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Zhang E, Hauser N, Sommerfield A, Sommerfield D, von Ungern‐Sternberg BS. A review of pediatric fasting guidelines and strategies to help children manage preoperative fasting. Paediatr Anaesth 2023; 33:1012-1019. [PMID: 37533337 PMCID: PMC10947285 DOI: 10.1111/pan.14738] [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: 04/04/2023] [Revised: 06/21/2023] [Accepted: 07/24/2023] [Indexed: 08/04/2023]
Abstract
Fasting for surgery is a routine step in the preoperative preparation for surgery. There have however been increasing concerns with regard to the high incidence of prolonged fasting in children, and the subsequent psycho-social distress and physiological consequences that this poses. Additionally, the past few years have yielded new research that has shown significant inter-individual variation in gastric emptying regardless of the length of the fast, with some patients still having residual gastric contents even after prolonged fasts. Additionally, multiple large-scale studies have shown no long-term sequalae from clear fluid aspiration, although two deaths from aspiration have been reported within the large Wake Up Safe cohort. This has led to a change in the recommended clear fluid fasting times in multiple international pediatric societies; similarly, many societies continue to recommend traditional fasting times. Multiple fasting strategies exist in the literature, though these have mostly been studied and implemented in the adult population. This review hopes to summarize the recent updates in fasting guidelines, discuss the issues surrounding prolonged fasting, and explore potential tolerance strategies for children.
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Affiliation(s)
- Eileen Zhang
- Department of Anaesthesia and Pain MedicinePerth Children's HospitalPerthWestern AustraliaAustralia
| | - Neil Hauser
- Department of Anaesthesia and Pain MedicinePerth Children's HospitalPerthWestern AustraliaAustralia
- Perioperative Medicine Team, Perioperative Care ProgramTelethon Kids InstitutePerthWestern AustraliaAustralia
- Division of Emergency Medicine, Anaesthesia and Pain MedicineThe University of Western AustraliaPerthWestern AustraliaAustralia
| | - Aine Sommerfield
- Department of Anaesthesia and Pain MedicinePerth Children's HospitalPerthWestern AustraliaAustralia
- Perioperative Medicine Team, Perioperative Care ProgramTelethon Kids InstitutePerthWestern AustraliaAustralia
| | - David Sommerfield
- Department of Anaesthesia and Pain MedicinePerth Children's HospitalPerthWestern AustraliaAustralia
- Perioperative Medicine Team, Perioperative Care ProgramTelethon Kids InstitutePerthWestern AustraliaAustralia
- Division of Emergency Medicine, Anaesthesia and Pain MedicineThe University of Western AustraliaPerthWestern AustraliaAustralia
| | - Britta S. von Ungern‐Sternberg
- Department of Anaesthesia and Pain MedicinePerth Children's HospitalPerthWestern AustraliaAustralia
- Perioperative Medicine Team, Perioperative Care ProgramTelethon Kids InstitutePerthWestern AustraliaAustralia
- Division of Emergency Medicine, Anaesthesia and Pain MedicineThe University of Western AustraliaPerthWestern AustraliaAustralia
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Joshi GP, Abdelmalak BB, Weigel WA, Harbell MW, Kuo CI, Soriano SG, Stricker PA, Tipton T, Grant MD, Marbella AM, Agarkar M, Blanck JF, Domino KB. 2023 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting: Carbohydrate-containing Clear Liquids with or without Protein, Chewing Gum, and Pediatric Fasting Duration-A Modular Update of the 2017 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting. Anesthesiology 2023; 138:132-151. [PMID: 36629465 DOI: 10.1097/aln.0000000000004381] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
These practice guidelines are a modular update of the "Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures." The guidance focuses on topics not addressed in the previous guideline: ingestion of carbohydrate-containing clear liquids with or without protein, chewing gum, and pediatric fasting duration.
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Ying Y, Xu HZ, Han ML. Enhanced recovery after surgery strategy to shorten perioperative fasting in children undergoing non-gastrointestinal surgery: A prospective study. World J Clin Cases 2022; 10:5287-5296. [PMID: 35812657 PMCID: PMC9210880 DOI: 10.12998/wjcc.v10.i16.5287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 04/02/2022] [Accepted: 04/28/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Enhanced recovery after surgery strategies are increasingly implemented to improve the management of surgical patients.
