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Ghimire A, Moharir A, Yamaguchi Y, Tram NK, Tobias JD. Preoperative gastric point-of-care ultrasound in nonelective surgical procedures in pediatric-aged patients. Saudi J Anaesth 2024; 18:17-22. [PMID: 38313729 PMCID: PMC10833037 DOI: 10.4103/sja.sja_379_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 05/10/2023] [Indexed: 02/06/2024] Open
Abstract
Background Airway management for nonelective surgical procedures in the setting of trauma, pain, and opioid use can be complicated by the potential for aspiration due to delayed gastric emptying. Point-of-care ultrasound (POCUS) remains a useful tool for evaluating gastric content and volume in various clinical settings. The authors evaluated gastric volume and content in children scheduled for urgent and semi-urgent procedures to assess their aspiration risk. Methods After obtaining consent, gastric POCUS was performed in the preoperative holding area for pediatric patients scheduled for both elective and nonelective surgery. Qualitative and quantitative measurements of the gastric antrum were taken, and the risk of gastric aspiration was calculated. Additional data collected included patient demographics, the type of surgery, nil per os (NPO) status at the time of surgery, NPO status at the time of injury, and administration of opioids. Results The study cohort included 100 patients ranging in age from 3 to 17 years old (mean age 9.2 years). Out of these 100 patients, gastric scanning was successfully conducted in 98 patients. Sixteen of fifty-nine nonelective patients (27%) had received opioids for pain control prior to surgery. Among the 34 patients who had suffered an acute injury, 7 (21%) had been NPO for <8 hours at the time of the injury. Ninety-nine out of hundred patients had been NPO for at least 6 hours at the time of the gastric ultrasound. Based on our gastric ultrasound findings, all patients who were appropriately NPO had either Grade 0 or Grade 1 risk for aspiration, indicating a low risk of aspiration. Conclusions The preliminary data show that when patients presenting for nonelective surgery are appropriately NPO, they may have a low risk of aspiration. This information may help guide the choice of anesthetic induction technique, particularly when concerns exist about the safety of a rapid sequence induction. It allows for a more stable and controlled induction of anesthesia.
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Affiliation(s)
- Anuranjan Ghimire
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, Japan
| | - Alok Moharir
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, Japan
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, Japan
| | - Yoshikazu Yamaguchi
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, Japan
- Department of Anesthesiology, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Nguyen K. Tram
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, Japan
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, Japan
| | - Joseph D. Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, Japan
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, Japan
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Baettig SJ, Filipovic MG, Hebeisen M, Meierhans R, Ganter MT. Pre-operative gastric ultrasound in patients at risk of pulmonary aspiration: a prospective observational cohort study. Anaesthesia 2023; 78:1327-1337. [PMID: 37587543 DOI: 10.1111/anae.16117] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2023] [Indexed: 08/18/2023]
Abstract
Point-of-care gastric sonography offers an objective approach to assessing individual pulmonary aspiration risk before induction of general anaesthesia. We aimed to evaluate the potential impact of routine pre-operative gastric ultrasound on peri-operative management in a cohort of adult patients undergoing elective or emergency surgery at a single centre. According to pre-operative gastric ultrasound results, patients were classified as low risk (empty, gastric fluid volume ≤ 1.5 ml.kg-1 body weight) or high risk (solid, mixed or gastric fluid volume > 1.5 ml.kg-1 body weight) of aspiration. After sonography, examiners were asked to indicate changes in aspiration risk management (none; more conservative; more liberal) to their pre-defined anaesthetic plan and to adapt it if patient safety was at risk. We included 2003 patients, 1246 (62%) of which underwent elective and 757 (38%) emergency surgery. Among patients who underwent elective surgery, 1046/1246 (84%) had a low-risk and 178/1246 (14%) a high-risk stomach, with this being 587/757 (78%) vs. 158/757 (21%) among patients undergoing emergency surgery, respectively. Routine pre-operative gastric sonography enabled changes in anaesthetic management in 379/2003 (19%) of patients, with these being a more liberal approach in 303/2003 (15%). In patients undergoing elective surgery, pre-operative gastric sonography would have allowed a more liberal approach in 170/1246 (14%) and made a more conservative approach indicated in 52/1246 (4%), whereas in patients undergoing emergency surgery, 133/757 (18%) would have been managed more liberally and 24/757 (3%) more conservatively. We showed that pre-operative gastric ultrasound helps to identify high- and low-risk situations in patients at risk of aspiration and adds useful information to peri-operative management. Our data suggest that routine use of pre-operative gastric ultrasound may improve individualised care and potentially impact patient safety.
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Affiliation(s)
- S J Baettig
- Institute of Anaesthesiology, Kantonsspital Winterthur, Winterthur, Switzerland
| | - M G Filipovic
- Department of Anaesthesiology and Pain Medicine, Inselspital Berne University Hospital, University of Berne, Berne, Switzerland
| | - M Hebeisen
- Department of Biostatistics, Institute of Epidemiology, Biostatistics and Prevention, University of Zurich, Zurich, Switzerland
| | - R Meierhans
- Department of Anaesthesiology, Kantonsspital Winterthur, Winterthur, Switzerland
| | - M T Ganter
- Institute of Anaesthesiology and Critical Care Medicine, Medical Faculty, Klinik Hirslanden Zurich | University of Zurich, Zurich, Switzerland
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Demirel A, Özgünay ŞE, Eminoğlu Ş, Balkaya AN, Onur T, Kılıçarslan N, Gamlı M. Ultrasonographic Evaluation of Gastric Content and Volume in Pediatric Patients Undergoing Elective Surgery: A Prospective Observational Study. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1432. [PMID: 37761393 PMCID: PMC10529717 DOI: 10.3390/children10091432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 08/11/2023] [Accepted: 08/17/2023] [Indexed: 09/29/2023]
Abstract
Anesthesia-related complications, such as pulmonary aspiration of gastric contents, occur in approximately 0.02-0.1% of elective pediatric surgeries. Aspiration risk can be reliably assessed by ultrasound examination of the gastric antrum, making it an essential non-invasive bedside tool. In this prospective observational study, since most of our patients are immigrants and have communication problems, we wanted to investigate gastric contents and the occurrence of "high risk stomach" in children undergoing elective surgery for the possibility of pulmonary aspiration, even if the children and/or parents reported their last oral intake time. This risk is defined by ultrasound findings of solid content in the antrum and/or a calculated gastric volume exceeding 1.25 mL/kg. Children aged 2-18 were included in the study. Both supine and right lateral decubitus (RLD) ultrasound examinations were performed on the antrum before surgery. Using a qualitative grading scale from 0 to 2, we evaluated the gastric fluid content. The cross-sectional area (CSA) of the antrum was measured in the RLD position, aiding the calculation of the gastric fluid volume according to an established formula by Perlas. Ultrasound measurements of 97 children were evaluated. The median fasting duration was 4 h for liquids and 9 h for thick liquids and solids. Solid content was absent in all the children. Five children (5.2%) exhibited a grade 2 antrum, implying that fluid content was visible in both the supine and RLD positions. The median antral CSA in the RLD was 2.36 cm2, with a median gastric volume of 0.46 mL/kg. For patients with a grade 0 antrum, a moderate and positive correlation was observed between the antral CSA and BMI, and a strong and positive correlation was evident between the antral CSA and age, similar to a grade 1 antrum. Only a single child (1%) had a potentially elevated risk of aspiration of gastric contents. Hence, the occurrence of a "high risk stomach" was 1% (95% confidence interval: 0.1-4.7%) and is consistent with the literature. As a necessary precaution, we propose the regular use of ultrasound evaluations of gastric contents, given their non-invasive, bedside-friendly, and straightforward implementation, for identifying risks when fasting times are uncertain and for ruling out unknown risk factors in each potential patient.
