Clear fluids fasting for elective paediatric anaesthesia: The European Society of Anaesthesiology consensus statement

Incidence of adverse respiratory events after adjustment of clear fluid fasting recommendations to 1 h: a prospective, observational, multi-institutional cohort study

BACKGROUND

Preoperative fasting reduces the risk of pulmonary aspiration during anaesthesia, and 2-h fasting for clear fluids has commonly been recommended. Based on recent evidence of shorter fasting times being safe, the Swiss Society of Paediatric Anaesthesia began recommending 1-h fasting for clear fluids in 2018. This prospective, observational, multi-institutional cohort study aimed to investigate the incidence of adverse respiratory events after implementing the new national recommendation.

METHODS

Eleven Swiss anaesthesia institutions joined this cohort study and included patients aged 0-15 yr undergoing anaesthesia for elective procedures after implementation of the 1-h fasting instruction. The primary outcome was the perioperative (defined as the time from anaesthesia induction to emergence) incidence of pulmonary aspiration, gastric regurgitation, and vomiting. Data are presented as median (inter-quartile range; minimum-maximum) or count (percentage).

RESULTS

From June 2019 to July 2021, 22 766 anaesthetics were recorded with pulmonary aspiration occurring in 25 (0.11%), gastric regurgitation in 34 (0.15%), and vomiting in 85 (0.37%) cases. No major morbidity or mortality was associated with pulmonary aspiration. Subgroup analysis by effective fasting times (<2 h [n=7306] vs ≥2 h [n=14 660]) showed no significant difference for pulmonary aspiration between these two groups (9 [0.12%] vs 16 [0.11%], P=0.678). Median effective fasting time for clear fluids was 157 [104-314; 2-2385] min.

CONCLUSIONS

Implementing a national recommendation of 1-h clear fluid fasting was not associated with a higher incidence of pulmonary aspiration compared with previously reported data.

Preoperative clear fluid fasting and endoscopy-measured gastric fluid volume in children

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.

Key Strategies for Optimizing Pediatric Perioperative Nutrition-Insight from a Multidisciplinary Expert Panel

Adequate nutrition is an essential factor in healing and immune support in pediatric patients undergoing surgery, but its importance in this setting is not consistently recognized. Standardized institutional nutrition protocols are rarely available, and some clinicians may be unaware of the importance of assessing and optimizing nutritional status. Moreover, some clinicians may be unaware of updated recommendations that call for limited perioperative fasting. Enhanced recovery protocols have been used in adult patients undergoing surgery to ensure consistent attention to nutrition and other support strategies in adult patients before and after surgery, and these are now under evaluation for use in pediatric patients as well. To support better adoption of ideal nutrition delivery, a multidisciplinary panel of experts in the fields of pediatric anesthesiology, surgery, gastroenterology, cardiology, nutrition, and research have gathered and reviewed current evidence and best practices to support nutrition goals in this setting.

Prospective audit on fasting status of elective ambulatory surgery patients, correlated to gastric ultrasound

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.

Pre-operative fasting in children: A guideline from the European Society of Anaesthesiology and Intensive Care

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.

Quality-improvement project to reduce actual fasting times for fluids and solids before induction of anaesthesia

Background

Despite well-defined recommendations, prolonged fasting times for clear fluids and solids are still common before elective surgery in adults. Extended fasting times may lead to discomfort, thirst, hunger and physiological dysfunctions. Previous studies have shown that prolonged fasting times are frequently caused by patients being misinformed as well as inadequate implementation of the current guidelines by medical staff.

This study aimed to explore how long elective surgery patients fast in a German secondary care hospital before and after the introduction of an educational note for patients and re-training for the medical staff.

Methods

A total of 1002 patients were enrolled in this prospective, non-randomised interventional study. According to the power calculation, in the first part of the study actual fasting times for clear fluids and solids were documented in 502 consecutive patients, verbally instructed as usual regarding the recommended fasting times for clear fluids (2 h) and solids (6 h). Subsequently, we implemented additionally to the verbal instruction a written educational note for the patients, including the recommended fasting times. Furthermore, the medical staff was re-trained regarding the fasting times using emails, newsletters and employee meetings. Thereafter, another 500 patients were included in the study.

