The Subtleties of Language as a Reason for Failure to Follow Preoperative Fasting Guidelines: The Differences Between Restricting, Allowing, and Encouraging

To the Editor In a recent editorial concerning preoperative fasting guidelines, Abola and Gan1 ask the question, “Why are we not following them?” They go on to state that if patients are not drinking clear fluids up until 2 hours before surgery, then individual hospital practices should change to conform to what has long since2 been recommended by the American Society of Anesthesiologists (ASA), reinforced by recently updated 2017 guidelines.3 Although they raise this important question, it goes relatively unanswered in the editorial as the authors principally focus on what they suggest are even more pertinent questions—that is, the composition of the fluid that patients should actually be drinking (eg, carbohydrate-containing fluids), and what the outcome benefits are of ensuring this preoperative oral hydration. To address the reasons why fasting guidelines are well endorsed (ie, by various societies, institutions, and individual practitioners), though are inconsistently implemented, we suggest that an important limitation lay in the subtleties and nuance of the language used in the guidelines that adds unnecessary uncertainty as to their exact meaning. Indeed, there is considerable power in language, and one of the reasons why many may not be following them is that the guidelines themselves are somewhat ambiguous as to their intent; accordingly, they may fail to explicitly direct perioperative caregivers. For example, up until only a few months ago, the ASA guidelines document2 restricted clear fluids for “at least” 2 hours preoperatively—that is, with the “at least” (instead of “no more than” or “up until”) perhaps being interpreted as a tacit suggestion that a longer restriction period might be better. Admittedly, although the language in the most up-to-date ASA document3 that now allows for clear fluids “up to” 2 hours is arguably more clear, it is still a far cry from the explicit language used by more recent guidelines promulgated by the American Society of Enhanced Recovery (ASER) in their joint consensus statement on perioperative fluid management.4 The ASER guidelines explicitly recommend unrestricted access to clear fluids “up to” 2 hours before surgery. In addition, similar European guidelines5 on preoperative fasting go further by stating that adults should actually be encouraged (ie, not just “allowed”) to drink clear fluids up to 2 hours before elective surgery. This explicit language of active encouragement is also used in the Canadian Anesthesiologists’ Society preoperative fasting guidelines.6 This differs markedly from the earlier ASA guideline that states it is appropriate to fast—that is, with “fast” possessing a negative and passive connotation of “withholding,” as opposed to a more positive and active connotation by providing language as to when it is acceptable to keep “drinking”—from intake of clear fluids “at least 2 hours before elective procedures requiring general anesthesia ….”2 In summary, we would submit that one of the reasons why preoperative fasting guidelines have not been as fastidiously followed as is ideal, is that the language used in them has left many practitioners, until very recently, without clear and explicit direction on what to actually do. Hilary P. Grocott, MD, FRCPC, FASEC. Scott Brudney, MBChB, FRCA, FFICM, FCCMDepartment of AnesthesiaUniversity of ManitobaWinnipeg, Manitoba, Canada[email protected]

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