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Affiliation(s)
- Asiye Demirel
- Department of Anesthesiology and Reanimation, Bursa Yuksek Ihtisas Training and Research Hospital, University of Health Sciences, Bursa 16310, Turkey; (Ş.E.Ö.); (Ş.E.); (A.N.B.); (T.O.); (N.K.); (M.G.)
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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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Cools E, Habre W. Rapid sequence induction in Paediatric Anaesthesia: A narrative review. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2023. [DOI: 10.1016/j.tacc.2023.101215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Bouvet L, Cordoval J, Barnoud S, Berlier J, Desgranges FP, Chassard D. Diagnostic performance of qualitative ultrasound assessment for the interpretation of point-of-care gastric ultrasound to detect high gastric fluid volume: A prospective randomized crossover study. J Clin Anesth 2022; 81:110919. [PMID: 35792453 DOI: 10.1016/j.jclinane.2022.110919] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 06/14/2022] [Accepted: 06/25/2022] [Indexed: 11/15/2022]
Abstract
STUDY OBJECTIVE This study aimed to assess whether elevating the head of the bed to 45° was associated with sensitivity >90% of the qualitative ultrasound assessment for the diagnosis of gastric fluid volume > 1.5 ml.kg-1. We also assessed the performance of qualitative assessment, composite ultrasound scale, and clinical algorithm, for the diagnosis of fluid volume > 1.5 ml.kg-1 according to whether the head of the bed was elevated to 45° or not. DESIGN Prospective randomized observer-blind crossover trial. SETTING Hospices Civils de Lyon, France. PATIENT Healthy adult volunteers. INTERVENTIONS Two separate study sessions in fasting volunteers: with and without head-of-bed elevation to 45°, in a randomized order. Each session consisted of three tests, each corresponding to a randomized and different volume of water (either 0, 50, 100, 150 or 200 ml); the same volumes were used in both sessions and in a randomized order. Gastric ultrasounds were performed three minutes after the ingestion of water by an investigator blinded to the volume ingested. MEASUREMENTS Diagnostic performance of each approach for the diagnosis of gastric fluid volume > 1.5 ml.kg-1. MAIN RESULTS Twenty volunteers were included, and 120 measurements were analyzed. The sensitivity of the qualitative assessment for the diagnosis of gastric fluid volume > 1.5 ml.kg-1 with and without head-of-bed elevation was 91% (95%CI: 75-98) and 75% (95%CI: 57-89), respectively. The clinical algorithm with head-of-bed elevation had significantly better sensitivity than the qualitative assessment with no head-of-bed elevation; there was no significant difference for other comparisons. CONCLUSIONS The results suggest that qualitative examination of gastric antrum in the supine position with head-of-bed elevation to 45° can discriminate between low and high gastric fluid volume with high sensitivity, while neither the composite ultrasound scale nor the clinical algorithm improved the diagnostic performance of gastric ultrasound for the diagnosis of gastric fluid volume > 1.5 ml.kg-1.
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Affiliation(s)
- Lionel Bouvet
- Department of Anesthesiology and Intensive Care, Hospices Civils de Lyon, Femme Mère Enfant Hospital, 59, boulevard Pinel, 69500 Bron, France; APCSe VetAgro Sup UP 2021.A101 - University of Lyon, Université Claude Bernard Lyon 1, 43 boulevard du 11 Novembre 1918, 69100 Villeurbanne, France.
| | - Julien Cordoval
- Department of Anesthesiology and Intensive Care, Hospices Civils de Lyon, Femme Mère Enfant Hospital, 59, boulevard Pinel, 69500 Bron, France.
| | - Sophie Barnoud
- Department of Anesthesiology and Intensive Care, Hospices Civils de Lyon, Femme Mère Enfant Hospital, 59, boulevard Pinel, 69500 Bron, France
| | - Jean Berlier
- Department of Anesthesiology and Intensive Care, Hospices Civils de Lyon, Femme Mère Enfant Hospital, 59, boulevard Pinel, 69500 Bron, France.
| | - François-Pierrick Desgranges
- APCSe VetAgro Sup UP 2021.A101 - University of Lyon, Université Claude Bernard Lyon 1, 43 boulevard du 11 Novembre 1918, 69100 Villeurbanne, France; Department of Anesthesiology and Intensive Care, L'Hôpital Nord-Ouest, Plateau d'Ouilly, 69655 Villefranche-sur-Saône, France
| | - Dominique Chassard
- Department of Anesthesiology and Intensive Care, Hospices Civils de Lyon, Femme Mère Enfant Hospital, 59, boulevard Pinel, 69500 Bron, France; APCSe VetAgro Sup UP 2021.A101 - University of Lyon, Université Claude Bernard Lyon 1, 43 boulevard du 11 Novembre 1918, 69100 Villeurbanne, France.
