Three Part Question
Can[patients considered for procedural sedation in the emergency department]who have [chewed chewing gum in the preceding six hours] be [deemed fasted]?
A 37 year old male presents with an anterior shoulder dislocation following a rugby match. He states he has not ingested solids for 6 hours or fluids for 2 hours. As you are consenting him for procedural sedation you notice he is chewing gum. Should this patient be regarded as fasted or should an alternate method of facilitating reduction be used due to an increased risk of aspiration?
Using Medline database 1966 to week 3 May 2013 via OVID.
[chewing gum] AND [anaesthesia] LIMIT to human, English, abstracts
29 papers of which 8 included data on patients relevant to the clinical question, 2 were unobtainable.
|Author, date and country
||Study type (level of evidence)
|Not applicable||Literature review||Does chewing gum increase the volume or acidity of gastric juice?||No risk theoretically||Not a patient study|
|Schoenfelder RC et al|
|Children (5-17 yr old)||Clinical trial||Does chewing gum increase gastric fluid volume and changes gastric ||Chewing gum in children have significantly larger gastric fluid volumeand higher pH.||Limited to children|
|Smith I et al|
|Not stated||Meta-analyses, systematic reviews, or RCTs with a high risk of bias||Should an operation be delayed?||No risk theoretically||Not a patient study|
|Søreide E et al|
|Adult females||Clinical trial||Effect on gastric fluid volume||Increased gastric fluid volume||No men in study|
|Dubin SA et al|
|Adults undergoing surgery||Clinical trial||Volume and pH of gastric content||There was no difference between groups in terms of gastric volume or pH||Non detected|
|Kradel et al|
|Based on one patient||Observational/Letter||Not applicable||Patient underwent anaesthesia while chewing gum, later found attached to nasogastric tube, highlights patient education issues||Only based on one patient|
The evidence about the risks of patients who have used chewing gum varies. Some studies conclude that chewing gum increases the volume of gastric contents while others do not. Whether this increases the risk of aspiration is unclear. All studies include patients who are undergoing anaesthesia and not sedation. Studies do not include injured patients who are the cohort of patients who are likely to present to the emergency department needing sedation.
Clinical Bottom Line
Patients who have chewed gum in the past 6 h may theoretically be at increased risk of aspiration. This should be considered when making a balanced decision about the use of procedural sedation.
- Poulton TJ. Gum chewing during pre-anesthetic fasting. Paediatr Anaesth. 2012;22:288–96.
- Schoenfelder RC, Ponnamma CM, Freyle D et al. Residual gastric fluid volume and chewing gum before surgery. Anesth Analg. 2006;102:415–17.
- Smith I, Kranke P, Murat I et al. Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 2011;28:556–569.
- Søreide E, Holst-Larsen H, Veel T et al The effects of chewing gum on gastric content prior to induction of general anesthesia. Anesth Analg. 1995;80:985–9.
- Dubin SA, Jense HG, McCranie JM et al. Sugarless gum chewing before surgery does not increase gastric fluid volume or acidity. Can J Anaesth 1994; 41;pp 603-6 .
- Kradel B, Hackett A, Johnstone R. NPO includes chewing gum Anesth Analg. 1992;74:621.