Fasting Guidelines for Pt Requiring Sedation or Anaesthesia



Canberra Hospital and Health ServicesClinical Guideline Fasting Guidelines for Patients Undergoing Procedures Requiring Sedation or AnaesthesiaContents TOC \h \z \t "Heading 1,1" Contents PAGEREF _Toc492465427 \h 1Guideline Statement PAGEREF _Toc492465428 \h 2Scope PAGEREF _Toc492465429 \h 3Section 1 – Definition of Clear Fluids PAGEREF _Toc492465430 \h 3Section 2 – Recommended Fasting Duration for Adults PAGEREF _Toc492465431 \h 3Section 3 – Recommended Fasting Duration for Children PAGEREF _Toc492465432 \h 4Section 4 – Fasting and Bowel Preparation for Endoscopy PAGEREF _Toc492465433 \h 5Section 5 – Pre-Operative Carbohydrate Drinks PAGEREF _Toc492465434 \h 5Section 6 – Chewing Gum PAGEREF _Toc492465435 \h 5Implementation PAGEREF _Toc492465436 \h 6Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc492465437 \h 6References PAGEREF _Toc492465438 \h 6Search Terms PAGEREF _Toc492465439 \h 7Guideline StatementBackgroundPatients should be fasted prior to any procedure where there is potential for a loss of protective airway reflexes. This includes sedation, general anaesthesia and planned conscious procedures where there may be an unanticipated need for sedation or general anaesthesia.The aim of fasting is to reduce the risk of peri-operative regurgitation. Regurgitation in a patient with impaired airway reflexes may be associated with aspiration of gastric contents and life threatening complications including airway obstruction, chemical pneumonitis and bacterial pneumonia.Conversely, an unnecessarily long duration of fasting is not without harm. Prolonged food fasting contributes to patient discomfort and a catabolic state associated with loss of protein and lean mass as well as impaired insulin resistanceADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1111/aas.12601", "ISBN" : "0001-5172", "ISSN" : "13996576", "PMID" : "26514824", "abstract" : "Background: The present article has been written to convey con-cepts of anaesthetic care within the context of an Enhanced Recovery After Surgery (ERAS) programme, thus aligning the practice of anaesthesia with the care delivered by the surgical team before, during and after surgery. Methods: The physiological principles supporting the imple-mentation of the ERAS programmes in patients undergoing major abdominal procedures are reviewed using an updated literature search and discussed by a multidisciplinary group composed of anaesthesiologists and surgeons with the aim to improve periop-erative care. Results: The pathophysiology of some key perioperative ele-ments disturbing the homoeostatic mechanisms such as insulin resistance, ileus and pain is here discussed. Conclusions: Evidence-based strategies aimed at controlling the disruption of homoeostasis need to be evaluated in the context of ERAS programmes. Anaesthesiologists could, therefore, play a crucial role in facilitating the recovery process. Complications after surgery are still a major problem. Enhanced Recovery after Surgery (ERAS) programmes may minimise some of the negative impact of surgery on organ function and this arti-cle describes the pathophysiology and the role of the anaesthesiologist in this context. Despite steady advances in anaesthetic and sur-gical techniques over the years, post-operative complications remain one of the major draw-backs of surgery, not only for the specific patient involved but also for their surgical care team and the health care system in general. Rarely do patients die on the operating table during the surgical procedure, but rather from the pathophysiological response to surgery and its complications. The progressive understand-ing of the physiological basis of surgical injury has been the rationale underpinning the research efforts of interdisciplinary teams, incor-porating surgeons, anaesthesiologists and nurses (among others) to minimise the surgical stress response and thereby improve outcomes. However, one of the immediate challenges to improve the quality of perioperative care is not to discover new knowledge, but rather to inte-grate what we already know into clinical prac-tice. To this end, the concept of \" fast-track surgery \" was introduced in the 1990s by Henrik Kehlet. It was demonstrated that by applying evidence-based perioperative principles to open colonic surgery, the post-operative length of hospital stay could be reduced to 2\u20133 days.", "author" : [ { "dropping-particle" : "", "family" : "Scott", "given" : "M. J.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Baldini", "given" : "G.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fearon", "given" : "K. C H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Feldheiser", "given" : "A.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Feldman", "given" : "L. S.