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Valla FV, Tume LN, Jotterand Chaparro C, Arnold P, Alrayashi W, Morice C, Nabialek T, Rouchaud A, Cercueil E, Bouvet L. Gastric Point-of-Care Ultrasound in Acutely and Critically Ill Children (POCUS-ped): A Scoping Review. Front Pediatr 2022; 10:921863. [PMID: 35874585 PMCID: PMC9298849 DOI: 10.3389/fped.2022.921863] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 05/31/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Point-of-care ultrasound (POCUS) use is increasing in pediatric clinical settings. However, gastric POCUS is rarely used, despite its potential value in optimizing the diagnosis and management in several clinical scenarios (i.e., assessing gastric emptying and gastric volume/content, gastric foreign bodies, confirming nasogastric tube placement, and hypertrophic pyloric stenosis). This review aimed to assess how gastric POCUS may be used in acute and critically ill children. Materials and Methods An international expert group was established, composed of pediatricians, pediatric intensivists, anesthesiologists, radiologists, nurses, and a methodologist. A scoping review was conducted with an aim to describe the use of gastric POCUS in pediatrics in acute and critical care settings. A literature search was conducted in three databases, to identify studies published between 1998 and 2022. Abstracts and relevant full texts were screened for eligibility, and data were extracted, according to the JBI methodology (Johanna Briggs Institute). Results A total of 70 studies were included. Most studies (n = 47; 67%) were conducted to assess gastric emptying and gastric volume/contents. The studies assessed gastric volume, the impact of different feed types (breast milk, fortifiers, and thickeners) and feed administration modes on gastric emptying, and gastric volume/content prior to sedation or anesthesia or during surgery. Other studies described the use of gastric POCUS in foreign body ingestion (n = 6), nasogastric tube placement (n = 5), hypertrophic pyloric stenosis (n = 8), and gastric insufflation during mechanical ventilatory support (n = 4). POCUS was performed by neonatologists, anesthesiologists, emergency department physicians, and surgeons. Their learning curve was rapid, and the accuracy was high when compared to that of the ultrasound performed by radiologists (RADUS) or other gold standards (e.g., endoscopy, radiography, and MRI). No study conducted in critically ill children was found apart from that in neonatal intensive care in preterms. Discussion Gastric POCUS appears useful and reliable in a variety of pediatric clinical settings. It may help optimize induction in emergency sedation/anesthesia, diagnose foreign bodies and hypertrophic pyloric stenosis, and assist in confirming nasogastric tube placement, avoiding delays in obtaining confirmatory examinations (RADUS, x-rays, etc.) and reducing radiation exposure. It may be useful in pediatric intensive care but requires further investigation.
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Affiliation(s)
- Frederic V. Valla
- Pediatric Intensive Care, Lyon University Children Hospital, Hospices Civils de Lyon, Lyon, France
| | - Lyvonne N. Tume
- School of Health and Society, University of Salford, Manchester, United Kingdom
| | - Corinne Jotterand Chaparro
- Department of Nutrition and Dietetics, Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
| | - Philip Arnold
- Department of Anaesthetics, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
| | - Walid Alrayashi
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston Children's Hospital, Boston, MA, United States
| | - Claire Morice
- Pediatric Intensive Care, Lyon University Children Hospital, Hospices Civils de Lyon, Lyon, France
| | - Tomasz Nabialek
- Pediatric Intensive Care, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Aymeric Rouchaud
- Pediatric Radiology Department, Lyon University Children Hospital, Hospices Civils de Lyon, Lyon, France
| | - Eloise Cercueil
- Pediatric Intensive Care, Lyon University Children Hospital, Hospices Civils de Lyon, Lyon, France
| | - Lionel Bouvet
- Department of Anesthesiology and Intensive Care, Lyon University Children Hospital, Hospices Civils de Lyon, Lyon, France
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Evain JN, Allain T, Dilworth K, Bertrand B, Rabattu PY, Mortamet G, Desgranges FP, Bouvet L, Payen JF. Ultrasound assessment of gastric contents in children before general anaesthesia for acute appendicitis. Anaesthesia 2022; 77:668-673. [PMID: 35319093 DOI: 10.1111/anae.15707] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
There is increasing evidence that a minority of adults with acute appendicitis have gastric contents, posing an increased risk of pulmonary aspiration. This study aimed to evaluate the proportion of children with acute appendicitis who have gastric contents considered to pose a higher risk of pulmonary aspiration. We analysed point-of-care gastric ultrasound data routinely collected in children before emergency appendicectomy in a specialist paediatric hospital over a 30-month period. Based on qualitative and quantitative antral assessment in the supine and right lateral decubitus positions, gastric contents were classified as 'higher-risk' (clear liquid with calculated gastric fluid volume > 0.8 ml.kg-1 , thick liquid or solid) or 'lower-risk' of pulmonary aspiration. The 115 children studied had a mean (SD) age of 11 (3) years; 37 (32%; 95%CI: 24-42%) presented with higher-risk gastric contents, including 15 (13%; 95%CI: 8-21%) with solid/thick liquid contents. Gastric contents could not be determined in 13 children as ultrasound examination was not feasible in the right lateral decubitus position. No cases of pulmonary aspiration occurred. This study shows that gastric ultrasound is feasible in children before emergency appendicectomy. This technique showed a range of gastric content measurements, which could contribute towards defining the risk of pulmonary aspiration.
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Affiliation(s)
- J-N Evain
- Department of Anaesthesia and Intensive Care, Grenoble-Alpes University Hospital, Grenoble, France
| | - T Allain
- Department of Anaesthesia and Intensive Care, Grenoble-Alpes University Hospital, Grenoble, France
| | - K Dilworth
- Department of Anaesthesia and Intensive Care, Grenoble-Alpes University Hospital, Grenoble, France
| | - B Bertrand
- Department of Anaesthesia and Intensive Care, Grenoble-Alpes University Hospital, Grenoble, France
| | - P-Y Rabattu
- Department of Paediatric Surgery, Grenoble-Alpes University Hospital, Grenoble, France
| | - G Mortamet
- Paediatric Intensive Care Unit, Grenoble-Alpes University Hospital, Grenoble, France
| | - F-P Desgranges
- Department of Anaesthesia, Villefranche-sur-Saône Hospital, Villefranche-sur-Saône, France
| | - L Bouvet
- Department of Anaesthesia and Intensive Care, Femme Mère Enfant Hospital, Hospices Civils de Lyon, Bron, France
| | - J-F Payen
- Department of Anaesthesia and Intensive Care, Grenoble-Alpes University Hospital, Grenoble, France
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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: 73] [Impact Index Per Article: 36.5] [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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10
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Moake MM, Presley BC, Hill JG, Wolf BJ, Kane ID, Busch CE, Jackson BF. Point-of-Care Ultrasound to Assess Gastric Content in Pediatric Emergency Department Procedural Sedation Patients. Pediatr Emerg Care 2022; 38:e178-e186. [PMID: 32769837 PMCID: PMC7854775 DOI: 10.1097/pec.0000000000002198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES There is debate regarding the timing of procedural sedation and analgesia (PSA) in relation to fasting status. Point-of-care ultrasound (POCUS) provides the ability to measure gastric content and is being used as a surrogate for aspiration risk in anesthesia. We sought to evaluate the gastric content of pediatric emergency department (PED) patients undergoing PSA using POCUS. METHODS We performed a prospective observational study using a convenience sample of pediatric patients undergoing PSA between July 1, 2018, and June 30, 2019. Following a brief history, gastric content was measured using POCUS in both supine and right lateral decubitus positions at 2-hour intervals until the time of PSA. Qualitative content and calculated volume were classified based on the Perlas Model of anesthesia "Risk" assessment. RESULTS Ninety-three patients were enrolled with 61.3% male and mean age of 6.5 years. Gastric content was determined in 92 patients. There were 79.3% that had "high risk" content at the time of PSA, with a median fasting time of 6.25 hours and no serious adverse events. Fasting duration had a weak to moderate ability to predict "risk" category (area under the curve = 0.73), with no patient (n = 17) who underwent multiple evaluations awaiting PSA progressing from "high" to "low risk." CONCLUSIONS The majority of PED patients undergoing PSA at our institution had "high risk" gastric content with no clinically significant change occurring during serial evaluations. This calls into question the utility of delaying PSA based upon fasting status and lends support to a more comprehensive risk-benefit approach when planning pediatric PSA.
