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Disma N, Frykholm P. Clear rules for clear fluids fasting in children. Br J Anaesth 2024; 132:18-20. [PMID: 37996274 DOI: 10.1016/j.bja.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 11/02/2023] [Accepted: 11/05/2023] [Indexed: 11/25/2023] Open
Abstract
Preoperative fasting guidelines published in 2022 by the European Society of Anaesthesiology and Intensive Care represent a paradigm shift in the preoperative preparation of children undergoing general anaesthesia. Schmitz and colleagues report the results from a multi-institutional prospective cohort study to determine if application of the recent guidelines increased the risk of regurgitation and pulmonary aspiration. This study provides support for the concept of reducing real fasting times by allowing clear fluids until 1 h before induction of anaesthesia. Although the study cohort was large, further prospective multicentre studies with even greater sample sizes are warranted to provide definitive evidence for the safety of the new fasting rules.
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Affiliation(s)
- Nicola Disma
- Unit for Research in Anaesthesia, Department of Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy.
| | - Peter Frykholm
- Department of Surgical Sciences, Section of Anaesthesiology and Intensive Care Medicine, Uppsala University, Uppsala, Sweden
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2
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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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3
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Zhang E, Hauser N, Sommerfield A, Sommerfield D, von Ungern‐Sternberg BS. A review of pediatric fasting guidelines and strategies to help children manage preoperative fasting. Paediatr Anaesth 2023; 33:1012-1019. [PMID: 37533337 PMCID: PMC10947285 DOI: 10.1111/pan.14738] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/21/2023] [Accepted: 07/24/2023] [Indexed: 08/04/2023]
Abstract
Fasting for surgery is a routine step in the preoperative preparation for surgery. There have however been increasing concerns with regard to the high incidence of prolonged fasting in children, and the subsequent psycho-social distress and physiological consequences that this poses. Additionally, the past few years have yielded new research that has shown significant inter-individual variation in gastric emptying regardless of the length of the fast, with some patients still having residual gastric contents even after prolonged fasts. Additionally, multiple large-scale studies have shown no long-term sequalae from clear fluid aspiration, although two deaths from aspiration have been reported within the large Wake Up Safe cohort. This has led to a change in the recommended clear fluid fasting times in multiple international pediatric societies; similarly, many societies continue to recommend traditional fasting times. Multiple fasting strategies exist in the literature, though these have mostly been studied and implemented in the adult population. This review hopes to summarize the recent updates in fasting guidelines, discuss the issues surrounding prolonged fasting, and explore potential tolerance strategies for children.
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Affiliation(s)
- Eileen Zhang
- Department of Anaesthesia and Pain MedicinePerth Children's HospitalPerthWestern AustraliaAustralia
| | - Neil Hauser
- Department of Anaesthesia and Pain MedicinePerth Children's HospitalPerthWestern AustraliaAustralia
- Perioperative Medicine Team, Perioperative Care ProgramTelethon Kids InstitutePerthWestern AustraliaAustralia
- Division of Emergency Medicine, Anaesthesia and Pain MedicineThe University of Western AustraliaPerthWestern AustraliaAustralia
| | - Aine Sommerfield
- Department of Anaesthesia and Pain MedicinePerth Children's HospitalPerthWestern AustraliaAustralia
- Perioperative Medicine Team, Perioperative Care ProgramTelethon Kids InstitutePerthWestern AustraliaAustralia
| | - David Sommerfield
- Department of Anaesthesia and Pain MedicinePerth Children's HospitalPerthWestern AustraliaAustralia
- Perioperative Medicine Team, Perioperative Care ProgramTelethon Kids InstitutePerthWestern AustraliaAustralia
- Division of Emergency Medicine, Anaesthesia and Pain MedicineThe University of Western AustraliaPerthWestern AustraliaAustralia
| | - Britta S. von Ungern‐Sternberg
- Department of Anaesthesia and Pain MedicinePerth Children's HospitalPerthWestern AustraliaAustralia
- Perioperative Medicine Team, Perioperative Care ProgramTelethon Kids InstitutePerthWestern AustraliaAustralia
- Division of Emergency Medicine, Anaesthesia and Pain MedicineThe University of Western AustraliaPerthWestern AustraliaAustralia
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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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5