AIM To evaluate the effects of new perioperative fasting protocols in children ≥ 3 mo of age undergoing non-gastrointestinal surgery.
METHODS This prospective pilot study included children ≥ 3 mo of age undergoing non-gastrointestinal surgery at the Children’s Hospital (Zhejiang University School of Medicine) from January 2020 to June 2020. The children were divided into either a conventional group or an ERAS group according to whether they had been enrolled before or after the implementation of the new perioperative fasting strategy. The children in the conventional group were fasted using conventional strategies, while those in the ERAS group were given individualized fasting protocols preoperatively (6-h fasting for infant formula/non-human milk/solids, 4-h fasting for breast milk, and clear fluids allowed within 2 h of surgery) and postoperatively (food permitted from 1 h after surgery). Pre-operative and postoperative fasting times, pre-operative blood glucose, the incidence of postoperative thirst and hunger, the incidence of perioperative vomiting and aspiration, and the degree of satisfaction were evaluated.
RESULTS The study included 303 patients (151 in the conventional group and 152 in the ERAS group). Compared with the conventional group, the ERAS group had a shorter pre-operative food fasting time [11.92 (4.00, 19.33) vs 13.00 (6.00, 20.28) h, P < 0.001), shorter preoperative liquid fasting time [3.00 (2.00, 7.50) vs 12.00 (3.00, 20.28) h, P < 0.001], higher preoperative blood glucose level [5.6 (4.2, 8.2) vs 5.1 (4.0, 7.4) mmol/L, P < 0.001], lower incidence of thirst (74.5% vs 15.3%, P < 0.001), shorter time to postoperative feeding [1.17 (0.33, 6.83) vs 6.00 (5.40, 9.20), P < 0.001], and greater satisfaction [7 (0, 10) vs 8 (5, 10), P < 0.001]. No children experienced perioperative aspiration. The incidences of hunger, perioperative vomiting, and fever were not significantly different between the two groups.
CONCLUSION Optimizing fasting and clear fluid drinking before non-gastrointestinal surgery in children ≥ 3 mo of age is possible. It is safe and feasible to start early eating after evaluating the recovery from anesthesia and the swallowing function.
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Affiliation(s)
- Yan Ying
- Department of General Surgery, Children's Hospital of Zhejiang University School of Medicine, Hangzhou 310052, Zhejiang Province, China
| | - Hong-Zhen Xu
- Department of General Surgery, Children's Hospital of Zhejiang University School of Medicine, Hangzhou 310052, Zhejiang Province, China
| | - Meng-Lan Han
- Department of General Surgery, Children's Hospital of Zhejiang University School of Medicine, Hangzhou 310052, Zhejiang Province, China
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Yimer AH, Haddis L, Abrar M, Seid AM. Adherence to pre-operative fasting guidelines and associated factors among pediatric surgical patients in selected public referral hospitals, Addis Ababa, Ethiopia: Cross sectional study. Ann Med Surg (Lond) 2022; 78:103813. [PMID: 35734657 PMCID: PMC9207049 DOI: 10.1016/j.amsu.2022.103813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 05/14/2022] [Accepted: 05/14/2022] [Indexed: 11/28/2022] Open
Abstract
Background Fasting before anesthesia is mandatory in children to reduce the complications of regurgitation, vomiting, and aspiration during anesthesia and surgery. Prolonged fasting times have several negative implications in children, because high fluid turnover quickly leads to dehydration, hypotension, metabolic disturbances, and hypoglycemia, resulting in poor anesthetic outcomes. Aims This study aimed to assess adherence to preoperative fasting guidelines and associated factors among pediatric patients undergoing elective surgery in Addis Ababa public hospitals in Ethiopia in 2020. Methods A cross-sectional survey was conducted in Addis Ababa, which selected public hospitals in Ethiopia, in 2020. A total of 279 pediatric patients aged <17 years scheduled for elective surgery were included in the study. Data analysis was performed using SPSS V.21, and the values of the variables and factors were checked for associations using logistic regression. Statistical significance was determined at P -value of <0.05. The results are presented in text, tables, charts, and graphs. Results A total of 279 pediatric patients responded to the analysis, with a 98.6% response rate. The majority of the participants (n = 251, 89.96%) did not follow the guidelines for preoperative fasting. The mean fasting time for clear liquids was 10 ± 4.03 (2–18 h) for breast milk 7.18 ± 2.26 (3.5–12 h), and for solid foods 13.5 ± 2.76 (8–19 h). The reasons for which the preoperative fasting delay was due to incorrect order were 35.1%, prior case procedures took longer times 34.1%, and changing sequence of schedule was 20.8%. Conclusion Most children had prolonged fasting. The staff's instructions and schedules were challenged to follow international fasting guidelines. Fasting practice in children still challenged. Fasting orders should be clearly led by organized body. Care givers should have basic information to fasting protocol.