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Affiliation(s)
| | | | | | - Bethany J Wolf
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Ian D Kane
- From the Department of Pediatric Emergency Medicine
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11
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Evain JN, Durand Z, Dilworth K, Sintzel S, Courvoisier A, Mortamet G, Desgranges FP, Bouvet L, Payen JF. Assessing gastric contents in children before general anesthesia for acute extremity fracture: An ultrasound observational cohort study. J Clin Anesth 2021; 77:110598. [PMID: 34801888 DOI: 10.1016/j.jclinane.2021.110598] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 11/08/2021] [Accepted: 11/10/2021] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE Children with acute extremity fractures are commonly considered to be at risk of pulmonary aspiration of gastric contents during the induction of anesthesia. This study aimed to evaluate the proportion of such children with high-risk gastric contents using preoperative gastric ultrasound. DESIGN Prospective observational cohort study. SETTING Specialist pediatric center over a 30-month period. PATIENTS Children undergoing surgery within 24 h of an acute extremity fracture. INTERVENTIONS None. MEASUREMENTS According to preoperative qualitative and quantitative ultrasound analysis of the antrum in the supine and right lateral decubitus positions, gastric contents were classified as high-risk (clear liquid with calculated gastric fluid volume > 0.8 mL.kg-1, thick liquid, or solid) or low-risk. Factors associated with high-risk gastric contents were identified by multivariable analysis. MAIN RESULTS Forty-one children (37%; 95% CI: 28-47) of the 110 studied (mean(SD) age: 10(3) years) presented with high-risk gastric contents, including 26 (24%; 95% CI: 16-33) with solids/thick liquid contents. Scanning in the supine position alone allowed a diagnosis of high-risk gastric contents in 23 children out of the 63 for whom right lateral decubitus positioning was unfeasible. Gastric contents remained undetermined in 41 children, including one with a non-contributory gastric US (antrum non-visualized). Proximal limb fractures (OR: 2.5; 95% CI: 1.0-6.2), preoperative administration of opioids (OR: 3.9; 95% CI: 1.1-13), and the absence of bowel sounds (OR: 8.0; 95% CI: 1.4-44) were associated with high-risk gastric contents. Performing surgery the day following the trauma was a protective factor (OR: 0.1; 95% CI: 0.0-0.6). No cases of pulmonary aspiration occurred. CONCLUSIONS At least one-third of children with an acute isolated extremity fracture had preoperative gastric contents identified as high risk for pulmonary aspiration. Although preoperative history can guide anesthetic strategy in this population, ultrasound allowed clear stratification of the risk of aspiration in most cases.
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Affiliation(s)
- Jean-Noël Evain
- Department of Anesthesia and Intensive Care, Grenoble-Alpes University Hospital, CS 10217, 38043 Grenoble Cedex 9, France.
| | - Zoé Durand
- Department of Anesthesia and Intensive Care, Grenoble-Alpes University Hospital, CS 10217, 38043 Grenoble Cedex 9, France
| | - Kelly Dilworth
- Department of Anesthesia and Intensive Care, Grenoble-Alpes University Hospital, CS 10217, 38043 Grenoble Cedex 9, France
| | - Sarah Sintzel
- Department of Anesthesia and Intensive Care, Grenoble-Alpes University Hospital, CS 10217, 38043 Grenoble Cedex 9, France
| | - Aurélien Courvoisier
- Department of Pediatric Surgery, Grenoble-Alpes University Hospital, CS 10217, 38043 Grenoble Cedex 9, France
| | - Guillaume Mortamet
- Pediatric Intensive Care Unit, Grenoble-Alpes University Hospital, CS 10217, 38043 Grenoble Cedex 9, France
| | - François-Pierrick Desgranges
- Department of Anesthesia, L'Hôpital Nord-Ouest, Villefranche sur Saône Hospital, 69655 Villefranche sur Saône, France
| | - Lionel Bouvet
- Department of Anesthesia and Intensive Care, Hospital Woman Mother Child, Hospices Civils de Lyon, 59 Boulevard Pinel, 69500 Bron, France
| | - Jean-François Payen
- Department of Anesthesia and Intensive Care, Grenoble-Alpes University Hospital, CS 10217, 38043 Grenoble Cedex 9, France
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12
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Bouvet L, Zieleskiewicz L, Hamada SR. Point-of-care gastric ultrasound: An essential tool for an individualised management in anaesthesia and critical care. Anaesth Crit Care Pain Med 2021; 40:100984. [PMID: 34763143 DOI: 10.1016/j.accpm.2021.100984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Lionel Bouvet
- Service d'anesthésie réanimation, Groupement Hospitalier Est, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, and APCSe VetAgro Sup UP 2021.A101, France.
| | - Laurent Zieleskiewicz
- Service d'anesthésie réanimation, Hôpital Nord, AP-HM, Marseille, Aix Marseille Université, C2VN, France
| | - Sophie R Hamada
- Service d'anesthésie réanimation, Hôpital Européen Georges Pompidou APHP, Université de Paris, and CESP, INSERM U 10-18, Université Paris-Saclay, France
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13
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Zdravkovic M, Berger-Estilita J, Kovacec JW, Sorbello M, Mekis D. A way forward in pulmonary aspiration incidence reduction: ultrasound, mathematics, and worldwide data collection. Braz J Anesthesiol 2021; 73:301-304. [PMID: 34102227 DOI: 10.1016/j.bjane.2021.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/26/2021] [Accepted: 05/08/2021] [Indexed: 12/20/2022] Open
Abstract
Aspiration of gastric contents during induction of general anesthesia remains a significant cause of mortality and morbidity in anesthesia. Recent data show that pulmonary aspiration still accounts for many cases with implications on mortality despite technical and technological evolution. Practical, ethical, and methodological issues prevent high-quality research in the setting of aspiration and rapid sequence induction/intubation, and significant controversy is ongoing. Patients' position, drugs choice, dosing and timing, use of cricoid force, and a reliable risk assessment are widely debated with significant questions still unanswered. We focus our discussion on three approaches to promote a better understanding of rapid sequence induction/intubation and airway management decision-making. Firstly, we review how we can use qualitative and quantitative assessment of fasting status and gastric content with the point-of-care ultrasound as an integral part of preoperative evaluation and planning. Secondly, we propose using imaging-based mathematical models to study different patient positions and aspiration mechanisms, including identifying aspiration triggers. Thirdly, we promote the development of a global data collection system aiming to obtain precise epidemiological data. Therefore, we fill the gap between evidence-based medicine and experts' opinion through easily accessible and diffused computer-based databases. A better understanding of aspiration epidemiology obtained through focused global data gathering systems, the widespread use of ultrasound-based prandial status evaluation, and development of advanced mathematical models might potentially guide safer airway management decision making in the 21st century.
