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Zhang B, Pan S, Zheng J, Li B, Miao Y, Liu G. Optimizing pediatric preoperative fasting management: a survey of practices and real durations in Chinese hospitals. BMC Anesthesiol 2025; 25:204. [PMID: 40269676 PMCID: PMC12016447 DOI: 10.1186/s12871-025-03064-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2025] [Accepted: 04/10/2025] [Indexed: 04/25/2025] Open
Abstract
BACKGROUND Rational preoperative fasting can reduce the risk of regurgitation and aspiration, enhance anesthesia safety and efficiency, and mitigate the adverse effects of prolonged fasting. This study investigates the existing practices of preoperative fasting management in Chinese pediatric patients and explores the real duration of preoperative fasting. METHODS This is a cross-sectional study. A questionnaire on fasting management in children was developed and an online survey was conducted among anesthesiologists. The survey mainly included the real implementation of pediatric fasting protocols, anesthesiologists' understanding of pediatric fasting management, and the application of gastric ultrasound. Moreover, data on pediatric preoperative fasting durations were collected from different hospitals across China. RESULTS A total of 770 questionnaires and 1285 records of preoperative fasting cases were obtained. The survey indicated variations in preoperative fasting protocols among hospitals. Most hospitals recommended fasting for clear fluids for 2 h, while the new 1-h regimen and the liberal regimen were less implemented due to concerns regarding regurgitation and aspiration risks. Fasting for breast milk, formula milk, and solid food was mainly based on traditional protocols, with fasting durations of 4 h, 6 h, and 8 h, respectively. Most anesthesiologists have experienced regurgitation and aspiration, but there were significant differences in their awareness of the prevention and prognosis of regurgitation and aspiration. Utilization of gastric ultrasound was limited, with a lack of equipment and familiarity among anesthesiologists. Real preoperative fasting durations for children were significantly longer than those recommended in the guidelines. Factors contributing to prolonged fasting were identified. CONCLUSIONS There is a big gap between preoperative fasting practices and the guidelines, and the real fasting durations of children before surgery are significantly longer than the guideline recommendations. Anesthesiologists should strengthen their understanding of preoperative fasting management in pediatric patients, master the skills of gastric ultrasound assessment, and timely address inefficiencies in pediatric preoperative fasting management.
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Affiliation(s)
- Bin Zhang
- Department of Anesthesiology, Children's Hospital Affiliated to Shandong University & Jinan Children's Hospital, Jinan, 250012, China
| | - Shoudong Pan
- Department of Anesthesiology, Children's Hospital, Capital Institute of Pediatrics, Beijing, 100020, China
| | - Jijian Zheng
- Department of Anesthesia, Shanghai Children's Medical Center Affiliated with Shanghai Jiaotong University School of Medicine, National Children's Medical Center, Shanghai, 200120, China
| | - Bo Li
- Department of Anesthesia, Shanghai Children's Medical Center Affiliated with Shanghai Jiaotong University School of Medicine, National Children's Medical Center, Shanghai, 200120, China
| | - Yi Miao
- Anesthesia and Perioperative Medicine Department, Xi'an Children's Hospital, Xi'an, 710000, China
| | - Guohua Liu
- Pediatric Research Institute, Children's Hospital Affiliated to Shandong University & Jinan Children's Hospital, No. 23976, Jingshi Road, Jinan, 250012, China.
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Liu X, Li X, Liu G, Yan Y, Fang H, Zhang B. Ultrasound evaluation of gastric emptying for two different quantities of milk in elementary school-aged children. Eur J Pediatr 2025; 184:163. [PMID: 39883252 DOI: 10.1007/s00431-025-06001-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2024] [Revised: 01/10/2025] [Accepted: 01/21/2025] [Indexed: 01/31/2025]
Abstract
Current guidelines recommend 6-h milk fasting in periprocedural settings; however, recent evidence suggests potential overconservativeness and supports more liberal pediatric fasting protocols. This study assessed the gastric emptying of two different milk quantities in elementary school-age children using gastric ultrasonography. This prospective crossover trial involved 30 healthy children who fasted overnight on two separate occasions within one month, consuming either 5 or 10 mL/kg of milk. Gastric ultrasonography assessed the gastric antrum cross-section area in the right lateral decubitus position at intervals until milk emptying. The time for the gastric antrum to return to baseline and the gastric emptying time was recorded. After consuming 5 mL/kg of milk, the time for the gastric antrum to return to baseline varied from 1.5 to 3.5 h (mean: 2.35 ± 0.56 h; median: 2.50 (2.00-2.63) hours). The gastric emptying time ranged from 1.5 to 4.0 h, with the mean and median time of 2.63 ± 0.54 h and 2.50 (2.50-3.00) hours, respectively. With 10 mL/kg of milk, the time for the gastric antrum to return to baseline ranged from 2.0 to 5.0 h, with a mean of 3.35 ± 0.62 h and a median time of 3.50 (3.00-4.00) hours. The gastric emptying time ranged from 2.0 to 5.0 h with a mean and median time of 3.62 ± 0.61 h and 3.50 (3.38-4.00) hours. Subgroup analysis revealed no significant differences between children of different genders or body mass indexes. CONCLUSION The gastric return and emptying times are different for both milk quantities, both shorter than the 6-h fasting recommendation, supporting the liberal fasting protocols recommended by the European Society of Anaesthesiology and Intensive Care. CLINICAL TRIALS REGISTRATION This trial was registered in the Chinese Clinical Trial Registry (Registration number ChiCTR2300077790) on November 20, 2023. WHAT IS KNOWN • The ESAIC guidelines recommend a 4-h fasting period for milk products in periprocedural settings for children. WHAT IS NEW • Our research demonstrates that cow's milk is emptied from the stomach within 4 h, supporting the ESAIC recommendations.
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Affiliation(s)
- Xiaofang Liu
- Department of Ultrasound, Children's Hospital Affiliated to Shandong University & Jinan Children's Hospital, Jinan, China
| | - Xianjun Li
- Department of Ultrasound, Children's Hospital Affiliated to Shandong University & Jinan Children's Hospital, Jinan, China
| | - Guohua Liu
- Pediatric Research Institute, Children's Hospital Affiliated to Shandong University & Jinan Children's Hospital, Jinan, China
| | - Yuxi Yan
- Department of Ultrasound, Children's Hospital Affiliated to Shandong University & Jinan Children's Hospital, Jinan, China
| | - Haotian Fang
- Department of Nursing, Children's Hospital Affiliated to Shandong University & Jinan Children's Hospital, Jinan, China
| | - Bin Zhang
- Department of Anesthesiology, Children's Hospital Affiliated to Shandong University & Jinan Children's Hospital, No. 23976, Jingshi Road, Jinan, 250012, China.
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Elghamry MR, Elkeblawy AM, Alshawadfy AM, Ramadan KM. Gastric ultrasound assessment of two preoperative fasting regimens in pediatric patients: A randomized clinical trial. Acta Anaesthesiol Scand 2025; 69:e14566. [PMID: 39711127 DOI: 10.1111/aas.14566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Revised: 11/02/2024] [Accepted: 12/06/2024] [Indexed: 12/24/2024]
Abstract
BACKGROUND Preoperative fasting aims to reduce the risk of pulmonary aspiration. Our aim was to compare the incidence of increased gastric content after preoperative liberal versus a standard fasting in children. METHOD Two hundred children, presented for elective surgeries, were instructed to follow either 6-4-2 (standard group) or 6-4-0 (liberal group) preoperative fasting regimens. Preoperative ultrasound was used to evaluate gastric contents. The primary outcome was the proportion of patients with an "at-risk stomach." Secondary outcomes included qualitative and quantitative gastric assessment, last meal, actual fasting duration, regurgitation, vomiting, aspiration incidence, surgery cancellation rate, and complications of prolonged fasting (e.g., hunger). RESULTS The actual fasting duration was significantly longer than prescribed in each group (p < 0.001 for both groups) and was significantly longer in the standard group (CI95%: 0.744-2.016, medium effect size η2 = 0.068). In the liberal group, 3% of patients had an "at-risk stomach," and 2% of cases were canceled. Qualitative gastric assessment was comparable between the two groups (OR 1.536, CI95%: 0.883-2.670, low effect size Cramer V = 0.139). However, the estimated gastric volume/weight ratio was significantly increased in the standard group (CI95%: 0.114-0.214; large effect size η2 = 0.171). In the standard group, 9% of patients were hungry, and 10% were thirsty; no patients experienced adverse effects in either group. CONCLUSION Prolonged preoperative fasting may be unnecessary. The 6-4-0 fasting regimen can be applied to pediatric patients before elective surgeries without increasing the incidence of "at risk stomach," but further studies with larger sample size are needed to confirm these results. TRIAL REGISTRATION ClinicalTrials.gov (Trial no.: NCT04961814).
