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da Mata AMB, do Carmo Tomaz AG, Andrade da Cunha GC, Zamberlan P, Bonfim MAC. Influence of Shortened Fasting Time on Perioperative Outcomes in Pediatric Patients: A Systematic Review. J Pediatr Surg 2024; 59:161607. [PMID: 39089894 DOI: 10.1016/j.jpedsurg.2024.06.016] [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: 08/31/2023] [Revised: 06/15/2024] [Accepted: 06/20/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND Prolonged preoperative fasting can cause hypoglycemia, dehydration, hypotension, and irritability, especially in children. Multimodal protocols such as the Enhanced Recovery After Operation (ERAS) and the Accelerated Full Postoperative Recovery (ACERTO, Aceleração da Recuperação Total Pós-Operatória) recommend a shortened fasting period. The aim of this study is to evaluate the association between shortened preoperative fasting and perioperative outcomes in pediatric patients. METHODS This study is a systematic review of the literature. The inclusion criteria were original studies published between January 2017-November 2022 that used shortened preoperative fasting protocols validated in patients aged 0-17 years and that evaluated the association of this practice with perioperative outcomes. The studies were obtained from the Latin American and Caribbean Literature on Health Sciences (LILACS), National Library of Medicine and National Institutes of Health (PubMed) and Science Direct databases. RESULTS A total of 6064 articles were obtained, of which eight were considered eligible. The results showed that shortened preoperative fast is safe in children and adolescents. The main benefits of this practice were higher preoperative blood glucose, no episodes of preoperative hypoglycemia, lower incidence of nausea, and minor complaints of crying. CONCLUSIONS Shortening the fasting time with high-carbohydrate drinks between one and 2 h before operation is safe in children and adolescents, being associated with better metabolic and emotional responses in the perioperative period. LEVELS OF EVIDENCE Level II.
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Affiliation(s)
- Amanda Michelly Braga da Mata
- Instituto da Criança e do Adolescente do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Enéas Carvalho de Aguiar, 647, Cerqueira César, São Paulo, 05403-000, Brazil.
| | - Ane Gabriele do Carmo Tomaz
- Instituto da Criança e do Adolescente do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Enéas Carvalho de Aguiar, 647, Cerqueira César, São Paulo, 05403-000, Brazil
| | - Gabriella Cristina Andrade da Cunha
- Instituto da Criança e do Adolescente do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Enéas Carvalho de Aguiar, 647, Cerqueira César, São Paulo, 05403-000, Brazil
| | - Patricia Zamberlan
- Instituto da Criança e do Adolescente do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Enéas Carvalho de Aguiar, 647, Cerqueira César, São Paulo, 05403-000, Brazil.
| | - Maria Aparecida Carlos Bonfim
- Instituto da Criança e do Adolescente do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Enéas Carvalho de Aguiar, 647, Cerqueira César, São Paulo, 05403-000, Brazil
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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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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: 4] [Impact Index Per Article: 4.0] [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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Sarhan KA, Hasaneen H, Hasanin A, Mohammed H, Saleh R, Kamel A. Ultrasound Assessment of Gastric Fluid Volume in Children Scheduled for Elective Surgery After Clear Fluid Fasting for 1 Versus 2 Hours: A Randomized Controlled Trial. Anesth Analg 2023; 136:711-718. [PMID: 35881513 DOI: 10.1213/ane.0000000000006157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND This study aimed to compare the gastric fluid volume (GFV) in children who fasted 1 versus 2 hours using ultrasound, after ingestion of a defined volume of clear fluid. METHODS Children scheduled for elective surgery were enrolled in this randomized, double-blinded, controlled trial. After receiving 3 mL kg -1 clear fluid, participants were randomized to have a gastric ultrasound after fasting for either 1 hour (1-hour group, n = 116) or 2 hours (2-hour group, n = 111). Our primary outcome was the GFV. Other outcomes included the antral cross-sectional area, frequency of high risk and low risk of aspiration, and qualitative grading for the gastric antrum. RESULTS Two hundred and twenty-seven children were available for final analysis. The median (Q1-Q3) GFV was higher in the 1-hour group versus the 2-hour group (0.61 [0.41-0.9] mL kg -1 vs 0.32 [0.23-0.47] mL kg -1 ; P value = .001). None of the study groups had GFV ≥1.5 mL kg -1 . The frequency (%) of GFV ≥1.25 mL kg -1 was comparable between both groups (2 [1.7%] vs 0 [0%], P value = .165). However, the frequency of GFV ≥0.8 mL kg -1 was higher in 1-hour group than in 2-hour group (34.5% vs 4.5%), and grade 2 antral grading score was 56.9% in 1-hour group vs 0.9% in 2-hour group ( P value <.001). CONCLUSIONS In healthy children scheduled for elective surgery receiving 3 mL kg -1 clear fluid, the median GFV after 1-hour fasting was double the volume after conventional 2-hour fasting. These findings should be considered whether weighting the risk/benefit of a liberal approach to preoperative fasting versus the risk of pulmonary aspiration.
