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

A comparative study using gastric ultrasound to evaluate the safety of shortening the fasting time before pediatric echocardiography: a randomized controlled non-inferiority study

PURPOSE

The objective of this study was to demonstrate that the gastric cross-sectional area (CSA) in the right lateral decubitus position (RLDP) during a 2-h fasting period is not larger than that during a conventional 4-h fasting period prior to pediatric echocardiography.

METHODS

93 patients aged under 3 years scheduled for echocardiography under sedation were enrolled and randomly allocated into two groups; 2-h fasting vs 4-h fasting. For group 4 h (n = 46), the patients were asked to be fasted for all types of liquid for more than 4 h, while group 2 h (n = 47) were asked to be fasted for all types of liquid for 2 h before echocardiography. Gastric ultrasound was performed before echocardiography, and CSARLDP was measured. We compared CSARLDP, incidence of at-risk stomach, fasting duration, and the incidence of major (pulmonary aspiration, aspiration pneumonia) and minor complications (nausea, retching, and vomiting, apnea, and bradycardia) between two groups.

RESULTS

The mean difference of CSARLDP (group 2 h-group 4 h) was 0.49 (- 0.18 to 1.17) cm2, and it was within the non-inferiority margin (Δ = 2.1 cm2). There was no difference in the incidence of at-risk stomach (P = 0.514). There was no significant difference in the incidence of major and minor complications between the two groups.

CONCLUSION

Two-hour fasting in pediatric patients who need an echocardiography did not increase major and minor complications and CSA significantly.

Preoperative fasting and the risk of pulmonary aspiration-a narrative review of historical concepts, physiological effects, and new perspectives

In the early days of anaesthesia, the fasting period for liquids was kept short. By the mid-20th century 'nil by mouth after midnight' had become routine as the principles of the management of 'full stomach' emergencies were extended to include elective healthy patients. Back then, no distinction was made between the withholding of liquids and solids. Towards the end of the last century, recommendations of professional anaesthesiology bodies began to reduce the fasting time of clear liquids to 2 h. This reduction in fasting time was based on the understanding that gastric emptying of clear liquids is rapid, exponential, and proportional to the current filling state of the stomach. Furthermore, there was no evidence of a link between drinking clear liquids and the risk of aspiration. Indeed, most instances of aspiration are caused by failure to identify aspiration risk factors and adjust the anaesthetic technique accordingly. In contrast, long periods of liquid withdrawal cause discomfort and may also lead to serious postoperative complications. Despite this, more than two decades after the introduction of the 2 h limit, patients still fast for a median of up to 12 h before anaesthesia, mainly because of organisational issues. Therefore, some hospitals have decided to allow patients to drink clear liquids within 2 h of induction of anaesthesia. Well-designed clinical trials should investigate whether these concepts are safe in patients scheduled for anaesthesia or procedural sedation, focusing on both aspiration risk and complications of prolonged fasting.

Design Specifications for an Automated System to Deliver Instructions About Preprocedure Fasting

PURPOSE

Many patients undergoing surgical and other medical procedures requiring sedation or anesthesia receive standardized "no eating or drinking after midnight" instructions. This "standardized" instruction does not change regardless of potential alterations in scheduling that result in significant delays in procedure start times. As a result, the duration of preprocedure fasting often far exceeds recommended requirements. A technological solution that automates the delivery of preprocedure fasting instructions to patients would likely improve the patient experience. The purpose of this study was to determine design specifications for the delivery of notifications to patients as part of an automated system.

DESIGN

A qualitative study was conducted with 14 adult participants using the persona-scenario method.

METHODS

Participants worked in groups to create realistic but fictitious personas and scenarios that described how individuals like themselves would interact with an automated preprocedure fasting instruction system. Data generated through the development of the scenarios were analyzed to first identify important themes, which were then interpreted into design specifications.

FINDINGS

Seven women and seven men, aged 25 to 75, developed 9 persona-scenarios, which captured outpatient and inpatient preprocedure fasting experiences, as well as perspectives of individuals who were not comfortable with technology, or those for which English was not the primary spoken language. Most scenarios described preprocedure fasting instructions delivered by an automated bidirectional short message service system. Two major themes were identified as patient priorities, including: (1) enhancing communication between patients and healthcare providers; and (2) the importance of using simple technology so that a greater number of patients with varying degrees of comfort and capabilities would be able to use the system confidently. A corresponding set of proposed design specifications was devised.

CONCLUSIONS

The results of this study provide actionable ways to operationalize patient-centered ideas in the design of an automated preprocedure fasting instruction system.

PERIOPERATIVE CARE IN DIGESTIVE SURGERY: THE ERAS AND ACERTO PROTOCOLS - BRAZILIAN COLLEGE OF DIGESTIVE SURGERY POSITION PAPER

BACKGROUND

The concept introduced by protocols of enhanced recovery after surgery modifies perioperative traditional care in digestive surgery. The integration of these modern recommendations components during the perioperative period is of great importance to ensure fewer postoperative complications, reduced length of hospital stay, and decreased surgical costs.

AIMS

To emphasize the most important points of a multimodal perioperative care protocol.

METHODS

Careful analysis of each recommendation of both ERAS and ACERTO protocols, justifying their inclusion in the multimodal care recommended for digestive surgery patients.

