cima management case study timetable

Exam timetable

View key dates to help you plan your studies. Plan your CIMA’s CGMA® exams. On-demand tests are available all year. There are four windows a year when you can sit the Case Study Exams (February, May, August, and November).

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The Self-Tailored Learning and Assessment Route

The self-tailored study and assessment route to completing the Professional Qualification is made up of nine subjects that are organised into three pillars and three levels.

The three pillars are designed to cover finance and a range of other business areas:

• The Enterprise Pillar - Develop and implement strategies
• The Performance Pillar - Track activities and ensure that strategies are realistic and effective
• The Financial Pillar - Prepare and understand financial statements to keep an eye on performance and inform company decisions

As you progress through the qualification, the content of each of the three levels encourage progressive, constant development of knowledge across the three pillars, ensuring you have the skills business need the most, positioning you to take on leadership roles within your organisation

Self-Tailored Learning and Assessment route structure

Nine subjects organised into three pillars and three levels

Objective Tests

Nine 90 minute computer-based and on-demand exams

Case Studies

You can take three three-hour exams at each level during four windows per year. You will need to pass all three objective tests (or have an exemption) before sitting the case study exam

Completion time

Three to four years

The Structure

The operational level.

At the Operational level, the focus is on short term decision making. Once you’ve completed it, you’ll be able to work with others in your organisation and use appropriate data and technology to translate medium term decisions into short term actionable plans.

Once you’ve finished the Operational level, you’ll be awarded the CIMA Diploma in Management Accounting (CIMA Dip MA).

Managing finance in a digital world

In this first subject of the Professional Qualification, you’ll learn about the central role that finance plays in an organisation, and how and why technologies used impact the finance function. 

You’ll learn how to use and examine data collected and processed by machines to create and preserve value for organisations. 

And you’ll get to know how the finance function is structured and shaped, and how it interacts with other parts of the organisation to achieve the objectives of the whole organisation.

Syllabus at a glance:

A. Role of the finance function

B. Technology in a digital world

C. Data and information in a digital world

D. Shape and structure of the finance function

E. Finance interacting with the organisation

Assessment: Objective Test

• Format: Computer Based
• Availability: Online and on-demand from the comfort of your own home or office or at any of the 5,500 Pearson VUE centres around the world
• Length: 90 minutes
• Questions: 60 objective test questions
• Marking: Computer marked
• Results: Provisional results available immediately followed by confirmation no more than 48 hours later

Management Accounting

Here, you’ll learn why costing is done and what it is used for, including appropriate costing methods and techniques and where digital costing might be used.

Then you’ll cover how budgets are prepared and implemented across the organisation and the impact these have. You’ll also learn how techniques are applied to ensure sound short term decision making against a backdrop of risk and uncertainty by using appropriate risk management tools.

A. Cost Accounting for decision and control

B. Budgeting and budgetary control

C. Short term commercial decision making

D. Risk and uncertainty in the short term

Financial Reporting

In your first Finance subject, you’ll find out who the regulators are, what they do and why and how regulations are applied.

You’ll learn how to prepare basic financial statements using financial reporting standards and how to distinguish between types of taxes, calculate corporation taxes and issues affecting taxation.

Finally, you’ll learn which tools are used to ensure that the organisation has enough cash to ensure its continuing operations.

A. Regulatory environment of financial reporting

B. Financial statements

C. Principles of taxation

D. Managing cash and working capital

• Format: Computer based

Operational Level Case Study

The case study exam tests the knowledge, skills and techniques that you’ve learned throughout the Operational level in a role simulation. You’ll be asked to respond to authentic work-based activities, mimicking a job role linked to the Operational level e.g. an entry-level finance professional.

Assessment: Case Study Exam

• Availability: Four windows each year (Feb, May, Aug, Nov) at any of the 5,000 Pearson VUE centres around the world or online at your home or office
• Length: 3 hours
• Questions: Role-based business simulations
• Marking: Human marked
• Results: Available around 6 weeks after the completion of the exam window

The Management Level

At the Management level, you’ll focus on translating long term decisions into medium term plans. Once you’ve completed it, you’ll be able to use data and relevant technology to manage organisational and individual performance, allocate resources to implement decisions; monitor and report implementation of decisions; as well as prepare and interpret financial statements to highlight business performance.

