The New Rules on Eating & Drinking Before Anesthesia

If you’ve undergone a procedure requiring anesthesia, you’ve likely been told by your healthcare provider to stop eating or drinking at midnight the night before the procedure occurs. This has been the standard rule of thumb promoted by anesthesiologists, surgeons, doctors and other healthcare providers for at least the last few decades. This rule was created as a safety precaution for patients to ensure their stomachs were mostly empty when put under as there are choking and contamination risks associated with anesthesia, particularly for certain kinds of surgery. However, the no food or drink after midnight rule is often handed out as a general blanket ban, with no consideration as to the type of procedure, the time the procedure is taking place the next day, the health of the patients or other factors that can have just as much impact on the success of the surgery. In addition, patients have historically done a less than perfect job of following this rule and have still come out of surgery safely time and time again.


Today, experts in the field are starting to question this antiquated rule. More than half of the members of the American Society of Anesthesiologists no longer recommend a complete ban on food and drink before surgery as they consider this practice to be overly cautious. The new guidelines do ask patients to refrain from eating eight hours prior to surgery, however they encourage patients to drink clear fluids all the way up to two hours prior to the surgery for all elective surgical procedures. But are these new recommendation safe? Should you fast starting at midnight prior to undergoing anesthesia or are the new thoughts on consuming clear liquids the way to go?

How Does Anesthesia Work?

To understand why doctors have been giving the no food, no drink order for so long, it’s important to understand what anesthesia is and how it works on the human body. Anesthesia is a combination of drugs given to a patient to either numb a particular region of the body (local anesthesia) or render the patient entirely unconscious (general anesthesia) so that a surgical procedure can be completed. Before anesthesia was invented in the 1800s, doctors had to perform painful and often difficult procedures such as amputations, tooth extractions and stitches for wounds with nothing to dull the pain other than a shot of whiskey or perhaps a measure of opium. Patients today forgo the whiskey and instead receive a combination of drugs administered by an anesthesiologist that make the surgery itself a completely pain-free experience.

When you go in for a surgical procedure requiring general anesthesia, the anesthesiologist will administer a combination of drugs in a quantity that will keep you under for the duration of the surgery. The drugs are quite safe and have very few side effects; however, they do tend to interfere with your natural ability to breathe, which is why patients are often intubated during a procedure requiring general anesthetic, and this is where the order to fast comes in. There is a general concern that if there are solids or liquids in your stomach at the time of surgery, they could be accidentally inhaled, causing asphyxiation, or the inability to breathe.

This idea was solidified during the 1950s when two research papers detailing the deaths of two pregnant women were released. These women died during delivery when the contents of their stomachs were accidentally ingested into the lungs. This deepest fear of anesthesiologists seemed to be confirmed, thus giving rise to the NPO policy.

NPO After Midnight

The official policy for not eating of drinking after midnight is known as “NPO after midnight” in the medical community and was accepted by the American Society of Anesthesiology up until 1999. NPO stands for nil per os, a Latin phrase meaning “nothing by mouth.” The idea is that by fasting at least eight hours prior to going under, your stomach will be mostly empty, making the likelihood that you accidentally breathe in material from your digestive tract that much less. There is also the secondary idea that you’re less likely to become nauseated from the anesthesia drugs if your stomach is empty, reducing the risk that you vomit during surgery and subsequently choke on the vomit.

NPO after midnight does seem like a reasonable idea based on these choking risks; however, the main examples often pointed to, such as the research papers detailing the deaths of the pregnant women mentioned previously, are based on outdated surgical methods that were unable to protect the patient’s lungs. These days, we use intubation to ensure patients continue to breathe while under anesthesia. The endotracheal tubes placed in surgical patients today ensure patients can breathe throughout their procedures and are designed to prevent choking in the event that some debris does enter the lungs.

Modern Surgical Realities

So does the advancement in medical science and the ability to keep patients breathing during surgery mean the NPO order is completely outdated and should be abolished immediately? Not entirely, however the guidelines should be revisited and are being challenged by top experts in the field of anesthesiology.

Around the turn of the century, approximately thirty studies were released showing that patients who ingested clear liquids up to two hours before their surgeries had emptier stomachs than those who had fasted since the prior evening, challenging the notion that NPO after midnight is the most effective way to prepare patients for surgery. Upon further review, it was found that in preparation for the coming fast, many patients would eat large, heavy dinners right before midnight to try and get in that one last meal before surgery. That meal would then sit in their stomachs overnight, barely digesting by the time they arrived for prep early the next morning. For many patients, simply being able to have a clear liquid drink in the morning eased their fears of hunger and stopped them from filling themselves up, causing them to have much emptier stomachs by the time of surgery.