We hypothesised, that after these quality improvement procedures, actual fasting times for clear fluids and solids would be more accurate on time.

Results

Actual fasting times for clear fluids were in the median 11.3 (interquartile range 6.8–14.3; range 1.5–25.5) h pre-intervention, and were significantly reduced to 5.0 (3.0–7.2; 1.5–19.8) h after the intervention (median difference (95%CI) − 5.5 (− 6.0 to − 5.0) h). The actual fasting times for solids also decreased significantly, but only from 14.5 (12.1–17.2; 5.4–48.0) h to 14.0 (12.0–16.3; 5.4–32.0) h after the interventions (median difference (95%CI) − 0.52 (− 1.0 to − 0.07) h).

Conclusions

The study showed considerably extended actual fasting times in elective adult surgical patients, which were significantly reduced by simple educational/training interventions. However, the actual fasting times still remained considerably longer than defined in recommended guidelines, meaning further process optimisations like obligatory fluid intake in the early morning are necessary to improve patient comfort and safety in future.

Trial registration

German registry of clinical studies (DRKS-ID: DRKS 00020530, retrospectively registered).

Pro-Con Debate: 1- vs 2-Hour Fast for Clear Liquids Before Anesthesia in Children

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.

Pre-operative fasting times for clear liquids at a tertiary children's hospital; what can be improved?

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.

Preoperative Fasting Time and Its Association with Hypoglycemia during Anesthesia in Pediatric Patients Undergoing Elective Procedures at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia

BACKGROUND

Preoperative fasting is important to reduce the risk of pulmonary aspiration during anesthesia. The influence of prolonged fasting time on glucose levels during anesthesia in children remains uncertain. Therefore, this study is aimed at assessing preoperative fasting time and its association with hypoglycemia during anesthesia in pediatric patients undergoing elective procedures at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. The research hypothesis of the study is as follows: there is a prolonged preoperative fasting time, and it influences the glucose levels during anesthesia among pediatric patients undergoing elective procedures at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia.

METHODS

Institutional based cross-sectional study was conducted among 258 pediatric patients who had undergone elective procedures in a tertiary care center. A systematic sampling method was used to select study participants. The data were collected through face-to-face interviews and medical record reviews. Binary logistic regression was used to identify associated factors of hypoglycemia during anesthesia among pediatric patients undergoing elective procedures. All explanatory variables with a p value of ≤0.25 from the bivariable logistic regression model were fitted into the multivariable logistic regression model to control the possible effect of confounders, and finally, the variables which had an independent association with hypoglycemia were identified based on adjusted odds ratio with 95% confidence interval, and a p value less than 0.05 was significant.

RESULTS

The mean (standard deviation) fasting hours from breast milk, solid foods, and clear fluids were 7.75 (2.89), 13.25 (3.14), and 12.31 (3.22), respectively. The majority (89.9%, 57.9%, and 100%) of participants had fasted from solid, breast milk, and clear fluids for more than 8, 6, and 4 hours, respectively. More than one-fourth (26.2%) of participants were hypoglycemic immediately after induction. Residence, order of nothing per mouth, source of patient, and duration of fasting from solid foods had a significant association with hypoglycemia during anesthesia in children.

CONCLUSION

Children undergoing elective procedures were exposed to unnecessarily long fasting times which were associated with hypoglycemia during anesthesia.

[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.

Observance of preoperative clear fluid fasting in pediatric anesthesia: oral and written information versus text message information. A before-and-after study

INTRODUCTION

Prolonged fasting before surgery is common in pediatrics. In the literature, it is responsible for hypotension, irritability and postoperative nausea and vomiting. Despite clear instructions given during the preanesthetic consultation, fasting rules are respected in only 30%-40% of cases. We aimed to evaluate the benefit of sending a text message the day before surgery to improve the parents' observance of fasting rules.

METHODS

We conducted a before-and-after study at the University Hospital of Poitiers. From August to October 2018, 172 parents of children under 15 years of age scheduled for all types of surgery were enrolled into two groups according to the period: the control group with parents receiving information on preoperative fasting rules during the preanesthetic consultation several days before surgery, and the text message group, receiving the same information during consultation plus a text message the day before the surgery.

