Introduction

Preoperative fasting, as defined by the American Society of Anesthesiologists (ASA), is a mandatory interval before
a procedure during which patients must refrain from consuming both liquids and solids orally, with the goal of
minimizing the volume and acidity of stomach contents to reduce the risk of regurgitation and aspiration during
anesthesia. This requirement applies to both adults and children and is essential in reducing the likelihood of
aspiration pneumonitis—particularly Mendelson Syndrome—during the induction of general anesthesia. While
preoperative fasting is a standard protocol, extended fasting periods are often excessive and have been associated
with adverse effects including distress, confusion, hypoglycemia, headaches, dehydration, electrolyte imbalances,
postoperative nausea and vomiting (PONV), and increased insulin resistance. General anesthesia suppresses
laryngeal reflexes, and research has shown that a gastric fluid volume of 25 ml (0.4 ml/kg) significantly increases
the risk of pulmonary aspiration. Studies have also indicated that consuming solid food up to 6 hours and light meals
up to 4 hours before anesthesia can raise both the volume and acidity of gastric contents. To address these issues,
updated guidelines from the ASA, European Society of Anesthesiology, and Royal College of Anaesthetists have
categorized intake into solids, clear fluids, breast milk, nonhuman milk, light solids, and heavy solids, with specific
fasting recommendations. In 2017, the ASA revised its guidelines, recommending that adults may consume a solid
meal up to 8 hours before elective surgery, a light meal up to 6 hours prior, and clear fluids—including water, fruit
juices without pulp, clear tea, and black coffee—up to 2 hours before surgery. For pediatric patients, clear fluids are
permitted up to 2 hours before surgery, breast milk up to 4 hours prior, and nonhuman milk, including infant
formula, up to 6 hours before. Despite these updated recommendations, many institutions continue to enforce
unnecessarily prolonged fasting protocols such as "nil by mouth after midnight," leading to patient discomfort,
anxiety, dehydration, hypovolemia, and hypoglycemia. Tertiary care hospitals often entrust the care of surgical
patients to postgraduate trainees, making it vital to evaluate whether their practices align with institutional policies
and international guidelines. Enhanced Recovery After Surgery (ERAS) programs advocate for reduced fasting
periods, which have been shown to improve recovery outcomes, reduce hospital stays, lower complication rates, and
decrease healthcare costs. However, patients with conditions like diabetes mellitus, increased intracranial pressure,
hiatus hernia, gastrointestinal obstruction, recurrent regurgitation, dyspepsia, prior gastrointestinal surgeries, or
those taking opioids or with morbid obesity, may experience delayed gastric emptying and require special
consideration. The present observational study aims to assess the extent to which the knowledge, attitude, and
practices of postgraduate trainees in surgical specialties and anesthesiology align with current preoperative fasting
guidelines. The primary objective is to assess the knowledge status of postgraduate trainees regarding fasting
guidelines, while the secondary objective is to evaluate their attitudes and current practices.

Materials and Methods

This cross-sectional observational study was conducted over a period of six months at a tertiary care hospital in
Mumbai, following approval from the institutional ethics committee. The study aimed to assess the knowledge,
attitude, and practices regarding preoperative fasting before anesthesia for elective surgery among postgraduate
trainees in various specialties, including anesthesiology, general surgery, ENT, orthopedics, plastic surgery,
gastrointestinal (GI) surgery, gynecology, ophthalmology, neurosurgery, and urosurgery. A total sample size of 150
postgraduate trainees was targeted, based on findings from a similar study conducted at the National Hospital in Sri
Lanka, where only 65% of healthcare workers were aware of existing fasting guidelines. This proportion was used to
calculate the required sample size for the current study. All eligible postgraduate trainees were personally
approached, and after obtaining informed consent, each participant was asked to complete a structured questionnaire
in the form of a case record form focusing on knowledge, attitudes, and practices related to preoperative fasting.
Responses were documented in an Excel sheet and analyzed accordingly. Data entry was performed using Microsoft
Excel 2013 64-bit, as part of Microsoft Office Professional Plus 2013. Statistical analysis was conducted using IBM
SPSS Statistics for Windows, Version 25.0 (IBM Corp., Armonk, NY, Released 2017). Data were summarized
using proportions, percentages, and contingency tables. Comparisons of awareness levels among different groups of
residents were carried out using the questionnaire responses, with statistical tests including the Chi-square test and
the Kruskal-Wallis test.
Results