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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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Aroonpruksakul N, Sangsungnern P, Kiatchai T. Apneic oxygenation with low-flow oxygen cannula for rapid sequence induction and intubation in pediatric patients: a randomized-controlled trial. Transl Pediatr 2022; 11:427-437. [PMID: 35558969 PMCID: PMC9085956 DOI: 10.21037/tp-21-484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 02/24/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Classical rapid sequence induction and intubation (RSII) is used to reduce pulmonary aspiration, but it increases the risk of hypoxemia. Apneic oxygenation (ApOx) has been studied to prolong safe apneic time, and to decrease the incidence of hypoxemia in adults. The aim of this study was to investigate the effectiveness of ApOx via low-flow nasal cannula to reduce the incidence of hypoxemia in pediatric rapid sequence induction. METHODS This prospective single-blind randomized controlled trial included patients aged 0-7 years, American Society of Anesthesiologists (ASA) physical status 1 to 3, who underwent elective or emergency surgery under general anesthesia with rapid sequence induction during February 2020 to March 2021. Participants were randomized to the ApOx group or the classical rapid sequence induction group. The ApOx group received oxygen flow via regular nasal cannula, as follows: 1 liter per minute (LPM) in age 0-1 month, 2 LPM in age 1-12 months, and 4 LPM in age 1-7 years. The classical group did not receive oxygen supplementation during intubation. The primary outcome was the incidence of hypoxemia, defined as oxygen saturation (SpO2) ≤92%. RESULTS Sixty-four participants were recruited. The incidence of hypoxemia in both groups was 8 of 32 participants (25%) (P=1.000). Among desaturated patients, the median time to desaturation was 29.5 and 35 seconds in the ApOx and classical groups, respectively (P=0.527). The median lowest SpO2 was 91% and 88.5% in the ApOx and classical groups, respectively (P=0.079). In non-desaturated patients, the median time to successful intubation was 40.5 and 35.5 seconds in the ApOx and classical groups, respectively (P=0.069). CONCLUSIONS In this small sample study, ApOx using age-adjusted low-flow nasal cannula was ineffective for reducing the incidence of hypoxemia in pediatric RSII. TRIAL REGISTRATION Thai Clinical Trials Registry TCTR20210802002.
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Affiliation(s)
- Naiyana Aroonpruksakul
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Peerapong Sangsungnern
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Taniga Kiatchai
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Funakoshi H, Kunitani Y, Goto T, Okamoto H, Hagiwara Y, Watase H, Hasegawa K. Association Between Repeated Tracheal Intubation Attempts and Adverse Events in Children in the Emergency Department. Pediatr Emerg Care 2022; 38:e563-e568. [PMID: 35100759 DOI: 10.1097/pec.0000000000002356] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
STUDY OBJECTIVES Studies have shown that multiple intubation attempts are associated with a higher risk of intubation-related adverse events. However, little is known about the relationship in children in the emergency department (ED). METHODS This is an analysis of the data from 2 prospective, observational, multicenter registries of emergency airway management. The data were collected from consecutive patients who underwent emergency airway management in 19 EDs across Japan from March 2010 to November 2017. We included children 18 years or younger who underwent tracheal intubation in the ED. The primary exposure was the number of intubation attempts (1 vs ≥2). The primary outcome was an adverse event during or immediately after the intubation. RESULTS A total of 439 children were eligible for the analysis. Of 279 children with first-pass success, 24 children (9%) had an adverse event. By contrast, of 160 children with ≥2 intubation attempts, 50 children patients (31%) had an adverse event. In the unadjusted model, multiple intubation attempts were significantly associated with a higher rate of adverse events (unadjusted odds ratio, 4.83; 95% confidence interval, 2.57-9.06; P < 0.001). This association remained significant after adjusting for 7 potential confounders and patient clustering within the hospital (adjusted odds ratio, 4.49; 95% confidence interval, 2.36-8.53; P < 0.001). Similar associations were found across different age groups and among children without cardiac arrest (all, P < 0.05). CONCLUSIONS In this analysis of large prospective multicenter data, multiple intubation attempts were associated with a significantly higher rate of intubation-related adverse events in children in the ED.
