Preoperative fasting for preventing perioperative complications in children

Pre-operative fasting times for clear liquids at a tertiary children's hospital; what can be improved?

Background

The goal of preoperative fasting is to prevent pulmonary aspiration during general anesthesia. Fasting times are often prolonged leading to patient discomfort and risk for adverse events. This retrospective quality improvement survey evaluated effective nil-per-os (NPO) times and causes for prolonged NPO times with the aim to suggest improvement strategies by a newly founded fasting task force.

Methods

Data from all electronic anesthesia records from 2019 at our institution were reviewed for fasting times. Our NPO instructions follow American Society of Anesthesiology guidelines and are calculated based on the patient’s arrival time (90 min before operating room [OR] time). Primary outcome was the effective NPO time for clear liquids, secondary outcomes were incidence of delays and the parental compliance with the NPO instructions. Data are presented as median (interquartile range).

Results

In total 9,625 cases were included in the analysis. NPO time was documented in 72.1% with a median effective NPO time of 7:13 h (7:36). OR in room times were documented in 72.8%, 2,075 (29.5%; median time 0:10 h [0:21]) were earlier and 4,939 (70.5%; median time 0:29 h [0:54]) were later than scheduled. Parental NPO compliance showed a median deviation for clear liquid intake of 0:55 h (8:30).

Conclusions

This study revealed that effective NPO times were longer than current ASA guidelines. Contributing causes include case delays and parental non-compliance to NPO instructions. Thus, task force recommendations include change NPO instruction calculations to scheduled OR time versus arrival time, and encourage parents to give their child clear liquids at the instructed time.

Evaluation of the effect of pre-operative over-fasting on post-operative vomiting in children undergoing bone marrow aspiration at a tertiary care setting in Sri Lanka: A prospective cohort study

Background and Aims

Non-adherence to standard fasting guidelines may result in perioperative complications. We aimed to determine the association between pre-operative over-fasting and post-operative vomiting amongst children undergoing bone marrow aspiration under general anaesthesia.

Methods

A prospective cohort study was conducted from May 2015 to April 2016 in children undergoing bone marrow aspiration under general anaesthesia and their caregivers. Children fasted for ≥3 hours from last clear fluid intake constituted the exposed group (n = 202) while children fasting for <3 h constituted the non-exposed group (n = 202). The primary outcome was the development of post-operative vomiting during the 6 h following induction of anaesthesia. The awareness of the caregiver regarding the importance of keeping the child fasting before anaesthesia was evaluated.

Results

The mean (standard deviation) duration time of fasting of the exposed and non-exposed groups were 7.2 (2.4) and 2.2 (0.3) h, respectively. Thirty-two (15.8%) children in the exposed group and 17 (8.4%) children in the non-exposed group developed post-operative vomiting. The relative risk of developing post-operative vomiting amongst over-fasting children was 1.9 (95% confidence interval [CI] = 1.1-3.3, P = 0.02), while adjusting to the age, it was 2.1 (95% CI = 1.1-4). Significantly more caregivers were clear about the fasting advice in the non-exposed group than in the exposed group (P < 0.001).

Conclusion

Over-fasting is a significant risk factor to develop post-operative vomiting in paediatric anaesthetic practice.

Enhanced recovery after surgery (ERAS) protocols: Time to change practice?

Radical cystectomy with pelvic lymph node dissection remains the standard treatment for patients with muscle invasive bladder cancer. Despite improvements in surgical technique, anesthesia and perioperative care, radical cystectomy is still associated with greater morbidity and prolonged in-patient stay after surgery than other urological procedures. Enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care pathways designed to achieve early recovery after surgical procedures by maintaining preoperative organ function and reducing the profound stress response following surgery. The key elements of ERAS protocols include preoperative counselling, optimization of nutrition, standardized analgesic and anesthetic regimens and early mobilization. Despite the significant body of evidence indicating that ERAS protocols lead to improved outcomes, they challenge traditional surgical doctrine, and as a result their implementation has been slow.The present article discusses particular aspects of ERAS protocols which represent fundamental shifts in surgical practice, including perioperative nutrition, management of postoperative ileus and the use of mechanical bowel preparation.

Hyperphosphatemia after sodium phosphate laxatives in low risk patients: prospective study

AIM

To establish the frequency of hyperphosphatemia following the administration of sodium phosphate laxatives in low-risk patients.

METHODS

One hundred consecutive ASA I-II individuals aged 35-74 years, who were undergoing colonic cleansing with oral sodium phosphate (OSP) before colonoscopy were recruited for this prospective study.

EXCLUSION CRITERIA

congestive heart failure, chronic kidney disease, diabetes, liver cirrhosis, intestinal obstruction, decreased bowel motility, increased bowel permeability, and hyperparathyroidism. The day before colonoscopy, all the participants entered a 24-h period of diet that consisted of 4 L of clear fluids with sugar or honey and 90 mL (60 g) of OSP in two 45-mL doses, 5 h apart. Serum phosphate was measured before and after the administration of the laxative.

RESULTS

The main demographic data (mean +/- SD) were: age, 58.9 +/- 8.4 years; height, 163.8 +/- 8.6 cm; weight, 71 +/- 13 kg; body mass index, 26 +/- 4; women, 66%. Serum phosphate increased from 3.74 +/- 0.56 to 5.58 +/- 1.1 mg/dL, which surpassed the normal value (2.5-4.5 mg/dL) in 87% of the patients. The highest serum phosphate was 9.6 mg/dL. Urea and creatinine remained within normal limits. Post-treatment OSP serum phosphate concentration correlated inversely with glomerular filtration rate (P < 0.007, R(2) = 0.0755), total body water (P < 0.001, R(2) = 0.156) and weight (P < 0.013, R(2) = 0.0635).

CONCLUSION

In low-risk, well-hydrated patients, the standard dose of OSP-laxative-induced hyperphosphatemia is related to body weight.