Once you’ve finished the Management Level, you’ll be awarded the CIMA Advanced Diploma in Management Accounting (CIMA Adv Dip MA).

Managing performance

You’ll learn the fundamentals of business subject and how new business and operating subjects can be developed to improve the performance of organisations.

Discover how different styles of leadership can be used to improve the performance of individuals to achieve organisational goals and how to use performance management concepts and techniques to implement strategies effectively and efficiently.

You’ll be able understand use of project management concepts and techniques useful in implementing strategies.

Syllabus at a glance 

A. Business subjects and value creation

B. Managing people performance

C. Managing projects

Advanced Management Accounting

You’ll learn how to use cost management, quality and process management and value management to provide organisations with cost advantage.

You’ll understand the criteria, process and techniques that are used to decide which projects to undertake, how to manage the performance of organisational units to ensure that they achieve their objectives.

Discover how to analyse risks and uncertainties that organisations face in the medium term, especially capital investment decision making, and how to manage those risks in the implementation of such decisions.

Syllabus at a glance

A. Managing the costs of creating value

B. Capital investment decision making

C. Managing and controlling the performance of organisational units

D. Risk and control

Advanced Financial Reporting

You’ll learn about sources and types of funds and how much they cost, as well as the key financial reporting standards on which financial statements will be based and the application of those standards to prepare group accounts.

You’ll also learn about the International Integrated Reporting Framework and its components and how to conduct analyses of financial statements and their limitations.

A. Financing capital projects

B. Financial reporting standards

C. Group accounts

D. Integrated reporting

E. Analysing financial statements

Management Level Case Study

The case study exam tests the knowledge, skills and techniques that you’ve learned throughout the Management level in a role simulation. You’ll be asked to respond to authentic work-based activities, mimicking a job role linked to the Management level e.g. a finance manager.

The Strategic Level 

The Strategic level focuses on long term strategic decision making. Once you’ve completed it, you’ll be able to support organisational leaders to craft strategy; evaluate and manage risks that might prevent organisations from successfully implementing strategy; value organisations; and source financial resources required to implement of strategy.

Strategic Management

You’ll learn about the foundation of strategic management and get an understanding of the dynamics of the organisational ecosystem and how it affects the strategy of the organisation.

Next, you’ll learn all about strategic choice and how options are generated, linking them to the purpose, values and vision of the organisation and how the options are evaluated, chosen and integrated to form the strategy of the organisation.

You’ll cover how strategy is implemented, how implementation objectives are achieved and how change is managed.

And you’ll learn about the different technologies that underpin digital transformation and various elements of digital strategy.

A. The Strategy process

B. Analysing the organisational ecosystem

C. Generating strategic options

D. Making strategic choices

E. Strategic control

F. Digital strategy

Risk Management

How to identify, evaluate and manage enterprise risks.

Where strategic risks emanate from, how to evaluate them and understand how oversight of these risks is critical to the governance of the organisation.

How internal controls can be used effectively in the risk management process and how to identify, analyse, remedy and report strategic risks including cyber risks.

A. Enterprise risk

B. Strategic risk

C. Internal controls

D. Cyber risk

Financial Strategy

You’ll learn about the different strategic financial objectives and policy options that are open to organisations.

Next, you’ll cover the types of funds available to organisations to finance the implementation of their strategies, including where and how they access these funds at the right time, in the right quantities and at the right cost.

Then you’ll move onto the sources of financial risk, how to evaluate and manage financial risk appropriately, and techniques in business valuation to assess whether a company has created and preserved value within the organisation.

Finally, you’ll learn the valuation techniques to calculate the value of organisations and the conditions applicable for such calculations, especially intangibles in the digital world. You’ll learn how to report intangible value and their drivers in integrated reporting.

A. Financial policy decisions

B. Sources of long term funds

C. Financial risks

D. Business valuation

Strategic Level Case Study

The case study exam tests the knowledge, skills and techniques that you’ve learned throughout the Strategic level in a role simulation. You’ll be asked to respond to authentic work-based activities, mimicking a job role linked to the Strategic level e.g. a senior finance manager.