RESULTS

Enhanced recovery programs (ERPs) such as ERAS and ACERTO protocols are a cornerstone in modern perioperative care. Nutritional therapy is fundamental in digestive surgery, and thus, both preoperative and postoperative nutrition care are key to ensuring fewer postoperative complications and reducing the length of hospital stay. The concept of prehabilitation is another key element in ERPs. The handling of crystalloid fluids in a perfect balance is vital. Fluid overload can delay the recovery of patients and increase postoperative complications. Abbreviation of preoperative fasting for two hours before anesthesia is now accepted by various guidelines of both surgical and anesthesiology societies. Combined with early postoperative refeeding, these prescriptions are not only safe but can also enhance the recovery of patients undergoing digestive procedures.

CONCLUSIONS

This position paper from the Brazilian College of Digestive Surgery strongly emphasizes that the implementation of ERPs in digestive surgery represents a paradigm shift in perioperative care, transcending traditional practices and embracing an intelligent approach to patient well-being.

Updates in Medical and Surgical Weight Loss

The number of individuals with obesity is at an all-time high, and the rate of obesity continues to climb each year. Obesity is a chronic disease with widespread effects throughout the body. Midwives and perinatal care providers need an understanding of the etiology, pathophysiology, and interventions for obesity. A review of evidence-based diet and lifestyle modifications, medications, and surgical procedures is presented.

Trends in preoperative carbohydrate load practice: A systematic review

BACKGROUND

The preoperative carbohydrate load (PCL) is intended to improve surgical outcomes by reducing the catabolic state induced by overnight fasting. However, there is disagreement on the optimal PCL prescription, leaving local institutions without a standardized PCL recommendation. Results from studies that do not prescribe PCL in identical ways cannot be pooled to draw larger conclusions on outcomes affected by the PCL. The aim of this systematic review is to catalog prescribed PCL characteristics, including timing of ingestion, percentage of carbohydrate contribution, and volume, to ultimately standardize PCL practice.

METHODS

A comprehensive search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized controlled trials were included if they studied at least one group of patients who were prescribed a PCL and the PCL was described with respect to timing of ingestion, carbohydrate contribution, and total volume.

RESULTS

A total of 67 studies with 6551 patients were included in this systematic review. Of the studies, 49.3% were prescribed PCL on the night before surgery and morning of surgery, whereas 47.8% were prescribed PCL on the morning of surgery alone. The mean prescribed carbohydrate concentration was 13.5% (±3.4). The total volume prescribed was 648.2 ml (±377).

CONCLUSION

Variation in PCL practices prevent meaningful data pooling and outcome analysis, highlighting the need for standardized PCL prescription. Efforts dedicated to the establishment of a gold standard PCL prescription are necessary so that studies can be pooled and analyzed with respect to meaningful clinical end points that impact surgical outcomes and patient satisfaction.

The Effect of Oral Fluid Administration 1 Hour before Surgery on Preoperative Anxiety and Gastric Volume in Pediatric Patients

INTRODUCTION

Today, preoperative fasting guidelines have changed, allowing clear liquid intake up to 1 h before surgery. However, concerns remain regarding the risk of aspiration associated with clear liquid intake. This study aimed to investigate the impact of clear fluid given 1 h before surgery on child anxiety and gastric volumes.

METHODS

A prospective, randomized, controlled study included 90 patients aged 5-12 years. The patients were randomly allocated into three groups by a computer-generated randomization: group F (n = 30): standard fasting group, group W (n = 30): patients who received oral water at a dose of 5 mL/kg 1 h before surgery, group C (n = 30): patients who received oral carbohydrate fluid at a dose of 5 mL/kg 1 h before surgery. All patients were assessed using the modified Yale Preoperative Anxiety Scale (m-YPAS) before and 1 h after fluid administration. Antral cross-sectional area (CSA) was measured with ultrasonography after intubation, and gastric residual volume (GRV) was calculated. Hemodynamic data, blood sugar level, and parental satisfaction were also recorded.

RESULTS

The m-YPAS scores obtained after 1 h were significantly lower in group C than in the other groups (p < 0.001). Antral CSA and GRV values were lower in group C and group W than in the fasting group (p < 0.001). Parental satisfaction was highest in group C.

CONCLUSION

This study suggests that allowing a carbohydrate-rich clear liquid intake 1 h before surgery can significantly reduce preoperative anxiety in pediatric patients without increasing the risk of aspiration.

Dysphagia as a Manifestation of Endocrine and Metabolic Disorders

Dysphagia is a common manifestation of endocrine and metabolic diseases. Swallowing is a complex neuromuscular process, with an interplay of sensory and motor function, that has voluntary and involuntary control. Disruptions in any of these processes can cause significant dysphagia. Endocrine disorders and metabolic derangements are systemic conditions that affect multiple organ systems. They contribute to the development of neuropathies, myopathies, and motility disorders that lead to swallowing difficulty. Malnutrition and critical illness can lead to deconditioning and atrophy which can cause dysphagia, which in turn can lead to further malnutrition and deconditioning.

Effects of Preoperative Oral Carbohydrate on Perioperative Maternal Outcomes Undergoing Cesarean Section: A Systematic Review and Meta-Analysis

Purpose

Preoperative oral carbohydrate (CHO) is a rapid postoperative rehabilitation protocol that improves perioperative outcomes and is widely used in adult surgical patients. However, pregnant women are excluded because of the possibility of aspiration due to delayed gastric emptying. This meta-analysis was conducted to evaluate the efficacy of preoperative oral CHO in elective cesarean section.