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Affiliation(s)
- Mona Raafat Elghamry
- Anesthesia, Surgical Intensive Care, and Pain Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Amira Mahfouz Elkeblawy
- Anesthesia, Surgical Intensive Care, and Pain Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
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Dulay E, Griffin B, Brannigan J, McBride C, Hudson A, Ullman A. Interventions to optimise preoperative fasting in paediatrics: a scoping review. Br J Anaesth 2024; 133:1201-1211. [PMID: 39304471 DOI: 10.1016/j.bja.2024.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 07/18/2024] [Accepted: 08/13/2024] [Indexed: 09/22/2024] Open
Abstract
BACKGROUND Preoperative fasting is the standard of care for patients undergoing a procedure under general anaesthesia. Despite the increased leniency of fasting guideline recommendations, prolonged preoperative fasting periods continue to disproportionally affect paediatric patients. This review maps existing interventions optimising paediatric fasting practices, to explore strategies that can be best applied in clinical practice. METHODS A search strategy applied to PubMed, CINAHL, Embase, Scopus, and the Cochrane Database involved four key concepts: (1) fasting, (2) preoperative, (3) paediatric, and (4) quality improvement intervention. The Preferred Reporting Items of Systematic Reviews and Meta-analyses extension for Scoping Reviews was utilised in this review. RESULTS Thirteen heterogeneous studies, involving approximately 31 000 children across five continents, were included. Each intervention studied fell into at least one of the following six themes: (1) change in facility protocol, (2) technology-based intervention, (3) individualised fasting programs, (4) processes to improve communication between clinicians, (5) processes to improve communication to parents and families, and (6) staff education. CONCLUSIONS A variety of interventions have been studied to optimise paediatric preoperative fasting duration. These interventions show potential in reducing preoperative fasting duration.
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Affiliation(s)
- Erika Dulay
- Children's Health Queensland Hospital and Health Service, South Brisbane, QLD, Australia; School of Nursing and Midwifery, Griffith University, Nathan, QLD, Australia; School of Nursing, Midwifery and Social Work, The University of Queensland, Brisbane, QLD, Australia.
| | - Bronwyn Griffin
- Children's Health Queensland Hospital and Health Service, South Brisbane, QLD, Australia; School of Nursing and Midwifery, Griffith University, Nathan, QLD, Australia
| | - James Brannigan
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Craig McBride
- Children's Health Queensland Hospital and Health Service, South Brisbane, QLD, Australia; Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Adrienne Hudson
- Children's Health Queensland Hospital and Health Service, South Brisbane, QLD, Australia; School of Nursing, Midwifery and Social Work, The University of Queensland, Brisbane, QLD, Australia; Learning and Workforce, Children's Health Queensland Hospital and Health Service, Brisbane, QLD, Australia; School of Nursing, Queensland University of Technology, Brisbane, QLD, Australia
| | - Amanda Ullman
- Children's Health Queensland Hospital and Health Service, South Brisbane, QLD, Australia; School of Nursing and Midwifery, Griffith University, Nathan, QLD, Australia; School of Nursing, Midwifery and Social Work, The University of Queensland, Brisbane, QLD, Australia; Children's Health Research Centre, Faculty of Medicine, Brisbane, QLD, Australia
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Gnech M, van Uitert A, Kennedy U, Skott M, Zachou A, Burgu B, Castagnetti M, Hoen L, O'Kelly F, Quaedackers J, Rawashdeh YF, Silay MS, Bogaert G, Radmayr C. European Association of Urology/European Society for Paediatric Urology Guidelines on Paediatric Urology: Summary of the 2024 Updates. Eur Urol 2024; 86:447-456. [PMID: 38627150 DOI: 10.1016/j.eururo.2024.03.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 03/04/2024] [Accepted: 03/25/2024] [Indexed: 11/15/2024]
Abstract
BACKGROUND AND OBJECTIVE We present an overview of the 2024 updates for the European Association of Urology (EAU)/European Society for Paediatric Urology (ESPU) guidelines on paediatric urology to offer evidence-based standards for perioperative management, minimally invasive surgery (MIS), hydrocele, congenital lower urinary tract obstruction (CLUTO), trauma/emergencies, and fertility preservation. METHODS A broad literature search was performed for each condition. Recommendations were developed and rated as strong or weak on the basis of the quality of the evidence, the benefit/harm ratio, and potential patient preferences. KEY FINDINGS AND LIMITATIONS Recommendations for perioperative management include points related to fasting, premedication, antibiotic prophylaxis, pain control, and thromboprophylaxis in patients requiring general anaesthesia. MIS use is increasing in paediatric urology, with no major differences observed among different MIS approaches. For hydrocele, observation is the initial approach recommended. For persistent cases, treatment varies according to the type of hydrocele. CLUTO cases should be managed in tertiary centres with multidisciplinary expertise in prenatal and postnatal management. Neonatal valve ablation remains the mainstay of treatment, but associated bladder dysfunction requires continuous treatment. Among urological traumas and emergencies, renal trauma is still an important cause of morbidity and mortality. Conservative management has become the standard approach in haemodynamically stable children. Ischaemic priapism is a medical emergency and requires stepwise management. Initial management of nonischaemic priapism is conservative. Fertility preservation in prepubertal children and adolescents has become an increasingly relevant issue owing to the ever-increasing number of cancer survivors receiving gonadotoxic therapies. A major limitation is the scarcity of relevant literature. CONCLUSIONS AND CLINICAL IMPLICATIONS This summary of the 2024 EAU/ESPU guidelines provides updated guidance for evidence-based management of some paediatric urological conditions. PATIENT SUMMARY We provide a summary of the updated European Association of Urology/European Society for Paediatric Urology guidelines on paediatric urology. There are recommendations on steps to take before and immediately after surgery, management of hydrocele, congenital lower urinary tract obstruction, and urological trauma/emergencies, as well as preservation of fertility. Recommendations are based on a comprehensive review of recent studies.
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Affiliation(s)
- Michele Gnech
- Department of Paediatric Urology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Allon van Uitert
- Department of Urology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Uchenna Kennedy
- Department of Pediatric Urology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Martin Skott
- Department of Urology, Section of Pediatric Urology, Aarhus University Hospital, Aarhus, Denmark
| | - Alexandra Zachou
- Department of HIV and Sexual Health, Chelsea & Westminster Hospital, London, UK
| | - Berk Burgu
- Department of Pediatric Urology, Ankara University School of Medicine, Ankara, Turkey
| | - Marco Castagnetti
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padua, Italy; Pediatric Urology Unit, Bambino Gesù Children's Hospital, Rome, Italy.
| | - Lisette't Hoen
- Department of Pediatric Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Fardod O'Kelly
- Division of Paediatric Urology, Beacon Hospital and University College Dublin, Dublin, Ireland
| | - Josine Quaedackers
- Department of Urology and Pediatric Urology, University Medical Center Groningen, Groningen, The Netherlands
| | - Yazan F Rawashdeh
- Department of Urology, Section of Pediatric Urology, Aarhus University Hospital, Aarhus, Denmark
| | - Mesrur Selcuk Silay
- Division of Pediatric Urology, Department of Urology, Birurni University, Istanbul, Turkey
| | - Guy Bogaert
- Department of Urology, University of Leuven, Leuven, Belgium
| | - Christian Radmayr
- Pediatric Urology, Medical University of Innsbruck, Innsbruck, Austria
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Webb AR, Kalam I, Lui N, Loughnan RM, Leong S. A pre and post interventional audit of an 'apple juice on arrival' protocol to reduce excessive clear fluid fasting times in paediatric patients. Anaesth Intensive Care 2024; 52:328-334. [PMID: 39212180 DOI: 10.1177/0310057x241263112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Many studies have reported prolonged fasting times in children, associated with negative metabolic and behavioural outcomes. We felt that although our paediatric preoperative clear fluid fasting guideline was only for 2 hours, prolonged fasting still occurred for some patients. We conducted an audit of paediatric fasting times, before and after introducing a new protocol of 'apple juice on arrival', in which, on arrival to the children's ward, all children received 3 ml/kg of apple juice. Data were collected prospectively from patients and their parents for two 4-week periods (before and after introduction of the protocol). Data included fasting time (solids and clear fluids), capillary blood glucose levels, knowledge of fasting requirements and sources of fasting information before surgery. Thirty-nine and 40 children, respectively, were included in each group before and after protocol introduction. Clear fluid fasting times reduced from an average of 9.9 hours pre-intervention to 3.5 hours post intervention (P < 0.01). In addition, mean preoperative blood sugar levels increased from 4.9 mmol/L (pre-intervention group) to 5.6 mmol/L in the post-intervention group (P < 0.001). The implementation of an apple juice on arrival protocol appeared to be an effective method to reduce clear fluid fasting times in children in our institution.
