either by general or regional anaesthesia, including sedation. The purpose of this obligatory fasting is to reduce the incidence of pulmonary aspiration of gastric contents secondary to the loss of airway reflexes. This potential consequence of anaesthesia has led to the universal adoption of preoperative fasting guidelines. The aim of this audit is to identify the duration of fasting and to investigate any cause of deviation from guidelines.