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gan", "given" : "T. J.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ljungqvist", "given" : "O.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lobo", "given" : "D. N.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rockall", "given" : "T. A.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schricker", "given" : "T.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Carli", "given" : "F.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Acta Anaesthesiologica Scandinavica", "id" : "ITEM-1", "issue" : "10", "issued" : { "date-parts" : [ [ "2015" ] ] }, "page" : "1212-1231", "title" : "Enhanced Recovery after Surgery (ERAS) for gastrointestinal surgery, part 1: Pathophysiological considerations", "type" : "article-journal", "volume" : "59" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "¹", "plainTextFormattedCitation" : "1", "previouslyFormattedCitation" : "¹" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }1.Unnecessarily prolonged abstinence from fluids contributes to patient thirst, discomfort, dehydration and modestly increased gastric volumes on anaesthetic inductionADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1007/BF03077179", "ISBN" : "1469-493X (Electronic)\\n1361-6137 (Linking)", "ISSN" : "1572-2082", "PMID" : "14584013", "abstract" : "BACKGROUND: Fasting before general anaesthesia aims to reduce the volume and acidity of stomach contents during surgery, thus reducing the risk of regurgitation/aspiration. Recent guidelines have recommended a shift in fasting policy from the standard 'nil by mouth from midnight' approach to more relaxed policies which permit a period of restricted fluid intake up to a few hours before surgery. The evidence underpinning these guidelines however, was scattered across a range of journals, in a variety of languages, used a variety of outcome measures and methodologies to evaluate fasting regimens that differed in duration and the type and volume of intake permitted during a restricted fasting period. Practice has been slow to change. OBJECTIVES: To systematically review the effect of different preoperative fasting regimens (duration, type and volume of permitted intake) on perioperative complications and patient wellbeing (including aspiration, regurgitation and related morbidity, thirst, hunger, pain, nausea, vomiting, anxiety) in different adult populations. SEARCH STRATEGY: Electronic databases, conference proceedings and reference lists from relevant articles were searched for studies of preoperative fasting in August 2003 and experts in the area were consulted. SELECTION CRITERIA: Randomised controlled trials which compared the effect on postoperative complications of different preoperative fasting regimens on adults were included. DATA COLLECTION AND ANALYSIS: Details of the eligible studies were independently extracted by two reviewers and where relevant information was unavailable from the text attempts were made to contact the authors. MAIN RESULTS: Thirty eight randomised controlled comparisons (made within 22 trials) were identified. Most were based on 'healthy' adult participants who were not considered to be at increased risk of regurgitation or aspiration during anaesthesia. Few trials reported the incidence of aspiration/regurgitation or related morbidity but relied on indirect measures of patient safety i.e. intra-operative gastric volume and pH. There was no evidence that the volume or pH of participants' gastric contents differed significantly depending on whether the groups were permitted a shortened preoperative fluid fast or continued a standard fast. Fluids evaluated included water, coffee, fruit juice, clear fluids and other drinks (e.g. isotonic drink, carbohydrate drink). Participants given a drink of water preoperatively were foun\u2026", "author" : [ { "dropping-particle" : "", "family" : "Brady", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kinn", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stuart", "given" : "P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Cochrane database of systematic reviews (Online)", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2003" ] ] }, "page" : "CD004423", "title" : "Preoperative fasting for adults to prevent perioperative complications.", "type" : "article-journal" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "²", "plainTextFormattedCitation" : "2", "previouslyFormattedCitation" : "²" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }2.Patients should be encouraged to minimise the duration of their solid and fluid fasting to the recommendation durations in this guideline.The recommended fasting durations are general in nature. Conditions associated with increased aspiration risk that may require