Questionnaires were distributed amongst 150 residents from anaesthesia, orthopaedic, OB GYN, ENT, surgery and
super-speciality (plastic surgery) departments. Response rate was 100%. Data collected and analysed. A probability
value (p value) less than 0.05 was considered statistically significant. Demographic data tabulated below. The table
1, represents the age distribution of individuals in a specific dataset. Most participants are within the 25-29 age
group, accounting for 56% of the total, indicating a younger demographic. The least represented age group is those
over 35 years, making up only 6.67%. This distribution provides insights into the predominant age groups engaging
in or affected by the observed activity. The mean age of the provided data set is approximately 26.75 years, with a
standard deviation of approximately 2.23 years. Out of 150 residents 79(52.67%) were females and 71(47.33%) are
male residents. The distribution of the departments among the participants is as follows: Anaesthesia has the highest
representation with 66 participants, accounting for 44.00% of the total. This is followed by Orthopaedics (Ortho)
with 28 participants (18.67%), Obstetrics and Gynaecology (OB GYN) with 24 participants (16.00%), and Surgery
with 15 participants (10.00%). Gastrointestinal (GI) Surgery has 5 participants (3.33%), while Ear, Nose, and Throat
(ENT) has 9 participants (6.00%). Plastic Surgery has the lowest representation with 3 participants, making up 2 %
of the total. The table illustrates the fasting hours for solids prior to surgery in adults. Notably, no residents
responded with a fasting window of 2 to 4 hours. The majority,107 (71.33%), are aware of ASA fasting period
guidelines of 6 to 8 hours, while as per 43 (28.67%) residents fasting period guideline is more than 8 hours. As per
60(40%) residents able to correctly describe ASA fasting guidelines pertaining to preoperative fasting for clear
fluids in adults is 2 hrs, whereas 69(46%)residents responded for 4 hrs fasting. According to 21 (14%) of the
residents it is 6-8 hrs and no one has responded for more than 8 hours fasting for clear liquids.