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Affiliation(s)
- Marko Zdravkovic
- University of Ljubljana, Faculty of Medicine, Ljubljana, Slovenia; University Medical Centre Maribor, Intensive Care and Pain Management, Department of Anaesthesiology, Maribor, Slovenia
| | - Joana Berger-Estilita
- University of Bern, Inselspital Bern University Hospital, Department of Anaesthesiology and Pain Medicine, Bern, Switzerland.
| | - Jozica Wagner Kovacec
- University Medical Centre Maribor, Intensive Care and Pain Management, Department of Anaesthesiology, Maribor, Slovenia
| | | | - Dusan Mekis
- University Medical Centre Maribor, Intensive Care and Pain Management, Department of Anaesthesiology, Maribor, Slovenia
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14
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Haskins SC, Bronshteyn Y, Perlas A, El-Boghdadly K, Zimmerman J, Silva M, Boretsky K, Chan V, Kruisselbrink R, Byrne M, Hernandez N, Boublik J, Manson WC, Hogg R, Wilkinson JN, Kalagara H, Nejim J, Ramsingh D, Shankar H, Nader A, Souza D, Narouze S. American Society of Regional Anesthesia and Pain Medicine expert panel recommendations on point-of-care ultrasound education and training for regional anesthesiologists and pain physicians-part I: clinical indications. Reg Anesth Pain Med 2021; 46:1031-1047. [PMID: 33632778 DOI: 10.1136/rapm-2021-102560] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 02/04/2021] [Indexed: 12/20/2022]
Abstract
Point-of-care ultrasound (POCUS) is a critical skill for all regional anesthesiologists and pain physicians to help diagnose relevant complications related to routine practice and guide perioperative management. In an effort to inform the regional anesthesia and pain community as well as address a need for structured education and training, the American Society of Regional Anesthesia and Pain Medicine (ASRA) commissioned this narrative review to provide recommendations for POCUS. The guidelines were written by content and educational experts and approved by the Guidelines Committee and the Board of Directors of the ASRA. In part I of this two-part series, clinical indications for POCUS in the perioperative and chronic pain setting are described. The clinical review addresses airway ultrasound, lung ultrasound, gastric ultrasound, the focus assessment with sonography for trauma examination and focused cardiac ultrasound for the regional anesthesiologist and pain physician. It also provides foundational knowledge regarding ultrasound physics, discusses the impact of handheld devices and finally, offers insight into the role of POCUS in the pediatric population.
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Affiliation(s)
- Stephen C Haskins
- Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA .,Anesthesiology, Weill Cornell Medical College, New York, New York, USA
| | - Yuriy Bronshteyn
- Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Anahi Perlas
- Anesthesiology and Pain Management, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Joshua Zimmerman
- Anesthesiology, University of Utah Health, Salt Lake City, Utah, USA
| | - Marcos Silva
- Anesthesiology and Pain Management, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Karen Boretsky
- Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Vincent Chan
- Anesthesiology and Pain Management, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Melissa Byrne
- Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Nadia Hernandez
- Anesthesiology, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jan Boublik
- Anesthesiology, Stanford Hospital and Clinics, Stanford, California, USA
| | - William Clark Manson
- Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Rosemary Hogg
- Anaesthesia, Belfast Health and Social Care Trust, Belfast, UK
| | - Jonathan N Wilkinson
- Intensive Care and Anaesthesia, Northampton General Hospital, Northampton, Northamptonshire, UK
| | | | - Jemiel Nejim
- Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA.,Anesthesiology, Weill Cornell Medical College, New York, New York, USA
| | - Davinder Ramsingh
- Anesthesiology, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Hariharan Shankar
- Anesthesiology, Clement Zablocki VA Medical Center/Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Antoun Nader
- Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dmitri Souza
- Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
| | - Samer Narouze
- Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
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15
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Zdravkovic M, Rice MJ, Brull SJ. The Clinical Use of Cricoid Pressure: First, Do No Harm. Anesth Analg 2021; 132:261-267. [PMID: 31397697 DOI: 10.1213/ane.0000000000004360] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Application of cricoid pressure (CP) during rapid sequence induction and intubation sequence has been a "standard" of care for many decades, despite limited scientific proof of its efficacy in preventing pulmonary aspiration of gastric contents. While some of the current rapid sequence induction and intubation guidelines recommend its use, other international guidelines do not, and many clinicians argue that there is insufficient evidence to either continue or abandon its use. Recently published articles and accompanying editorials have reignited the debate on the efficacy and safety of CP application and have generated multiple responses that pointed out the various (and significant) limitations of the available evidence. Thus, a critical discussion of available data must be undertaken before making a final clinical decision on such an important patient safety issue. In this review, the authors will take an objective look at the available scientific evidence about the effectiveness and safety of CP in patients at risk of pulmonary aspiration of gastric contents. We suggest that current data are inadequate to impose clinical guidelines on the use of CP because we acknowledge that currently there is not, and there may never be, a method to prevent aspiration in all patients. In addition, we reiterate that a universally accepted medical-legal standard for approaching the high-risk aspiration patient does not exist, discuss the differences in practice between the US and international practitioners regarding use of CP, and propose 5 recommendations on how future studies might be designed to obtain optimal scientific evidence about the effectiveness and safety of CP in patients at risk for pulmonary aspiration.
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Affiliation(s)
- Marko Zdravkovic
- From the Department of Anaesthesiology, Intensive Care and Pain Management, University Medical Centre Maribor, Maribor, Slovenia.,Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Mark J Rice
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sorin J Brull
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Jacksonville, Florida
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16
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Abstract
Children have unique characteristics that make them particularly vulnerable to perioperative adverse events. Skilled airway management is a cornerstone of high-quality anesthetic management. The use of hybrid airway techniques is a critical tool for the pediatric anesthesiologist. Point-of-care ultrasonography has an expanding role in airway management, from preoperative assessment of airway pathology and gastric contents to confirmation of tracheal intubation and identification of the cricothyroid membrane. The exciting fields of 3-dimensional printing, artificial intelligence, and machine learning are areas of innovation that will transform pediatric difficult airway management in years to come.