individualised recommendations include women beyond the 1st trimester of pregnancy, emergency or trauma cases, obese patients, patients with severe gastro-oesophageal reflux or upper gastrointestinal motility disorders, and patients who have undergone bariatric surgery (including adjustable gastric banding).Key ObjectiveThis guideline provides advice to staff and patients scheduled to undergo procedures with a potential need for sedation or anaesthesia as to the required duration of fasting to optimise patient safety while minimising patient discomfort. AlertMorning fasting does not require automatic withholding of morning medications. Most medications can be consumed with a small sip of water and patients should be provided with specific advice as to which medications to consume and which to withhold.Back to Table of ContentsScopeThis guideline applies to all staff involved in the management and care of patients planned for procedures where there is potential need for anaesthesia or sedation.This document applies to the following Canberra Hospital Health Services (CHHS) staff working within their scope of practice:Medical OfficersRegistered Nurses and MidwivesStudent Nurses and Midwives working under supervisionBack to Table of ContentsSection 1 – Definition of Clear FluidsThe following table provides examples for what are to be considered ‘clear fluids’ for the purpose of the following recommendations.Clear FluidsNot Considered Clear FluidsWaterClear cordialBlack tea or black coffeeFruit juices not containing pulp (e.g. apple juice)Drinks containing milkCloudy fruit juices and juices containing pulp (e.g. some orange juice)Alcohol Back to Table of Contents Section 2 – Recommended Fasting Duration for AdultsRecommended Fasting Duration for AdultsSolids/ Non-Clear Fluids/ Nasogastric FeedsWithhold for 6 hoursFor a case booked on a morning list:No food after 0200For cases booked on an afternoon list:An early breakfast may be consumed, but no food to be taken after 0700Recommended Fasting Duration for AdultsClear FluidsWithhold for 2 hoursClear fluid consumption should be limited to 200ml/hrFor a case booked on a morning listFinish drinking by 0600Finish drinking by 0500 if scheduled for cardiac surgeryFor a case booked on an afternoon listFinish drinking by 1100Longer periods of fasting should be avoided without a specific reasonBack to Table of Contents Section 3 – Recommended Fasting Duration for ChildrenParents should be encouraged to consider feeding their child shortly prior to commencement of formal fasting, to minimise an unnecessarily prolonged duration.Recommended Fasting Duration for ChildrenSolids, including Lollies and Nasogastric FeedsWithhold for 6 hoursFor a case booked on a morning list: No food after 0200For cases booked on an afternoon list: An early breakfast may be consumed, but no food to be taken after 0700 Formula/ Non-Breast MilkChildren Under 6 Months of AgeChildren Over 6 Months OldWithhold for 4 hoursFor a case booked on a morning listFinish last feed by 0400For a case booked on an afternoon listFinish last feed by 0900Withhold for 6 hoursFor a case booked on a morning listFinish last feed by 0200For a case booked on an afternoon listFinish last feed by 0700Breast MilkChildren Under 6 Months OldChildren Over 6 Months OldWithhold for 3 hoursFor a case booked on a morning listFinish last feed by 0500For a case booked on an afternoon listFinish last feed by 1000Withhold for 6 hoursFor a case booked on a morning listFinish last feed by 0200For a case booked on an afternoon listFinish last feed by 0700Recommended Fasting Duration for ChildrenClear FluidsWithhold for 2 hoursFor a case booked on a morning list: Finish drinking clear fluid by 0600For a case booked on an afternoon list: Finish drinking clear fluid by 1100Clear fluid fasting time may be shortened to 1 hour at the discretion of the case anaesthetistAvoid extending fasting times beyond the recommended durationBack to Table of Contents Section 4 – Fasting and Bowel Preparation for EndoscopyPatients undergoing colonoscopy may be prescribed a split-dose bowel preparation including 500ml of ColonLytely on the morning of the procedure.Consumption of 500ml ColonLytely dose must be complete a minimum of 2 hours prior to scheduled procedure time (i.e. 0600 for a morning list, or 1100 for an afternoon list).Patients may continue to consume up to 200ml/hr of water up until 2 hours before their procedure.Gastric residual volume in these patients has been shown to be equivalent to those completing bowel preparation the evening before the procedureADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.gie.2015.08.081", "ISSN" : "10976779", "PMID" : "26382050", "abstract" : "Background and Aims Split-dose bowel preparation for colonoscopy results in superior preparation