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Affiliation(s)
- Ashley R Webb
- Department of Anaesthesia, Peninsula Health, Frankston, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Ikram Kalam
- Department of Anaesthesia, Peninsula Health, Frankston, Australia
| | - Nicholas Lui
- Department of Anaesthesia, Peninsula Health, Frankston, Australia
| | - Rachael M Loughnan
- Department of Anaesthesia, Peninsula Health, Frankston, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Samuel Leong
- Department of Anaesthesia, Peninsula Health, Frankston, Australia
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Cho E, Kwak JH, Huh J, Kang IS, Ryu KH, Lee SH, Ahn JH, Choi HK, Song J. A comparative study using gastric ultrasound to evaluate the safety of shortening the fasting time before pediatric echocardiography: a randomized controlled non-inferiority study. J Anesth 2024; 38:516-524. [PMID: 38849566 DOI: 10.1007/s00540-024-03360-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 05/09/2024] [Indexed: 06/09/2024]
Abstract
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.
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Affiliation(s)
- Eunah Cho
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ji Hee Kwak
- Department of Pediatrics, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - June Huh
- Department of Pediatrics, Samsung Medical Center, Heart Vascular Stroke Institute, Grown-Up Congenital Heart Clinic, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, Republic of Korea
| | - I-Seok Kang
- Department of Pediatrics, Samsung Medical Center, Heart Vascular Stroke Institute, Grown-Up Congenital Heart Clinic, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, Republic of Korea
| | - Kyoung-Ho Ryu
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sung Hyun Lee
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jin Hee Ahn
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyeong-Kyeong Choi
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jinyoung Song
- Department of Pediatrics, Samsung Medical Center, Heart Vascular Stroke Institute, Grown-Up Congenital Heart Clinic, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, Republic of Korea.
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Rüggeberg A, Meybohm P, Nickel EA. Preoperative fasting and the risk of pulmonary aspiration-a narrative review of historical concepts, physiological effects, and new perspectives. BJA OPEN 2024; 10:100282. [PMID: 38741693 PMCID: PMC11089317 DOI: 10.1016/j.bjao.2024.100282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 03/27/2024] [Indexed: 05/16/2024]
Abstract
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.
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Affiliation(s)
- Anne Rüggeberg
- Department of Anaesthesiology and Pain Therapy, Helios Klinikum Emil von Behring, Berlin, Germany
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Eike A. Nickel
- Department of Anaesthesiology and Pain Therapy, Helios Klinikum Emil von Behring, Berlin, Germany
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Frykholm P, Hansen TG, Engelhardt T. Preoperative fasting in children. The evolution of recommendations and guidelines, and the underlying evidence. Best Pract Res Clin Anaesthesiol 2024; 38:103-110. [PMID: 39445555 DOI: 10.1016/j.bpa.2024.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 03/14/2024] [Indexed: 10/25/2024]
Abstract
This review discusses the evolution of preoperative fasting guidelines and examines the incidence of pulmonary aspiration of gastric contents and suggested treatments. Nine guidelines developed by professional societies and published in peer-reviewed journals since 1994 were identified. The recommendations on preoperative fasting for various categories have undergone only small adaptations in the following three decades in pediatric anesthesia. We found twelve published studies of the incidence of pulmonary aspiration, which ranges from 0.6 to 12 in 10,000 anesthetics in children. However, this variation reflects differences in the definition of aspiration as well as differences in study design. The main risk factors identified are emergency surgery, ASA physical status, and patient age. Several additional risk factors have been suggested, including non-compliance to fasting guidelines. The duration of clear fluid fasting is not associated with an increased risk of pulmonary aspiration which may be reflected in future guideline updates in pediatric anesthesia.
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Affiliation(s)
- Peter Frykholm
- Department of Surgical Sciences, Section of Anaesthesiology and Intensive Care Medicine, Uppsala University, 751 85 Uppsala, Sweden; Uppsala Centre for Paediatric Anaesthesia and Intensive Care Research, Uppsala University Hospital, 751 85 Uppsala, Sweden.
| | - Tom G Hansen
- Department of Anesthesia & Intensive Care, Akershus University Hospital, Lørenskog, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Thomas Engelhardt
- Department of Anesthesia, Montreal Children's Hospital, Montreal, Canada
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Frykholm P, Disma N, Andersson H, Beck C, Bouvet L, Cercueil E, Elliott E, Hofmann J, Isserman R, Klaucane A, Kuhn F, de Queiroz Siqueira M, Rosen D, Rudolph D, Schmidt AR, Schmitz A, Stocki D, Sümpelmann R, Stricker PA, Thomas M, Veyckemans F, Afshari A, překladu: A, Harazim H, Ťoukálková M, Valouchová V, Štourač P. Předoperační lačnění u dětí - Doporučený postup Evropské společnosti pro anesteziologii a intenzivní péči. ANESTEZIOLOGIE A INTENZIVNÍ MEDICÍNA 2024; 35:58-80. [DOI: 10.36290/aim.2024.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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11
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Rüggeberg A, Nickel E. [Traditions are difficult to break!]. DIE ANAESTHESIOLOGIE 2023; 72:753-754. [PMID: 37698731 DOI: 10.1007/s00101-023-01339-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/21/2023] [Indexed: 09/13/2023]
Affiliation(s)
- Anne Rüggeberg
- Abteilung für Anästhesie und Schmerztherapie, Helios Klinikum Emil von Behring, Walterhöferstraße 11, 14165, Berlin, Deutschland.
| | - Eike Nickel
- Abteilung für Anästhesie und Schmerztherapie, Helios Klinikum Emil von Behring, Walterhöferstraße 11, 14165, Berlin, Deutschland
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Laird A, Bramley L, Barnes R, Englin A, Winderlich J, Mount E, Nataraja RM, Pacilli M. Effects of a Preoperative Carbohydrate Load on Postoperative Recovery in Children: A Randomised, Double-Blind, Placebo-Controlled Trial. J Pediatr Surg 2023; 58:1824-1831. [PMID: 37280132 DOI: 10.1016/j.jpedsurg.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 04/27/2023] [Accepted: 05/07/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Nausea and vomiting are common causes for prolonged postoperative length of hospital stay (LOS) in children. A preoperative carbohydrate load may reduce postoperative nausea and vomiting by improving the perioperative metabolic state. The aim of this study was to determine if a preoperative carbohydrate-containing drink would lead to an improvement in the perioperative metabolic state and consequently reduce the incidence of postoperative nausea, vomiting and LOS in children undergoing day-case surgical procedures. METHOD Randomised, double-blind, placebo-controlled trial involving children aged 4 to 16-years undergoing day-case surgical procedures. Patients were randomised to receive a carbohydrate-containing drink or a placebo. During the induction of anaesthesia, a venous blood gas, and blood glucose and ketone levels were measured. Postoperatively, the incidence of nausea, vomiting, and LOS were documented. RESULTS 120 patients were randomised with 119/120 (99.2%) undergoing analysis. Blood glucose level was higher in the carbohydrate group; 5.4 mmol/L [3.3-9.4] versus 4.9 mmol/L [3.6-6.5] (p = 0.01). Blood ketone level was lower in the carbohydrate group; 0.2 mmol/L versus 0.3 mmol/L (p = 0.003). The incidence of nausea and vomiting was not different (p > 0.9 and p = 0.8, respectively). LOS in the carbohydrate group was 26 min shorter than the placebo group (p = 0.02). CONCLUSION Although a preoperative carbohydrate load may provide a more stable metabolic state at the induction of anaesthesia, we did not find a reduction in postoperative nausea and vomiting. A preoperative carbohydrate load has also minimal effects on the postoperative LOS. TYPE OF STUDY Randomised clinical trial. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Ashleigh Laird
- Department of Paediatrics and Surgery, School of Clinical Sciences, Monash University, 246 Clayton Road, Melbourne, Australia
| | - Lynsey Bramley
- Department of Nutrition and Dietetics, Monash Children's Hospital, 246 Clayton Road, Melbourne, Australia
| | - Richard Barnes
- Department of Anaesthetics, Monash Children's Hospital, 246 Clayton Road, Melbourne, Australia
| | - Anna Englin
- Department of Anaesthetics, Monash Children's Hospital, 246 Clayton Road, Melbourne, Australia
| | - Jacinta Winderlich
- Department of Nutrition and Dietetics, Monash Children's Hospital, 246 Clayton Road, Melbourne, Australia
| | - Elizabeth Mount
- Department of Nutrition and Dietetics, Monash Children's Hospital, 246 Clayton Road, Melbourne, Australia
| | - Ramesh M Nataraja
- Department of Paediatrics and Surgery, School of Clinical Sciences, Monash University, 246 Clayton Road, Melbourne, Australia; Department of Paediatric Surgery, Monash Children's Hospital, 246 Clayton Road, Melbourne, Australia
| | - Maurizio Pacilli
- Department of Paediatrics and Surgery, School of Clinical Sciences, Monash University, 246 Clayton Road, Melbourne, Australia; Department of Paediatric Surgery, Monash Children's Hospital, 246 Clayton Road, Melbourne, Australia.