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Affiliation(s)
- Hiraku Funakoshi
- From the Department of Emergency and Critical Care Medicine, Tokyobay Urayasu Ichikawa Medical Center, Chiba
| | - Yuri Kunitani
- From the Department of Emergency and Critical Care Medicine, Tokyobay Urayasu Ichikawa Medical Center, Chiba
| | - Tadahiro Goto
- Graduate School of Medical Sciences, University of Fukui, Fukui
| | - Hiroshi Okamoto
- Department of Critical Care Medicine, St. Luke's International Hospital
| | - Yusuke Hagiwara
- Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Hiroko Watase
- Department of Surgery, University of Washington, Seattle, WA
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Pre-operative fasting in children: A guideline from the European Society of Anaesthesiology and Intensive Care. Eur J Anaesthesiol 2022; 39:4-25. [PMID: 34857683 DOI: 10.1097/eja.0000000000001599] [Citation(s) in RCA: 80] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Current paediatric anaesthetic fasting guidelines have recommended conservative fasting regimes for many years and have not altered much in the last decades. Recent publications have employed more liberal fasting regimes with no evidence of increased aspiration or regurgitation rates. In this first solely paediatric European Society of Anaesthesiology and Intensive Care (ESAIC) pre-operative fasting guideline, we aim to present aggregated and evidence-based summary recommendations to assist clinicians, healthcare providers, patients and parents. We identified six main topics for the literature search: studies comparing liberal with conservative regimens; impact of food composition; impact of comorbidity; the use of gastric ultrasound as a clinical tool; validation of gastric ultrasound for gastric content and gastric emptying studies; and early postoperative feeding. The literature search was performed by a professional librarian in collaboration with the ESAIC task force. Recommendations for reducing clear fluid fasting to 1 h, reducing breast milk fasting to 3 h, and allowing early postoperative feeding were the main results, with GRADE 1C or 1B evidence. The available evidence suggests that gastric ultrasound may be useful for clinical decision-making, and that allowing a 'light breakfast' may be well tolerated if the intake is well controlled. More research is needed in these areas as well as evaluation of how specific patient or treatment-related factors influence gastric emptying.
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Hara Y, Hagiwara Y, Inoue N. Effects of the new fasting standard on sedation in the pediatric emergency room. Pediatr Int 2022; 64:e14840. [PMID: 33991157 DOI: 10.1111/ped.14840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/02/2021] [Accepted: 05/11/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND This study compared adherence to the fasting-time guidelines of the International Committee for the Advancement of Procedural Sedation (ICAPS) and the North American Society of Anesthesiologists (ASA) and complication rates in pediatric patients requiring procedure sedation and analgesia during treatment in the emergency room (ER). METHODS This retrospective, single-center study was performed between 2016 and 2020, and enrolled patients who received procedural sedation and analgesia in the ER with the fasting times recommended in the ICAPS and ASA guidelines. RESULTS In total, 857 patients were included. The most frequent indication for procedural sedation and analgesia was fracture reduction in 420 patients (49.0%). Ketamine, the most commonly administered drug, was given to 710 patients (82.8%). Adherence to the ICAPS guidelines was higher (P < 0.01), with 772 (95.7%) and 351 (41.0%) patients, respectively, adhering to the ICAPS and ASA recommendations for food and drink fasting times. Complications occurred in 130 patients (15.2%), including SpO2 <90% in 75 patients (8.7%) and vomiting in 20 patients (2.3%). No serious complications, such as aspiration, cardiac arrest, or death, occurred. The complication rate between the two groups did not differ significantly, with 50 (14.2%) and 127 (15.5%) patients experiencing complications according to the ICAPS and ASA guidelines, respectively (P = 0.586). CONCLUSIONS The fasting recommendations of the ICAPS guidelines, which propose risk stratification to determine the appropriate fasting time for procedural sedation and analgesia, are more tolerable to patients and the rate of adverse events did not appear to be different from that experienced when following the ASA guidelines.