Methods

PubMed, Embase, Web of Science, and the Cochrane Library were searched from inception to July 2023. Randomized controlled trials were included. The risk of bias was assessed using the Cochrane tool. Risk ratios and 95% confidence intervals were calculated. Meta-analysis was performed using random-effects models to estimate risk ratios and mean differences (MDs) with 95% confidence intervals (CIs). The outcomes included thirst and hunger scores, incidence of vomiting and nausea, time to flatus, and homeostatic model assessment of insulin resistance (HOMA-IR).

Results

A total of nine studies with 1211 patients were included in the analysis. The levels of thirst and hunger were evaluated using a 10-point visual analog scale, with 0 representing the best and 10 representing the worst. The severity of hunger (weighted mean difference (WMD: -2.34, 95% CI: -3.13 to -1.54), time to flatus (WMD: -3.51 hours, 95% CI: -6.85 to -0.17), and HOMA-IR (WMD: -1.04, 95% CI: -1.31 to -0.77) were significantly lower in the CHO group compared to the control group. However, there were no significant differences in the severity of thirst or the incidence of vomiting and nausea between the CHO and control groups.

Conclusion

Preoperative oral CHO during cesarean section alleviates thirst and hunger, shortens the time of postoperative flatus, and reduces HOMA-IR. However, the available evidence is insufficient to reach a clear consensus on the benefits or harms of preoperative oral CHO during cesarean section. Therefore, it is premature to make a definitive recommendation for or against its routine use.

Society for Ambulatory Anesthesia Updated Consensus Statement on Perioperative Blood Glucose Management in Adult Patients With Diabetes Mellitus Undergoing Ambulatory Surgery

WHAT OTHER GUIDELINES ARE AVAILABLE ON THIS TOPIC

Since the publication of the SAMBA Consensus Statement for perioperative blood glucose management in the ambulatory setting in 2010, several recent guidelines have been issued by the American Diabetes Association (ADA), the American Association of Clinical Endocrinologists (AACE), the Endocrine Society, the Centre for Perioperative Care (CPOC), and the Association of Anaesthetists of Great Britain and Ireland (AAGBI) on DM care in hospitalized patients; however, none are specific to ambulatory surgery.

HOW DOES THIS GUIDELINE DIFFER FROM THE PREVIOUS GUIDELINES

Previously posed clinical questions that were outdated were revised to reflect current clinical practice. Additional questions were developed relating to the perioperative management of patients with DM to include the newer therapeutic interventions.

Preoperative free access to water compared to fasting for planned cesarean under spinal anesthesia: a randomized controlled trial

BACKGROUND

Contemporary guidance for preoperative feeding allows solids up to 6 hours and clear fluids up to 2 hours before anesthesia. Clinical trial evidence to support this approach for cesarean delivery is lacking. Many medical practitioners continue to follow conservative policies of no intake from midnight to the time of surgery, especially in pregnant women.

OBJECTIVE

This study aimed to evaluate the pragmatic approach of permitting free access to water up to the call to dispatch to the operating theater vs fasting from midnight in preoperative oral intake restriction for planned cesarean delivery under spinal anesthesia on perioperative vomiting and maternal satisfaction.

STUDY DESIGN

A randomized controlled trial was conducted in the obstetrical unit of the University of Malaya Medical Centre from October 2020 to May 2022. A total of 504 participants scheduled for planned cesarean delivery were randomized: 252 undergoing preoperative free access to water up to the call to dispatch to the operating theater (intervention group) and 252 undergoing fasting from midnight (fasting arm). The primary outcomes were perioperative vomiting and maternal satisfaction. Analyses were performed using t test, Mann-Whitney U test, and chi-square test, as appropriate.

RESULTS

Of note, 9 of 252 patients (3.6%) in the intervention group and 24 of 252 patients (9.5%) in the control group had vomiting at up to 6 hours after completion of cesarean delivery (relative risk, 0.38; 95% confidence interval, 0.18-0.79; P=.007), and the maternal satisfaction scores (0-10 visual numerical rating scale) were 9 (interquartile range, 8-10) in the intervention group and 5 (interquartile range, 3-7) in the control group (P<.001). Assessed before dispatch to the operating theater, feeling of thirst was reported by 69 of 252 patients (27.4%) in the intervention group and 134 of 252 patients (53.2%) in the control group (relative risk, 0.52; 95% confidence interval, 0.41-0.65; P<.001), capillary glucose levels were 4.8±0.7 mmol/L in the intervention group and 4.9±0.8 mmol/L in the control group (P=.048), and preoperative intravenous fluid hydration was commenced in 49 of 252 patients (19.4%) in the intervention group and 76 of 252 patients (30.2%) in the control group (relative risk, 0.65; 95% confidence interval, 0.47-0.88; P=.005). In the operating theater, ketone was detected in the catheterized urine in 38 of 252 patients (15.1%) in the intervention group and 78 of 252 patients (31.0%) in the control group (relative risk, 0.49; 95% confidence interval, 0.25-0.59; P<.001), and the numbers of doses of vasopressors needed to correct hypotension were 2.3±1.7 in the intervention group and 2.7±2.2 in the control (P=.009). The recommendation rates for preoperative oral intake regimen to a friend were 95.2% (240/252) in the intervention group and 39.7% (100/252) in the control group (relative risk, 2.40; 95% confidence interval, 2.06-2.80; P<.001), in favor of free access to water. Other assessed maternal and neonatal outcomes were not different.