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Aschkenasy G, Leder O, Pardes R, Nir EA, Shteyer E, Orlanski-Meyer E, Turner D, Gozal Y. Preoperative clear fluid fasting and endoscopy-measured gastric fluid volume in children. Paediatr Anaesth 2023. [PMID: 36916832 DOI: 10.1111/pan.14662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 03/02/2023] [Accepted: 03/03/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND In light of new recommendations to shorten clear fluid fasting time before anesthesia, our study aimed at exploring residual fluid volume in the stomach after different fasting times. We intended to perform direct endoscopic aspiration of stomach contents under vision, as part of routine gastroscopy assessment. Hereby we would be able to quantify true residual gastric fluid volume and acidity in children and measure their correlation with fasting times. METHODS The study was performed as a single-center, prospective study in pediatric perioperative day care at a university-affiliated tertiary care center. Aspiration of gastric fluid contents was performed in anesthetized children aged 1-18 years undergoing an elective gastroscopy. Recorded data included patient fast time, last meal content, last clear fluid content, and aspirated gastric volume and pH, as well as patient characteristics. RESULTS We included 253 gastroscopies, performed in 245 children. Mean fasting time for clear fluids was 6.9 h (range 1 h 40 min - 18 h 35 min) (SD 4.5). Mean age was 9.8 years (SD 5.1) and mean body weight was 33.2 kg (SD 18.7). Mean residual gastric volume was 12 mL (0-90) (SD 13.5) or 0.34 mL/kg (SD 0.37) and mean pH was 1.5 (SD 0.9). No significant correlation was observed between clear fluid fasting time and the child's residual gastric fluid volume per kg body weight (r = -.103, p = .1), nor between clear fluid fasting time and the pH of the residual gastric fluid (r = -.07, p = .3). In more than half of the patients the residual gastric volume was less than 10 mL, unrelated to fasting time. CONCLUSIONS In children undergoing gastroscopy, we could not demonstrate any association between clear fluid fasting time and the child's residual gastric fluid volume per kg body weight. Since we did not see a clinically relevant association between clear fluids fasting time and gastric residual volume, this study may support the recommendation to shorten clear fluids fasting time.