Assessment of Practical Experience Requirements (PER)

Once you complete the Strategic level, your last step before earning the CGMA designation and becoming a CIMA member is to demonstrate that you have a minimum of three years’ relevant work experience (this can be accumulated before, during and after your studies). Your experience is assessed through the Practical Experience Requirements (PER) application.

Award: 

The Chartered Global Management Accountant (CGMA) designation and membership of The Chartered Institute of Management Accountants (ACMA or FCMA).

What study methods can you use?

Your learning is supported with over 60 hours of on-demand video., tuition provider courses.

If you like to learn with others, appreciate the support of having a tutor on -hand and benefit from the structure of the formal study, look at signing up with a tuition provider. You’ll find online-only courses, classroom, and a mixture of both. Costs will vary between providers, so check with them directly for information on fees.

Distance learning

Want to study in your time, on your terms? Choose when and where you study with CIMAstudy.com — the only online learning resource reviewed and approved by CIMA, delivered in partnership with Kaplan. Costs vary depending on the level of the course you’re taking: check the breakdown of fees on CIMAstudy.com.

Online and distance learning with CIMAstudy.com

CIMAStudy.com is the only online learning resource reviewed and approved by CIMA, delivered in partnership with Kaplan. It’s ideal if you live somewhere with little or no tuition provision, or if you prefer to self-study at your own pace.

Can’t decide?

Whatever your learning style, the CGMA Study Hub is your go-to resource. With articles, webcasts, videos, and access to all CIMA- approved study products, you’ll find a study aid that works for you. There’s even a well-being section to help you through your studies, with resources on everything from exam nerves to getting motivated.

Which learning and assessment route should I take?

Shape your studies how you want, using a tuition provider or opting to self-study, or enrol on the CGMA Finance Leadership Programme for a fully guided study experience.

Am I eligible for exemptions? 

If you have a degree or a qualification, you might be exempt from certain Certificate in Business Accounting or CGMA Professional Qualification exams. That means you could qualify sooner than you think.

Start your registration

Before you choose your registration route, make sure you have the following to hand:

• Your contact details, including address, phone and email
• Your current employment details (if you are working)
• Details of your tuition provider (if you are studying)

Register for Self-Tailored Learning and Assessment Route

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CIMA Exam Dates – Plan for Your 2024 Exams!

There are four opportunities a year when you can sit case study exams – february, may, august and november..

Planning and preparation are crucial when it comes to passing your CIMA exams. Therefore, it’s essential to know the cima exam dates you can work towards.

CIMA Subscription

Remember your annual CIMA subscription needs to be renewed every year on January 1st . You can find out more and pay on CIMA’s website.

Certificate in Business Accounting Exams

On-demand computer-based assessments are available to sit all year round.

Professional Qualification Exams

Computer-based assessments can be taken on demand throughout the year.

CIMA Case Study Exam Timetable 2024

There are four opportunities a year when you can sit case study exams – February, May, August, and November . Exams within each window will be available for three days, from Wednesday to Friday.

February 2024 CIMA Exam Dates

Operational

• Exam entry opening – August 3rd, 2023
• Exam entry closing – January 23rd, 2024
• Pre-seen material released – September 15th, 2023
• Exam dates -February 7th to 9th, 2024
• Results published -March 28th, 2024

Management/Gateway

• Exam entry opening – August 2nd, 2023
• Exam entry closing – January 30th, 2024
• Pre-seen material released – September 29th, 2023
• Exam dates – February 14th to 16th to 2024
• Results published – April 4th, 2024

Strategic/CGMA

• Exam entry opening – August 9th, 2023
• Exam entry closing – February 6th, 2024
• Exam dates – February 21st to 23th, 2024
• Results published – April 11th, 2024

May 2024 CIMA Exam Dates

• Exam entry opening – October 18th, 2023
• Exam entry closing – April 23rd, 2024
• Pre-seen material released – March 22nd, 2024
• Exam dates – May 8th to 10th, 2024
• Results published – June 27th, 2024
• Exam entry opening – October 25th, 2023
• Exam entry closing – April 30th, 2024
• Pre-seen material released – March 27th, 2024
• Exam dates – May 15th to 17th, 2024
• Results published – July 4th, 2024
• Exam entry opening – November 1st, 2023
• Exam entry closing – May 8th, 2024
• Pre-seen material released – April 5th, 2024
• Exam dates – May 22nd to 24th, 2024
• Results published – July 11th, 2024