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Affiliation(s)
- Aragaw Hamza Yimer
- Department of Anesthesia, College of Medicine and Health Science, Dire Dawa University, Dire Dawa, Ethiopia
- Corresponding author.
| | - Lidya Haddis
- Department of Anesthesia, School of Medicine, College of Health Science, Addis Ababa University, Addis Ababa, Ethiopia
| | - Meron Abrar
- Department of Anesthesia, School of Medicine, College of Health Science, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ahmed Muhye Seid
- School of Medicine, College of Medicine and Health Science, Dire Dawa University, Dire Dawa, Ethiopia
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Tudor-Drobjewski B, Marhofer P, Kimberger O, Huber W, Roth G, Triffterer L. Randomised controlled trial comparing preoperative carbohydrate loading with standard fasting in paediatric anaesthesia. Br J Anaesth 2018; 121:656-661. [DOI: 10.1016/j.bja.2018.04.040] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 04/03/2018] [Accepted: 04/09/2018] [Indexed: 12/12/2022] Open
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Tsukamoto M, Hitosugi T, Yokoyama T. Influence of Fasting Duration on Body Fluid and Hemodynamics. Anesth Prog 2018; 64:226-229. [PMID: 29200368 DOI: 10.2344/anpr-65-01-01] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Fasting before general anesthesia aims to reduce the volume and acidity of stomach contents, which reduces the risk of regurgitation and aspiration. Prolonged fasting for many hours prior to surgery could lead to unstable hemodynamics, however. Therefore, preoperative oral intake of clear fluids 2 hours prior to surgery is recommended to decrease dehydration without an increase in aspiration risk. In this study, we investigated the body fluid composition and hemodynamics of patients undergoing general anesthesia as the first case of the day versus the second subsequent case. We retrospectively reviewed the general anesthesia records of patients over 20 years old who underwent oral maxillofacial surgery. We investigated patient demographics, preoperative fasting time, anesthetic time, urine output, infusion volume, and opioid and vasopressor use. With respect to body fluid and hemodynamics, we extracted the data from the induction of anesthesia through 2 hours of anesthesia time. Thirty patients were suitable for this study. Patients were divided into 2 groups: patients who underwent surgery as the first case of the day (am group: n = 15) and patients who underwent surgery as the second case (pm group: n = 15). There were no significant differences between the 2 groups in patient demographics. In the pm group, fasting time for a light meal (832 minutes) was significantly longer than for the am group (685 minutes), p = .005. In the pm group, fasting time for clear fluids (216 minutes) was also significantly longer than for the am group (194 minutes), p = .005. Body fluid composition was not significantly different between the 2 groups. In addition, cardiac parameters intraoperatively were stable. In the pm group, vasopressors were used in 4 patients at the induction of anesthesia (p = .01). There were not statistically significant changes in cardiac function or body fluid composition between patients treated as the first case of the day vs patients who underwent surgery with general anesthesia as the second case of the day.