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Affiliation(s)
- Gabriella Aschkenasy
- Department of Anesthesiology, Perioperative Medicine and Pain Treatment, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Oren Leder
- Institute of Pediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Rivka Pardes
- Department of Anesthesiology, Perioperative Medicine and Pain Treatment, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Eshel A Nir
- Department of Anesthesiology, Rambam Health Care Campus, Haifa, Israel
| | - Eyal Shteyer
- Pediatric Liver Unit, Institute of Pediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Esther Orlanski-Meyer
- Institute of Pediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Dan Turner
- Institute of Pediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Yaacov Gozal
- Department of Anesthesiology, Perioperative Medicine and Pain Treatment, Shaare Zedek Medical Center, Jerusalem, Israel
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Marsman M, Kappen TH, Vernooij LM, van der Hout EC, van Waes JA, van Klei WA. Association of a Liberal Fasting Policy of Clear Fluids Before Surgery With Fasting Duration and Patient Well-being and Safety. JAMA Surg 2023; 158:254-263. [PMID: 36598762 PMCID: PMC9857800 DOI: 10.1001/jamasurg.2022.5867] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 09/16/2022] [Indexed: 01/05/2023]
Abstract
Importance Current fasting guidelines for procedures under anesthesia are poorly implemented, leading to negative metabolic sequelae. Recent studies in children showed support of liberal clear fluid intake; adult physiology can support clear fluid intake, but implementation studies are lacking. Objective To evaluate the successfulness of implementation of a liberal clear fluid policy with regard to fasting duration, well-being, and safety in adults scheduled for anesthesia. Design, Setting, and Participants This was a quality improvement study conducted from January 2016 to July 2021 at a tertiary referral hospital in the Netherlands. Adults scheduled for nonemergency procedures under anesthesia were included in the study. Patients undergoing obstetrics procedures or those who were intubated preoperatively were excluded. Interventions Stepwise introduction of a liberal fluid fasting policy, allowing for ingestion of clear fluids until arrival at the operating room. Main Outcomes and Measures The primary outcome was change in fasting duration. Secondary outcomes were patient well-being, measured as preoperative thirst, amount of fluid ingested, postoperative nausea and vomiting (PONV), and administration of antiemetics. Safety was measured as incidence of regurgitation and aspiration (pneumonia). Results Of the 76 451 patients (mean [SD] age, 56 [17] years; 39 530 male individuals [52%] 36 921) included in the study, 59 036 (78%) followed the standard policy, and 16 815 (22%) followed the liberal policy. Time series analysis showed an estimated fasting duration decrease of 3:07 hours (IQR, 1:36-7:22; P < .001) after implementation of the liberal policy. Postimplementation median (IQR) fasting duration was 1:20 (0:48-2:24) hours. The incidence of regurgitation changed from 18 (95% CI, 14-21) to 24 (95% CI, 17-32) in 10 000 patients, and the incidence of aspiration changed from 1.7 (95% CI, 0.6-2.7) to 2.4 (95% CI, 0.5-4.7) in 10 000 patients. In the liberal policy, thirst feelings decreased (37% [4982 of 8615] vs 46% [3373 of 7362]; P < .001). PONV incidence decreased from 10.6% (6339 of 59 636) to 9.4% (1587 of 16 815; P < .001) and antiemetic administration decreased from 11.0% (6538 of 59 636) to 9.5% (1592 of 16 815; P < .001). Conclusions and Relevance Results of this quality improvement study suggest that a liberal fasting policy was associated with a clinically relevant reduction in fasting duration and improved patient well-being with regard to preoperative thirst and PONV. Although a slightly higher incidence of regurgitation could not be ruled out, wider implementation of such a policy may be advocated as results are still within the clinically accepted risks margins. Results suggest that surgical procedures in patients who drink clear fluids within 2 hours before anticipated anesthesia should not be postponed or canceled.