August 2024 CIMA Exam Dates

• Exam entry opening – January 24th, 2024
• Exam entry closing – July 25th, 2024
• Exam dates – August 7th to 9th, 2024
• Results published – September 26th, 2024
• Exam entry opening – January 31st, 2024
• Exam entry closing – July 23rd, 2024
• Exam dates – August 14th to 16th, 2024
• Results published – October 3rd, 2024
• Exam entry opening – February 7th, 2024
• Exam entry closing – July 30th, 2024
• Exam dates – August 21st to 23rd, 2024
• Results published – October 10th, 2024

November 2024 CIMA Exam Dates

• Exam entry opening – April 24th, 2024
• Exam entry closing – October 22nd, 2024
• Pre-seen material released – September 20th, 2024
• Exam dates – November 6th to 8th, 2024
• Results published – January 2nd, 2025
• Exam entry opening – May 1st, 2024
• Exam entry closing – October 29th, 2024
• Pre-seen material released – September 27th, 2024
• Exam dates – November 13th to 15th, 2024
• Results published – January 9th, 2025
• Exam entry opening – May 8th, 2024
• Exam entry closing – November 5th, 2024
• Pre-seen material released – October 4th, 2024
• Exam dates – November 20th to 22nd, 2024

Bookmark these dates to ensure you’re always prepared for your CIMA exams!

Read About Target Costing

Everything You Need to Know About Accounting Standards

What Is Scaled Scoring for CIMA OT Exams?

Current Ratio & Quick Ratio: Use of Liquidity Ratios

CIMA Exams: New Resources to Pass OT & Case Study

CIMA Classroom vs. Online Learning: Which is Better for You?

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Good afternoon

I have purchased CIMA operational E1 cima study. Am I right that I don’t have to renew my CIMA subscription until date date that I want to enrol for the exams? also is there only one date in November 2023 for this operational module? is this online or do I have to attend the course facilities?

Hello Maggie, The best place to get an answer is to email your query to [email protected] . They will be able to answer your question there.

The best place to get an answer is to email [email protected] . They will be able to answer your question there.

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CIMA - PC Exams (PearsonVUE)

View key dates to help you plan your CGMA® CIMA exams. Objective Tests on demand exams are available all year.  Case Study Exams are session based, with 4 exam windows a year ( February, May, August & November) You can take your exams at our Pearson Vue Centers or you can take your exams online from your home or office. 

CharterQuest is PearsonVUE certified at all 3 campuses. CIMA students can book for their PC exams on our online pc exams portal if the exam registration is open. The exam fee is paid to CharterQuest and this will be remitted to PearsonVUE on the student’s behalf. Book Online now. 

In 2015 CIMA introduced PC Exams for all student assessments. CIMA Students have Objective Tests and Case study exams which they can write via our PearsonVUE Licensed centers at all campuses. 

study exams which they can write via our PearsonVUE Licensed centers at all campuses. 

There are four (4) cycles in which any case study can be written at specified exam week windows: February, May, August and November. 

CIMA students who are not currently enrolled with CharterQuest can also book to write their exams at our PC exam centres.   Click here   to only book your exam without taking any of our courses. 

PearsonVUE has set up practice exams for students. Try CIMA Practice exams    here   . 

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CIMA 2024 Exam Timetable

There are four windows a year when you can sit the case study exams (February; May; August; and November). Within each window, exams will be available for three days from Wednesday to Friday.

Pre-seen material for the case studies can be found on the  Study Hub . See the below dates and mark the CIMA Exam deadlines. 

February 2024

August 2024

November 2024

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CIMA's Question Tutorials

Get hands-on experience of our computer-based assessments. CIMA ® offers two types of question tutorials to cover the objective tests and case study exams.

The question tutorials provide you with examples of the types of questions encountered in the exam. They can be used to experience the test driver and how items are presented. They give you the opportunity to explore this technology and become familiar with how the online system works.