CONCLUSION

Compared with fasting, free access to water in planned cesarean delivery reduced perioperative vomiting and was strongly favored by women. In addition, several pre- and intraoperative secondary outcomes were improved. However, postcesarean delivery recovery and neonatal outcomes were not different.

Should We Stop Glucagon-Like Peptide-1 Receptor Agonists Before Surgical or Endoscopic Procedures? Balancing Limited Evidence With Clinical Judgment

The American Society of Anesthesiologists (ASA) Task Force recently recommended discontinuing glucagon-like peptide-1 receptor agonist (GLP-1 RA) agents before surgery because of the potential risk of pulmonary aspiration. However, there is limited scientific evidence to support this recommendation, and holding GLP-1 RA treatment may worsen glycemic control in patients with diabetes. As we await further safety data to manage GLP-1 RA in the perioperative period, we suggest an alternative multidisciplinary approach to manage patients undergoing elective surgery. Well-conducted observational and prospective studies are needed to determine the risk of pulmonary aspiration in persons receiving GLP-1 RA for the treatment of diabetes and obesity, as well as the short-term impact of discontinuing GLP-1 RA on glycemic control before elective procedures in persons with diabetes.

Glucagon-Like Peptide-1 Receptor Agonist Use and Residual Gastric Content Before Anesthesia

Importance

Glucagon-like peptide-1 receptor agonist (GLP-1 RA) use is rapidly increasing in the US, driven by its expanded approval for weight management in addition to hyperglycemia management in patients with type 2 diabetes. The perioperative safety of these medications, particularly with aspiration risk under anesthesia, is uncertain.

Objective

To assess the association between GLP-1 RA use and prevalence of increased residual gastric content (RGC), a major risk factor for aspiration under anesthesia, using gastric ultrasonography.

Design, Setting, and Participants

This cross-sectional study prospectively enrolled patients from a large, tertiary, university-affiliated hospital from June 6 through July 12, 2023. Participants followed preprocedural fasting guidelines before an elective procedure under anesthesia. Patients with altered gastric anatomy (eg, from previous gastric surgery), pregnancy, recent trauma (<1 month), or an inability to lie in the right lateral decubitus position for gastric ultrasonography were excluded.

Exposure

Use of a once-weekly GLP-1 RA.

Main Outcomes and Measures

The primary outcome was the presence of increased RGC, defined by the presence of solids, thick liquids, or more than 1.5 mL/kg of clear liquids on gastric ultrasonography. Analysis was adjusted for confounders using augmented inverse probability of treatment weighting, a propensity score-based technique. Secondarily, the association between the duration of drug interruption and the prevalence of increased RGC was explored.

Results

Among the 124 participants (median age, 56 years [IQR, 46-65 years]; 75 [60%] female), the prevalence of increased RGC was 56% (35 of 62) in patients with GLP-1 RA use (exposure group) compared with 19% (12 of 62) in patients who were not taking a GLP-1 RA drug (control group). After adjustment for confounding, GLP-1 RA use was associated with a 30.5% (95% CI, 9.9%-51.2%) higher prevalence of increased RGC (adjusted prevalence ratio, 2.48; 95% CI, 1.23-4.97). There was no association between the duration of GLP-1 RA interruption and the prevalence of increased RGC (adjusted odds ratio, 0.86; 95% CI, 0.65-1.14).

Conclusions and Relevance

Use of a GLP-1 RA was independently associated with increased RGC on preprocedural gastric ultrasonography. The findings suggest that the preprocedural fasting duration suggested by current guidelines may be inadequate in this group of patients at increased risk of aspiration under anesthesia.

Gastric point-of-care ultrasonography in patients undergoing radical gastrointestinal surgery before anesthetic induction: an observational cohort study

BACKGROUND

Pulmonary aspiration of gastric contents is a serious perioperative complication. Patients with gastric cancer may experience delayed gastric emptying. However, the role of qualitative and quantitative gastric ultrasound assessments in this patient population before anesthesia induction has not yet been determined.

METHODS

Adult patients with gastrointestinal cancer were recruited and examined using gastric point-of-care ultrasound (POCUS) before anesthetic induction from March 2023 to August 2023 in a tertiary cancer center. Three hundred patients with gastric cancer were conducted with POCUS prior to induction, and three hundred patients with colorectal cancer were included as controls. The cross-sectional area (CSA) of the gastric antrum and gastric volumes (GV) were measured and calculated. We determined the nature of the gastric contents and classified the antrum using a 3-point grading system. A ratio of GV to body weight > 1.5mL/Kg was defined as a high risk of aspiration.

RESULTS

In patients with gastric cancer, 70 patients were classified as grade 2 (23%, including 6 patients with solid gastric contents) and 63 patients (21%) were identified as having a high risk of aspiration. Whereas in patients with colorectal cancer, only 11 patients were classified as grade 2 (3.7%), and 27 patients (9.7%) were identified as having a high risk of aspiration. A larger tumor size (OR:1.169, 95% CI 1.045-1.307, P = 0.006), tumor located in antrum (OR:2.304, 95% CI 1.169-4.539,P = 0.016), gastrointestinal obstruction (OR:21.633, 95% CI 4.199-111.443, P < 0.0001) and more lymph node metastasis (OR:2.261, 95% CI 1.062-4.812, P = 0.034) were found to be positively while tumor site at cardia (OR:0.096, 95% CI 0.019-0.464, P = 0.004) was negatively associated with high aspiration risk in patients with gastric cancer.

