Scarlett McNally: Nil-by-mouth rules need updating to implement SipTilSend
BMJ 2025; 388 doi: https://doi.org/10.1136/bmj.r306 (Published 19 February 2025) Cite this as: BMJ 2025;388:r306
- Scarlett McNally, professor
- scarlettmcnally{at}cantab.net
Follow Scarlett on X @scarlettmcnally
Rules and protocols are helpful in medicine. I’ve argued for streamlined standardised pathways,1 and I also value the doctor’s unique role in knowing when to deviate from a protocol with an individual patient. But this is challenging when no single entity is in charge and there’s a groundswell of opinion about the need to change a particular rule.
For many decades, one tenet of anaesthesia has been that the stomach must be empty before surgery to reduce the risk of aspiration (stomach contents entering the lungs).2 There are a few exceptions for extremely urgent operations. The typical nil-by-mouth schedule has been no food for six hours before surgery and only “free, clear fluids” until two hours before it, then nothing in the final two hours. In reality it can be hard to predict how long some operations will take, so patients later in the list are often starved for too long, leading to dehydration, discomfort, and many needing drips. As a surgeon, I can recollect many patients having their operations cancelled or procedures under sedation being delayed because well meaning staff had given them breakfast or even just a cup of tea. Relaxing the rule on nothing being allowed in the final two hours would reduce the number of patients requiring an overnight stay for aftercare or because their emergency procedure has had to be delayed.
New reports show that 5% of elective patients who have starved for the full six hours and over 50% of emergency patients have a “full stomach” when scanned before being operated on34—yet the rate of aspiration is very low, at under 0.3%.3 It’s also worth mentioning that the new GLP-1 receptor agonist drugs for weight loss reduce stomach emptying, even when the drugs are stopped for one to three weeks before surgery.5 The Medicines and Healthcare Products Regulatory Agency has issued an alert about the risk of aspiration with anaesthesia or sedation in patients using GLP-1 receptor agonists.6
Several organisations have started to allow patients to sip clear fluids until being sent for by the operating team.7 The anaesthetic team in Tayside have pioneered “SipTilSend” and have given hundreds of talks, sharing their resources worldwide.8 The National Hip Fracture audit in Scotland and other publications have shown that this approach is safe.3478910 Sheffield Teaching Hospitals NHS Foundation Trust highlighted two key areas for successful implementation: the need for SipTilSend to be standardised with “opt-out” options; and good patient education.11
Change in the NHS
Making change in the NHS is difficult. The best change projects have leadership from frontline clinicians, buy-in from other staff, and patient engagement. The paradox is that these clinicians are often too busy to write the policies or business cases that allow their idea to be implemented.
As deputy director of the Centre for Perioperative Care, I’ve found it a joy to work on collaborative projects across the whole healthcare team with input from board partners and charity and patient advisers.12 We judged that, for SipTilSend to be implemented widely, it needed three things: a template policy that NHS staff can adapt to request ratification through their organisation’s governance processes (possibly as an appendix to the starvation or sedation policy); a template patient information leaflet about SipTilSend for local adaptation; and a web page of resources, videos, and leaflets.913
We can include children in this new approach, defining maximum volumes of 3 mL/kg/hour up to the adult dose of 170 mL/hour and incorporating new European guidance that breast milk for babies shouldn’t be given in the three hours before surgery.14
SipTilSend ties in with new work promoting early “DrEaMing”—encouraging patients to drink, eat, and mobilise after surgery.15 Simple, patient centred messages are getting through. It’s lovely to see this work trickle through the NHS.
Footnotes
Competing interests: Scarlett McNally is a consultant orthopaedic surgeon, deputy director of the Centre for Perioperative Care, and president of the Medical Women’s Federation.
Provenance and peer review: Commissioned; not externally peer reviewed.