T. C. Miller, J. Schofield, M. Ashe, W. Bansema, K. Gillespie, H. Llewellyn, H. F. Tiong, N. Masip, S. Roberts

Alder Hey Children's NHS Foundation Trust, UK


Preoperative fasting is crucial to minimise the risk of pulmonary aspiration during anaesthesia. International guidelines emphasise the need for balancing fasting times to ensure patient comfort, while addressing the physiological impacts of prolonged fasting.1

This quality improvement project (QIP) focuses on the implementation of a new perioperative fasting guideline "Sip ‘Til Send," at Alder Hey Children’s NHS Foundation Trust.


The previous guideline presented challenges particularly on the emergency list where unexpected changes led to prolonged fasting, impacting the quality of care and experience patients received awaiting surgery. This heightened stress for patients and their families, and increased the possibility of dehydration, ketone body accumulation and hypoglycaemia.

This necessitated revising the guideline to align with the Trust's vision and goals.

Strategy for change

The change involved a comprehensive literature review, survey of guidelines in other paediatric hospitals, and an audit of existing practices. We revised the guideline based on the "Sip ‘Til Send" approach; allowing 3ml/kg/hr of clear fluids pre-operatively. This approach has been adopted by over 30 UK trusts, in addition to healthcare organisations in Europe, Asia, Australia, and New Zealand, minimising fasting times while ensuring patient safety and comfort.3 Our education programme updated ward areas and sought patient and staff opinion.

Measure of improvement

"Sip ‘Til Send" implementation significantly reduced average fluid fasting time from 4h54m (Range 23m – 16h1m May 2022) to 1h29m ( Range 6m - 12h11m,  Oct 2023), a 70% reduction benefiting all paediatric patients, particularly those undergoing emergency surgery. The updated guideline enhanced patient and family experiences, while also improving relations with ward staff who report patients were “happier” as staff “have something to offer”. Reduced phone communication between theatre and wards concerning extending fasting times allowed better task focus for both teams.

No adverse incidents have been reported, and continuous monitoring is ongoing.

Lessons learnt

This QIP highlighted the importance of a multidisciplinary approach, involving collaboration with preoperative areas, communications teams, and patient documentation distributors. The success of the change was attributed to aligning the fasting guideline with the Trust's vision, the qualitative feedback gained regarding enhanced staff and patient/family experience was extremely encouraging. Lessons learnt include the value of adaptability in different ward areas, and the positive impact of streamlined care.


Message for others

The success of the "Sip ‘Til Send" guideline emphasises the potential for positive change in perioperative management. Re-evaluating this small aspect of care enabled us to prioritise comfort and experience without reducing patient safety4. Collaboration, evidence-based practices, with a focus on organisational goals can lead to meaningful improvements in patient care. The implementation of this revised guideline not only reduced fluid fasting times but also fostered improved teamwork, communication, and overall cohesion within the multidisciplinary team.


  1. Thomas M, Morrison C, Newton R, Schindler E. Consensus statement on clear fluids fasting for elective pediatric general anesthesia. Pediatric Anesthesia 2018;28:411-414
  2. McCracken, G.C. and Montgomery, J. (2018) “Postoperative nausea and vomiting after unrestricted clear fluids before day surgery,” European Journal of Anaesthesiology, 35(5), pp. 337–342.
  3. J Gan, K Chima, A Sogbodjor, E Roderick, K Good, M Lane. Abolishing Fasting Times in paediatric patients:Let them drink..! Best Abstracts for APA Online meeting 2020. Paediatric anaesthesia. 2021; 352-359
  4. Andersson H, Zaren B, Frykholm P. Low incidence of pulmonary aspiration in children allowed intake of clear fluids until called to the operating suite. Paediatr Anaesth 2015; 25:770–777.
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