CONCLUSION

The Gastric POCUS prior to induction provides an assessment of the status of gastric emptying and can identify the patients at high risk of aspiration, especially those with gastric cancer.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ( www.chictr.org.cn ) identifier: ChiCTR2300069242; registered 10 March 2023.

Preoperative Evaluation of Patients Undergoing Eye Surgery

Ophthalmic surgery encompasses a wide range of procedures addressing various ocular conditions. Although generally considered low risk, a thorough preoperative evaluation is still crucial in optimizing patient outcomes and ensuring safe surgical interventions. This review provides a comprehensive overview of the preoperative assessment and management of patients presenting for ophthalmic surgery, specifically focusing on cataract surgery. We discuss the role of routine preoperative testing, the assessment of intraocular factors, and the evaluation of systemic comorbidities and medications. The review emphasizes the importance of individualized decision-making based on patient-specific factors and collaborative efforts between ophthalmologists and the health-care team.

Effects of caloric and nutrient content of oral fluids on gastric emptying in volunteers: a randomised crossover study

BACKGROUND

Previous studies demonstrated conflicting results regarding the determinants of gastric emptying for fluids. Our aim was to compare gastric emptying times of fluids with different caloric and nutrient content.

METHODS

Healthy adult volunteers underwent gastric ultrasound assessment for 4 h after consuming beverages with different caloric and nutrient content using a crossover design (oat drink with 3% fat [310 kcal], mango juice [310 kcal], oat drink with 0.5% fat [185 kcal], and blackcurrant juice [175 kcal]). Gastric emptying time, gastric content volume, and the area under the curve (AUC) of gastric content volume-time profiles were calculated.

RESULTS

Eight females and eight males completed the study protocol. The mean (sd) gastric emptying times were 89 (32) min for blackcurrant juice, 127 (54) min for oat drink with 0.5% fat, 135 (36) min for mango juice, and 152 (40) min for oat drink with 3% fat. Gastric emptying times were slower for oat drink with 3% fat (P=0.007) and mango juice (P=0.025) than for blackcurrant juice. At 1 h after ingestion, gastric content volume was greater for mango juice (P=0.021) and oat drink with 3% fat (P=0.003) than for blackcurrant juice. The AUC was greater for oat drink with 3% fat than mango juice (P=0.029), oat drink with 0.5% fat (P=0.004), and blackcurrant juice (P=0.002), and for mango juice than blackcurrant juice (P=0.019).

CONCLUSIONS

Caloric and nutrient content significantly affected gastric emptying times. A high-calorie fruit juice (mango) exhibited delayed emptying times compared with a low-calorie fruit juice (blackcurrant).

CLINICAL TRIAL REGISTRATION

ISRCTN17147574.

Ultrasound evaluation of gastric emptying time of standardized high-calorie liquid meals in healthy adults: A double-blind cross-over randomized study

BACKGROUND AND AIMS

Commercially available high-calorie drinks containing fat and protein can be used as dietary supplements in surgical patients. According to preoperative fasting guidelines, high-calorie drinks are non-clear fluids and should not be consumed 6 h before elective procedures. The aim of this study was to evaluate the gastric emptying time of commercially available high-calorie drink formulations in healthy adults using gastric ultrasound.

METHODS

25 healthy adult volunteers were included in this double-blind, cross-over prospective study. On three study sessions, fasted volunteers ingested one of the three study products: a solution of 75 g of glucose in 200 ml of water, a fat-free liquid meal, and a nutritionally complete liquid meal with equal volume and energy content. Gastric ultrasound examinations were performed to evaluate the gastric contents qualitatively and the volume of the gastric contents was calculated from the cross-sectional area of the gastric antrum measured in right lateral position by using a validated model. Repeated gastric ultrasounds were performed at baseline and half-hourly after ingesting the products in supine and right lateral position until the criteria for an empty stomach were met.

RESULTS

The glucose solution and the standard fat-free high-calorie drink with the same caloric content had a median gastric emptying time of 150 min. The nutritionally complete liquid meal had a median gastric emptying time of 180 min. Gastric emptying was complete in all participants before 6 h had elapsed since ingesting the study products.

CONCLUSIONS

High calorie liquid meals have a gastric emptying time longer than the recommended fasting time for clear fluids, but shorter than the recommended fasting time for solids in healthy adults.

A convenient machine learning model to predict full stomach and evaluate the safety and comfort improvements of preoperative oral carbohydrate in patients undergoing elective painless gastrointestinal endoscopy

BACKGROUND AND AIMS

Assessment of the patient's gastric contents is the key to avoiding aspiration incidents, however, there is no effective method to determine whether elective painless gastrointestinal endoscopy (GIE) patients have a full stomach or an empty stomach. And previous studies have shown that preoperative oral carbohydrates (POCs) can improve the discomfort induced by fasting, but there are different perspectives on their safety. This study aimed to develop a convenient, accurate machine learning (ML) model to predict full stomach. And based on the model outcomes, evaluate the safety and comfort improvements of POCs in empty- and full stomach groups.

METHODS

We enrolled 1386 painless GIE patients between October 2022 and January 2023 in Nanjing First Hospital, and 1090 patients without POCs were used to construct five different ML models to identify full stomach. The metrics of discrimination and calibration validated the robustness of the models. For the best-performance model, we further interpreted it through SHapley Additive exPlanations (SHAP) and constructed a web calculator to facilitate clinical use. We evaluated the safety and comfort improvements of POCs by propensity score matching (PSM) in the two groups, respectively.

