Sip Til Send

Professor Scarlett McNally

CPOC Deputy Director

This is to explain a new recommended policy that has developed organically at multiple hospitals around the world.

Sip Til Send¹ is a worldwide initiative allowing patients to sip small volumes of water (or similar fluid) while waiting before surgery until they are sent for to have their operation. Historically, policies about patients due for operations stated no food for 6 hours before surgery, clear fluids until 2 hours before surgery and then ‘Nil By Mouth’ (NBM) until their operation. In practice, it can be difficult to predict when the operation will start, so some patients are kept starved for hours. This can cause dehydration and discomfort. Allowing people to sip water until they are sent for by the operating theatre team means that they are hydrated and more comfortable^1,2,3,4,5,6, with less nausea, fewer headaches and a lower chance of needing an intravenous drip.

Should we worry about the stomach being full?

The restrictions on what patients can eat or drink before surgery are to reduce the risk of aspiration (stomach contents entering the lungs). Recent ultrasound studies show that a ‘full stomach’ is common even if NBM times are followed (affecting over 5% of people)^2,5 and problems of aspiration are very rare, affecting only 1 in 7000 people³.

What is the new protocol?

No food for 6 hours before surgery
Unlimited clear fluids (water, black tea, black coffee, squash, juice without bits or oral carbohydrate drinks) until 2 hours before surgery
‘Sip Til Send’
- Water, black tea, black coffee or squash
- up to 170mls per hour (= one NHS cup) until the operating team send for the patient.
- For a child, the amount is up to 3ml per kilogram body weight per hour.
This applies to all patients unless a senior clinician has requested an individual “opt out”.

How does this link with post-operative work?

The Centre for Perioperative Care aims to improve the care for patients from the moment surgery is contemplated until full recovery. Please note that there is a post-operative initiative of “DrEaMing” – meaning Drinking Eating and Mobilising. Patients who achieve these activities within 24 hours of their surgery have better results. Good hydration improves people’s ability to mobilise after surgery – please watch the lovely video from Tayside that includes many useful concepts.

Can we just start?

Yes. Many UK NHS Trusts and Boards have already adopted this policy, which is logical, reasonable and defensible. CPOC strongly recommends others to do so.

Are there contra-indications?

The policy should be for all patients, including Obstetric patients and children unless a senior clinician has made an individual decision for the patient. There are some clinical situations where an individual anaesthetist may prefer to use the traditional 2-hour fluid fasting period including:

Significant history of symptomatic gastro-oesophageal reflux disease or hiatus hernia
Class-3 obesity (BMI >40)
Documented history of gastric immobility e.g. autonomic dysfunction related to diabetes
Admission for gastrointestinal surgery where the patient has a known obstructing lesion
Significant dementia or learning difficulties where a patient is unable to limit/manage their own water consumption
Any patient on thickened fluids
Patients who have had a stroke affecting swallowing
Patients who have a bowel obstruction or ileus

Any tips for our implementation?

Many Hospitals have successfully implemented Sip Til Send. They suggest that this needs clear messages, education for staff, posters and information for patients. You may wish:

To use the resources at www.cpoc.org.uk?
To schedule a journal club or clinical Governance session about it?
To print out some posters?
To print an article into the staff magazine?
To discuss with the housekeeping staff?
To discuss with the administrative, reception and booking staff?
To adapt the information that goes to patients – You may wish to include words such as:
- NEW Sip Til Send policy – to keep patients more comfortable.
- You may drink clear fluids before your surgery.
- Clear fluids include water, black coffee, black tea, diluted squash, or fruit juice without bits.
- Do not eat any solid food, milky drinks, fizzy drinks, or sweets (including chewing gum) 6 hours before your surgery.
- You may drink unlimited amounts of clear fluids until 2 hours before the intended start time of your operation. After that, you will be encouraged to sip up to 1 glass (170mls) of clear fluids every hour.
- Feel free to bring in a water bottle. We can give you a cup if you prefer.”

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