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Demirel A, Özgünay ŞE, Eminoğlu Ş, Balkaya AN, Onur T, Kılıçarslan N, Gamlı M. Ultrasonographic Evaluation of Gastric Content and Volume in Pediatric Patients Undergoing Elective Surgery: A Prospective Observational Study. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1432. [PMID: 37761393 PMCID: PMC10529717 DOI: 10.3390/children10091432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 08/11/2023] [Accepted: 08/17/2023] [Indexed: 09/29/2023]
Abstract
Anesthesia-related complications, such as pulmonary aspiration of gastric contents, occur in approximately 0.02-0.1% of elective pediatric surgeries. Aspiration risk can be reliably assessed by ultrasound examination of the gastric antrum, making it an essential non-invasive bedside tool. In this prospective observational study, since most of our patients are immigrants and have communication problems, we wanted to investigate gastric contents and the occurrence of "high risk stomach" in children undergoing elective surgery for the possibility of pulmonary aspiration, even if the children and/or parents reported their last oral intake time. This risk is defined by ultrasound findings of solid content in the antrum and/or a calculated gastric volume exceeding 1.25 mL/kg. Children aged 2-18 were included in the study. Both supine and right lateral decubitus (RLD) ultrasound examinations were performed on the antrum before surgery. Using a qualitative grading scale from 0 to 2, we evaluated the gastric fluid content. The cross-sectional area (CSA) of the antrum was measured in the RLD position, aiding the calculation of the gastric fluid volume according to an established formula by Perlas. Ultrasound measurements of 97 children were evaluated. The median fasting duration was 4 h for liquids and 9 h for thick liquids and solids. Solid content was absent in all the children. Five children (5.2%) exhibited a grade 2 antrum, implying that fluid content was visible in both the supine and RLD positions. The median antral CSA in the RLD was 2.36 cm2, with a median gastric volume of 0.46 mL/kg. For patients with a grade 0 antrum, a moderate and positive correlation was observed between the antral CSA and BMI, and a strong and positive correlation was evident between the antral CSA and age, similar to a grade 1 antrum. Only a single child (1%) had a potentially elevated risk of aspiration of gastric contents. Hence, the occurrence of a "high risk stomach" was 1% (95% confidence interval: 0.1-4.7%) and is consistent with the literature. As a necessary precaution, we propose the regular use of ultrasound evaluations of gastric contents, given their non-invasive, bedside-friendly, and straightforward implementation, for identifying risks when fasting times are uncertain and for ruling out unknown risk factors in each potential patient.
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Affiliation(s)
- Asiye Demirel
- Department of Anesthesiology and Reanimation, Bursa Yuksek Ihtisas Training and Research Hospital, University of Health Sciences, Bursa 16310, Turkey; (Ş.E.Ö.); (Ş.E.); (A.N.B.); (T.O.); (N.K.); (M.G.)
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Gerth MA, Mußmann YM, Büchler B, Hartmann EK, Wittenmeier E. [Preoperative fasting in children-Experiences with implementing a liberal fasting policy]. DIE ANAESTHESIOLOGIE 2023; 72:565-572. [PMID: 37380810 PMCID: PMC10400684 DOI: 10.1007/s00101-023-01303-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/16/2023] [Accepted: 05/03/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Traditional fasting rules for children prior to elective operations ("6‑4‑2 rule") often lead to prolonged fasting times with possible adverse events (discomfort, hypoglycemia, metabolic disorders, agitation/delirium). A new liberal fasting policy allowing children to drink clear fluids until being called to the operating room ("6‑4‑0") was established in our university hospital. This article describes our experiences and retrospectively examines the effects. OBJECTIVE Evaluation of real fasting times before and up to 6 months after the intervention (success and durability of changing fasting policy). Evaluation of impact on outcome parameters, such as patients' resp. parents' satisfaction as well as perioperative agitation, arterial hypotension after induction and postoperative nausea and vomiting (PONV). MATERIAL AND METHODS Retrospective evaluation of methods and interventions from 1 month before to 6 months after changing the fasting policy (June-December 2020). Statistical analysis using descriptive statistics, odds ratio and χ2-test. RESULTS Of 216 analyzed patients 44 were in the pre-change group and 172 in the post-change group. We could significantly reduce clear fluids fasting times over the 6 months after the intervention (median fasting time: from 6.1 h to 4.5 h; p = 0.034) and achieve our aim (fasting time for clear fluids less than or equal to 2h) in 47% of the patients. Fasting times became longer again reaching pre-change intervals in the 4th and 5th month, so reminder measures turned out to be necessary. By reminding the staff we could reduce fasting times again in the 6th month and restore patients' resp. parents' satisfaction. Satisfaction was improved by shorter fasting times (median school grade from 2.8 to 2.2; p = 0.004; odds ratio for better satisfaction 5.24, 2.1-13.2), and preoperative agitation was reduced (agitation modified PAED scale 1-2 in only 34.5% instead of 50%, p = 0.032). In the liberal fasting group, we observed a nonsignificant smaller incidence of hypotension after induction (7% vs. 14%, p = 0.26) while PONV was too rare in both groups for statistical purposes. CONCLUSION With multiple interventions we could significantly reduce fasting times for clear fluids and improve patients' resp. parents' satisfaction as well as preoperative agitation. These interventions included regular presence in all staff meetings, a handout for both parents and staff, as well as a remark on the anesthesia protocol. Children who were operated on later in the day, benefited most from the new liberal fasting policy as they were allowed to drink until being called to the operating room. Following our experience, we consider simple and safe fasting rules for the whole staff as most important for change management. Nevertheless, we could not reduce the fasting intervals in all cases and had to remind the staff after 5 months to preserve this success. For enduring success, we suggest regular staff updates during the change process instead of one single kick-off information event.
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Affiliation(s)
- Mathias Alexander Gerth
- Klinik für Anästhesiologie, Universitätsmedizin, Johannes Gutenberg Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland.
| | | | - Britta Büchler
- Institut für medizinische Biometrie, Epidemiologie und Informatik (IMBEI), Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | - Erik Kristoffer Hartmann
- Klinik für Anästhesiologie, St. Marien- und St. Annastiftskrankenhaus Ludwigshafen, Ludwigshafen, Deutschland
| | - Eva Wittenmeier
- Klinik für Anästhesiologie, Universitätsmedizin, Johannes Gutenberg Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
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Anderson BJ, Cortinez LI. Perioperative Acetaminophen Dosing in Obese Children. CHILDREN 2023; 10:children10040625. [PMID: 37189874 DOI: 10.3390/children10040625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 03/14/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023]
Abstract
Acetaminophen is a commonly used perioperative analgesic drug in children. The use of a preoperative loading dose achieves a target concentration of 10 mg/L associated with a target analgesic effect that is 2.6 pain units (visual analogue scale 1–10). Postoperative maintenance dosing is used to keep this effect at a steady-state concentration. The loading dose in children is commonly prescribed per kilogram. That dose is consistent with the linear relationship between the volume of distribution and total body weight. Total body weight is made up of both fat and fat-free mass. The fat mass has little influence on the volume of distribution of acetaminophen but fat mass should be considered for maintenance dosing that is determined by clearance. The relationship between the pharmacokinetic parameter, clearance, and size is not linear. A number of size metrics (e.g., fat-free and normal fat mass, ideal body weight and lean body weight) have been proposed to scale clearance and all consequent dosing schedules recognize curvilinear relationships between clearance and size. This relationship can be described using allometric theory. Fat mass also has an indirect influence on clearance that is independent of its effects due to increased body mass. Normal fat mass, used in conjunction with allometry, has proven a useful size metric for acetaminophen; it is calculated using fat-free mass and a fraction (Ffat) of the additional mass contributing to total body weight. However, the Ffat for acetaminophen is large (Ffat = 0.82), pharmacokinetic and pharmacodynamic parameter variability high, and the concentration–response slope gentle at the target concentration. Consequently, total body weight with allometry is acceptable for the calculation of maintenance dose. The dose of acetaminophen is tempered by concerns about adverse effects, notably hepatotoxicity associated with use after 2–3 days at doses greater than 90 mg/kg/day.
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16
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Rüggeberg A, Nickel EA. Unrestricted drinking before surgery: an iterative quality improvement study. Anaesthesia 2022; 77:1386-1394. [PMID: 36130830 DOI: 10.1111/anae.15855] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 01/11/2023]
Abstract
Average pre-operative fasting times for clear liquids are many times longer than those specified in national and international guidelines. We sought to decrease fasting times by applying a quality management tool aimed at continuous improvement. Through the application of iterative 'plan-do-study-act' cycles, tools to reduce pre-operative liquid fasting times were developed and applied, the effects measured, analysed and interpreted and the conclusions used to inform the next plan-do-study-act cycle. The first step was the introduction of unrestricted drinking until the patient was called to the operating theatre, with training of anaesthetic staff, adaption of local standard procedures and verbal information for patients. This did not result in short liquid fasting times, median (IQR [range]) 12.0 (9.5-14.0 [0.8-23.5]) h. In the second cycle, fasting cards were introduced as a subliminal written training tool for staff, patients and their relatives. This enabled short liquid fasting times to be achieved for outpatients (2.6 (0.8-5.1 [0.3-16]) h) and pre-admission patients (3.4 (1.8-9.4 [0.2-17.2]) h), but not for inpatients (6.5 (2.0-11.7 [0.2-16.2]) h). The third cycle included lectures for ward staff, putting up information posters throughout the hospital, revision of all written materials and provision of screencasts on the homepage for staff and patients. This decreased median liquid fasting time to 2.1 (1.2-3.8 [0.4-18.8]; p < 0.0001) h, with inpatients having the shortest fasting time of 1.4 (1.1-3.8 [0.4-18.8]) h. Repeated quality improvement cycles, adapted to local context, can support sustained reductions in pre-operative liquid fasting times.