• are tailored for each qualification/subject and provide examples of question types you are likely to encounter in the live exam*. Please note: these tutorials should not be viewed as a full test.
• provide answers to the questions throughout the exam, by clicking on the ‘answer’ button at the top left of the screen.
• provide candidates with an opportunity to practice a full-length case study exam.
• should be taken using the supporting material – pre-seen, model answers, and marking guidance, see additional resources below.

*Please note there are some slight differences between the functionality of the question tutorials and the live exams; in the live exams there is no ‘navigator’ button – candidates can move to the next question by pressing ‘next’. Questions can be flagged for review and reviewed at the end of the exam via the review screen.

How to register for a free question tutorial

• click ‘create account’ and complete the details
• select an exam
• checkout and submit your request
• take the exam immediately or completed it within 1 month
• get an email with details of the exam

Additional Resources

• Operational case study question tutorial supporting material
• Management case study question tutorial supporting material
• Strategic case study question tutorial supporting material
• Level 4 EPA 1 role simulation question tutorial supporting material

Exam tutorials

These are designed to familiarise you with the exam software and functionality you will encounter at the test centre. They are not tailored towards any one qualification.

Take the exam tutorial here »

NB: The above system requirements may only apply to running the tutorials. CIMA’s online exams details »

How to pass the Management Case Study

With the next set of exams coming up we thought it would be great to give you an overview of the management case study, also known as CGMA gateway. The aim of CIMA's CGMA Professional Management case study is to apply the knowledge you have learnt across the whole management level.

• Open access
• Published: 15 July 2024

The use of point of care gastric ultrasound and anesthesia management in pediatric patients with preoperative fasting non-adherence scheduled for elective surgical procedures: a retrospective study

• Marc D. Mecoli 1 , 2 , 3 ,
• Kirti Sahu 1 , 2 ,
• Joseph W. McSoley 1 , 2 ,
• Lori A. Aronson 1 , 2 &
• Suryakumar Narayanasamy 1 , 2  

BMC Anesthesiology volume  24 , Article number:  237 ( 2024 ) Cite this article

173 Accesses

1 Altmetric

Metrics details

Failure to adhere to perioperative fasting requirements increases aspiration risk and can lead to delay or cancellation of surgery. Point of care gastric ultrasound may guide decision-making to delay, cancel or proceed with surgery.

This study aimed to describe gastric contents using point of care gastric ultrasound in pediatric patients with known fasting guideline violations presenting for elective surgery. This was a single-center retrospectivechart review of gastric ultrasound scans in patients presenting for elective surgeries with “nothing by mouth” violation (per fasting guidelines) or unclear fasting status. The primary outcome is description of gastric contents using point of care ultrasound. The ultrasound findings were classified as low-risk for aspiration (empty, clear fluid < 1.5 ml/kg), high-risk (solids, clear fluid > 1.5 ml/kg), or inconclusive study. Gastric ultrasound findings were communicated to the attending anesthesiologist. For patients proceeding without delay the estimated time saved was defined as the difference between ultrasound scan time and presumed case start time based on American Society of Anesthesiologists fasting guidelines.

We identified 106 patients with a median age of 4.8 years. There were 31 patients (29.2%) that had ultrasound finding of high-risk gastric contents. These patients had cases that were delayed, cancelled or proceeded with rapid sequence intubation. Sixty-six patients (62.3%) were determined to be low-risk gastric contents and proceeded with surgery without delay. For these patients, a median of 2.6 h was saved. No aspiration events were recorded for any patients.

Conclusions

It is feasible to use preoperative point of care gastric ultrasound to determine stomach contents and risk-stratify pediatric patients presenting for elective surgical procedures with fasting non-adherence. Preoperative gastric ultrasound may have a role in determining changes in anesthetic management in this patient population.