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Affiliation(s)
- Grace Hsu
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, Suite M905, Philadelphia, PA 19104, USA.
| | - John E Fiadjoe
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, Suite M905, Philadelphia, PA 19104, USA. https://twitter.com/Jef042
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17
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Abstract
Gastric ultrasound (US) is a growing modality within the point-of-care ultrasound (POCUS) field. It provides the ability to directly measure an individual patient's gastric content and has potential use as both a clinical and a research tool. Here, we review the historical development of current gastric US models and their clinical application within the field of general anesthesia, describe the US findings and technique for using POCUS to assess gastric content, and discuss the current and potential applications of gastric POCUS within the emergency department.
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18
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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: 17] [Impact Index Per Article: 4.3] [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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19
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Vernieuwe L, Van de Putte P, Deen J, Bouchez S. Focus on PoCUS or hocus pocus? Integrating point-of-care ultrasound into residency and clinical practice. ACTA ANAESTHESIOLOGICA BELGICA 2020. [DOI: 10.56126/71.2.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Point-of care ultrasound (PoCUS) is a new clinical diagnostic paradigm that plays an instrumental role in the ongoing anesthesiologist’s evolving role towards a perioperative physician. Currently, there are few approved curricula that incorporate a PoCUS program into anesthesia residency. This article examines relevant PoCUS applications for anesthesiologists, presents an overview of existing international guidelines for education and training, and reflects on the need for specialty-wide standards. We present a possible framework, that could offer a first move towards a structured PoCUS pathway for Belgian anesthesia residents and facilitate its incorporation into national anesthesia practice.
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20
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Desgranges F, Chassard D, Bouvet L. Antral area in the semi‐recumbent position to identify a stomach at risk of pulmonary aspiration in the adult non‐pregnant patient. Anaesthesia 2020; 75:694. [DOI: 10.1111/anae.15017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
| | - D. Chassard
- Hospices Civils de Lyon Femme Mère Enfant Teaching Hospital Lyon France
| | - L. Bouvet
- Hospices Civils de Lyon Femme Mère Enfant Teaching Hospital Lyon France
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21
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Zhang YL, Li H, Zeng H, Li Q, Qiu LP, Dai RP. Ultrasonographic evaluation of gastric emptying after ingesting carbohydrate-rich drink in young children: A randomized crossover study. Paediatr Anaesth 2020; 30:599-606. [PMID: 32162448 DOI: 10.1111/pan.13853] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 02/26/2020] [Accepted: 03/08/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND A recent consensus statement in Europe has suggested that the fasting time for clear liquid in children can be shortened to 1 hour before a surgery. However, the study to show that 1-hour fasting time for clear fluids is safe in young children is still lacking. This study aimed to investigate the gastric emptying time for carbohydrate-rich drink and regular 5% glucose solution in children aged 3-7 years. METHODS After overnight fasting, individuals were randomly assigned to ingest 5 mL kg-1 of either carbohydrate-rich drink or 5% glucose solution. One week later, the same subjects were asked to ingest the other one. Ultrasonography was performed to examine the gastric contents. Gastric antral cross-sectional area was measured, and the gastric fluid volume was calculated before and after fluid ingestion within 120 minutes. The primary outcome was the gastric emptying time for both the clear fluids calculated using the antral cross-sectional area and logarithms of gastric fluid volume. The degrees of thirst and hunger of two drinks were evaluated using a visual analogue scale as the secondary outcomes. RESULTS Data from 16 individuals were analyzed. In the glucose solution group, the antral cross-sectional area and logarithms of gastric fluid volume returned to baseline at 30 minutes after ingestion. However, in the carbohydrate-rich drink group, the median [interquartile range; range] antral cross-sectional area (3.69 [2.64-5.15; 1.83-8.93] cm2 vs 2.41 [2.10-2.96; 1.81-4.37] cm2 , P < .001) and mean (95% confidence interval) logarithms of gastric fluid volume (2.54 [2.30-2.79] mL vs 2.12 [1.94-2.30] mL, P = .048) were still higher than at 60 minutes and returned to the baseline values at 90 minutes after ingestion, respectively. The degree of thirst was lower in the glucose solution group than that in the carbohydrate-rich drink group. CONCLUSIONS Gastric emptying of carbohydrate-rich drink is slower than that of 5% glucose solution but the residual gastric fluid volume is low one hour after ingestion of 5 mL kg-1 of either fluid.
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Affiliation(s)
- Yan-Ling Zhang
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Hui Li
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Hua Zeng
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Qiao Li
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Li-Ping Qiu
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Ru-Ping Dai
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, China.,Anesthesia Medical Research Centre, Central South University, Changsha, China
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22
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Stein ML, Park RS, Kovatsis PG. Emerging trends, techniques, and equipment for airway management in pediatric patients. Paediatr Anaesth 2020; 30:269-279. [PMID: 32022437 DOI: 10.1111/pan.13814] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/24/2019] [Accepted: 12/28/2019] [Indexed: 12/21/2022]
Abstract
Pediatric patients present unique anatomic and physiologic considerations in airway management, which impose significant physiologic limits on safe apnea time before the onset of hypoxemia and subsequent bradycardia. These issues are even more pronounced for the pediatric difficult airway. In the last decade, the development of pediatric sized supraglottic airways specifically designed for intubation, as well as advances in imaging technology such that current pediatric airway equipment now finally rival those for the adult population, has significantly expanded the pediatric anesthesiologist's tool kit for pediatric airway management. Equally important, techniques are increasingly implemented that maintain oxygen delivery to the lungs, safely extending the time available for pediatric airway management. This review will focus on emerging trends and techniques using existing tools to safely handle the pediatric airway including videolaryngoscopy, combination techniques for intubation, techniques for maintaining oxygenation during intubation, airway management in patients at risk for aspiration, and considerations in cannot intubate cannot oxygenate scenarios.