quality. However, some endoscopy units remain hesitant to prescribe split-dose preparation given theoretical concerns about possible aspiration caused by gastric residual fluid when a second dose is given close to the time of endoscopy. Our aim was to compare gastric residual volume (GRV) in patients taking split-dose bowel preparation and those taking preparation the evening before colonoscopy. Methods We performed a prospective observational comparison of GRV among random inpatients undergoing same-day EGD and colonoscopy either after a split-dose bowel preparation or after a bowel preparation the prior evening. Results GRV was measured in 150 patients undergoing EGD and colonoscopy: 75 who completed a split-dose bowel preparation 2 to 3 hours before endoscopy and 75 who completed the bowel preparation regimen the prior evening. The mean GRV 2 to 3 hours after the last ingestion of bowel preparation among split-dose group patients was 21 \u00b1 24 mL (\u00b1 standard deviation; range, 0 to 125 mL), which was not different from the mean GRV of 24 \u00b1 22 mL (range, 0 to 135 mL) in patients who ingested the preparation the prior evening (P =.08). GRV had no association with the presence of diabetes, gastroparesis, or opioid use. Conclusions GRV is the same after a split preparation and fasting for 2 to 3 hours or after preparation with overnight fasting. The data suggest that the risk of aspiration is identical after either preparation technique and thus that sedation for colonoscopy can be performed safely 2 hours after bowel preparation ingestion.", "author" : [ { "dropping-particle" : "", "family" : "Agrawal", "given" : "Deepak", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Elsbernd", "given" : "Benjamin", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Singal", "given" : "Amit G.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rockey", "given" : "Don", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Gastrointestinal Endoscopy", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2016" ] ] }, "page" : "574-580", "publisher" : "American Society for Gastrointestinal Endoscopy", "title" : "Gastric residual volume after split-dose compared with evening-before polyethylene glycol bowel preparation", "type" : "article-journal", "volume" : "83" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "³", "plainTextFormattedCitation" : "3", "previouslyFormattedCitation" : "³" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }3.Back to Table of ContentsSection 5 – Pre-Operative Carbohydrate Drinks The role of pre-operative carbohydrate drinks are supported by Enhanced Recovery After Surgery programsADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1111/aas.12601", "ISBN" : "0001-5172", "ISSN" : "13996576", "PMID" : "26514824", "abstract" : "Background: The present article has been written to convey con-cepts of anaesthetic care within the context of an Enhanced Recovery After Surgery (ERAS) programme, thus aligning the practice of anaesthesia with the care delivered by the surgical team before, during and after surgery. Methods: The physiological principles supporting the imple-mentation of the ERAS programmes in patients undergoing major abdominal procedures are reviewed using an updated literature search and discussed by a multidisciplinary group composed of anaesthesiologists and surgeons with the aim to improve periop-erative care. Results: The pathophysiology of some key perioperative ele-ments disturbing the homoeostatic mechanisms such as insulin resistance, ileus and pain is here discussed. Conclusions: Evidence-based strategies aimed at controlling the disruption of homoeostasis need to be evaluated in the context of ERAS programmes. Anaesthesiologists could, therefore, play a crucial role in facilitating the recovery process. Complications after surgery are still a major problem. Enhanced Recovery after Surgery (ERAS) programmes may minimise some of the negative impact of surgery on organ function and this arti-cle describes the pathophysiology and the role of the anaesthesiologist in this context. Despite steady advances in anaesthetic and sur-gical techniques over the years, post-operative complications remain one of the major draw-backs of surgery, not only for the specific patient involved but also for their surgical care team and the health care system in general. Rarely do patients die on the operating table during the surgical procedure, but rather from the pathophysiological response to surgery and its complications. The progressive understand-ing of the physiological basis of surgical injury has been the rationale underpinning the research efforts of interdisciplinary teams, incor-porating surgeons, anaesthesiologists and nurses (among others) to minimise the surgical stress response and thereby improve outcomes. However, one of the immediate challenges to improve the quality of perioperative care is not to discover new knowledge, but rather to inte-grate what we already know into clinical prac-tice. To this end, the concept of \" fast-track surgery \" was introduced in the 1990s by Henrik Kehlet. It was demonstrated that by applying evidence-based perioperative principles to open colonic surgery, the post-operative length of hospital stay could be reduced to 2\u20133 days.", "author" : [ { "dropping-particle" : "", "family" : "Scott", "given" : "M. J.