In addition to the reality that NPO orders don’t always work to empty the patient’s stomach properly, it’s important to consider the modern realities of today’s medical environment. In the past, patients would spend the night in the hospital before the surgery and would be put under at the crack of dawn, making the after-midnight fast both enforceable and relatively painless. Today, most surgeries are outpatient procedures, meaning the patient is at home the night before the surgery and returns home soon after the procedure is complete. Surgeries are also scheduled throughout the day all the way into the late afternoon. It’s not reasonable to expect a patient to fast starting at midnight the prior evening if their surgery isn’t scheduled until three o’clock in the afternoon the following day.

The Benefits of Not Fasting

Based on the realities of the modern medical landscape alone, many anesthesiologists are changing their guidelines for fasting before surgery, but there’s more. A number of prominent studies have been conducted in recent years showing that allowing patients to drink clear liquids up to two hours prior to surgery does not increase the risk of choking or other complications associated with not fasting prior to receiving anesthesia and actually reduces the risks of complications of surgery in general. Patients allowed to drink clear fluids experience less anxiety overall, require less IV fluids both during and after surgery, maintain a better metabolic rate when put under and recover better after the procedure is complete due to more steady blood sugar levels. Many patients also report feeling better overall without the stress of a complete fast on the day that an already stressful event is taking place.

The New Guidelines

Not every doctor or anesthesiologist is on board with the new recommendations for fasting before surgery, so it’s important to check with your doctor before any procedures and follow their instructions carefully. There might certain health risks or other considerations in play when your doctor makes the NPO after midnight recommendation, and there are still certain procedures that require a completely empty stomach for various other reasons.

However, for basic elective procedures with few risks, a patient should refrain from eating solid food at least eight hours prior to their scheduled start time but can continue to consume clear liquids up to two hours prior to the procedure. Clear liquids include water, juice, sports drinks such as Gatorade as well as coffee and tea without milk. Due to its high protein and fat content, you should refrain from drinking milk eight hours prior to surgery as it takes longer to digest than other fluids. If you absolutely must eat something less than eight hours before your surgery, plain toast or crackers are the best options as they are easily digestible and will clear from your system quickly.

Modern medicine is constantly changing. The best doctors in the world are continually striving to make advancements that both improve patient comfort and outcomes. The guidelines surrounding fasting before surgery are one of those areas where new technology coupled with a better understanding of surgical procedures has allowed for new guidelines to be set. Mandatory NPO after midnight policies have been abolished and over fifty percent of anesthesiologists belonging to the American Society of Anesthesiologists surveyed recommend these new guidelines. It is now considered generally safe to have clear liquids two hours prior to surgery, and you can feel safe having a sip of juice to rev your metabolism, soothe your stomach and calm your nerves the morning of a procedure. However, always consult with your doctor and follow his/her guidelines.

Surgery and other procedures requiring anesthesia are stressful. The best way to prepare for any surgery is to be proactive. Take care of your health prior to going under by maintaining a health weight, an ideal body mass index (BMI) and eating a healthy diet. If you’d like more information on BMI, ideal weight and other health factors that can affect your risks of complications during surgery, check out www.healthstatus.com/calculators/ for more information.

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HealthStatus has been operating since 1998 providing the best interactive health tools on the Internet, millions of visitors have used our health risk assessment, body fat and calories burned calculators. The HealthStatus editorial team has continued that commitment to excellence by providing our visitors with easy to understand high quality health content for many years.

Mary Garland
15. February 2021
Mary Garland
15. February 2021
Please let me know how your procedure went, and if any complications arose. I'm facing carpal tunnel surgery tomorrow afternoon, and would like to know if it's OK to drink black coffee very early in the morning to avoid a horrible migraine headache that is worse than the procedure itself. Thanks. Mary G. email: [email protected] ;

Eva Lehde
12. November 2019
Eva Lehde
12. November 2019
I am having Carpal tunnel release surgery at one thirty pm. I could go days without eating but can’t imagine going without a drink that long. I believe I will have black coffee and water up until I get to the hospital two hours before surgery. I am only having a nerve lock, not general . Still I was told nothing after midnight. I can’t find any info on the risk of liquids with a nerve block.