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Affiliation(s)
- Mary Lyn Stein
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Raymond S Park
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Pete G Kovatsis
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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23
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Okada Y, Toyama H, Kamata K, Yamauchi M. A clinical study comparing ultrasound-measured pyloric antrum cross-sectional area to computed tomography-measured gastric content volume to detect high-risk stomach in supine patients undergoing emergency abdominal surgery. J Clin Monit Comput 2019; 34:875-881. [DOI: 10.1007/s10877-019-00438-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 11/28/2019] [Indexed: 10/25/2022]
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24
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Bouvet L, Zieleskiewicz L, Loubradou E, Alain A, Morel J, Argaud L, Chassard D, Leone M, Allaouchiche B. Reliability of gastric suctioning compared with ultrasound assessment of residual gastric volume: a prospective multicentre cohort study. Anaesthesia 2019; 75:323-330. [DOI: 10.1111/anae.14915] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2019] [Indexed: 12/28/2022]
Affiliation(s)
- L. Bouvet
- Department of Anaesthesia and Intensive Care Hospices Civils de Lyon Hôpital Femme Mère Enfant Lyon France
- Department of Anaesthesia and Intensive Care APCSe VetAgro Sup UPSP 2016.A101 Marcy‐l'Etoile France
| | - L. Zieleskiewicz
- Department of Anaesthesia and Intensive Care Hôpital Nord Assistance Publique –Hôpitaux de Marseille Marseille France
| | - E. Loubradou
- Department of Anaesthesia and Intensive Care Hospices Civils de Lyon Hôpital Femme Mère Enfant Lyon France
| | - A. Alain
- Department of Anaesthesia and Intensive Care Hôpital Nord Assistance Publique –Hôpitaux de Marseille Marseille France
| | - J. Morel
- Department of Anaesthesia and Intensive Care Centre Hospitalier Universitaire de Saint‐Étienne Saint‐Étienne France
| | - L. Argaud
- Department of Anaesthesia and Intensive Care Civils de Lyon Groupement Hospitalier Centre Lyon France
| | - D. Chassard
- Department of Anaesthesia and Intensive Care Hospices Civils de Lyon Hôpital Femme Mère Enfant Lyon France
- Department of Anaesthesia and Intensive Care APCSe VetAgro Sup UPSP 2016.A101 Marcy‐l'Etoile France
| | - M. Leone
- Department of Anaesthesia and Intensive Care Hôpital Nord Assistance Publique –Hôpitaux de Marseille Marseille France
| | - B. Allaouchiche
- Department of Anaesthesia and Intensive Care APCSe VetAgro Sup UPSP 2016.A101 Marcy‐l'Etoile France
- Department of Anaesthesia and Intensive Care Hospices Civils de Lyon Groupement Hospitalier Sud Pierre‐Bénite Cedex France
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25
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Zdravkovic M, Berger‐Estilita J, Sorbello M, Hagberg CA. An international survey about rapid sequence intubation of 10,003 anaesthetists and 16 airway experts. Anaesthesia 2019; 75:313-322. [DOI: 10.1111/anae.14867] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2019] [Indexed: 12/14/2022]
Affiliation(s)
- M. Zdravkovic
- Department of Anaesthesiology, Intensive Care and Pain Management University Medical Centre Maribor Maribor Slovenia
- Faculty of Medicine University of Maribor Maribor Slovenia
| | - J. Berger‐Estilita
- Department of Anaesthesiology and Pain Medicine, Inselspital Bern University Hospital Bern Switzerland
| | - M. Sorbello
- Department of Anesthesia and Intensive Care AOU Policlinico Vittorio Emanuele Catania Italy
| | - C. A. Hagberg
- Department of Anesthesiology, Critical Care and Pain Medicine University of Texas MD Anderson Cancer Center Houston TX USA
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26
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27
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Bouvet L, Barnoud S, Desgranges F, Chassard D. Effect of body position on qualitative and quantitative ultrasound assessment of gastric fluid contents. Anaesthesia 2019; 74:862-867. [DOI: 10.1111/anae.14664] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2019] [Indexed: 02/02/2023]
Affiliation(s)
- L. Bouvet
- Department of Anaesthesia and Intensive Care Hospices Civils de Lyon Hôpital Femme Mère Enfant Lyon France
- Department of Anaesthesia University of Lyon Université Claude Bernard Lyon 1 Centre Léon Bérard INSERM LabTAU UMR1032 Lyon France
| | - S. Barnoud
- Department of Anaesthesia and Intensive Care Hospices Civils de Lyon Hôpital Femme Mère Enfant Lyon France
| | - F.‐P. Desgranges
- Department of Anaesthesia and Intensive Care Hospices Civils de Lyon Hôpital Femme Mère Enfant Lyon France
| | - D. Chassard
- Department of Anaesthesia and Intensive Care Hospices Civils de Lyon Hôpital Femme Mère Enfant Lyon France
- Department of Anaesthesia University of Lyon Université Claude Bernard Lyon 1 Villeurbanne France
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28
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Desgranges FP, Chassard D, Bouvet L. Pre-operative gum chewing: forbidden, allowed or recommended. Anaesthesia 2019; 74:539. [DOI: 10.1111/anae.14616] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- F.-P. Desgranges
- Hospices Civils de Lyon; Femme Mère Enfant Teaching Hospital; Lyon France
| | - D. Chassard
- Hospices Civils de Lyon; Femme Mère Enfant Teaching Hospital; Lyon France
| | - L. Bouvet
- Hospices Civils de Lyon; Femme Mère Enfant Teaching Hospital; Lyon France
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Schmitz A, Schmidt AR. Can we use ultrasound examination of gastric content as a diagnostic test in clinical anaesthesia? Paediatr Anaesth 2019; 29:112-113. [PMID: 30724017 DOI: 10.1111/pan.13555] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Achim Schmitz
- Department of Anaesthesia and Children's Research Center, University Children's Hospital, Zurich, Switzerland
| | - Alexander R Schmidt
- Department of Anaesthesia and Children's Research Center, University Children's Hospital, Zurich, Switzerland
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Charlesworth M, Wiles MD. Pre-operative gastric ultrasound - should we look inside Schrödinger's gut? Anaesthesia 2018; 74:109-112. [DOI: 10.1111/anae.14516] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- M. Charlesworth
- Department of Cardiothoracic Anaesthesia and Intensive Care; Wythenshawe Hospital; Manchester University Hospitals; Manchester UK
| | - M. D. Wiles
- Department of Anaesthesia; Sheffield Teaching Hospitals NHS Foundation Trust; Sheffield UK
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Fawcett WJ, Thomas M. Pre-operative fasting in adults and children: clinical practice and guidelines. Anaesthesia 2018; 74:83-88. [DOI: 10.1111/anae.14500] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2018] [Indexed: 01/26/2023]
Affiliation(s)
- W. J. Fawcett
- Department of Anaesthesia; Royal Surrey County Hospital NHS Foundation Trust; Guildford UK
| | - M. Thomas
- Department of Anaesthesia; Great Ormond Street Hospital for Children; NHS Foundation Trust; London UK
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Ohashi Y, Walker JC, Zhang F, Prindiville FE, Hanrahan JP, Mendelson R, Corcoran T. Preoperative Gastric Residual Volumes in Fasted Patients Measured by Bedside Ultrasound: A Prospective Observational Study. Anaesth Intensive Care 2018; 46:608-613. [DOI: 10.1177/0310057x1804600612] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The purpose of this prospective observational study was to measure gastric volumes in fasted patients using bedside gastric ultrasound. Patients presenting for non-emergency surgery underwent a gastric antrum assessment, using the two-diameter and free-trace methods to determine antral cross-sectional area. Gastric residual volume (GRV) was calculated using a validated formula. Univariate and multivariable analyses were performed to examine any potential relationships between ‘at risk’ GRVs (>100 ml) and patient factors. Two hundred and twenty-two successful scans were performed; of these 110 patients (49.5%) had an empty stomach, nine patients (4.1%) had a GRV >100 ml, and a further six patients (2.7%) had a GRV >1.5 ml/kg. There was no significant relationship between ‘at risk’ GRV and obesity, diabetes mellitus, gastro-oesophageal reflux disease or opioid use, although our study had insufficient power to exclude an influence of one or more of these factors. Our results indicate that despite compliance with fasting guidelines, a small percentage of patients still have GRVs that pose a pulmonary aspiration risk. Anaesthetists should consider this background incidence when choosing anaesthesia techniques for their patients. While future observational studies are required to determine the role of preoperative bedside gastric ultrasound, it is possible that this technique may assist anaesthetists in identifying patients with ‘at risk’ GRVs.