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Affiliation(s)
- Marije Marsman
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Teus H. Kappen
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Information Technology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Lisette M. Vernooij
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Judith A. van Waes
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Wilton A. van Klei
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
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Response to: reply to: New ESAIC fasting guidelines for clear fluids in children. Ugeskr Laeger 2023; 40:149-150. [PMID: 36592013 DOI: 10.1097/eja.0000000000001773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Degeeter T, Demey B, Van Caelenberg E, De Baerdemaeker L, Coppens M. Prospective audit on fasting status of elective ambulatory surgery patients, correlated to gastric ultrasound. Acta Chir Belg 2023; 123:43-48. [PMID: 34110976 DOI: 10.1080/00015458.2021.1940438] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Recent guidelines advocate a preoperative fasting interval of 6 h for solid food, 4 h for breast milk and 2 h for clear fluids. Long nil per mouth intervals give rise to complications and discomfort in the perioperative period. Gastric ultrasound is easily accessible and generates reliable information about gastric content. PATIENTS AND METHODS One hundred patients were offered a questionnaire regarding preoperative fasting. Important outcome measures were hour of last meal, last clear fluids intake, the source of preoperative information. Gastric ultrasound was performed in prone position and lateral decubitus. RESULTS The mean duration of fasting for solid food was 13h29 and 9h51 for clear fluids. 48% of patients were well aware of the correct fasting guidelines. The most frequent source of information was the preoperative phone call. Gastric ultrasound only found insignificant amounts of gastric content. DISCUSSION Too few patients are aware of the correct guidelines or fear complications and therefore adhere to the nil per mouth from midnight as most conservative measure. A phone call informing patients about the hour of surgery and allowing clear fluid intake until 2 h before surgery, is still not convincing enough. Some health care providers advise their patients the nil per mouth from midnight rule, due to risk of interfering with the operating room schedule. CONCLUSION It is still difficult to implement liberal intake of clear fluids according to current guidelines. Ambulatory surgery patients have long fasting intervals with decrease of subjective well-being and increased incidence of hunger and thirst.
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Affiliation(s)
- Thibo Degeeter
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Birgit Demey
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Els Van Caelenberg
- University Hospital Ghent, Head Nurse Ambulatory Surgery Unit, Ghent, Belgium
| | - Luc De Baerdemaeker
- Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
| | - Marc Coppens
- Department of Basic and Applied Medical Sciences, Head of the Ambulatory Surgery Unit, University Hospital Ghent, Ghent University, Ghent, Belgium
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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: 3.5] [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: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Wollmer E, Ungell AL, Nicolas JM, Klein S. Review of paediatric gastrointestinal physiology relevant to the absorption of orally administered medicines. Adv Drug Deliv Rev 2022; 181:114084. [PMID: 34929252 DOI: 10.1016/j.addr.2021.114084] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 11/13/2021] [Accepted: 12/13/2021] [Indexed: 12/11/2022]
Abstract
Despite much progress in regulations to improve paediatric drug development, there remains a significant need to develop better medications for children. For the design of oral dosage forms, a detailed understanding of the specific gastrointestinal (GI) conditions in children of different age categories and how they differ from GI conditions in adults is essential. Several review articles have been published addressing the ontogeny of GI characteristics, including luminal conditions in the GI tract of children. However, the data reported in most of these reviews are of limited quality because (1) information was cited from very old publications and sometimes low quality sources, (2) data gaps in the original data were filled with textbook knowledge, (3) data obtained on healthy and sick children were mixed, (4) average data obtained on groups of patients were mixed with data obtained on individual patients, and (5) results obtained using investigative techniques that may have altered the outcome of the respective studies were considered. Consequently, many of these reviews draw conclusions that may be incorrect. The aim of the present review was to provide a comprehensive and updated overview of the available original data on the ontogeny of GI luminal conditions relevant to oral drug absorption in the paediatric population. To this end, the PubMed and Web of Science metadatabases were searched for appropriate studies that examined age-related conditions in the oral cavity, esophagus, stomach, small intestine, and colon. Maturation was observed for several GI parameters, and corresponding data sets were identified for each paediatric age group. However, it also became clear that the ontogeny of several GI traits in the paediatric population is not yet known. The review article provides a robust and valuable data set for the development of paediatric in vitro and in silico biopharmaceutical tools to support the development of age-appropriate dosage forms. In addition, it provides important information on existing data gaps and should provide impetus for further systematic and well-designed in vivo studies on GI physiology in children of specific age groups in order to close existing knowledge gaps and to sustainably improve oral drug therapy in children.