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Baldini", "given" : "G.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fearon", "given" : "K. C H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Feldheiser", "given" : "A.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Feldman", "given" : "L. S.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gan", "given" : "T. J.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ljungqvist", "given" : "O.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lobo", "given" : "D. N.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rockall", "given" : "T. A.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schricker", "given" : "T.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Carli", "given" : "F.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Acta Anaesthesiologica Scandinavica", "id" : "ITEM-1", "issue" : "10", "issued" : { "date-parts" : [ [ "2015" ] ] }, "page" : "1212-1231", "title" : "Enhanced Recovery after Surgery (ERAS) for gastrointestinal surgery, part 1: Pathophysiological considerations", "type" : "article-journal", "volume" : "59" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "¹", "plainTextFormattedCitation" : "1", "previouslyFormattedCitation" : "¹" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }1 and may be prescribed for selected patients at the time of pre-operative consultation.Back to Table of ContentsSection 6 – Chewing Gum Chewing gum poses a potential risk as a foreign body in the airway. It may be chewed before surgery, but must be confirmed as discarded a minimum of 2 hours before surgery.Back to Table of ContentsImplementation These guidelines will be communicated, with agreement sought, through the Surgical Service Taskforce, Surgical Services Executive, SAOH Nursing 3, 4, 5, Unit meetings.All staff involved in the preparation and facilitation of patients for proposed surgery or procedural sedation will be fully informed regarding the implementation of Fasting Guidelines.Posters of the new fasting guidelines will be created and displayed in all areas identifying the change of process, and consumer advice leaflets will be updated with the new munication messages will also be placed on the HUB for all staff.Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationPoliciesHealth Directorate Nursing and Midwifery Continuing Competence PolicyConsent and TreatmentProceduresCHHS Patient Identification and Procedure Matching PolicyLegislationHealth Records (Privacy and Access) Act 1997Human Rights Act 2004Back to Table of ContentsReferencesADDIN Mendeley Bibliography CSL_BIBLIOGRAPHY 1.Scott, M. J. et al. Enhanced Recovery after Surgery (ERAS) for gastrointestinal surgery, part 1: Pathophysiological considerations. Acta Anaesthesiol. Scand. 59, 1212–1231 (2015).2.Brady, M., Kinn, S. & Stuart, P. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst. Rev. CD004423 (2003). doi:10.1007/BF030771793.Agrawal, D., Elsbernd, B., Singal, A. G. & Rockey, D. Gastric residual volume after split-dose compared with evening-before polyethylene glycol bowel preparation. Gastrointest. Endosc. 83, 574–580 (2016).4.Smith, I. et al. Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology. Eur. J. Anaesthesiol. 28, 556–569 (2011).5.Guidelines on Pre-Anaesthesia Consultation and Patient Preparation - Appendix 1: Fasting Guidelines. ANZCA Professional Document PS07 at anzca.edu.au6.Brady, M. et al. Preoperative fasting for preventing perioperative complications in children. Cochrane Database Syst. Rev. CD005285 (2009). doi:10.1002/14651858.CD005285.pub27.American Society of Anesthesiologists Committee on standards and practice parameters. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Com. Anesthesiology 114, 495–511 (2011).Back to Table of ContentsSearch Terms Fasting, Elective Surgery, Surgery, Procedural Sedation, Sedation, Food, Drink, NBM, Nil By Mouth, Pre-OperativeBack to Table of ContentsDisclaimer: This document has been developed by Health Directorate, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.(to be completed by the HCID Policy Team)Date AmendedSection AmendedApproved ByEg: 17 August 2014Section 1ED/CHHSPC Chair ................
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