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Affiliation(s)
- Y. Ohashi
- Department of Anaesthesia and Pain Medicine, Fiona Stanley Fremantle Hospitals Group, Perth, Western Australia
| | - J. C. Walker
- Consultant Anaesthetist, Anaesthetic Department, Royal Bournemouth Hospital, Bournemouth, United Kingdom
| | - F. Zhang
- Department of Radiology, Sir Charles Gairdner Hospital, Perth, Western Australia
| | - F. E. Prindiville
- Sonographer, Department of Imaging Services, Royal Perth Hospital, Perth, Western Australia
| | - J. P. Hanrahan
- General Practitioner, Queens Park Medical Centre, Perth, Western Australia
| | - R. Mendelson
- Emeritus Consultant Radiologist, Department of Diagnostic and Interventional Radiology, Royal Perth Hospital; Clinical Professor, University of Western Australia; Adjunct Professor, Notre Dame University; Perth, Western Australia
| | - T. Corcoran
- Director of Research, Department of Anaesthesia and Pain Medicine, Royal Perth Hospital; Clinical Professor, School of Medicine and Pharmacology, University of Western Australia; Raine Clinical Research Fellow, Raine Foundation/WA Health Department; Adjunct Clinical Professor, School of Public Health and Preventive Medicine, Monash University Australia; Perth, Western Australia
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Bouvet L, Bellier N, Gagey-Riegel AC, Desgranges FP, Chassard D, De Queiroz Siqueira M. Ultrasound assessment of the prevalence of increased gastric contents and volume in elective pediatric patients: A prospective cohort study. Paediatr Anaesth 2018; 28:906-913. [PMID: 30207013 DOI: 10.1111/pan.13472] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 07/24/2018] [Accepted: 07/30/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Though pulmonary aspiration of gastric contents occurs mainly in the setting of emergency surgery, it may also occur in children scheduled for elective surgery without any obvious clinical risk factor. Increased gastric content volume is one the predisposing factors for pulmonary aspiration that could affect such children and may be identified using ultrasound examination of the gastric antrum. AIMS We aimed to assess the prevalence of "at-risk stomach" defined by ultrasound visualization of any solid content in the antrum and/or by calculated gastric fluid volume > 1.25 mL/kg, in children scheduled for elective surgery. METHODS Children scheduled for elective surgery were consecutively included into this prospective cohort study. Preoperative ultrasound examination of the antrum was performed in both the supine and the right lateral decubitus positions. Gastric fluid content was assessed using a 0-2 qualitative grading scale. The antral cross-sectional area was also measured in both the supine and the right lateral decubitus positions, allowing the calculation of the gastric fluid volume according to a formula previously described. RESULTS We analyzed 200 elective children. Median duration of fasting was 4 hours for liquids and >13 hours for solids. None of the children included in this study had evidence of solid content. Six (3%) children had a Grade 2 antrum (fluid content seen in both the supine and the right lateral decubitus positions). Two children had a gastric fluid volume >1.25 mL/kg. The prevalence of "at-risk stomach" was 1% (95% confidence interval: 0.2%-3.9%). CONCLUSION According to our results, only 1% of elective children had potentially increased risk for pulmonary aspiration. Further studies should be performed in order to define the target population of elective children for which ultrasound assessment of gastric content should be performed prior to general anesthesia.
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Affiliation(s)
- Lionel Bouvet
- Department of Anesthesia and Intensive Care, Hospices Civils de Lyon, Femme Mère Enfant Hospital, Bron, France.,INSERM, LabTAU UMR1032, University of Lyon, Université Claude Bernard Lyon 1, Centre Léon Bérard, Lyon, France
| | - Nicolas Bellier
- Department of Anesthesia and Intensive Care, Hospices Civils de Lyon, Femme Mère Enfant Hospital, Bron, France
| | - Anne-Charlotte Gagey-Riegel
- Department of Anesthesia and Intensive Care, Hospices Civils de Lyon, Femme Mère Enfant Hospital, Bron, France
| | - François-Pierrick Desgranges
- Department of Anesthesia and Intensive Care, Hospices Civils de Lyon, Femme Mère Enfant Hospital, Bron, France.,University of Lyon, Université Claude Bernard Lyon 1, Villeurbanne, France
| | - Dominique Chassard
- Department of Anesthesia and Intensive Care, Hospices Civils de Lyon, Femme Mère Enfant Hospital, Bron, France.,University of Lyon, Université Claude Bernard Lyon 1, Villeurbanne, France
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Choi SW, Wong GTC. The art and science of statistical predictions: does a picture need a thousand words? Anaesthesia 2018; 73:784-787. [DOI: 10.1111/anae.14282] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- S. W. Choi
- Department of Anaesthesiology; University of Hong Kong; Hong Kong HKSAR
| | - G. T. C. Wong
- Department of Anaesthesiology; Queen Mary Hospital; Hong Kong HKSAR
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Van de Putte P, Perlas A. The link between gastric volume and aspiration risk. In search of the Holy Grail? Anaesthesia 2017; 73:274-279. [DOI: 10.1111/anae.14164] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- P. Van de Putte
- Department of Anaesthesiology; AZ Monica, campus Deurne; Deurne Belgium
- Department of Anaesthesiology; UMC Radboud; Nijmegen the Netherlands
| | - A. Perlas
- Department of Anaesthesia and Pain Management; Toronto Western Hospital; University Health Network; University of Toronto; Toronto, ON Canada
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