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Affiliation(s)
- A Rüggeberg
- Department of Anaesthesiology and Pain Therapy, Helios Klinikum Emil von Behring, Berlin, Germany
| | - E A Nickel
- Department of Anaesthesiology and Pain Therapy, Helios Klinikum Emil von Behring, Berlin, Germany
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New ESAIC fasting guidelines for clear fluids in children: Much ado about nothing or is it? Eur J Anaesthesiol 2022; 39:639-641. [PMID: 35822222 DOI: 10.1097/eja.0000000000001674] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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18
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Owusu-Agyemang P, Tsai JY, Kapoor R, Van Meter A, Tan GM, Peters S, Opitz L, Pedrotti D, DeSoto HS, Zavala AM. Survey of Anesthesia, Sedation, and Non-sedation Practices for Children Undergoing Repetitive Cranial or Craniospinal Radiotherapy. Cureus 2022; 14:e24075. [PMID: 35573580 PMCID: PMC9097856 DOI: 10.7759/cureus.24075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2022] [Indexed: 11/24/2022] Open
Abstract
Background Children undergoing cranial or craniospinal radiotherapy may require over 30 treatments within a six-week period. Facilitating these many treatments with the patient under anesthesia presents a significant challenge, and the most preferred anesthetic methods remain unknown. The primary goal of this study was to determine the most preferred anesthetic methods and agents for children undergoing daily cranial or craniospinal radiotherapy. Methods An 83-item web-based survey was developed. An introductory email was sent to 505 physicians and child-life specialists with expertise in pediatric anesthesia and/or affiliated with pediatric radiation oncology departments. Results The response rate was 128/505 (25%) and included specialists from Africa (5, 4%), Asia (18, 14%), Australia/Oceania (5, 4%), Europe (45, 35%), North America (50, 39%), and South America (5, 4%). The 128 respondents included 91 anesthesiologists (71%), 20 physicians who were not anesthesiologists (16%), 14 child life/social education specialists (11%), one radiotherapist, one pediatric radiation nurse, and one non-specified medical professional (all = 2%). Of the 128 respondents, 95 (74%) used anesthesia or sedation to facilitate repetitive cranial or craniospinal radiotherapy. Overall, total intravenous anesthesia without intubation was preferred by 67 of 95 (71%) specialists during one or more forms of radiotherapy. During photon-based radiotherapy, total intravenous anesthesia without intubation was the preferred anesthetic method with the patient in the supine (57/84, 68%) and prone positions (25/40, 63%). Propofol was the most used anesthetic agent for both supine (73/84, 87%) and prone positions (38/40, 95%). For proton radiotherapy, total intravenous anesthesia without intubation was the most preferred anesthetic method for the supine (32/42, 76%) and prone treatment positions (11/18, 61%), and propofol was the most used anesthetic (supine: 40/43, 93%; prone: 16/18, 89%). Conclusions In this survey of 95 specialists responsible for anesthesia or sedation of children undergoing repetitive cranial or craniospinal radiotherapy, propofol-based total intravenous anesthesia without intubation was the preferred anesthetic technique.
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Wong ANY, Ragg PG, Chong SW, Morton H, Oliver L. Multicenter Survey on Staff Understanding of Preoperative Fasting Guidelines. J Perianesth Nurs 2022; 37:369-373. [PMID: 35177321 DOI: 10.1016/j.jopan.2021.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 05/05/2021] [Accepted: 05/15/2021] [Indexed: 11/20/2022]
Abstract
PURPOSE To assess the knowledge of nursing staff regarding pediatric preoperative fasting in a tertiary pediatric center and a general hospital. DESIGN Anonymous electronic survey with nine questions modified to each institution. METHODS This was a prospective quantitative study. Nursing staff at a tertiary pediatric center and pediatric nursing staff at a general hospital with pediatric services were eligible for participation. An anonymous electronic survey with nine questions via Survey Monkey was used over a 2-month period. FINDINGS There were 295 participants from the tertiary pediatric center and 24 from the general hospital which represented 10% of overall nursing staff at the tertiary pediatric center and approximately 50% of pediatric nursing staff at the general hospital. At both the tertiary pediatric center and the general hospital, 50 to 80% of participants correctly answered most questions. More participants were correct for the fasting times for infants less than 6 month of age than for those over 6 months old. For clear fluids, 61 (20.7%) and 13 (4.4%) considered jelly and breast milk as clear fluids respectively at the tertiary pediatric center. CONCLUSIONS Preoperative fasting continues to be a core area of pediatric care that is not completely understood. Our survey showed that although the majority of staff claim to be able to access the hospital guidelines, knowledge of these guidelines can be improved. In light of ongoing changing evidence, it is clear that education is a key factor in reducing morbidity and improving patient experience related to preoperative fasting.
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Affiliation(s)
- Abigail N Y Wong
- Department of Anaesthesia and Pain Management, Gold Coast University Hospital, Southport, Queensland, Australia.
| | - Philip G Ragg
- Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Simon W Chong
- Department of Anaesthesia, Western Health, Victoria, Australia
| | - Helen Morton
- Pre Admission Resource Centre, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Laura Oliver
- Pre Admission Resource Centre, The Royal Children's Hospital, Parkville, Victoria, Australia
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20
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Carroll AR, McCoy AB, Modes K, Krehnbrink M, Starnes LS, Frost PA, Johnson DP. Decreasing pre-procedural fasting times in hospitalized children. J Hosp Med 2022; 17:96-103. [PMID: 35504576 PMCID: PMC9097721 DOI: 10.1002/jhm.12782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 01/11/2022] [Accepted: 01/18/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Prolonged pre-procedural fasting in children is associated with decreased patient and family satisfaction and increased patient hemodynamic instability. Practice guidelines recommend clear liquid fasting times of 2 h. We aimed to decrease pre-procedural clear liquid fasting time from 10 h 13 min to 5 h for pediatric hospital medicine (PHM) patients. METHODS All children admitted to the PHM service at a quaternary care children's hospital with an NPO (nil per os) order associated with a procedure requiring general anesthesia or sedation from November 2, 2017 to September 19, 2021 were included. The primary outcome measure was the average time from clear liquid fasting end time to anesthesia start time. The process measure was the percent of NPO orders including a documented clear liquid fasting end time. Balancing measures were aspiration events and case delays/cancellations. Statistical process control charts were used to analyze outcomes. RESULTS Shortly after implementation of a SmartPhrase in the NPO order, there was special cause variation resulting in a centerline shift from a mean of 10 h 13 min to 6 h 37 min and an increase in the process measure from a baseline of 2%-52%. Following implementation of a hospital-wide change to the NPO order format, another centerline shift to 6 h 7 min occurred which has been sustained for 6 months. No aspiration events and four NPO violations occurred during the intervention period. CONCLUSION Quality improvement methodology and higher reliability interventions safely decreased the average pre-procedural fasting time in hospitalized children.
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Affiliation(s)
- Alison R. Carroll
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Allison B. McCoy
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Katharina Modes
- Department of Anesthesiology, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, TN
| | - Marni Krehnbrink
- Department of Pediatrics, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville Tennessee
| | - Lauren S. Starnes
- Department of Pediatrics, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville Tennessee
| | - Patricia A. Frost
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - David P. Johnson
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, Tennessee
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21
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Pre-operative fasting in children: A guideline from the European Society of Anaesthesiology and Intensive Care. Eur J Anaesthesiol 2022; 39:4-25. [PMID: 34857683 DOI: 10.1097/eja.0000000000001599] [Citation(s) in RCA: 91] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Current paediatric anaesthetic fasting guidelines have recommended conservative fasting regimes for many years and have not altered much in the last decades. Recent publications have employed more liberal fasting regimes with no evidence of increased aspiration or regurgitation rates. In this first solely paediatric European Society of Anaesthesiology and Intensive Care (ESAIC) pre-operative fasting guideline, we aim to present aggregated and evidence-based summary recommendations to assist clinicians, healthcare providers, patients and parents. We identified six main topics for the literature search: studies comparing liberal with conservative regimens; impact of food composition; impact of comorbidity; the use of gastric ultrasound as a clinical tool; validation of gastric ultrasound for gastric content and gastric emptying studies; and early postoperative feeding. The literature search was performed by a professional librarian in collaboration with the ESAIC task force. Recommendations for reducing clear fluid fasting to 1 h, reducing breast milk fasting to 3 h, and allowing early postoperative feeding were the main results, with GRADE 1C or 1B evidence. The available evidence suggests that gastric ultrasound may be useful for clinical decision-making, and that allowing a 'light breakfast' may be well tolerated if the intake is well controlled. More research is needed in these areas as well as evaluation of how specific patient or treatment-related factors influence gastric emptying.