Dani
5. September 2019
Dani
5. September 2019
My thoughts EXACTLY!! People can be in a car accident right after feasting at Red Lobster.. Right?? And they go straight into whatever surgery they may need to have. This has ALWAYS been how I thought and felt about NPO after midnight.. I don't understand.. At all!! I feel horrible for the people who have to wait until 3 or 4pm.. That's absolutely ridiculous!! My mother in law had surgery on her neck recently.. She was told NPO after midnight.. She never went in to surgery until 6pm!! I was sooo PISSED!!! That's 18 hours of not EATING OR DRINKING!!! People could pass out from their sugar being low, they could be borderline dehydrated, etc.. I just think it's bogus!! But, just my personal opinion.. ???

Sebastian Wienke
10. April 2019
Sebastian Wienke
10. April 2019
@Jeri Aronowitz another anesthetist here: It depends, "normally" a meal takes about 6-8 hours to leave the stomach. It depends on the meal's components, fatty stuff lasts up to 11 hours. But the stomach is never "empty", and there are certain patient conditions which raise the risk for inhalation of gastric content. The risk can be lowered, but is never zero. In your husband's case, it was unfortunate. Best of luck to you both.

Jeri Aronowitz
19. March 2019
Jeri Aronowitz
19. March 2019
My husband was fed a Turkey sandwich they say at 11pm the night before and aspirated during surgery leading him to be on a vent for 6 days. They were sucking pieces of turkey out of his lungs. Why would they do that!! He was even laying flat because he had a temp pace maker so he had to lie flat. How did he eat the sandwich? He doesn't remember anything. Then they tried to tell me that maybe he had a digestion problem because the turkey had not digested. Crazy pissed about the whole thing. He will never b the same.

Jennifer R Priore
14. April 2018
Jennifer R Priore
14. April 2018
There was a medication an anesthesiologist gave me before surgery to make the hunger pain go away. Do you know what medication this might have been or what could work for someone with severe hunger pains as the hospital has had him listed as NPO for forty eight hours now.

Jake
5. March 2018
Jake
5. March 2018
The reason you're told to not eat or drink anything is because when you get put to sleep, your sphincter muscle that keeps your food down relaxes, allowing stomach contents to regurgitate into your throat. Also, your gag reflex goes away, so all that stuff from your stomach can go into your lungs. If that happens, it is life-threatening and easily fatal. With emergency surgery, special precautions are taken to protect the airway, but if your anesthesiologist doesn't know that you've eaten, it's extremely risky. Emergency surgery is, by definition, emergent, so you can't take the time to let the food digest. You accept the fact that, even though the anesthesia part may be dangerous, it's not as risky as postponing the surgery until all the food is out of your stomach. You're always better off being honest with the anesthesiologist, even if it means your surgery is delayed or even cancelled. But if you drink clear liquids over two hours before your procedure, most anesthesiologists will not delay the procedure. BTW I'm an anesthesiologist. : )

Jake
5. March 2018
Jake
5. March 2018
The reason you're told to not eat or drink anything is because when you get put to sleep, your sphincter muscle that keeps your food down relaxes, allowing stomach contents to regurgitate into your throat. Also, your gag reflex goes away, so all that stuff from your stomach can go into your lungs. If that happens, it is life-threatening and easily fatal. With emergency surgery, special precautions are taken to protect the airway, but if your anesthesiologist doesn't know that you've eaten, it's extremely risky. Emergency surgery is, by definition, emergent, so you can't take the time to let the food digest. You accept the fact that, even though the anesthesia part may be dangerous, it's not as risky as postponing the surgery until all the food is out of your stomach. You're always better off being honest with the anesthesiologist, even if it means your surgery is delayed or even cancelled. But if you drink clear liquids over two hours before your procedure, most anesthesiologists will not delay the procedure.

Kayla P
2. March 2018
Kayla P
2. March 2018
You make a super valid point.... As for me. Surgery at 9:15.... Which really means like 10ish and i ate at 2:30am. Hope that 30 mins doesn't kill me although i doubt it will

kim m.
15. January 2018
kim m.
15. January 2018
I have had a couple of planned surgeries like major back surgery and rotator cuff surgery, two for endometriosis and one for ovarian cyst and then I have had two emergency surgeries which were my appendix and my gallbladder. I fast for the planned ones and for the emergency ones I am pretty sure I had eaten and drank in the 8-12 hours prior and I made it. I still have a couple more back surgeries to go and every time I am on the night before surgery and in fasting mode I just keep thinking of all the emergency surgeries doctors do every day routinely for them and I know those people have eaten and drank, some in the hour just prior to coming in for the emergency surgery. So I know there are dangers but it can't be that big of a deal right bc doctors do emergency surgeries on a daily basis with no problems right? That's where my head wanders on the night before my surgery when I'm trying to keep from eating lol.