Peer Review reports

Introduction

Pulmonary aspiration is a dreaded anesthetic complication that contributes to significant postoperative morbidity and mortality [ 1 , 2 ]. Despite many technological advances in perioperative care, pulmonary aspiration is continuing to be the leading cause of death in airway management related complications [ 3 ]. Perioperative fasting guidelines aim to reduce the risk of pulmonary aspiration by ensuring an empty stomach at the time of anesthetic induction in healthy patients [ 4 , 5 ]. However, these guidelines do not consider individual risk factors affecting gastric motility and can vary in different societies and institutions [ 5 , 6 , 7 ]. Nothing by mouth (NPO) guideline violations, defined as not following appropriate fasting instructions, have a reported incidence of 1.5 − 4.5% in the pediatric population. Causes of NPO violations include lack of understanding of NPO instructions, patient eating without parental knowledge, scheduling changes in surgical case time, language barriers, and an inconsolable child, among many others [ 8 , 9 ]. Regardless of the reason, case cancellations can lead to delays in access to care, inconvenience and frustration for the patients and their families [ 10 ].

Point of care (POC) gastric ultrasound provides objective, real-time assessment of gastric content and volume. It has been shown to be a reliable diagnostic modality for accurately assessing gastric content and volume [ 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 ]. POC gastric ultrasound assessment of gastric contents could reduce the risk of pulmonary aspiration [ 20 ]. Gastric ultrasound evaluation may minimize case delays, reduce cancellations, and allow for safer anesthetic management by objectively assessing gastric contents in patients at increased risk for aspiration, including patients with NPO violations [ 14 , 15 , 16 , 21 ]. The exact amount of gastric volume that is at risk for aspiration or safe is still unknown and debated [ 22 ]. Although the safest minimum gastric volume is unknown, it has been generally accepted that clear liquids less than 1.5 ml/kg is consistent with baseline gastric secretions and even volumes higher than 1.5 ml/kg could be present in 1-9% of appropriately fasted patients depending on the study population [ 13 , 21 , 23 ]. Gastric volume greater than 1.5 ml/kg and the presence of solid contents can increase the risk of aspiration related complications. [ 17 , 18 ]. We have been using gastric ultrasound to objectively verify gastric contents in pediatric patients for the past few years. The purpose of this retrospective study was to describe the POC gastric ultrasound findings and anesthetic management in pediatric patients with known NPO violations presenting for surgery.

Study design and population

Institutional Review Board (IRB) approval was obtained prior to study commencement (IRB# 2023 − 0292). Existing records of all gastric ultrasound scans performed in perioperative patients presenting for elective surgical procedures with known NPO violation based on ASA preoperative fasting guidelines [ 4 ] or unclear NPO status between December 2022 and April 2023 were included.

The primary outcome was the preoperative ultrasound findings of the gastric contents. The ultrasound findings were classified as low-risk for aspiration (empty, clear fluid < 1.5 ml/kg), high-risk (solids, clear fluid > 1.5 ml/kg), or inconclusive study as previously described by Spencer and colleagues [ 23 ]. Secondary outcomes include the estimated time saved in patients with gastric ultrasound as compared to following standard ASA fasting guidelines.

• Gastric ultrasound

Per institutional practice, gastric ultrasound scans are performed by a small subset of anesthesiologists experienced in point-of-care (POC) gastric ultrasound exams at the request of the anesthesia team caring for the patient. The anesthesiologists performing gastric ultrasound at our institutional have all previously participated in the departmental POC gastric ultrasound education curriculum using the I-AIM framework described in the 2021 American Society of Regional Anesthesia and Pain Medicine expert panel recommendations on point-of-care ultrasound education and training [ 12 , 24 ].

All gastric ultrasound scans are performed using a 3-5 MHz curvilinear probe (Venue G.O. or LOGIQ S7 [G.E. Healthcare, Chicago, IL, USA] or TE7 [Mindray, Mahwah, NJ, USA] ultrasound machines). All patients are scanned in the right lateral decubitus position with the probe in a parasagittal orientation. The gastric antrum is visualized at the aorta and superior mesenteric artery level. The predicted antral volume for clear fluids is determined using a cross-sectional area as described by Spencer and colleagues [ 23 ]. A procedure note describing ultrasound findings and interpretation is placed in the medical record and communicated to the family and the anesthesiologist assigned to the case. The anesthesia team determines case management, induction technique, and choice of airway.