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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: 80] [Impact Index Per Article: 40.0] [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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Ghodke S, Reddy NV, Hiremath R, Nimbannavar S, Kulkarni M. Comparison of USG-Guided gastric volume at 1 h and 2 h of giving clear fluids for elective pediatric surgeries and its effect on postoperative nausea and vomiting. JOURNAL OF MARINE MEDICAL SOCIETY 2022. [DOI: 10.4103/jmms.jmms_17_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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14
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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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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: 3.3] [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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Schmidt AR, Fehr J, Man J, D'Souza G, Wang E, Claure R, Mendoza J. Pre-operative fasting times for clear liquids at a tertiary children's hospital; what can be improved? Anesth Pain Med (Seoul) 2021; 16:266-272. [PMID: 34289299 PMCID: PMC8342827 DOI: 10.17085/apm.21025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/10/2021] [Indexed: 12/28/2022] Open
Abstract
Background The goal of preoperative fasting is to prevent pulmonary aspiration during general anesthesia. Fasting times are often prolonged leading to patient discomfort and risk for adverse events. This retrospective quality improvement survey evaluated effective nil-per-os (NPO) times and causes for prolonged NPO times with the aim to suggest improvement strategies by a newly founded fasting task force. Methods Data from all electronic anesthesia records from 2019 at our institution were reviewed for fasting times. Our NPO instructions follow American Society of Anesthesiology guidelines and are calculated based on the patient’s arrival time (90 min before operating room [OR] time). Primary outcome was the effective NPO time for clear liquids, secondary outcomes were incidence of delays and the parental compliance with the NPO instructions. Data are presented as median (interquartile range). Results In total 9,625 cases were included in the analysis. NPO time was documented in 72.1% with a median effective NPO time of 7:13 h (7:36). OR in room times were documented in 72.8%, 2,075 (29.5%; median time 0:10 h [0:21]) were earlier and 4,939 (70.5%; median time 0:29 h [0:54]) were later than scheduled. Parental NPO compliance showed a median deviation for clear liquid intake of 0:55 h (8:30). Conclusions This study revealed that effective NPO times were longer than current ASA guidelines. Contributing causes include case delays and parental non-compliance to NPO instructions. Thus, task force recommendations include change NPO instruction calculations to scheduled OR time versus arrival time, and encourage parents to give their child clear liquids at the instructed time.
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Affiliation(s)
- Alexander R Schmidt
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - James Fehr
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Janice Man
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Genevieve D'Souza
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Ellen Wang
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Rebecca Claure
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Julianne Mendoza
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Marsman M, Pouw N, Moons LMG, van Klei WA, Kappen TH. Gastric fluid volume in adults after implementation of a liberal fasting policy: a prospective cohort study. Br J Anaesth 2021; 127:e85-e87. [PMID: 34238548 DOI: 10.1016/j.bja.2021.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 06/04/2021] [Accepted: 06/06/2021] [Indexed: 10/20/2022] Open
Affiliation(s)
- Marije Marsman
- Department of Anaesthesiology, Universitair Medisch Centrum, Utrecht, the Netherlands.