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Affiliation(s)
- Masanori Tsukamoto
- Department of Dental Anesthesiology, Kyushu University Hospital, Fukuoka, Japan
| | - Takashi Hitosugi
- Department of Dental Anesthesiology, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
| | - Takeshi Yokoyama
- Department of Dental Anesthesiology, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
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Carvalho CALDB, Carvalho AAD, Nogueira PLB, Aguilar-Nascimento JED. CHANGING PARADIGMS IN PREOPERATIVE FASTING: RESULTS OF A JOINT EFFORT IN PEDIATRIC SURGERY. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2018; 30:7-10. [PMID: 28489159 PMCID: PMC5424677 DOI: 10.1590/0102-6720201700010003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 01/17/2017] [Indexed: 12/23/2022]
Abstract
Background: Current researches associate long fasting periods to several adverse consequences. The fasting abbreviation to 2 h to clear liquids associated with the use of drinks containing carbohydrates attenuates endocrinometabolic response to surgical trauma, but often is observed children advised to not intake food from 00:00 h till the scheduled surgical time, regardless of what it is. Aim: To evaluate the safety of a protocol of preoperative fasting abbreviation with a beverage containing carbohydrates, and early postoperative feeding in children underwent elective small/mid-size surgical procedures during a national task-force on pediatric surgery. Methods: Thirty-six patients were prospectively included, and for several reasons five were excluded. All 31 who remained in the study received a nutritional supplement containing 150 ml of water plus 12.5% maltodextrin 2 h before the procedure. Data of the pre-operative fasting time, anesthetic complications and time of postoperative refeeding, were collected. Results: Twenty-three (74.2%) were males, the median age was 5 y, and the median weight was 20 kg. The median time of pre-operative fasting was 145 min and the time of post-operative refeeding was 135 min. There were no adverse effects on the anesthetic procedures or during surgery. Post-operatively, two children (6.5%) vomited. Conclusion: The abbreviation of pre-operative fasting to 2 h with beverage containing carbohydrate in pediatric surgery is safe. Early refeeding in elective small/mid-size procedures can be prescribed. Racional: Trabalhos atuais associam longos períodos de jejum com diversas consequências adversas. A abreviação do jejum de 2 h para líquidos claros associado ao uso de bebidas contendo carboidratos atenua resposta endocrinometabólica ao trauma, porém frequentemente as crianças são orientadas a não ingerir alimentos a partir das 00:00 h do dia anterior à operação, independente do horário do procedimento cirúrgico. Objetivo: Avaliar a segurança de um protocolo de abreviação do jejum pré-operatório, com o uso de bebida contendo carboidratos, e realimentação precoce. Métodos: Foram avaliados prospectivamente 36 crianças submetidas a procedimentos cirúrgicos eletivos de pequeno e médio porte. Cinco foram posteriormente excluídos do estudo. Todos os 31 remanescentes receberam suplemento nutricional com maltodextrina 12,5% em 150 ml de água aproximadamente 2 h antes do procedimento. Foram coletados dados do tempo de jejum pré-operatório, complicações anestésicas e tempo de realimentação. Resultados: Vinte e três (74,2%) eram do gênero masculino, com idade mediana de cinco anos e peso mediano de 20 kg. O tempo mediano de jejum pré-operatório foi de 145 min e o tempo mediano para realimentação foi de 135 min. Não houve eventos adversos durante a anestesia ou operação. No período pós-operatório, duas (6,5%) crianças vomitaram. Conclusão: A abreviação de jejum pré-operatório para 2 h com uso de bebida contendo carboidratos, em operações eletivas de crianças, é seguro e não está associado ao maior risco de broncoaspiração pulmonar. Realimentação precoce pode ser prescrita nos procedimentos cirúrgicos analisados.
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George JA, Koka R, Gan TJ, Jelin E, Boss EF, Strockbine V, Hobson D, Wick EC, Wu CL. Review of the enhanced recovery pathway for children: perioperative anesthetic considerations. Can J Anaesth 2017; 65:569-577. [PMID: 29270915 DOI: 10.1007/s12630-017-1042-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 11/22/2017] [Accepted: 11/25/2017] [Indexed: 01/08/2023] Open
Abstract
PURPOSE Enhanced recovery after surgery (ERAS) pathways have been used for two decades to improve perioperative recovery in adults. Nevertheless, little is known about their effectiveness in children. The purpose of this review was to consider pediatric ERAS pathways, review the literature concerned with their potential benefit, and compare them with adult ERAS pathways. SOURCE A PubMed literature search was performed for articles that included the terms enhanced recovery and/or fast track in the pediatric perioperative period. Pediatric patients included those from the neonatal period through teenagers and/or youths. PRINCIPAL FINDINGS The literature search revealed a paucity of articles about pediatric ERAS. This lack of academic investigation is likely due in part to the delayed acceptance of ERAS in the pediatric surgical arena. Several pediatric studies examined individual components of adult-based ERAS pathways, but the overall study of a comprehensive multidisciplinary ERAS protocol in pediatric patients is lacking. CONCLUSION Although adult ERAS pathways have been successful at reducing patient morbidity, the translation, creation, and utility of instituting pediatric ERAS pathways have yet to be realized.