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Revisiting Pediatric NPO Guidelines: a 5-Year Update and Practice Considerations. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00482-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Jeong JY, Ahn JH, Shim JG, Lee SH, Ryu KH, Lee SH, Cho EA. Gastric emptying of preoperative carbohydrate in elderly assessed using gastric ultrasonography: A randomized controlled study. Medicine (Baltimore) 2021; 100:e27242. [PMID: 34664868 PMCID: PMC8448003 DOI: 10.1097/md.0000000000027242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 08/23/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Preoperative carbohydrate loading enhances postoperative recovery and reduces patient discomfort. However, gastric emptying of liquids can be delayed in elderly populations. Therefore, this study aimed to evaluate the gastric emptying of 400 mL of a carbohydrate drink ingested 2 hours before surgery in elderly patients. METHODS In this prospective, randomized controlled study, patients aged >65 years were allocated to either fast from midnight (nil per os [NPO] group, n = 29) or drink 400 mL of a carbohydrate drink 2 hours before surgery (carbohydrate group, n = 29). The gastric antrum was assessed using ultrasonography in the supine position, followed by the right lateral decubitus (RLD) position. The gastric antrum was graded as grade 0 (fluid not seen in both positions), grade 1 (fluid only seen in the RLD position), and grade 2 (fluid seen in both positions). The gastric antral cross-sectional area (CSA) and aspirated residual gastric volume were measured. RESULTS In 58 patients, the incidence of grade 2 stomach was 13.8% in NPO group and 17.2% in carbohydrate group (P = .790). The gastric antral CSA in the supine position was larger in carbohydrate group than in NPO group (4.42 [3.72-5.18] cm2 vs 5.31 [4.35-6.92] cm2, P = .018). The gastric antral CSA in the RLD position was not different in NPO and carbohydrate groups (P = .120). There was no difference in gastric volume (2 [0-7.5] vs 3 [0-13.4], P = .331) in NPO group versus carbohydrate group. CONCLUSION The incidence of grade 2 stomach was not different between NPO group and carbohydrate group in elderly patients.
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Affiliation(s)
- Jae Yong Jeong
- Department of Urology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jin Hee Ahn
- Department of Anaesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae-Geum Shim
- Department of Anaesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sung Hyun Lee
- Department of Anaesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyoung-Ho Ryu
- Department of Anaesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sung-Ho Lee
- Department of Anaesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Eun-Ah Cho
- Department of Anaesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Nguyen KN, Davis PJ. The 1-Hour Versus 2-Hour Clear Liquid Fasting Pro-Con Debate: What Problem Are We Solving? Anesth Analg 2021; 133:578-580. [PMID: 34403385 DOI: 10.1213/ane.0000000000005658] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Khoa N Nguyen
- From the Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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25
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Hansen TG, Engelhardt T. Pre-operative fasting for clear fluids in children: Is 1 hour the answer? Acta Anaesthesiol Scand 2021; 65:1011-1012. [PMID: 33638159 DOI: 10.1111/aas.13809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 02/11/2021] [Accepted: 02/15/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Tom G. Hansen
- Department of Anaesthesiology & Intensive Care – Paediatrics Odense University Hospital Odense Denmark
- Department of Clinical Research – Anaesthesiology University of Southern Denmark Odense Denmark
| | - Thomas Engelhardt
- Department of Anesthesia McGill University Health CenterMontreal Children’s Hospital Montreal QC Canada
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Disma N, Frykholm P, Cook-Sather SD, Lerman J. Pro-Con Debate: 1- vs 2-Hour Fast for Clear Liquids Before Anesthesia in Children. Anesth Analg 2021; 133:581-591. [PMID: 34403386 DOI: 10.1213/ane.0000000000005589] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Perioperative fasting guidelines are designed to minimize the risk of pulmonary aspiration of gastrointestinal contents. The current recommendations from the American Society of Anesthesiologists (ASA) and the European Society of Anaesthesiology and Intensive Care (ESAIC) are for a minimum 2-hour fast after ingestion of clear liquids before general anesthesia, regional anesthesia, or procedural sedation and analgesia. Nonetheless, in children, fasting guidelines also have consequences as regards to child and parent satisfaction, hemodynamic stability, the ability to achieve vascular access, and perioperative energy balance. Despite the fact that current guidelines recommend a relatively short fasting time for clear fluids of 2 hours, the actual duration of fasting time can be significantly longer. This may be the result of deficiencies in communication regarding the duration of the ongoing fasting interval as the schedule changes in a busy operating room as well as to poor parent and patient adherence to the 2-hour guidelines. Prolonged fasting can result in children arriving in the operating room for an elective procedure being thirsty, hungry, and generally in an uncomfortable state. Furthermore, prolonged fasting may adversely affect hemodynamic stability and can result in parental dissatisfaction with the perioperative experience. In this PRO and CON presentation, the authors debate the premise that reducing the nominal minimum fasting time from 2 hours to 1 hour can reduce the incidence of prolonged fasting and provide significant benefits to children, with no increased risks.
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Affiliation(s)
- Nicola Disma
- From the Unit for Research & Innovation, Department of Paediatric Anaesthesia, Istituto Giannina Gaslini, Genova, Italy
| | - Peter Frykholm
- Department of Surgical Sciences, Section of Anaesthesiology and Intensive Care Medicine, Uppsala University, Uppsala, Sweden
| | - Scott D Cook-Sather
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jerrold Lerman
- Department of Anesthesiology, Oishei Children's Hospital, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
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Daly M, Howe R. Myringotomy and insertion of grommets as day surgery: a case study. ACTA ACUST UNITED AC 2021; 30:142-147. [PMID: 33565937 DOI: 10.12968/bjon.2021.30.3.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This evidence-based case study follows a child from a nursing assessment on the day of his elective surgery at a children's hospital for myringotomy and insertion of grommets under general anaesthesia through to his arrival at the operating room. Potential pre-operative problems are identified and two problems that arose are discussed in detail. The main care provider in this case was a student nurse referred to as 'the nurse', supported by a qualified nurse, referred to as the 'registered nurse', who performed some assessments.
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Affiliation(s)
- Michelle Daly
- Second Year Student Nurse, BSc in Children's and General Nursing, University College Dublin, School of Nursing, Midwifery and Health Systems, Dublin, Ireland
| | - Rachel Howe
- Lecturer/Assistant Professor, University College Dublin, School of Nursing, Midwifery and Health Systems, Dublin, Ireland
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Rüggeberg A, Dubois P, Böcker U, Gerlach H. [Preoperative fluid fasting : Establishment of a liberal fluid regimen using fasting cards]. Anaesthesist 2021; 70:469-475. [PMID: 34106289 DOI: 10.1007/s00101-021-00918-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 12/07/2020] [Accepted: 01/08/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Preoperative fasting times for clear liquids surpass by far the recommendations of the specialist societies. The aim of this study was to introduce a liberal regimen for preoperative fasting of clear liquids using fasting cards as a training tool and to evaluate the implementation. MATERIAL AND METHODS We developed a liberalized regimen of preoperative clear fluid fasting times, which allows patients to drink water, apple juice, tea and coffee until being called to the operating theatre. Each patient receives a bed-side fasting card with written information specifying fasting times for solid food and liquids. Patients who are allowed to drink water, apple juice, tea and coffee until the call to the operating theatre receive a blue fasting card. Patients with coexisting diseases or conditions that can affect gastric emptying or who need longer fasting times because of the surgical procedure get a yellow fasting card on which fasting times for fluids and solids can be documented individually. Patients who need to be nil per os (for example patients with ileus or bowel obstruction, emergency care) receive a red fasting card. On the back of the card the information is written in English, Turkish, Russian and Arabic. After a period of 8 months all surgical ward managers were asked to complete a questionnaire to assess the implementation of the new fasting regimen. RESULTS The response rate of the questionnaire was 100%. Without exception all interviewees would recommend the use of our liberalized fasting regimen. Almost all would also support the implementation of fasting cards. Out of 11 wards 9 found that patients were more relaxed and asked for intravenous fluids less often while waiting for surgery. The multilingual nature of the cards makes it easier to deal with patients who do not speak German. All ward managers consistently approved the new regimen in the event they themselves would need an operation. In order to make the fasting cards also usable in the future for rescue centers and functional units, such as endoscopy, echo or cardiac catheters, the reasons for fasting on the blue and yellow cards have been extended to operation or examination and on the red card to illness, operation or upcoming examination. CONCLUSION Patients should be allowed to drink water and hypotonic clear fluids until shortly before an operation to avoid complications of overly long fasting times. Fasting cards help to implement this by providing easy to understand information for patients and healthcare workers. This concept should be clearly structured, transparent for everyone, written down and brought to the attention of the patient without a language barrier.
