C. M. Perry, Great North Children's Hospital, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK


Excessive fasting can lead to psychological and physiological changes in young patients, with behavioural changes that are challenging for parents, nursing staff, and anaesthetists. Prolonged fasting times are known to cause dehydration and increase anxiety (1).


Despite introducing 6-4-1 fluid fasting guidelines in October 2017, an audit of data still demonstrated prolonged fasting times in our institution.

Strategy for change: 

Learning from the publication of successful implementation of 6-4-0 strategies in other institutions (2,3), we implemented a similar 6-4-0 – “Sips to theatre” protocol in October 2021 with carefully described steps, including an initial water or squash on arrival (3-5ml/kg), and ongoing access to carefully controlled “sips”. We selected 3 appropriate wards with elective day case and day of surgery patients for a 24-month period.

Careful education of the concept of “sips until theatre” was carried out in a cascade manner on these wards.

Measure of improvement: 

Fasting times prior to theatre were monitored and a reporting system for perioperative regurgitation events was established. A nursing satisfaction survey was completed to establish if the delivery of the protocol was seen as a positive step.

The median fluid fasting time reduced from around 310 mins (2017, on 6-4-2) to 224 mins (2020, on 6-4-1) to 150 mins (mid-2023 with 6-4-0).

YEAR          PROTOCOL                   MEDIAN FOOD FASTING (MINS)                     MEDIAN FLUID FASTING (MINS)   % < 4hr FLUID FAST

2010     6-4-2            732                                                            390                                                   n/a

2014     6-4-2            775                                                            425                                                   39.7

2017     6-4-2            731                                                            311                                                   35

2018     6-4-1            757                                                            237                                                   50.4

2020     6-4-1            696                                                            224                                                   55

2023     6-4-0            840                                                            150                                                   68.5

Three reported peri-operative regurgitation events were investigated.  Two were deemed unlikely to be related, but one may have been linked to incorrect implementation of the trial guideline. In this case, a 3yr old was intubated after intraoperative regurgitation of chocolately fluid. The child was extubated after completion of surgery, had an uneventful recovery and was discharged the following morning.

The nursing survey demonstrated 100% support for the new guideline, mainly due to general improvement in patient behaviour and perceived experience.

Lessons learnt:

Careful education of the fasting protocol is imperative. We felt it was safer to only allow fluids provided by our nursing staff, rather than allowing patients to drink freely from their own water bottles.

Message for others:

Allowing sips until theatre has been a positive step reportedly improving the experience of the children, parents, ward staff and anaesthetic teams. There has not been any evidence of an increase in aspiration-related morbidity or mortality.


  1. AAGBI Safety guideline, Preoperative Assessment and Patient Preparation: The Role of the Anaesthetist 2010
  2. Andersson H, Hellström PM, Frykholm P. Introducing the 6-4-0 fasting regimen and the incidence of prolonged preoperative fasting in children. Paediatr Anaesth. 2018 Jan;28(1):46-52.
  3. Andersson H, Zarén B, Frykholm P. Low incidence of pulmonary aspiration in children allowed intake of clear fluids until called to the operating suite. Paediatr Anaesth. 2015 Aug;25(8):770-777.
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