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Affiliation(s)
- Yutaro Hara
- Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Fuchu, Japan
| | - Yusuke Hagiwara
- Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Fuchu, Japan
| | - Nobuaki Inoue
- Department of Human Resources Development, National Center for Global Health and Medicine, Bureau of International Health Cooperation, Shinjuku, Japan
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Revisiting Pediatric NPO Guidelines: a 5-Year Update and Practice Considerations. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00482-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Disma N, Frykholm P, Cook-Sather SD, Lerman J. Pro-Con Debate: 1- vs 2-Hour Fast for Clear Liquids Before Anesthesia in Children. Anesth Analg 2021; 133:581-591. [PMID: 34403386 DOI: 10.1213/ane.0000000000005589] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Perioperative fasting guidelines are designed to minimize the risk of pulmonary aspiration of gastrointestinal contents. The current recommendations from the American Society of Anesthesiologists (ASA) and the European Society of Anaesthesiology and Intensive Care (ESAIC) are for a minimum 2-hour fast after ingestion of clear liquids before general anesthesia, regional anesthesia, or procedural sedation and analgesia. Nonetheless, in children, fasting guidelines also have consequences as regards to child and parent satisfaction, hemodynamic stability, the ability to achieve vascular access, and perioperative energy balance. Despite the fact that current guidelines recommend a relatively short fasting time for clear fluids of 2 hours, the actual duration of fasting time can be significantly longer. This may be the result of deficiencies in communication regarding the duration of the ongoing fasting interval as the schedule changes in a busy operating room as well as to poor parent and patient adherence to the 2-hour guidelines. Prolonged fasting can result in children arriving in the operating room for an elective procedure being thirsty, hungry, and generally in an uncomfortable state. Furthermore, prolonged fasting may adversely affect hemodynamic stability and can result in parental dissatisfaction with the perioperative experience. In this PRO and CON presentation, the authors debate the premise that reducing the nominal minimum fasting time from 2 hours to 1 hour can reduce the incidence of prolonged fasting and provide significant benefits to children, with no increased risks.
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Affiliation(s)
- Nicola Disma
- From the Unit for Research & Innovation, Department of Paediatric Anaesthesia, Istituto Giannina Gaslini, Genova, Italy
| | - Peter Frykholm
- Department of Surgical Sciences, Section of Anaesthesiology and Intensive Care Medicine, Uppsala University, Uppsala, Sweden
| | - Scott D Cook-Sather
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jerrold Lerman
- Department of Anesthesiology, Oishei Children's Hospital, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
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Rüggeberg A, Dubois P, Böcker U, Gerlach H. [Preoperative fluid fasting : Establishment of a liberal fluid regimen using fasting cards]. Anaesthesist 2021; 70:469-475. [PMID: 34106289 DOI: 10.1007/s00101-021-00918-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 12/07/2020] [Accepted: 01/08/2021] [Indexed: 01/01/2023]
Abstract
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.