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Affiliation(s)
- Anne Rüggeberg
- Klinik für Anästhesie, operative Intensivmedizin und Schmerztherapie, Vivantes Klinikum Neukölln, Rudower Str. 48, 12351, Berlin, Deutschland.
| | - Peggy Dubois
- Pflegedirektion, Vivantes Klinikum Neukölln, Berlin, Deutschland
| | - Ulrich Böcker
- Klinik für Innere Medizin, Gastroenterologie, Diabetologie und Hepatologie, Vivantes Klinikum Neukölln, Rudower Straße 48, 12351, Berlin, Deutschland
| | - Herwig Gerlach
- Klinik für Anästhesie, operative Intensivmedizin und Schmerztherapie, Vivantes Klinikum Neukölln, Rudower Str. 48, 12351, Berlin, Deutschland
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Thomasseau A, Rebollar Y, Dupuis M, Marschal N, Mcheik J, Debaene B, Frasca D, Boisson M. Observance of preoperative clear fluid fasting in pediatric anesthesia: oral and written information versus text message information. A before-and-after study. Paediatr Anaesth 2021; 31:557-562. [PMID: 33523536 DOI: 10.1111/pan.14145] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/22/2021] [Accepted: 01/24/2021] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Prolonged fasting before surgery is common in pediatrics. In the literature, it is responsible for hypotension, irritability and postoperative nausea and vomiting. Despite clear instructions given during the preanesthetic consultation, fasting rules are respected in only 30%-40% of cases. We aimed to evaluate the benefit of sending a text message the day before surgery to improve the parents' observance of fasting rules. METHODS We conducted a before-and-after study at the University Hospital of Poitiers. From August to October 2018, 172 parents of children under 15 years of age scheduled for all types of surgery were enrolled into two groups according to the period: the control group with parents receiving information on preoperative fasting rules during the preanesthetic consultation several days before surgery, and the text message group, receiving the same information during consultation plus a text message the day before the surgery. RESULTS There was a difference in observance of clear fluid fasting instructions (between 2 and 3 h before the admission at hospital) in favor of the text message group 33% versus 92% OR 29.2 (10.9-95.2) p < 0.001, and in average fasting time for clear fluids 8.7 h ± 4.8 h vs. 4.3 h ± 2.4 h (p < 0.001). CONCLUSION Sending of a reminder text message to the parents the day before the surgery resulted in a significant increase in observance of fasting rules in children undergoing scheduled surgery.
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Affiliation(s)
- Alexandre Thomasseau
- Service d'anesthésie-réanimation et médecine périopératoire, CHU de Poitiers, Poitiers cedex, France
| | - Yohann Rebollar
- Service d'anesthésie-réanimation et médecine périopératoire, CHU de Poitiers, Poitiers cedex, France
| | - Maxime Dupuis
- Service d'anesthésie-réanimation et médecine périopératoire, CHU de Poitiers, Poitiers cedex, France
| | - Nathalie Marschal
- Service d'anesthésie-réanimation et médecine périopératoire, CHU de Poitiers, Poitiers cedex, France
| | - Jiad Mcheik
- Service médico-chirurgical de pédiatrie, CHU de Poitiers, Poitiers cedex, France.,Faculté de Médecine et de Pharmacie, Université de Poitiers, Poitiers, France
| | - Bertrand Debaene
- Service d'anesthésie-réanimation et médecine périopératoire, CHU de Poitiers, Poitiers cedex, France.,Faculté de Médecine et de Pharmacie, Université de Poitiers, Poitiers, France
| | - Denis Frasca
- Service d'anesthésie-réanimation et médecine périopératoire, CHU de Poitiers, Poitiers cedex, France.,Faculté de Médecine et de Pharmacie, Université de Poitiers, Poitiers, France
| | - Matthieu Boisson
- Service d'anesthésie-réanimation et médecine périopératoire, CHU de Poitiers, Poitiers cedex, France.,Faculté de Médecine et de Pharmacie, Université de Poitiers, Poitiers, France
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Gandolfo AS, Cardoso PF, Buscatti IM, Velhote MCP, Bonfim MAC, Helito AC. Implementation of a preoperative fasting abbreviation protocol in a tertiary pediatric center. Clinics (Sao Paulo) 2021; 76:e2995. [PMID: 34378730 PMCID: PMC8311631 DOI: 10.6061/clinics/2021/e2995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Adriana S. Gandolfo
- Instituto da Crianca e do Adolescente, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Priscilla F.N. Cardoso
- Instituto da Crianca e do Adolescente, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Izabel M. Buscatti
- Instituto da Crianca e do Adolescente, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Manoel Carlos P. Velhote
- Instituto da Crianca e do Adolescente, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Maria Aparecida C. Bonfim
- Instituto da Crianca e do Adolescente, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Alberto C. Helito
- Instituto da Crianca e do Adolescente, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Corresponding author. E-mail:
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Abstract
PURPOSE OF REVIEW Preoperative fasting guidelines are generalized to elective procedures and usually do not distinguish between the ambulatory and inpatient setting. Prevalence of aspiration is low while prolonged preoperative fasting is common clinical reality. Recently, changes in preoperative fasting guidelines have been widely discussed. RECENT FINDINGS Rates of prolonged clear fluid fasting (>4 h) prior to surgery are reported in up to 80% of patients with mean fasting duration of up to 16 h and beyond. Prolonged fasting may result in adverse effects such as intraoperative hemodynamic instability, postoperative delirium, patient discomfort, and extended hospital length of stay. Liberal approaches allowing clear fluids up to 1 h prior to anesthesia or until premedication/call to the operating room have shown no increase in adverse events among children. Various anesthesia societies now encourage clear fluid intake up to 1 h prior to pediatric elective anesthesia. Similar reports in the adult cohort are scarce. SUMMARY Allowing sips of water until call to the operating room may help reducing prolonged preoperative fasting and improving patient comfort while keeping a flexibility in operating room schedule. The feasibility and safety of a liberal clear fluid fasting regimen among adults undergoing elective anesthesia needs to be evaluated in future studies.
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Akl N, Sommerfield A, Slevin L, Drake-Brockman TF, Wong S, Winters JC, Ungern-Sternberg BSV, Sommerfield D. Anaesthesia, pain and recovery profiles in children following dental extractions. Anaesth Intensive Care 2020; 48:306-313. [PMID: 32819166 DOI: 10.1177/0310057x20942532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The aim of this prospective cohort study was to describe the anaesthetic practices, rates of postoperative pain and the recovery trajectory of children having urgent dental extractions at our institution. Demographic, anaesthetic and surgical details of children undergoing dental extractions were obtained by case note review. Parent-proxy pain scores were collected via telephone on the day of surgery and on postoperative days, as well as details of analgesia given, behavioural disturbance, and nausea and vomiting. Follow-up was continued until each child no longer had pain. Datasets were analysed for 143 patients. Fasting times were prolonged, with 81 children (56.6%) fasted for over four hours from fluids. Moderate or severe pain was recorded in 14 children (9.8%) postoperatively on the day of surgery, with higher rates in children who had a greater number of teeth extracted. Low rates of moderate to severe pain were observed during follow-up, affecting six children (4.2%) on postoperative day 1 and three children (2.1%) on postoperative day 2 with primarily simple analgesia administered at home. Only eight children (5.6%) had nausea and/or vomiting on the day of surgery. Rates of reported behavioural disturbance at home were low, extending beyond the second postoperative day in only two children (1.4%), and only four children (2.8%) attended a dentist during the follow-up period. In conclusion, the low rates of pain and nausea and vomiting reported in the days following surgery for urgent dental procedures suggest that children can be cared for at home with simple analgesia.
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Affiliation(s)
- Natalie Akl
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, Australia
| | - Aine Sommerfield
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, Australia.,Department of Paediatric Dentistry, Perth Children's Hospital, Perth, Australia
| | - Lliana Slevin
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, Australia.,Department of Paediatric Dentistry, Perth Children's Hospital, Perth, Australia
| | - Thomas Fe Drake-Brockman
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, Australia.,Medical School, The University of Western Australia, Perth, Australia
| | - Susan Wong
- Telethon Kids Institute, Perth, Australia
| | - John C Winters
- Telethon Kids Institute, Perth, Australia.,Dental School, The University of Western Australia, Perth, Australia
| | - Britta S von Ungern-Sternberg
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, Australia.,Medical School, The University of Western Australia, Perth, Australia.,Department of Paediatric Dentistry, Perth Children's Hospital, Perth, Australia
| | - David Sommerfield
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, Australia.,Medical School, The University of Western Australia, Perth, Australia
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Andersson H, Frykholm P. Gastric content assessed with gastric ultrasound in paediatric patients prescribed a light breakfast prior to general anaesthesia: A prospective observational study. Paediatr Anaesth 2019; 29:1173-1178. [PMID: 31608517 DOI: 10.1111/pan.13755] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 10/02/2019] [Accepted: 10/07/2019] [Indexed: 01/29/2023]
Abstract
BACKGROUND A light breakfast has been found to empty from the stomach within 4 hours in healthy volunteers. AIM The aim of this study was to investigate whether a light breakfast of yoghurt or gruel empties from the stomach within 4 hours, in children scheduled for general anaesthesia. METHOD In this observational cohort study, children aged 1-6 years scheduled for elective general anaesthesia were prescribed free intake of yoghurt or gruel 4 hours prior to induction. They were subsequently examined with gastric ultrasound within 4 hours of ingestion. In case of gastric contents, the gastric antral area was measured, and gastric content volume (GCV) was calculated. RESULTS Twenty children were included in the study and the ingested amount of gruel or yoghurt ranged 2.5-25 mL kg-1 . In 15 cases, the stomach was empty with juxtaposed walls and no further measurements were made. In four cases, there was fluid present in the stomach, but the calculated gastric contents were <0.5 mL kg-1 . One patient had solids in the stomach, and GCV in this patient was calculated to 2.1 mL kg-1 . The patient with solids present had ingested 25 mL kg-1 of gruel 4 hours prior to assessment. The planned procedure was therefore delayed 1 hour. There were no cases of pulmonary aspiration or vomiting. CONCLUSION A light breakfast 4 hours prior to induction may be considered, but there is need for further studies on safe limits for the volume ingested.