Cindy
22. November 2017
Cindy
22. November 2017
Ok this is torture!! To not eat after midnight and surgery is not until 2 pm the next day?? I will starve by then!!!!!

Tsietsi
14. November 2017
Tsietsi
14. November 2017
I am diabetic and cannot afford prolonged period without eating at all. It looks like there will be more risk if I do not eat for a prolonged period before the actual operation. Whilst I cannot confirm the time I will be operated, my admission is at 12H00 and have been informed to stop eating from 7H00 in the morning. What is your advise?

Ameera
11. October 2017
Ameera
11. October 2017
How did it go..?

Jesus
23. September 2017
Jesus
23. September 2017
So did you make it or not? What happened? It's now September and we've been wondering

jamie
10. September 2017
jamie
10. September 2017
im having radioplasty or whatever its called tomrw, lower back where they go in with a hollow needle and cauterize the nerves in my spine. my arrival time is 1130 meaning my procedure wont be until noon at the earliest and I was given the npo after midnight order, I feel this is outdated and ridiculous. I am a very thirsty person that is constantly drinking something and am ready to ignore this and continue clear fluids until 2 hours prior unless someone feels this procedure is risky and I shouldn't?

Janet
14. August 2017
Janet
14. August 2017
I recently had surgery on my wrist to remove a cyst. Because i could not have any water, my veins totally revolted, which meant it was 4 ATTEMPS at getting the iv started.

Susan
8. August 2017
Susan
8. August 2017
i agree local anesthesia for a tenex procedure. plan to have my usual coffee with a cracker or two. surgery at 12 will eat around 5am.

jeffery
28. July 2017
jeffery
28. July 2017
I'll find out tomorrow if the sweet cherries I just ate will kill me or nit. Its 1:08 am, surgery is at. 11am. I also had a toasted bagel at midnight. If you hear back from me tomorrow...... Well that would be a good implication now wouldn't it! LOL

Jerry Korrell
20. July 2017
Jerry Korrell
20. July 2017
Docs are so afraid of being sued, they run scared. I had a lower back pain med injection a while ago, no anesthesia other than a topical local, and the surgery center was insistent about nothing at all by mouth after midnight. RIDICULOUS! Of course, I ignored them and had my usual coffee and toast at 5:30 a.m. prior to my 7:30 a.m. procedure.

hen
22. June 2017
hen
22. June 2017
what about alcohol the night before surgery? only like 2-3 drinks or so? am i gonna die nobody told me until after that i wasn't supposed to do that

aphroditie
11. June 2017
aphroditie
11. June 2017
What are the rules for wine consumption in the month before planned anesthesia? My husband just had they claim "DT's and that it doesn't take much consumption just regular?

Lou ferogko
13. April 2017
Lou ferogko
13. April 2017
What date was this written?

Clare T
1. March 2017
Clare T
1. March 2017
If I had to guess, and clearly this is just an educated guess.. toasting the bread will make it crisp. In the toasting process, crisping the bread is further cooking it and breaking it down. Not only will it be easier to digest, already slightly "predigested" or partially broken down; the "crunch" of the toast is more satisfying and provides a more thorough feeling of Appetite Satisfaction while experiencing a Biting or Chewing experience.

bobisocks
31. January 2017
bobisocks
31. January 2017
What is the date this article was written?

Lindsey
24. January 2017
Lindsey
24. January 2017
Bread undergoes a chemical process during toasting. Crackers are essentially thin bread bites that have been baked in a way that offers the same chemical changes. These chemical changes cause bread to break down into chemicals that are easier and more efficient for our bodies to process

Denise Ripley
21. October 2016
Denise Ripley
21. October 2016
Plain toast? So, that is an odd choice. Would you then be able to eat a slice of bread that is not toasted?

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HealthStatus has been operating since 1998 providing the best interactive health tools on the Internet, millions of visitors have used our health risk assessment, body fat and calories burned calculators. The HealthStatus editorial team has continued that commitment to excellence by providing our visitors with easy to understand high quality health content for many years.

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