Präoperative Nüchternheit 2008: Ärztliches Handeln zwischen Empirie und Wissenschaft

[Preoperative fasting in children-Experiences with implementing a liberal fasting policy]

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.

[Preoperative fluid fasting : Establishment of a liberal fluid regimen using fasting cards]

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.

[Anesthesia for electroconvulsive therapy]

Electroconvulsive therapy (ECT) is an important component in the treatment of depression and schizophrenia in Germany. For this intervention patients undergo short-term general anesthesia and muscle relaxation. Before anesthesia can be carried out patients are subject to a comprehensive examination. For general anesthesia all established hypnotics can be used, but differences with respect to the success of the ECT have been described. Short-acting or reversible relaxants should be preferentially used. The risks of general anesthesia during ECT are estimated to be low but a transient hemodynamic instability of patients can occur. Treatment can be performed as an inpatient but also as an outpatient procedure.

[Anesthesiological care of trauma patients in orthogeriatric co-management]

Elderly patients increasingly need to undergo surgery under anesthesia, especially following trauma. A timely interdisciplinary approach to the perioperative management of these patients is decisive for the long-term outcome. Orthogeriatric co-management, which includes geriatricians and anesthesiologists from an early stage, is of great benefit for geriatric patients. Patient age, comorbidities and self-sufficiency in activities of daily life are decisive for an anesthesiological assessment of the state of health and preoperative risk stratification. If necessary additional investigations, such as echocardiography must be carried out, in order to guarantee optimal perioperative anesthesiological management. Certain medical factors can delay the initiation of anesthesia and it is absolutely necessary that these are taken into consideration for surgical management. Not every form of anesthesia is equally suitable for every geriatric patient.

[Anesthesia for medical students : A brief guide to practical anesthesia in adults with a web-based video illustration]

In Germany, Austria and Switzerland, anesthesiologists are the second largest group of physicians in hospitals, but this does not correspond to the amount of anesthesiology teaching that medical students receive in medical schools. Accordingly, the chances of medical students recognizing anesthesiology as a promising personal professional career are smaller than in other disciplines with large teaching components. Subsequent difficulties to recruit anesthesiology residents are likely, although many reasons support anesthesiology as a professional career.Traditional strategies to teach medical students in anesthesiology in medical school consist of airway management or cardiopulmonary resuscitation attempts in manikins. Anesthesiology is a complex interaction consisting of anatomy, physiology, pharmacology, clinical evaluation, experience, knowledge, and manual skills. While some medical schools offer teaching in high fidelity simulators, clinical teaching in the operating room is often limited. When medical students opt for a clinical rotation in anesthesiology, there is a chance to demonstrate the fascinating world of anesthesiology, but this chance has to be utilized carefully by anesthesiologists, as young talents have to be discovered, supported, and challenged.We have put together a short guide for medical students for a clinical rotation in anesthesiology in adults in order to generate basic knowledge and interest in anesthesiology as well as a sense of achievement. Basic knowledge about premedication, induction, maintenance and strategies for anesthesia is discussed. Further, the most important anesthesia drugs are discussed and manual skills, such as intravenous cannulation, mask ventilation, intubation, and regional anesthesia are featured with QR-code based video illustrations on a smartphone or personal computer. We did not discuss possible local mannerism and special patient groups (e. g., children, special medical history), local guidelines, or standard operating procedures.Medical students can be inspired by anesthesiology when not simply told about the tools of the trade and strategies, but instead by gaining knowledge and clinical skills that render a sense of achievement, likely during a clinical rotation into anesthesiology. A short theoretical instruction of anesthesiology enables rapid and targeted orientation even before a clinical rotation. Whether this subsequently results in a higher recruiting chance is currently unknown.

[Anesthesiological care in orthogeriatric co-management. Perioperative treatment of geriatric trauma patients]

Elderly patients increasingly need to undergo surgery under anesthesia, especially following trauma. A timely interdisciplinary approach to the perioperative management of these patients is decisive for the long-term outcome. Orthogeriatric co-management, which includes geriatricians and anesthesiologists from an early stage, is of great benefit for geriatric patients. Patient age, comorbidities and self-sufficiency in activities of daily life are decisive for an anesthesiological assessment of the state of health and preoperative risk stratification. If necessary additional investigations, such as echocardiography must be carried out, in order to guarantee optimal perioperative anesthesiological management. Certain medical factors can delay the initiation of anesthesia and it is absolutely necessary that these are taken into consideration for surgical management. Not every form of anesthesia is equally suitable for every geriatric patient.

[Preoperative risk evaluation from the perspective of anaesthesiology]

Medical and technical progress together with demographic changes has led to a more complex perioperative care for patients. Accordingly, an optimal preoperative assessment in particular an adequate risk evaluation is more important than ever. A recently published joint recommendation of the German Society of Anaesthesiology and Intensive Care Medicine, the German Society of Surgery and the German Society of Internal Medicine aims to reduce considerable uncertainties in the preoperative risk evaluation especially with regard to"technical tests" by providing transparent and comprehensive arrangements. Consequently, routine screening will be abandoned in favour of targeted patient and operation-oriented individual risk assessment. This approach will change the preoperative risk evaluation in a scientific, organisational and economic way. The following article on preoperative risk evaluation is based on the valuable and helpful recommendation and aims to provide additional important aspects from the perspective of anaesthesiologists.

[Peri-operative adjustment and treatment of diabetes mellitus]

In all disciplines of operative medicine the number of patients who suffer from diabetes mellitus is increasing dramatically. The reason is that nowadays up to 10% of the population is suffering from this disease. These patients must be treated with respect to the diabetes and also subsequent related conditions to prevent peri-operative complications. A special problem is that many patients do not know that they are suffering from diabetes. Pre-operatively and during the peri-operative course the coordinated efforts of surgeons, anaesthesiologists and diabetes specialists are essential to reach an optimal result. In all hospitals obligatory algorithms must be established for the treatment of these patients.

[Anesthesia in ambulatory patients]

The share of ambulatory procedures is increasing with advances in operative and anesthesiological methods and pressured by economical necessities. Following legal regulations procedures with and without hospital stay underlie the same quality measures. Multimodal concepts comprising anesthesiological and operative procedures, pain therapy as well as postoperative care allow for quality improvements in respect to operative outcome and patient satisfaction.