For the study, the following data were extracted and recorded on a data sheet: age, gender, surgical procedure, NPO times, gastric ultrasound findings, induction technique, case delay or cancellation, airway used, and aspiration events. For patients proceeding without delay, the estimated time saved was calculated as the difference between ultrasound scan time and presumed case start time based on ASA fasting guidelines (2 h for clears, 6 h for milk/formula, 8 h for solids). Cost savings analysis was performed using customary operating room service charges published by Cincinnati Children’s Hospital Medical Center under Sect. 3727.42 of Ohio Revised Code. OR charge for first 15 min = $3,285, and additional 15 min = $1,034.

Cincinnati Children’s Hospital Medical Center (CCHMC) is a 673-bed non-profit organization serving as the University of Cincinnati Academic Health Center’s major teaching facility for pediatrics and the only children’s hospital in the Cincinnati metropolitan area (population of 2.3 million). CCHMC performs more than 45,000 anesthetics annually.

Statistical analysis

Statistical analysis was performed using Microsoft Excel software. Descriptive data, median and interquartile ranges (IQR) for continuous variables, and frequencies and percentages for categorical variables were analyzed.

During the 15-month study period, we identified 106 patients with gastric ultrasound examinations performed for NPO violation prior to non-urgent surgical procedures. Eight anesthesiologists certified in POC gastric ultrasound performed gastric ultrasound examinations in the study cohort. Demographic data are presented in Table  1 .

Low-risk : Ultrasound evidence of gastric antrum consistent with low risk for aspiration (defined as an empty gastric antrum or clear fluids < 1.5 ml/kg) was noted in 66 patients (62.3%) identified as NPO violators as per the current ASA guidelines. All of these patients proceeded with surgery without delay. A median of 2.6 h (IQR 1 to 3.5) was saved for these patients. This represents median $10,523 (IQR $6,387 to $16,727) operating room cost as estimated by customary per hour operating room service charges. High-risk : Ultrasound evidence of high-risk antrum (clear liquids > 1.5 ml/kg or presence of any amount of solids) was noted in 31 (29.2%) patients. Only two patients had clear fluid greater than 1.5 ml/kg. One surgery proceeded after a two-hour wait. The other patient was asked to wait, but the family rescheduled the case. In patients with thick or solid material ( n  = 29), 22 (76%) cases were canceled. Five cases were delayed to comply with the appropriate NPO guidelines and proceeded as usual. Three cases were delayed to comply with NPO guidelines and proceeded with rapid sequence induction (RSI). One patient’s procedure was deemed urgent by the surgeon, secondary to a dental abscess, and the anesthesia team proceeded with RSI after five hours of fasting after the patient ate low-fat yogurt.

Gastric ultrasound findings, risk level assessment, and management decision data are summarized in Table  2 . No aspiration events were recorded for any of the patients.

Our study demonstrated that gastric ultrasound provided objective evidence which may have guided decision-making for patients with known NPO violations or unclear NPO status in pediatric patients undergoing elective surgery. Approximately 60% of the patients had ultrasound evidence of either an empty antrum or low-volume clear fluid, and the elective surgeries proceeded without delay. This positively impacts the family experience and improves operating room utilization.

The gastric fluid volume that minimizes the risk of pulmonary aspiration is still being debated [ 22 ]. Multiple ultrasound and endoscopic studies demonstrated that up to 95–97% of appropriately fasted children have a residual gastric volume < 1.25–1.5 ml/kg [ 23 , 25 ]. We used 1.5 ml/kg as the threshold to minimize the risk of unnecessary cancellation because children are rarely anesthetized immediately following gastric scanning. The intake nurse confirms NPO verification within the first few minutes of assessment in Same-Day Surgery. Confirmation triggers a call for POC gastric ultrasound, where gastric ultrasound is performed well before induction time in the preoperative holding area. While we do not have formal documentation of the scan time duration, the scan typically takes less than five minutes during the preoperative evaluation stage. POC gastric ultrasound does not cause a delay to the start of the procedure. We believe most patients at or close to the 1.5 ml/kg threshold reached a lower volume by anesthesia induction. In patients with inconclusive ultrasound scans due to patient movement, colonic air artifact or other factors, the decision to proceed, delay or cancel these procedures was made without information from the ultrasound study by the primary anesthesiologist provider. In patients with solid material in the stomach, the decision to cancel, delay or perform RSI was at the attending anesthesiologist’s discretion.