RESULTS

Random Forest (RF) model showed the greatest discrimination with the area under the receiver operating characteristic curve (AUROC) 0.837 [95% confidence interval (CI): 79.1-88.2], F1 71.5%, and best calibration with a Brier score of 15.2%. The web calculator can be visited at https://medication.shinyapps.io/RF_model/. PSM results demonstrated that POCs significantly reduced the full stomach incident in empty stomach group (p < 0.05), but no differences in full stomach group (p > 0.05). Comfort improved in both groups and was more significant in empty stomach group.

CONCLUSIONS

The developed convenient RF model predicted full stomach with high accuracy and interpretability. POCs were safe and comfortably improved in both groups, with more benefit in empty stomach group. These findings may guide the patients' gastrointestinal preparation.

Transition of Care for Older Adults Undergoing General Surgery

The demand for surgical intervention and hospitalization is expected to increase with the growth of the older adult population. Despite advances in technology and minimally invasive surgical procedures, the needs of the older adult in the perioperative period are unique. Transitions of care from the decision to support surgery through surgical intervention, subsequent hospitalization, and postacute discharge must be supported to achieve optimal patient outcomes. The clinical nurse specialist is well suited to address care delivery and assure implementation of best practices across the continuum.

A review of pediatric fasting guidelines and strategies to help children manage preoperative fasting

Fasting for surgery is a routine step in the preoperative preparation for surgery. There have however been increasing concerns with regard to the high incidence of prolonged fasting in children, and the subsequent psycho-social distress and physiological consequences that this poses. Additionally, the past few years have yielded new research that has shown significant inter-individual variation in gastric emptying regardless of the length of the fast, with some patients still having residual gastric contents even after prolonged fasts. Additionally, multiple large-scale studies have shown no long-term sequalae from clear fluid aspiration, although two deaths from aspiration have been reported within the large Wake Up Safe cohort. This has led to a change in the recommended clear fluid fasting times in multiple international pediatric societies; similarly, many societies continue to recommend traditional fasting times. Multiple fasting strategies exist in the literature, though these have mostly been studied and implemented in the adult population. This review hopes to summarize the recent updates in fasting guidelines, discuss the issues surrounding prolonged fasting, and explore potential tolerance strategies for children.

Randomized Controlled Trial Comparing the Effects of Preoperative Carbohydrate and Non-carbohydrate Loading on Gastric Emptying in Diabetic and Non-diabetic Patients Posted for Elective Surgery

Background Preoperative fasting for six hours and accepting clear fluids till two hours of surgery is followed as a regular practice. Carbohydrate-rich fluids antagonize catabolism and are claimed to be tolerated better. This study aims to compare the effect of carbohydrate-rich drinks on gastric volume and blood sugar control in diabetic and non-diabetic patients undergoing elective surgery with plain water. Methods Two hundred forty patients aged 40 to 65 undergoing elective surgery under regional anesthesia were randomized into diabetic control, diabetic study, non-diabetic control, and non-diabetic study. Control groups were given 400 ml of plain water, while the study group received 50 grams of dextrose dissolved in 400 ml of water two hours prior to surgery. Gastric volume was evaluated using USG, and thirst and discomfort were assessed using the Likert scale. Perioperatively, blood sugar values were monitored and kept under control using insulin. Results Mean gastric volume (ml) in diabetic control (35.3±12.95 ml), diabetic study (31.2±11.75 ml), non-diabetic control (29±11.42 ml), and non-diabetic study (30.4±9.12 ml) showed no statistically significant difference (p>0.05). Capillary blood glucose (CBG) values two hours post fluid intake showed a significant increase in CBG levels in the diabetic study (183.2±28.67 mg/dl) compared to the diabetic control group (138.66±15.81 mg/dl). The values returned to baseline within six hours. Thirst and discomfort were significantly lower in the study group of diabetic and non-diabetic populations. Conclusion We conclude that carbohydrate loading does not affect gastric volume in diabetics and non-diabetics. However, the sugar values do increase which may warrant hourly checking and administration of insulin in diabetics.

Perioperative Nutritional Management in Enhanced Recovery after Bariatric Surgery

Obesity is a crucial health problem because it leads to several chronic diseases with an increased risk of mortality and it is very hard to reverse with conventional treatment including changes in lifestyle and pharmacotherapy. Bariatric surgery (BS), comprising a range of various surgical procedures that modify the digestive tract favouring weight loss, is considered the most effective medical intervention to counteract severe obesity, especially in the presence of metabolic comorbidities. The Enhanced Recovery After Bariatric Surgery (ERABS) protocols include a set of recommendations that can be applied before and after BS. The primary aim of ERABS protocols is to facilitate and expedite the recovery process while enhancing the overall effectiveness of bariatric procedures. ERABS protocols include indications about preoperative fasting as well as on how to feed the patient on the day of the intervention, and how to nourish and hydrate in the days after BS. This narrative review examines the application, the feasibility and the efficacy of ERABS protocols applied to the field of nutrition. We found that ERABS protocols, in particular not fasting the patient before the surgery, are often not correctly applied for reasons that are not evidence-based. Furthermore, we identified some gaps in the research about some practises that could be implemented in the presence of additional evidence.

Preoperative considerations for patients with diabetes

INTRODUCTION

Patients undergoing surgery require a thorough assessment preoperatively. Hyperglycemia is associated with poor outcomes, and stability of glucose levels is an important factor in preoperative management. Diabetes presents a particular challenge since patients are often on multiple medications encompassing glycemic management and cardiovascular therapies.