RESULTS

There was a difference in observance of clear fluid fasting instructions (between 2 and 3 h before the admission at hospital) in favor of the text message group 33% versus 92% OR 29.2 (10.9-95.2) p < 0.001, and in average fasting time for clear fluids 8.7 h ± 4.8 h vs. 4.3 h ± 2.4 h (p < 0.001).

CONCLUSION

Sending of a reminder text message to the parents the day before the surgery resulted in a significant increase in observance of fasting rules in children undergoing scheduled surgery.

Ultrasound assessment of gastric emptying time after intake of clear fluids in children scheduled for general anesthesia-A prospective observational study

BACKGROUND

While many clinics have changed their local regimen toward a more liberal policy regarding clear fluid fasting for general anesthesia, there is a lack of studies evaluating gastric emptying time in a clinical setting.

AIMS

Based on this and before implementation of a more liberal preoperative clear fluid fasting policy for children, we studied gastric emptying time of clear fluids in children and hypothesized that the mean gastric emptying time would be 1 hour.

METHODS

Between March and December 2019, children scheduled for general anesthesia at our University Children's Hospital were enrolled in this prospective observational study. After overnight fasting, gastric emptying was examined by sonographic measurements of the gastric antral area before and 5, 15, 30, 45, and 60 minutes after intake of water or fruit juice.

RESULTS

Twenty-six children were enrolled in this study, and 24 aged 11 (range 4-17) years were included for statistical analysis. The median ingested fluid volume was 4.7 (range 1.8-11.8) mL kg^-1 . The gastric antral area of the children initially increased and subsequently decreased after intake of clear fluids and correlated significantly with fasting time (r = -0.55, P < .0001). After 1 hour, the gastric antral area had returned to the baseline level in 20 children but not in four children with a fluid intake >5 mL kg^-1 . There was no difference in the gastric antral area between water and fruit juice. Using a linear regression model, the calculated mean gastric emptying time of clear fluids was 52 minutes.

CONCLUSION

This study showed that the gastric emptying time of children after intake up to 5 mL kg^-1 clear fluids was <1 hour in a clinical setting. These results support the more liberal fasting regimen favoring a 1-hour fasting time and suggest 5 mL kg^-1 as an upper limit for clear fluids (eg, water, sugared water or tea or diluted fruit juice) from 2 hours to 1 hour before induction of anesthesia in children.

Nulla Per Os (NPO) guidelines: time to revisit?

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.

Impact of clear fluid fasting on pulmonary aspiration in children undergoing general anesthesia: Results of the German prospective multicenter observational (NiKs) study

BACKGROUND

A preliminary national audit of real fasting times including 3324 children showed that the fasting times for clear fluids and light meals were frequently shorter than recommended in current guidelines, but the sample size was too small for subgroup analyses.

AIMS

Therefore, the primary aim of this extended study with more participating centers and a larger sample size was to determine whether shortened fasting times for clear fluids or light meals have an impact on the incidence of regurgitation or pulmonary aspiration during general anesthesia in children. The secondary aim was to evaluate the impact of age, emergent status, ASA classification, induction method, airway management or surgical procedure.

METHODS

After the Ethics Committee's approval, at least more than 10 000 children in total were planned to be enrolled for this analysis. Patient demographics, real fasting times, anesthetic and surgical procedures, and occurrence of target adverse events defined as regurgitation or pulmonary aspiration were documented using a standardized case report form.

RESULTS

At fifteen pediatric centers, 12 093 children scheduled for surgery or interventional procedures were included between October 2018 and December 2019. Fasting times were shorter than recommended in current guidelines for large meals in 2.5%, for light meals in 22.4%, for formula milk in 5.3%, for breastmilk in 10.9%, and for clear fluids in 39.2%. Thirty-one cases (0.26%) of regurgitation, ten cases (0.08%) of suspected pulmonary aspiration, and four cases (0.03%) of confirmed pulmonary aspiration were reported, and all of them recovered quickly without any consequences. Fasting times for clear fluids shortened from 2 hours to 1 hour did not affect the incidence of adverse events (upper limit 95% CI 0.08%). The sample size of the cohort with fasting times for light meals shorter than 6 hours was too small for a subgroup analysis. An age between one and 3 years (odds ratio 2.7,95% CI 1.3 to 5.8%; P < .01) and emergent procedures (odds ratio 2.8,95% CI 1.4 to 5.7;P < .01) increased the incidence of adverse events, whereas ASA classification, induction method, or surgical procedure had no influence. The clear fluid fasting times were shortest under 6/4/0 as compared to 6/4/1 and 6/4/2 fasting regimens, all with an incidence of 0.3% for adverse events.