Amongst 150 residents 85(56.67%) responded that 2 hours is preoperative fasting for clear fluids in paediatric
population followed by 42 (28%) believes that it is 8 hours for clear fluids. 11 (7.33%) residents responded it to be 4
hours, 8 (5.33%) residents responded for 6 hours and 4 (2.67%) residents responded to be 10 hours of fasting.
Amongst 150 residents only 6 (4%) residents are aware of 4 hours fasting for breast milk in paediatric patients as per
ASA. 99(66%) of residents believes that 6 hours of and 39(26%) residents believes in 8 hours of fasting for breast
milk which is not recommended by ASA. 2.67% residents responded for 10 hours and 1.33% responded for 2 hours
fasting for breast milk. Out of 150 residents only 73 (48%) able to correctly describe ASA fasting guidelines for
solids is 6 hrs in childrens,69 (46%) residents responded as 8 hrs ,6 (4%) responded as 10 hrs and 2(1.33%)
residents responded as 4 hrs. Figure demonstrates there is not much difference between knowledge and actual
practice for fasting in adults for solids. Significant difference found in fasting guidelines in adults for clear fluids,
out of 150 trainees 60 have knowledge of fasting but only 44 are following in actual practice. For paediatric fasting,
a significant difference is found in guidelines for solids, clear fluids and breast milk.72 residents are aware of 6
hours fasting for solids but only 58 follow actual practice. For breast milk 6 residents are aware of correct
knowledge and whereas 20 residents are following 4hrs fasting .85 residents are aware of 2 hrs fasting for clear
fluids but only 20 residents are following in actual practice. In case Adults for solid food majority 96 (64%)
residents give 8 hrs fasting instructions and 10(6.67%) residents use to give 6 hrs instructions to patients, whereas 40
(26.67%) give 10 hrs and 4 (2.67%) residents use to give 12 hrs fasting instruction for solid food for adult patients.
Only 44(29%) respondents correctly follow 2 hrs fasting instructions for clear fluids for adults,6 (4%) residents
follow 4 hrs fasting ,10(6.67%) use to follow 6 hrs and 20(13.33%) use to give 8 hrs fasting ,6 (4%) give 10 hrs
fasting, whereas 4 (2.67%) residents use to give 12 hrs long fasting instructions for clear to adult patients. Out of
150 residents only 20 (13.33%) give correct instructions of 4 hrs fasting for breast milk,30(20%) respondents give 2
hrs fasting, maximum residents 40(26.67) follow 6 hrs fasting for breast milk. 30(20%) residents use to give 8 hrs
fasting,20(13.33%) residents follow 10 hrs fasting whereas 10(6.67%) residents use to give 12 hrs fasting
instructions to paediatric patients for breast milk. Out of 150 PG trainees only 20(13.33%) give 2 hrs fasting
instructions for clear fluids in children. 40(26%) residents likes to give 4 hrs fasting majority 50(33%) respondents
follow to give 6 hrs fasting instructions and 20(13.33%) use to give 8 hrs fasting instructions.10(6.67%) Residents
follows 10 hrs whereas remaining 10(6.67%) trainees use to follow prolonged 12 hrs fasting for clear fluids in
paediatric patients. Maximum residents 92(61.33%) use to give 8 hrs fasting for solids ,58(38.67%) residents give 6
hrs fasting instructions for solids in children. 68 (45%) trainees prefer to give 10 hrs fasting and 52(34.67%) prefer
to give 12 hrs prolonged fasting instructions to paediatric patients. This table shows the sources of information used
by the respondents. The majority of information comes from seniors (50.67%), followed by textbooks (37.33%). A
smaller number of respondents cited other sources and articles (6.00% each). This table shows who informed
patients about fasting prior to surgery. Surgeons are the most common source (42.67%), followed by a combination
of all sources (40%). Nursing staff and anaesthesiologists are less frequently cited. This table shows who monitored
patients about fasting prior to surgery. Staff nurses are the most common source (46.43%), followed by resident
doctors (30.36%). A small percentage reported that no one (7.14%) or they themselves (5.36%). Table represents
that 83.33% residents were ready to take patients under regional anaesthesia who took clear fluid 2 hrs prior and
16.67% were not accepting. In case of general anaesthesia 73.33% residents were ready to accept whereas 26.67%
were not ready to accept patients who took clear fluid 2 hrs prior. Table shows that as per 13(8.67%) residents clear
fluid 2 hrs prior decreases stress response ,15(10%) residents thought that it causes less intraoperative hypotension,
as per 46(30%) residents it improves patient comfort whereas only 1(0.67%) resident thought that it enhances
postoperative recovery. According to the majority of residents 76(50%) clear fluid 2 hrs prior to surgery gives all of
the above benefits. 105(70%) residents responded that limiting preoperative fasting is beneficial whereas 32(21%)
residents thought that it may be beneficial, as per 13(8.67%) residents it is not beneficial. This table shows the
different problems faced by patients. Dehydration is the most common problem as per 60(40%) residents, followed
by hypovolemia and hypoglycemia as per33 (22%) residents, irritability and discomfort as per (21.33%) residents,
and all of the above as per (16.67%) residents. Out of 150 residents 96(64%) residents responded that guidelines are
adequate for Indian patients whereas as per 31(20.67%) residents guidelines may be inadequate for Indian patients,
as per 23(15.33%) residents guidelines are adequate for Indian patients. Above table suggests that as per 68(45.33%)
residents implementation of ASA fasting guidelines will lose flexibility of altering the list of cases,50(33.33%)
residents thought that it will not affect flexibility of the list of cases whereas 32(21.33%) thought that it may affect.
Table suggests that 55(36.67%) residents thought that implementation of ASA fasting guidelines will cause loss of
control on scheduling cases,56(37.33%) thought that it may affect whereas 39(26%) residents thought that it will not
loose the control on scheduling cases. According to 63(42%) residents, high workload is a limiting factor for not
implementing ASA fasting. As per above table 43 (32%) residents thought that patient will not understand fasting
instructions properly which is also limiting factor for implementation of ASA fasting guidelines,59(39.33%)
residents thought that patient may not understand whereas 48(32%) residents thought that patients can understand so
it is not limiting factor for implementation of ASA fasting guidelines. As per 65(43%) high workload may be
responsible and as per 22(14.67%) high workload is not responsible for implementation of ASA fasting guidelines.
As per 78(52%) trainees nursing staff follow instructions, 42(28%) residents thought that nursing staff may not
follow instructions properly, whereas 30(20%) residents thought that nursing staff doesn’t follow instructions so it
may be the limiting factor for implementation of ASA fasting guidelines. As per 58(38.67%) residents there is no
difference between fasting instructions given by surgical specialties residents and anaesthesia residents. But
52(34.67%) residents thought that there may be a difference, whereas according to 40(26.67%) residents there are
differing fasting instructions between surgeons and anaesthesia residents so it is limiting factor for implementation
of ASA fasting guidelines.