AREAS COVERED

A PubMed search of published data and reviews on preoperative approaches in diabetes was conducted. Consensus opinion drives most of the guidelines and recommendations for management of diabetes in surgical patients. Pathophysiology is often complex with varying levels of glucose and surgical stress. Establishing well-controlled diabetes prior to surgical intervention should be standard practice in non-emergent procedures. We review the best practices for implementing preoperative assessment, with diabetes with a focus on diabetes medications.

EXPERT OPINION

The management of a patient preoperatively varies by region and country. Institutions differ in approaches to preoperative evaluation and the establishment of consistent approaches would provide a platform for monitoring patient outcomes. Multidisciplinary teams and pre-assessment clinics for preoperative evaluation can enhance patient care for those undergoing surgery.

Randomized controlled trial of liberal vs. standard fasting instructions in percutaneous cardiac procedures

BACKGROUND

Pre-procedural fasting to reduce aspiration risk is usual care prior to surgery requiring anesthesia. Prolonged fasting, however, can result in dehydration and may adversely affect patient experience and outcomes. Previous studies suggest that providing a supplemental beverage to patients undergoing cardiac and a variety of other surgical procedures improves patients' subjective assessment of thirst and hunger and potentially decreases the need for inotrope and vasopressor therapy. Less is known, however, about the effects of ad libitum clear liquids up to 2 h prior to surgery.

METHODS

Adult patients undergoing transcatheter aortic valve replacement (TAVR) or arrhythmia ablation were randomized (1:1) to ad libitum clear liquids up to 2 h prior to their procedure vs. nil per os (NPO) after midnight (control group, usual care). The primary endpoint was a composite satisfaction score that included patient-reported thirst, hunger, headache, nausea, lightheadedness, and anxiousness prior to surgery. The incidence of case-delay was recorded. Intraoperative vasopressor administration, changes in creatinine, anti-emetic use, and hospital length of stay (LOS) were recorded. Safety endpoints including aspiration were assessed.

RESULTS

A total of 200 patients were randomized and 181 patients were included in the final analysis. Overall, 92% of patients were ASA class III or IV and 23% of patients had NYHA class III or IV symptoms. Groups were well balanced with no significant differences in age, sex or baseline cardiac or renal disease. The composite satisfaction score (primary endpoint) was not significantly different between groups (Ad libitum median = 12, IQR = [6, 17], vs Standard NPO median = 10, IQR = [5, 15], [95% CI = [-1, 4]). No significant differences between the two groups were observed in any of the individual survey questions (thirst, hunger, headache, nausea, lightheadedness, anxiousness). No significant differences between groups were observed for intra-operative vasopressor use, changes in creatinine, rescue anti-emetic use or hospital LOS. There were no case delays attributed to the intervention. There were no cases of suspected aspiration.

CONCLUSION

No adverse events or case delays were observed in the ad libitum clears group. No significant benefit, however, was observed in patient satisfaction or any of the pre-specified secondary endpoints in patients randomized to ad libitum clear liquids up to 2 h prior to their procedure.

TRIAL REGISTRATION

NCT04079543.

Prospective evaluation of an enhanced recovery after surgery (ERAS) pathway in a Norwegian cohort of patients with suspected or advanced ovarian cancer

OBJECTIVE

This prospective cohort study evaluated the introduction of an enhanced recovery after surgery (ERAS) pathway in a tertiary gynecologic oncology referral center. Compliance and clinical outcomes were studied in two separate surgical cohorts.

METHODS

Patients undergoing laparotomy for suspected or verified advanced ovarian cancer at Oslo University Hospital were prospectively included in a pre- and post-implementation cohort. A priori, patients were stratified into: cohort 1, patients planned for surgery of advanced disease; and cohort 2, patients undergoing surgery for suspicious pelvic tumor. Baseline characteristics, adherence to the pathway, and clinical outcomes were assessed.

RESULTS

Of the 439 included patients, 235 (54%) underwent surgery for advanced ovarian cancer in cohort 1 and 204 (46%) in cohort 2. In cohort 1, 53% of the patients underwent surgery with an intermediate/high Aletti complexity score. Post-ERAS, median fasting times for solids (13.1 hours post-ERAS vs 16.0 hours pre-ERAS, p<0.001) and fluids (3.7 hours post-ERAS vs 11.0 hours pre-ERAS, p<0.001) were significantly reduced. Peri-operative fluid management varied less and was reduced from median 15.8 mL/kg/hour (IQR 10.8-22.5) to 11.5 mL/kg/hour (IQR 9.0-15.4) (p<0.001). In cohort 2 only there was a statistically significant reduction in length of stay (mean (SD) 4.3±1.5 post-ERAS vs 4.6±1.2 pre-ERAS, p=0.026). Despite stable readmission rates, there were significantly more serious complications reported in cohort 1 post-ERAS.

CONCLUSIONS

ERAS increased adherence to current standards in peri-operative management with significant reduction in fasting times for both solids and fluids, and peri-operative fluid administration. Length of stay was reduced in patients with suspicious pelvic tumor. Despite serious complications being common in patients with advanced disease undergoing debulking surgery, a causal relationship with the ERAS protocol could not be established. Implementing ERAS and continuous performance auditing are crucial to advancing peri-operative care of patients with ovarian cancer.

Influence of semaglutide use on the presence of residual gastric solids on gastric ultrasound: a prospective observational study in volunteers without obesity recently started on semaglutide

PURPOSE

Glucagon-like peptide-1 (GLP-1) receptor agonists (GLP-1RAs) have become increasingly popular as both diabetic and weight loss therapies. One effect of this class of medication is delayed gastric emptying, which may impact the risk of aspiration during anesthesia delivery.