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Affiliation(s)
- Hanna Andersson
- Department of Surgical Sciences, Section of Anaesthesia and Intensive Care Medicine, Uppsala University Hospital, Uppsala, Sweden
| | - Peter Frykholm
- Department of Surgical Sciences, Section of Anaesthesia and Intensive Care Medicine, Uppsala University Hospital, Uppsala, Sweden
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Isserman R, Elliott E, Subramanyam R, Kraus B, Sutherland T, Madu C, Stricker PA. Quality improvement project to reduce pediatric clear liquid fasting times prior to anesthesia. Paediatr Anaesth 2019; 29:698-704. [PMID: 31070840 DOI: 10.1111/pan.13661] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 04/29/2019] [Accepted: 05/05/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Unnecessarily long preprocedural fasting can cause suffering and distress for children and their families. Institutional fasting policies are designed to consistently achieve minimum fasting times, often without regard to the extent to which actual fasting times exceed these minimums. Children at our hospital frequently experienced clear liquid fasting times far in excess of required minimums. AIMS The aim of this study was to utilize quality improvement methodology to reduce excess fasting times, with a goal of achieving experienced clear liquid fasting times ≤4 hours for 60% of our patients. METHODS This quality improvement project was conducted between July 2017 and August 2018. A multidisciplinary team performed a series of Plan-Do-Study-Act cycles focused on children undergoing elective procedures at a large children's hospital. Key drivers for clear liquid fasting times and relevant balancing measures were identified. Data were analyzed using control charts and statistical process control methods. RESULTS Approximately 16 000 children were involved in this project. Over the course of the project, the percentage of children with goal clear liquid fasting times improved from the baseline of 20%-63%, with a change in the mean fasting time from 9 hours to 6 hours. There were no significant effects on balancing measures (case delays/cancellations and clinically significant aspiration events). CONCLUSION Using quality improvement methodology, we safely improved the duration of preoperative fasting experienced by our patients. Our results provide additional data supporting the safety of more permissive 1-hour clear liquid fasting minimums. We suggest other institutions pursue similar efforts to improve patient and family experience.
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Affiliation(s)
- Rebecca Isserman
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia (CHOP), University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Elizabeth Elliott
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia (CHOP), University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Rajeev Subramanyam
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia (CHOP), University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Blair Kraus
- The Center for Healthcare Quality and Analytics, Children's Hospital of Philadelphia (CHOP), Philadelphia, Pennsylvania
| | - Tori Sutherland
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia (CHOP), University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Chinonyerem Madu
- The Center for Healthcare Quality and Analytics, Children's Hospital of Philadelphia (CHOP), Philadelphia, Pennsylvania
| | - Paul A Stricker
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia (CHOP), University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Ultrasound assessment of gastric emptying time after a standardised light breakfast in healthy children: A prospective observational study. Eur J Anaesthesiol 2019; 35:937-941. [PMID: 30095551 DOI: 10.1097/eja.0000000000000874] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Current guidelines recommend 6 h of fasting for solids before anaesthesia. However, prolonged fasting may lead to discomfort, hunger, thirst, misbehaviour and lipolysis. To prevent this, a more liberal fasting regimen has been empirically implemented in our children's hospital, allowing a shorter fasting time of 4 h for a standardised light breakfast. AIM The aim of this study was to determine the gastric emptying time after a standardised light breakfast in healthy children. DESIGN A prospective observational noninterventional study. METHODS After fasting overnight, the children had a standardised light breakfast. Before and afterwards, ultrasound examinations of the gastric antrum were performed hourly to determine the gastric antral area (GAA), which is a surrogate parameter for gastric volume in children in the right lateral position (RLP). Demographic data and fasting times are presented as mean ± SD (range) and GAA as median (interquartile range). RESULTS Twenty-two children aged 7.8 (2.5 to 13.6) years volunteered for this study. After fasting overnight [735 ± 120 (467 to 930) min], the initial GAA was 3.06 (2.35 to 4.03) cm in RLP. After the light breakfast, GAA in RLP initially increased and decreased subsequently. After 4 h, GAA in RLP was lower than the initial value (median of differences -0.54, 95% confidence interval -1.00 to -0.07, P < 0.05). Correlation between GAA in RLP and fasting time was significant (r = -0.62, P < 0.0001). Using a linear regression model, the calculated mean gastric emptying time after the standardised light breakfast was 211 min for GAA = 3.06 cm. CONCLUSION The study showed a mean gastric emptying time of less than 4 h after a standardised light breakfast in children. These results encourage our current clinical practice and support the efforts towards a more liberal fasting regimen for light meals in paediatric anaesthesia. TRIAL REGISTRATION German Registry of Clinical Studies (DRKS-ID: DRKS 00013893).
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37
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Seet E, Kumar CM, Eke T, Joshi GP. Starving Patients Before Cataract Surgery Under Regional Anesthesia. Anesth Analg 2018; 127:1448-1451. [DOI: 10.1213/ane.0000000000003504] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Bouvet L, Bellier N, Gagey-Riegel AC, Desgranges FP, Chassard D, De Queiroz Siqueira M. Ultrasound assessment of the prevalence of increased gastric contents and volume in elective pediatric patients: A prospective cohort study. Paediatr Anaesth 2018; 28:906-913. [PMID: 30207013 DOI: 10.1111/pan.13472] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 07/24/2018] [Accepted: 07/30/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Though pulmonary aspiration of gastric contents occurs mainly in the setting of emergency surgery, it may also occur in children scheduled for elective surgery without any obvious clinical risk factor. Increased gastric content volume is one the predisposing factors for pulmonary aspiration that could affect such children and may be identified using ultrasound examination of the gastric antrum. AIMS We aimed to assess the prevalence of "at-risk stomach" defined by ultrasound visualization of any solid content in the antrum and/or by calculated gastric fluid volume > 1.25 mL/kg, in children scheduled for elective surgery. METHODS Children scheduled for elective surgery were consecutively included into this prospective cohort study. Preoperative ultrasound examination of the antrum was performed in both the supine and the right lateral decubitus positions. Gastric fluid content was assessed using a 0-2 qualitative grading scale. The antral cross-sectional area was also measured in both the supine and the right lateral decubitus positions, allowing the calculation of the gastric fluid volume according to a formula previously described. RESULTS We analyzed 200 elective children. Median duration of fasting was 4 hours for liquids and >13 hours for solids. None of the children included in this study had evidence of solid content. Six (3%) children had a Grade 2 antrum (fluid content seen in both the supine and the right lateral decubitus positions). Two children had a gastric fluid volume >1.25 mL/kg. The prevalence of "at-risk stomach" was 1% (95% confidence interval: 0.2%-3.9%). CONCLUSION According to our results, only 1% of elective children had potentially increased risk for pulmonary aspiration. Further studies should be performed in order to define the target population of elective children for which ultrasound assessment of gastric content should be performed prior to general anesthesia.
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Affiliation(s)
- Lionel Bouvet
- Department of Anesthesia and Intensive Care, Hospices Civils de Lyon, Femme Mère Enfant Hospital, Bron, France.,INSERM, LabTAU UMR1032, University of Lyon, Université Claude Bernard Lyon 1, Centre Léon Bérard, Lyon, France
| | - Nicolas Bellier
- Department of Anesthesia and Intensive Care, Hospices Civils de Lyon, Femme Mère Enfant Hospital, Bron, France
| | - Anne-Charlotte Gagey-Riegel
- Department of Anesthesia and Intensive Care, Hospices Civils de Lyon, Femme Mère Enfant Hospital, Bron, France
| | - François-Pierrick Desgranges
- Department of Anesthesia and Intensive Care, Hospices Civils de Lyon, Femme Mère Enfant Hospital, Bron, France.,University of Lyon, Université Claude Bernard Lyon 1, Villeurbanne, France
| | - Dominique Chassard
- Department of Anesthesia and Intensive Care, Hospices Civils de Lyon, Femme Mère Enfant Hospital, Bron, France.,University of Lyon, Université Claude Bernard Lyon 1, Villeurbanne, France
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