Discussion

Preoperative fasting refers to the period during which patients are prohibited from consuming solids or liquids
before undergoing anesthesia for surgery. This study aims to explore the knowledge, attitudes, and practices of
postgraduate trainees in surgical specialties and anesthesiology concerning preoperative fasting. Traditionally,
patients have been instructed to remain nil by mouth starting from midnight. This longstanding practice primarily
aimed to reduce the volume and acidity of gastric contents, thereby minimizing the risk of aspiration or
regurgitation, conditions associated with Mendelson syndrome.

International preoperative fasting guidelines were initially established by the American Society of Anesthesiologists
(ASA) in 1999 and were most recently updated in 2017. According to these guidelines, the minimum fasting period
is 6 hours for solids and 2 hours for clear fluids [1]. Many international guidelines now acknowledge the negative
effects of prolonged fasting and advocate for more liberal practices to reduce insulin resistance, enhance patient
well-being, and promote quicker postoperative recovery [2]. Despite these advancements, the practice of “NPO after
midnight” remains common in many hospitals. Extended fasting periods can lead to adverse effects such as
dehydration, electrolyte imbalances, hypoglycemia, inappropriate stress responses, and increased postoperative
nausea and vomiting [3].

In a study conducted in May 2020 by Nipun Gupta et al. [4] involving 166 consenting postgraduate trainees from
anesthesiology and surgical specialties, 71.33% of residents reported knowing the latest ASA guidelines for 6 to 8
hours of fasting for solids, while 40% were aware of the 2-hour fasting period for clear fluids in adults. Additionally,
56% were aware of the 2-hour guideline for clear fluids, 4% of the 4-hour fasting period for breast milk, and 48%
knew of the 6-hour fasting recommendation for solids in pediatric patients. While 70% of residents advised 6 to 8
hours of fasting for solids in adults, only 29.33% correctly instructed 2 hours for clear fluids. In pediatric cases, only
13.33% gave appropriate instructions of 4 hours for breast milk and 2 hours for clear fluids, while 38.67% continued
to advise 6 hours of fasting for children.

In the same study, 50% of trainees stated that they learned about fasting guidelines from their seniors, 37% from
standard textbooks, and 6% each from articles and other sources. According to Gupta et al. [4], 54% of respondents
in their study also learned from seniors, followed by 25% from textbooks and smaller numbers from other sources
and articles. While seniors serve as the primary source of practical knowledge, this approach risks passing on
incomplete concepts and improper practices. In contrast, textbooks and high-quality journal articles offer more
reliable information.

Regarding the communication of fasting instructions to patients, 42.67% of residents indicated that surgeons usually
provided this information, while 9.33% said it was given by nursing staff, 8% by anesthesiologists, and 40% said all
groups were involved. In a study by Vibhore Rai et al. [5], 14.7% stated that anesthesiologists, surgeons, and
nursing staff collectively informed patients, with nursing staff mentioned most frequently at 26.1%. In another study
by Pratibha Panjiar et al. [6], 28% reported that nursing staff gave the instructions, 7% named surgeons, 13% cited
anesthesiologists, and 18% indicated all three groups were involved. An audit by Arun et al. [7] concluded that
enhancing nurse education and improving coordination among anesthesiologists, surgeons, and nursing staff could
help reduce unnecessary preoperative fasting.

Monitoring of patients in the preoperative period was primarily done by staff nurses (46.43%), followed by resident
doctors (30.36%), while 7.14% reported that no one monitored what the patient consumed. This highlights that
inadequate monitoring may contribute to improper fasting compliance. Regarding anesthesia practices, 90% of
residents were willing to proceed under monitored anesthesia care (MAC), 83.33% under regional anesthesia, and
73.33% under general anesthesia. Rai et al. [5] similarly reported that 73.9% accepted patients under MAC after
clear fluids 2 hours prior, 89.1% for regional anesthesia, and 68.1% for general anesthesia.