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Affiliation(s)
- Anne Rüggeberg
- Klinik für Anästhesie, operative Intensivmedizin und Schmerztherapie, Vivantes Klinikum Neukölln, Rudower Str. 48, 12351, Berlin, Deutschland.
| | - Peggy Dubois
- Pflegedirektion, Vivantes Klinikum Neukölln, Berlin, Deutschland
| | - Ulrich Böcker
- Klinik für Innere Medizin, Gastroenterologie, Diabetologie und Hepatologie, Vivantes Klinikum Neukölln, Rudower Straße 48, 12351, Berlin, Deutschland
| | - Herwig Gerlach
- Klinik für Anästhesie, operative Intensivmedizin und Schmerztherapie, Vivantes Klinikum Neukölln, Rudower Str. 48, 12351, Berlin, Deutschland
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Boretsky K. Perioperative Point-of-Care Ultrasound in Children. CHILDREN (BASEL, SWITZERLAND) 2020; 7:E213. [PMID: 33171903 PMCID: PMC7694522 DOI: 10.3390/children7110213] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 10/26/2020] [Accepted: 11/03/2020] [Indexed: 01/09/2023]
Abstract
Anesthesiologists and other acute care physicians perform and interpret portable ultrasonography-point-of-care ultrasound (POCUS)-at a child's bedside, in the perioperative period. In addition to the established procedural use for central line and nerve block placement, POCUS is being used to guide critical clinical decisions in real-time. Diagnostic point-of-care applications most relevant to the pediatric anesthesiologist include lung ultrasound for assessment of endotracheal tube size and position, pneumothorax, pleural effusion, pneumonia, and atelectasis; cardiac ultrasound for global cardiac function and hydration status, and gastric ultrasound for aspiration risk stratification. This article reviews and discusses select literature regarding the use of various applications of point-of-care ultrasonography in the perioperative period.
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Affiliation(s)
- Karen Boretsky
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
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14
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Kars MS, Gomez Morad A, Haskins SC, Boublik J, Boretsky K. Point-of-care ultrasound for the pediatric regional anesthesiologist and pain specialist: a technique review. Reg Anesth Pain Med 2020; 45:985-992. [DOI: 10.1136/rapm-2020-101341] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 08/04/2020] [Accepted: 08/08/2020] [Indexed: 01/11/2023]
Abstract
Point-of-care ultrasound (PoCUS) has been well described for adult perioperative patients; however, the literature on children remains limited. Regional anesthesiologists have gained interest in expanding their clinical repertoire of PoCUS from regional anesthesia to increasing numbers of applications. This manuscript reviews and highlights emerging PoCUS applications that may improve the quality and safety of pediatric care.In infants and children, lung and airway PoCUS can be used to identify esophageal intubation, size airway devices such as endotracheal tubes, and rule in or out a pulmonary etiology for clinical decompensation. Gastric ultrasound can be used to stratify aspiration risk when nil-per-os compliance and gastric emptying are uncertain. Cardiac PoCUS imaging is useful to triage causes of undifferentiated hypotension or tachycardia and to determine reversible causes of cardiac arrest. Cardiac PoCUS can assess for pericardial effusion, gross ventricular systolic function, cardiac volume and filling, and gross valvular pathology. When PoCUS is used, a more rapid institution of problem-specific therapy with improved patient outcomes is demonstrated in the pediatric emergency medicine and critical care literature.Overall, PoCUS saves time, expedites the differential diagnosis, and helps direct therapy when used in infants and children. PoCUS is low risk and should be readily accessible to pediatric anesthesiologists in the operating room.