| | - Niels Pouw
- Department of Anaesthesiology, Universitair Medisch Centrum, Utrecht, the Netherlands
| | - Leon M G Moons
- Department of Internal Medicine, Dermatology and Gastroenterology, Universitair Medisch Centrum, Utrecht, the Netherlands
| | - Wilton A van Klei
- Department of Anaesthesiology, Universitair Medisch Centrum, Utrecht, the Netherlands
| | - Teus H Kappen
- Department of Anaesthesiology, Universitair Medisch Centrum, Utrecht, the Netherlands
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Reply to: role of the acidity and volume of gastric fluid in obstetric anaesthesia. Eur J Anaesthesiol 2021; 38:200-201. [PMID: 33394800 DOI: 10.1097/eja.0000000000001352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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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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Yip A, Hogan S, Carey S. Interventions Aimed at Reducing Fasting Times in Acute Hospital Patients: A Systematic Literature Review. Nutr Clin Pract 2020; 36:133-152. [PMID: 32970377 DOI: 10.1002/ncp.10579] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 08/23/2020] [Indexed: 11/11/2022] Open
Abstract
Despite current guidelines recommending fasting from solids for ≤6 hours and clear fluids for ≤2 hours prior to surgery, outdated practices endure; patients fast for unnecessarily prolonged periods because of beliefs regarding aspiration risk upon anaesthesia induction. This literature review aimed to identify and evaluate current interventions aiming to reduce preoperative fasting times for acutely ill hospital patients, summarizing effective interventional strategies and associated outcomes. EMBASE, MEDLINE, PreMEDLINE, and CINAHL were systematically searched. Quality of evidence was assessed using Cochrane risk-of-bias tools. Studies, of any type, reporting fasting times as a primary or secondary outcome were included. A total of 1918 potential studies were identified; of these, 16 studies were included. Seven studies investigated the effect of changing fasting protocol on gastric fluid volume/residual gastric volume (GFV/RGV) and gastric pH as surrogate measures for aspiration risk. No significant differences in GFV/RGV and gastric pH due to reduced preoperative fasting were reported, thus no change in aspiration risk. Eight studies documented improvements in patient-reported outcomes with shorter fasting times. However, this review identified a paucity of studies that trialled interventions to reduce fasting times as the primary aim. These interventions were multimodal and multidisciplinary in nature, incorporating principles of implementation science to successfully achieve significant reductions in fasting times. This review highlights that reducing the preoperative fasting period is safe while improving patient's physical and psychological well-being. Further high-quality studies that investigate multimodal interventions, and that utilize implementation science principles, are required in this area.
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Affiliation(s)
- Adela Yip
- School of Life and Environmental Sciences, University of Sydney, Sydney, Australia
| | - Sophie Hogan
- School of Life and Environmental Sciences, University of Sydney, Sydney, Australia.,Department of Nutrition & Dietetics, Royal Prince Alfred Hospital, Sydney, Australia
| | - Sharon Carey
- School of Life and Environmental Sciences, University of Sydney, Sydney, Australia.,Department of Nutrition & Dietetics, Royal Prince Alfred Hospital, Sydney, Australia
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Dongare PA, Bhaskar SB, Harsoor SS, Garg R, Kannan S, Goneppanavar U, Ali Z, Gopinath R, Sood J, Mani K, Bhatia P, Rohatgi P, Das R, Ghosh S, Mahankali SS, Singh Bajwa SJ, Gupta S, Pandya ST, Keshavan VH, Joshi M, Malhotra N. Perioperative fasting and feeding in adults, obstetric, paediatric and bariatric population: Practice Guidelines from the Indian Society of Anaesthesiologists. Indian J Anaesth 2020; 64:556-584. [PMID: 32792733 PMCID: PMC7413358 DOI: 10.4103/ija.ija_735_20] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 06/20/2020] [Accepted: 06/22/2020] [Indexed: 02/07/2023] Open
Affiliation(s)
- Pradeep A Dongare
- Assistant Professor, Department of Anaesthesiology, ESIPGIMSR, Bengaluru, India
| | - S Bala Bhaskar
- Department of Anaesthesiology, Vijayanagar Institute of Medical Sciences, Ballari, India
| | - S S Harsoor
- Professor, Department of Anaesthesiology, Dr BR Ambedkar Medical College and Hospital, Bengaluru, India
| | - Rakesh Garg