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Affiliation(s)
- Jessica A George
- The Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University and School of Medicine, Baltimore, MD, USA. .,SOM Anes Pediatric Anesthesiology, Bloomberg Children's Bldg 6339, 1800 Orleans Street, Baltimore, MD, 21287, USA.
| | - Rahul Koka
- The Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University and School of Medicine, Baltimore, MD, USA.,SOM Anes Pediatric Anesthesiology, Bloomberg Children's Bldg 6339, 1800 Orleans Street, Baltimore, MD, 21287, USA
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook University, Stony Brook, NY, USA
| | - Eric Jelin
- Department of General Pediatric Surgery, Johns Hopkins Bloomberg Children's Center and Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Emily F Boss
- Department of Otolaryngology-Head and Neck Surgery and Health Policy & Management, Johns Hopkins University, School of Medicine and Bloomberg School of Public Health, Baltimore, MD, USA
| | - Val Strockbine
- Department of General Pediatric Surgery, Johns Hopkins Bloomberg Children's Center and Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Deborah Hobson
- Department of Surgery, The Johns Hopkins Hospital and Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Elizabeth C Wick
- Department of Surgery, The Johns Hopkins Hospital and Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Christopher L Wu
- The Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University and School of Medicine, Baltimore, MD, USA
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Yamamoto T, Yoshida M, Watanabe S, Kawahara H. Effects of intraoperative administration of carbohydrates during long-duration oral and maxillofacial surgery on the metabolism of carbohydrates, proteins, and lipids. Oral Maxillofac Surg 2015. [PMID: 26201694 DOI: 10.1007/s10006-015-0517-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE Insulin resistance in patients undergoing invasive surgery impairs glucose and lipid metabolism and increases muscle protein catabolism, which may result in delayed recovery and prolonged hospital stay. We examined whether intraoperative administration of carbohydrates during long-duration oral and maxillofacial surgery under general anesthesia affects carbohydrate, proteins, and lipid metabolism and the length of hospital stay. METHODS We studied 16 patients with normal liver, kidney, and endocrine functions, and ASA physical status I or II, but without diabetes. Patients were randomly assigned to receive 0.1 g/kg/h of (n = 8) or lactated Ringer's solution (n = 8). Blood was collected before (T0) and 4 h after (T1) the start of surgery. We analyzed the plasma levels of glucose, ketone bodies, 3-methylhistidine (3-MH), and the length of hospital stay. RESULTS At T0, no statistically significant differences were observed in the levels of glucose, ketone bodies, and 3-MH between the groups. At T1, no statistically significant difference in glucose levels was found between the groups. However, ketone bodies were significantly lower, and the changes in 3-MH levels were significantly less pronounced in the glucose-treated group compared with controls. No significant differences were observed between the groups in terms of length of hospital stay. CONCLUSIONS The administration of low doses of glucose during surgery was safe, did not cause hyperglycemia or hypoglycemia, and inhibited lipid metabolism and protein catabolism. Additional experiments with larger cohorts will be necessary to investigate whether intraoperative management with glucose facilitates postoperative recovery of patients with oral cancer.
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Affiliation(s)
- Toru Yamamoto
- Department of Dental Anesthesiology, Tsurumi University School of Dental Medicine, 2-1-3, Tsurumi, Tsurumi-ku, Yokohama-shi, Kanagawa, 230-0062, Japan.
| | - Mitsuhiro Yoshida
- Department of Dental Anesthesiology, Hiroshima University, Hiroshima, Japan
| | - Seiji Watanabe
- Department of Dental Anesthesiology, Kyushu Dental University, Kitakyushu, Japan
| | - Hiroshi Kawahara
- Department of Dental Anesthesiology, Tsurumi University School of Dental Medicine, 2-1-3, Tsurumi, Tsurumi-ku, Yokohama-shi, Kanagawa, 230-0062, Japan
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