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Dongare PA, Bhaskar SB, Harsoor SS, Garg R, Kannan S, Goneppanavar U, Ali Z, Gopinath R, Sood J, Mani K, Bhatia P, Rohatgi P, Das R, Ghosh S, Mahankali SS, Singh Bajwa SJ, Gupta S, Pandya ST, Keshavan VH, Joshi M, Malhotra N. Perioperative fasting and feeding in adults, obstetric, paediatric and bariatric population: Practice Guidelines from the Indian Society of Anaesthesiologists. Indian J Anaesth 2020; 64:556-584. [PMID: 32792733 PMCID: PMC7413358 DOI: 10.4103/ija.ija_735_20] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 06/20/2020] [Accepted: 06/22/2020] [Indexed: 02/07/2023] Open
Affiliation(s)
- Pradeep A Dongare
- Assistant Professor, Department of Anaesthesiology, ESIPGIMSR, Bengaluru, India
| | - S Bala Bhaskar
- Department of Anaesthesiology, Vijayanagar Institute of Medical Sciences, Ballari, India
| | - S S Harsoor
- Professor, Department of Anaesthesiology, Dr BR Ambedkar Medical College and Hospital, Bengaluru, India
| | - Rakesh Garg
- Additional Professor, Department of Onco-Anaesthesia, Pain and Palliative Medicine, DR BRAIRCH, AIIMS, New Delhi, India
| | - Sudheesh Kannan
- Professor, Department of Anaesthesiology, BMCRI, Bengaluru, India
| | - Umesh Goneppanavar
- Professor, Department of Anaesthesiology, Dharwad Institute of Mental Health and Neurosciences, Dharwad, India
| | - Zulfiqar Ali
- Associate Professor, Department of Anesthesiology and Critical Care, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Ramachandran Gopinath
- Professor and Head,Department of Anaesthesiology and Intensive Care, ESIC Medical College and Hospital, Hyderabad, India
| | - Jayashree Sood
- Honorary. Joint Secretary, Board of Management, Chairperson, Institute of Anaesthesiology, Pain and Perioperative Medicine, Sir Ganga Ram Hospital, New Delhi, India
| | - Kalaivani Mani
- Scientist IV, Department of Biostatistics, AIIMS, New Delhi, India
| | - Pradeep Bhatia
- Professor and Head, Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, India
| | | | - Rekha Das
- Professor and Head, Department Anaesthesiology, Critical care and Pain, Acharya Harihar Post Graduate Institute of Cancer, Cuttack, India
| | - Santu Ghosh
- Assistant Professor, Department of Biostatistics, St John's Medical College, Bengaluru, India
| | | | - Sukhminder Jit Singh Bajwa
- Professor and Head, Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Punjab, India
| | - Sunanda Gupta
- Professor and Head, Department of Anaesthesiology, Geetanjali Medical College and Hospital, Udaipur, India
| | - Sunil T Pandya
- Chief of Anaesthesia and Surgical ICU, AIG Hospitals, Hyderabad, India
| | - Venkatesh H Keshavan
- Senior Consultant and Chief, Department of Neuroanaesthesia and Critical Care, Apollo Hospitals, Bengaluru, India
| | - Muralidhar Joshi
- Head, Department of Anaesthesia and Pain Medicine, Virinchi Hospitals, Hyderabad, India
| | - Naveen Malhotra
- Professor, Department of Anaesthesiology and In Charge Pain Management Centre, Pt BDS PGIMS, Haryana, India
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16
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Pfaff KE, Tumin D, Miller R, Beltran RJ, Tobias JD, Uffman JC. Perioperative aspiration events in children: A report from the Wake Up Safe Collaborative. Paediatr Anaesth 2020; 30:660-666. [PMID: 32319164 DOI: 10.1111/pan.13893] [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: 03/28/2019] [Revised: 04/02/2020] [Accepted: 04/15/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Perioperative aspiration, while rare, is a serious complication of anesthetic care. Consequences of aspiration may include physical obstruction, wheezing, and pneumonia, resulting in mild to severe hypoxemia and even death. AIM We used a multi-institutional registry of pediatric patients to identify factors that influence the rate and resulting harm of perioperative pulmonary aspiration. METHODS The Wake Up Safe registry was queried for all severe adverse events reported from 29 institutions from 2010 to 2017. Aspiration events were identified through the "respiratory adverse event" data entry form or through free text search. Multivariable regression was used to predict aspiration events, and contributory factors were identified by reviewing free text case comments. RESULTS Analysis included 2 440 810 anesthetics administered involving patients ≤18 years of age. There were 135 pulmonary aspiration events, for an incidence of 0.006%. Within these 135 cases, 110 cases (82%) resulted in escalation of care and 51 (38%) resulted in patient harm, including 2 deaths (1.5%). In multivariable analysis, patients undergoing emergency surgery (OR 2.0 [1.2-3.5]) or with higher ASA status were more likely to experience aspiration (ASA 3 (OR 5.0 [2.6-9.1]); ASA ≥ 4 (OR 5.5 [3.8-16.8])). Noted causes of aspiration included gastrointestinal comorbid conditions (19%), postcoughing event or laryngospasm (14%), nil per os (NPO) violation (11%), blood or secretions in the airway following or during the procedure (6%), and oral premedication reaction (3%). CONCLUSION Although infrequent, death was reported as a consequence of perioperative aspiration in two patients. The frequency with which NPO violations were identified as a potential cause of aspiration highlights the struggles institutions face with adherence to NPO regulations, as these cases may be preventable. Furthermore, preventive measures may be needed to address other common causes of aspiration, such as gastrointestinal comorbid conditions.
