Disclaimer: This article is intended solely for informational and educational purposes only. It does not constitute medical advice.
The American Society of Anesthesiologists (ASA) issued an update to its preoperative fasting guidelines in 2023, addressing carbohydrate-containing clear liquids, chewing gum, and pediatric fasting duration (Joshi et al., 2023). The task force found strong evidence supporting ingestion of carbohydrate-containing clear liquids, whether simple or complex, up to two hours before elective procedures requiring general anesthesia, regional anesthesia, or procedural sedation, with volumes up to 400 mL considered appropriate. Notably, no aspiration events were observed across the trials reviewed, reinforcing the safety of this practice in healthy patients.
Evidence remained insufficient to recommend protein-containing liquids preferentially, and the group issued a conditional recommendation against delaying surgery in adults who have been chewing gum, provided the gum is removed before anesthetic induction. For pediatric patients, the guideline stopped short of recommending a shortened one-hour fasting window over the traditional two hours due to very low-quality evidence. However, the ASA issued a best-practice statement urging clinicians to avoid prolonged fasting beyond two hours whenever feasible, given well-documented adverse consequences of extended fasting in children.
The European Society of Anaesthesiology and Intensive Care Medicine (ESAIC) updated its guideline on postoperative delirium (POD) in 2024, incorporating new research through February 2022 (Aldecoa et al., 2024). The revised guideline strongly recommends evaluating preoperative risk factors for delirium—including advanced age, ASA physical status greater than 2, elevated Charlson Comorbidity Index, and impaired Mini-Mental State Examination scores—as part of routine anesthesia consultation. Notably, the task force does not recommend prophylactic use of any single drug, including dexmedetomidine, to prevent POD, despite meta-analytic evidence suggesting benefit in some contexts; this reflects concerns about cardiovascular side effects and heterogeneous study populations.
Multicomponent nonpharmacological interventions, however, received a strong recommendation based on moderate-quality evidence from randomized trials combining geriatric assessment with individualized care bundles. When pharmacological treatment becomes necessary for severe distress, low-dose haloperidol is suggested as a short-term, symptom-oriented option, while benzodiazepines are explicitly not recommended outside the context of alcohol withdrawal. Processed EEG monitoring received only a weak recommendation due to persistent uncertainty about its reliability in older patients with reduced cortical electrical activity.
Most recently, the ASA published a 2026 guideline on perioperative pain management using local and regional analgesia for cardiothoracic, mastectomy, and abdominal surgery (Joshi et al., 2026). Fascial plane blocks received strong recommendations across most open surgical categories in adults, including cardiothoracic procedures, abdominal and pelvic surgery, and mastectomy, based on moderate-quality evidence of reduced pain and opioid consumption.
For minimally invasive procedures, recommendations were more nuanced: fascial plane blocks were strongly recommended for minimally invasive abdominal surgery but only conditionally recommended for minimally invasive cardiothoracic surgery and open hernia repair, reflecting variation in the certainty of evidence. In children, fascial plane blocks were strongly recommended for open cardiothoracic surgery and conditionally recommended for hernia repair.
These recent practice guideline updates for anesthesiology reflect a broader trend toward procedure-specific, risk-stratified recommendations rather than blanket approaches. Limiting factors in the evidence base continue to be small sample sizes, inconsistent outcome measures, and methodological heterogeneity. Anesthesiologists and CRNAs should remain up-to-date in their knowledge as clinical research evolves and should aim to employ evidence-based best practices.
References
- Aldecoa, C., Bettelli, G., Bilotta, F., et al. (2024). Update of the European Society of Anaesthesiology and Intensive Care Medicine evidence-based and consensus-based guideline on postoperative delirium in adult patients. European Journal of Anaesthesiology, 41(2), 81–108. https://doi.org/10.1097/EJA.0000000000001876
- Joshi, G. P., Abdelmalak, B. B., Weigel, W. A., et al. (2023). 2023 American Society of Anesthesiologists practice guidelines for preoperative fasting: Carbohydrate-containing clear liquids with or without protein, chewing gum, and pediatric fasting duration—A modular update of the 2017 American Society of Anesthesiologists practice guidelines for preoperative fasting. Anesthesiology, 138(2), 132–151. https://doi.org/10.1097/ALN.0000000000004381
- Joshi, G. P., Mariano, E. R., Elkassabany, N. M., et al. (2026). 2026 American Society of Anesthesiologists practice guideline on perioperative pain management using local and regional analgesia for cardiothoracic surgeries, mastectomy, and abdominal surgeries. Anesthesiology, 144(1), 19–43. https://doi.org/10.1097/ALN.0000000000005790