- Additional Professor, Department of Onco-Anaesthesia, Pain and Palliative Medicine, DR BRAIRCH, AIIMS, New Delhi, India
| | - Sudheesh Kannan
- Professor, Department of Anaesthesiology, BMCRI, Bengaluru, India
| | - Umesh Goneppanavar
- Professor, Department of Anaesthesiology, Dharwad Institute of Mental Health and Neurosciences, Dharwad, India
| | - Zulfiqar Ali
- Associate Professor, Department of Anesthesiology and Critical Care, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Ramachandran Gopinath
- Professor and Head,Department of Anaesthesiology and Intensive Care, ESIC Medical College and Hospital, Hyderabad, India
| | - Jayashree Sood
- Honorary. Joint Secretary, Board of Management, Chairperson, Institute of Anaesthesiology, Pain and Perioperative Medicine, Sir Ganga Ram Hospital, New Delhi, India
| | - Kalaivani Mani
- Scientist IV, Department of Biostatistics, AIIMS, New Delhi, India
| | - Pradeep Bhatia
- Professor and Head, Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, India
| | | | - Rekha Das
- Professor and Head, Department Anaesthesiology, Critical care and Pain, Acharya Harihar Post Graduate Institute of Cancer, Cuttack, India
| | - Santu Ghosh
- Assistant Professor, Department of Biostatistics, St John's Medical College, Bengaluru, India
| | | | - Sukhminder Jit Singh Bajwa
- Professor and Head, Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Punjab, India
| | - Sunanda Gupta
- Professor and Head, Department of Anaesthesiology, Geetanjali Medical College and Hospital, Udaipur, India
| | - Sunil T Pandya
- Chief of Anaesthesia and Surgical ICU, AIG Hospitals, Hyderabad, India
| | - Venkatesh H Keshavan
- Senior Consultant and Chief, Department of Neuroanaesthesia and Critical Care, Apollo Hospitals, Bengaluru, India
| | - Muralidhar Joshi
- Head, Department of Anaesthesia and Pain Medicine, Virinchi Hospitals, Hyderabad, India
| | - Naveen Malhotra
- Professor, Department of Anaesthesiology and In Charge Pain Management Centre, Pt BDS PGIMS, Haryana, India
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Abstract
Background
Children are required to fast before elective general anesthesia. This study hypothesized that prolonged fasting causes volume depletion that manifests as low blood pressure. This study aimed to assess the association between fluid fasting duration and postinduction low blood pressure.
Methods
A retrospective cohort study was performed of 15,543 anesthetized children without preinduction venous access who underwent elective surgery from 2016 to 2017 at Children’s Hospital of Philadelphia. Low blood pressure was defined as systolic blood pressure lower than 2 standard deviations below the mean (approximately the 2.5th percentile) for sex- and age-specific reference values. Two epochs were assessed: epoch 1 was from induction to completion of anesthesia preparation, and epoch 2 was during surgical preparation.
Results
In epoch 1, the incidence of low systolic blood pressure was 5.2% (697 of 13,497), and no association was observed with the fluid fasting time groups: less than 4 h (4.6%, 141 of 3,081), 4 to 8 h (6.0%, 219 of 3,652), 8 to 12 h (4.9%, 124 of 2,526), and more than 12 h (5.0%, 213 of 4,238). In epoch 2, the incidence of low systolic blood pressure was 6.9% (889 of 12,917) and varied across the fasting groups: less than 4 h (5.6%, 162 of 2,918), 4 to 8 h (8.1%, 285 of 3,531), 8 to 12 h (5.9%, 143 of 2,423), and more than 12 h (7.4%, 299 of 4,045); after adjusting for confounders, fasting 4 to 8 h (adjusted odds ratio, 1.33; 95% CI, 1.07 to 1.64; P = 0.009) and greater than 12 h (adjusted odds ratio, 1.28; 95% CI, 1.04 to 1.57; P = 0.018) were associated with significantly higher odds of low systolic blood pressure compared with the group who fasted less than 4 h, whereas the increased odds of low systolic blood pressure associated with fasting 8 to 12 h (adjusted odds ratio, 1.11; 95% CI, 0.87 to 1.42; P = 0.391) was nonsignificant.
Conclusions
Longer durations of clear fluid fasting in anesthetized children were associated with increased risk of postinduction low blood pressure during surgical preparation, although this association appeared nonlinear.
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What We Already Know about This Topic
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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: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [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: 6.4] [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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