Presumably, many of the cases with known NPO violations would have been canceled, although our study could not determine that outcome. Reducing case cancellation and delays positively impacts patient care, family satisfaction, and improves operating room utilization. For the cases proceeding without delay we estimated saving a median 2.6 h of operating room time per patient. We estimate up to $10,523 in lost operating room charges could have been saved per patient. However, this does not take into account being able to adjust operating room scheduled to move up other patients when delay occurs because of NPO violation. Prospective studies and more detailed cost-savings analysis may be warranted to better understand the effect of gastric ultrasound on operating room utilization.

Our findings are similar to previously published reports in adult patients. Alakkad et al. showed that preoperative gastric ultrasound in adult patients with known NPO non-adherence undergoing elective surgical procedures led to changes in anesthetic management in 71% of the patients [ 16 ]. Approximately half of the patients had a revised surgery time with a trend toward a lower incidence of surgical delays. Similarly, Van de Putte et al. used gastric ultrasound in 37 adult patients with NPO violations. They found that gastric ultrasound helped change anesthetic management in 54% of cases, with a trend toward lower case cancellations and delays [ 14 ].

Serial gastric ultrasound examination has been used to demonstrate decreasing gastric contents over time in patients being considered for procedural sedation in the emergency department [ 26 ]. Gagey et al. demonstrated qualitative gastric ultrasounds may change anesthetic management in pyloromyotomy patients, as 88.2% no longer required RSI after aspiration of stomach contents [ 27 ].

In our study, we identified some patients with a large amount of clear liquid (> 1.5 ml/kg) in whom gastric ultrasound was used to serially monitor the gastric content over time to ensure it was below the threshold before proceeding with anesthesia.

The present study has several limitations. Due to the study’s retrospective nature, we could not control the decision to perform gastric ultrasound in patients with NPO violations. We did not always have access to detailed information about NPO status, only that there was a known violation or unclear NPO status. We were not able to determine the degree to which the ultrasound findings influenced the anesthesiologist’s decisions to proceed with, delay or cancel cases. This was a single-center study with multiple anesthesiologists with expertise in performing gastric ultrasound quickly. The generalizability of the results to other institutions needs to be confirmed with future prospective multicenter trials. Finally, although no patients in the study were noted to have pulmonary aspiration, our sample size is too small to determine the overall influence of gastric ultrasound on patient safety outcomes due to the low incidence of pulmonary aspiration in pediatric surgical patients.

Using POC gastric ultrasound as a risk assessment tool is feasible to determine gastric contents in pediatric surgical patients with known NPO violations and may be helpful in formulating an appropriate anesthetic plan. Further studies are needed to determine the type and timing of oral intake that warrants performing gastric ultrasound in pediatric patients with known NPO violations.

We studied the use of preoperative gastric ultrasound in preoperative patients scheduled for elective surgical procedures who had suspected or known NPO violations. We demonstrated that risk stratification based on gastric ultrasound findings is feasible and may associated with differences in anesthesia decision-making.

Data availability

Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

American Society of Anesthesiologists

Cincinnati Children’s Hospital Medical Center

Institutional Review Board

Nil per os / Nothing by mouth

Point of care

Rapid sequence induction

Strengthening the reporting of observational studies in epidemiology

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Acknowledgements

The authors thank Maria Ashton, MS, RPH, MBA, for writing assistance, editing, and proofreading.

This study was supported by the Department of Anesthesiology, Cincinnati Children’s Hospital Medical Center.

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Marc D. Mecoli, Kirti Sahu, Joseph W. McSoley, Lori A. Aronson & Suryakumar Narayanasamy

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Study conception, study design, data collection, preparation of figures and tables: MM, SN. Data analysis, writing and editing, and approval of the manuscript: MM, SN, KS, JM, LA. All author reviewed the manuscript.

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Mecoli, M.D., Sahu, K., McSoley, J.W. et al. The use of point of care gastric ultrasound and anesthesia management in pediatric patients with preoperative fasting non-adherence scheduled for elective surgical procedures: a retrospective study. BMC Anesthesiol 24 , 237 (2024). https://doi.org/10.1186/s12871-024-02628-0

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