Residents identified multiple benefits of allowing clear fluids 2 hours before surgery. Of them, 8.67% said it reduces
stress response, 10% cited less intraoperative hypotension, 30% believed it improves patient comfort, and 0.67%
mentioned enhanced postoperative recovery, while 50% acknowledged all of these benefits. In comparison, Panjiar
et al. [6] found that 81% of anesthesiologists highlighted improved comfort, 35% decreased stress response, 32%
reduced intraoperative hypotension, 23% enhanced recovery, and 7% supported all the benefits of allowing clear
fluids 2 hours preoperatively.

Overall, 75% of residents in the study were aware of the benefits of limiting preoperative fasting. Gupta et al. [4]
also found that 69% of trainees recognized these benefits, although actual implementation lagged behind. Only 40%
of trainees accurately described clear fluid fasting guidelines, and just 29.33% applied them correctly in practice.
Similar findings were observed in studies conducted in Lebanon and Sri Lanka, where awareness existed but
practical implementation was limited [8,9].

Regarding patient concerns, 40% of residents cited dehydration as the most common problem due to prolonged
fasting, followed by hypovolemia and hypoglycemia (22%), irritability and discomfort (21.33%), and 16.67%
reported all of the above. Panjiar et al. [6] found that over two-thirds of respondents acknowledged discomfort
from extended fasting. Prolonged fasting is also linked to dehydration, hypotension, hypovolemia, electrolyte
imbalances, metabolic stress, hypoglycemia, and insulin resistance [10,11].

Fifty percent of the residents believed that the duration of fasting should differ based on pathological conditions like
diabetes or uremia, while the other half felt the guidelines should be uniform. When examining barriers to ASA
guideline implementation, 45.33% believed it would lead to loss of flexibility in case scheduling, 36.67% thought it
would reduce control over scheduling, and 42% cited high workload as a hindrance. Additionally, 32% stated that
patients would not understand the instructions properly, 20% felt nursing staff did not follow instructions, and
26.67% noted inconsistencies between instructions from surgeons and anesthesiologists. In a study by Rai et al. [5],
76.9% of respondents cited lack of control over case scheduling as the primary reason for non-compliance, 43.3%
mentioned high workload, and 30.3% believed patients would not understand instructions. Panjiar et al. [6] found
similar barriers: 54.8% cited case scheduling issues, 31.3% high workload, and 35.5% poor surgeon knowledge of
the guidelines. Gupta et al. [4] also noted that 49% of respondents were concerned about flexibility in scheduling
and 52% reported inconsistent fasting instructions between anesthesiologists and surgeons.

This study was limited to residents in anesthesia, orthopedics, ENT, OBGY, and general surgery in a metropolitan
tertiary care setting. Nurses and other healthcare professionals were not included, nor were practitioners from
peripheral or private hospitals. Consequently, the findings cannot be generalized nationwide. The relatively small
sample size and the retrospective, memory-based reporting also limit the study's broader applicability.

Conclusion
Our study indicates that while most postgraduate residents are familiar with ASA fasting guidelines, their
implementation and understanding of the benefits of limiting fasting periods are lacking. To address this, it is
essential to establish comprehensive educational training programs aimed at enhancing the knowledge and
awareness of postgraduate trainees, nurses, and medical staff regarding preoperative fasting guidelines and their
advantages. Common obstacles to adherence include limited control over surgical scheduling, concerns about losing
flexibility in case lists, heavy workloads, and inadequate knowledge among nurses and surgeons. Improving
coordination, communication, and teamwork among surgeons, anesthesiologists, and nursing staff is crucial for
effective patient management. Implementing formal training on guidelines, developing standard fasting protocols,
and adhering to them rigorously can help reduce unnecessary preoperative fasting and shift away from the
traditional practice of overnight fasting before elective surgeries.

References

1. Practice Guidelines for Preoperative Fasting, ASA, 2017

2. ASA Guidelines Update, 2017

4. Gupta N et al., 2020

5. Rai V et al., 2020

6. Panjiar P et al., 2019

7. Arun et al., Hospital Audit

8. Dagher et al., 2019 (Lebanon)

9. Gunawardhana, 2012 (Sri Lanka)

10. Pratibha Panjiar et al., 2019

11. Additional literature on fasting-related metabolic stress