METHODS

In this prospective study, we used gastric ultrasound to evaluate the presence of solid gastric contents in both supine and lateral positions after an eight-hour fast in those taking GLP-1RA compared with controls. Participants underwent a second ultrasound evaluation two hours later after drinking 12 fluid ounces of water (approximately 350 mL).

RESULTS

Twenty adults voluntarily enrolled, giving a total of ten participants in each group. In the supine position, 70% of semaglutide participants and 10% of control participants had solids present on gastric ultrasound (risk ratio [RR], 3.50; 95% confidence interval [CI], 1.26 to 9.65; P = 0.02.) In the lateral position, 90% of semaglutide participants and 20% of control participants had solids identified on gastric ultrasound (RR, 7.36; 95% CI, 1.13 to 47.7; P = 0.005). Two hours after drinking clear liquids, the two groups did not differ in the lateral position, but in the supine position, 90% of control group participants were rated as empty compared with only 30% of semaglutide group participants (P = 0.02).

CONCLUSIONS

This study provides preliminary evidence that GLP-1RAs may affect gastric emptying and residual gastric contents following an overnight fast and two hours after clear liquids, which may have implications for aspiration risk during anesthetic care.

ERCP-related adverse events: incidence, mechanisms, risk factors, prevention, and management

INTRODUCTION

Endoscopic retrograde cholangiopancreatography (ERCP) is a commonly performed procedure for pancreaticobiliary disease. While ERCP is highly effective, it is also associated with the highest adverse event (AE) rates of all commonly performed endoscopic procedures. Thus, it is critical that endoscopists and caregivers of patients undergoing ERCP have clear understandings of ERCP-related AEs.

AREAS COVERED

This narrative review provides a comprehensive overview of the available evidence on ERCP-related AEs. For the purposes of this review, we subdivide the presentation of each ERCP-related AE according to the following clinically relevant domains: definitions and incidence, proposed mechanisms, risk factors, prevention, and recognition and management. The evidence informing this review was derived in part from a search of the electronic databases PubMed, Embase, and Cochrane, performed on 1 May 20231 May 2023.

EXPERT OPINION

Knowledge of ERCP-related AEs is critical not only given potential improvements in peri-procedural quality and related care that can ensue but also given the importance of reviewing these considerations with patients during informed consent. The ERCP community and researchers should aim to apply standardized definitions of AEs. Evidence-based knowledge of ERCP risk factors should inform patient care decisions during training and beyond.

A Sticky Situation: The Unfortunate Consequence of Chewing Gum

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Foreign substances can interfere with the TEE probe, causing poor image quality.

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Operators should be aware of the reasons for diffusely anechoic TEE images.

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Poor identification of echocardiographic artifacts may lead to adverse outcomes.

Adult Cardiac Surgery-Associated Acute Kidney Injury: Joint Consensus Report

OBJECTIVES

Acute kidney injury (AKI) is increasingly recognized as a source of poor patient outcomes after cardiac surgery. The purpose of the present report is to provide perioperative teams with expert recommendations specific to cardiac surgery-associated AKI (CSA-AKI).

METHODS

This report and consensus recommendations were developed during a joint, in-person, multidisciplinary conference with the Perioperative Quality Initiative and the Enhanced Recovery After Surgery Cardiac Society. Multinational practitioners with diverse expertise in all aspects of cardiac surgical perioperative care, including clinical backgrounds in anesthesiology, surgery and nursing, met from October 20 to 22, 2021, in Sacramento, California, and used a modified Delphi process and a comprehensive review of evidence to formulate recommendations. The quality of evidence and strength of each recommendation were established using the Grading of Recommendations Assessment, Development, and Evaluation methodology. A majority vote endorsed recommendations.

RESULTS

Based on available evidence and group consensus, a total of 13 recommendations were formulated (4 for the preoperative phase, 4 for the intraoperative phase, and 5 for the postoperative phase), and are reported here.

CONCLUSIONS

Because there are no reliable or effective treatment options for CSA-AKI, evidence-based practices that highlight prevention and early detection are paramount. Cardiac surgery-associated AKI incidence may be mitigated and postsurgical outcomes improved by focusing additional attention on presurgical kidney health status; implementing a specific cardiopulmonary bypass bundle; using strategies to maintain intravascular euvolemia; leveraging advanced tools such as the electronic medical record, point-of-care ultrasound, and biomarker testing; and using patient-specific, goal-directed therapy to prioritize oxygen delivery and end-organ perfusion over static physiologic metrics.

Procedural sedation in pediatric dentistry: a narrative review

Procedural sedation and analgesia are now considered standard care for managing pain and anxiety in pediatric dental patients undergoing diagnostic and therapeutic procedures outside of the operating room. Anxiolysis, which combines both pharmacologic and non-pharmacologic approaches, plays a significant role in procedural sedation. Non-pharmacologic interventions such as Behavior Management Technology can help reduce preprocedural agitation, ease the transition to sedation, reduce the required amount of medication for effective sedation, and decrease the occurrence of adverse events. As the introduction of novel sedative regimen and methods in pediatric dentistry, the potential role of mainstay sedatives administered by new routes, for new indications, and with new delivery techniques, should be considered. The purpose of this paper is to examine and discuss the current state of sedation techniques in pediatric dentistry.