CONCLUSION

This study shows that a clear fluid fasting time shortened from 2 hours to 1 hour does not affect the incidence of regurgitation or pulmonary aspiration, that an age between one and 3 years and emergent status increase the incidence of regurgitation or pulmonary aspiration, and that pulmonary aspiration followed by postoperative respiratory distress is rare and usually shows a quick recovery.

Duration of preoperative clear fluid fasting and peripheral intravenous catheterization in children: A single-center observational cohort study of 9693 patients

BACKGROUND

Children routinely undergo inhalational induction of general anesthesia. Intravenous line placement typically occurs after induction of anesthesia and can be challenging, particularly in infants and young children.

AIMS

We conducted a retrospective observational study to determine whether there was an association between clear liquid fasting time and the number of peripheral intravenous catheter insertion attempts in anesthetized children. The secondary aim was to identify factors associated with multiple attempts to insert intravenous lines.

METHODS

After institutional research board approval, we retrieved a data set of all children between 0 months and 18 years who received general anesthesia at our hospital between January 1, 2016, and September 30, 2017. Data included age, gender, weight, race, ASA status, gestational age, number of peripheral intravenous catheter insertion attempts, any assistive device for insertion, and insertion site. Inclusion criteria were mask induction, ASA status 1 or 2, nonemergency, ambulatory surgical procedures, and placement of a single intravenous line during the anesthetic.

RESULTS

A total of 9693 patients were included in the study. Of which 8869 patients required one insertion attempt and 824 underwent multiple insertion attempts. 50% of patients in the single insertion attempt group had clear liquid fasting time <6.9 hours compared to 51.8% of patients requiring multiple attempts. Logistic regression model adjusted for age, ASA status, gender, and BMI did not find an association between duration of clear liquid fasting time and rate of multiple insertion attempts for intravenous catheters (OR: 0.99, 95% CI: 0.98-1.01, P = .47).

CONCLUSION

Clear liquid fasting time was not associated with multiple insertion attempts for intravenous line insertion in children receiving general anesthesia. Factors such as patient age, ethnicity, time of day of induction of anesthesia, and American Society of Anesthesiologists Physical Status classification show a greater association with the risk of multiple intravenous line insertion attempts.

Edible Oils Attenuate Button Battery-Induced Injury in Porcine Esophageal Segments

Objective: The objective of the study is to test whether the use of edible oil might be an early treatment strategy for reducing button battery-induced esophageal injury. Methods: A button battery was inserted into esophageal segments collected from pigs. The esophageal segments were randomly allotted to one of the following six treatments: (1) untreated (nothing injected), (2) lemon juice, (3) orange juice, (4) colza oil, (5) peanut oil, and (6) olive oil. Every hour, the battery discharge and the pH value were measured in the esophageal tissue. After treatment for 6 h, the residual voltage of the battery was measured and the esophageal tissue was processed with H&E staining. Results: In esophageal segments of the untreated group, a large area of the mucous membrane was severely eroded. Partial erosion was observed in esophageal tissues treated with either lemon juice or orange juice. Furthermore, the esophageal tissues were basically intact, had little damage when treated with oils. The highest extra-esophageal discharge voltage was recorded in the untreated group, a medium amount of discharge voltage was recorded in the lemon juice and orange juice groups, and the lowest discharge voltage was recorded in all the edible oils groups. Conclusions: Edible oils immersed the battery, reduced the surrounding electrolysis, and thus attenuated battery discharge. As a result, treatment with edible oils attenuated the pH alkalization and tissue damage in button battery injury of pig esophageal segments. These results indicate that edible oils might be used in the treatment of button battery ingestion.

Quality improvement project to reduce pediatric clear liquid fasting times prior to anesthesia

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.