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Affiliation(s)
- Kayla E Pfaff
- Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA.,Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Dmitry Tumin
- Brody School of Medicine East Carolina University, Greenville, NC, USA
| | - Rebecca Miller
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Ralph J Beltran
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joshua C Uffman
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
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17
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Morrison CE, Ritchie-McLean S, Jha A, Mythen M. Two hours too long: time to review fasting guidelines for clear fluids. Br J Anaesth 2020; 124:363-366. [PMID: 31959387 DOI: 10.1016/j.bja.2019.11.036] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 11/01/2019] [Accepted: 11/18/2019] [Indexed: 01/15/2023] Open
Affiliation(s)
| | | | - Arunita Jha
- Department of Anaesthesia, National Hospital for Neurology and Neurosurgery, London, UK
| | - Monty Mythen
- Department of Anaesthesia and Perioperative Medicine, University College London Hospitals, London, UK; University College London Hospitals and Great Ormond Street Hospital National Institute of Health Research Biomedical Research Centres, London, UK
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18
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Green SM, Leroy PL, Roback MG, Irwin MG, Andolfatto G, Babl FE, Barbi E, Costa LR, Absalom A, Carlson DW, Krauss BS, Roelofse J, Yuen VM, Alcaino E, Costa PS, Mason KP. An international multidisciplinary consensus statement on fasting before procedural sedation in adults and children. Anaesthesia 2019; 75:374-385. [PMID: 31792941 PMCID: PMC7064977 DOI: 10.1111/anae.14892] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2019] [Indexed: 01/29/2023]
Abstract
The multidisciplinary International Committee for the Advancement of Procedural Sedation presents the first fasting and aspiration prevention recommendations specific to procedural sedation, based on an extensive review of the literature. These were developed using Delphi methodology and assessment of the robustness of the available evidence. The literature evidence is clear that fasting, as currently practiced, often substantially exceeds recommended time thresholds and has known adverse consequences, for example, irritability, dehydration and hypoglycaemia. Fasting does not guarantee an empty stomach, and there is no observed association between aspiration and compliance with common fasting guidelines. The probability of clinically important aspiration during procedural sedation is negligible. In the post-1984 literature there are no published reports of aspiration-associated mortality in children, no reports of death in healthy adults (ASA physical status 1 or 2) and just nine reported deaths in adults of ASA physical status 3 or above. Current concerns about aspiration are out of proportion to the actual risk. Given the lower observed frequency of aspiration and mortality than during general anaesthesia, and the theoretical basis for assuming a lesser risk, fasting strategies in procedural sedation can reasonably be less restrictive. We present a consensus-derived algorithm in which each patient is first risk-stratified during their pre-sedation assessment, using evidence-based factors relating to patient characteristics, comorbidities, the nature of the procedure and the nature of the anticipated sedation technique. Graded fasting precautions for liquids and solids are then recommended for elective procedures based upon this categorisation of negligible, mild or moderate aspiration risk. This consensus statement can serve as a resource to practitioners and policymakers who perform and oversee procedural sedation in patients of all ages, worldwide.
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Affiliation(s)
- S M Green
- Department of Emergency Medicine, Loma Linda University, Loma Linda, CA, USA
| | - P L Leroy
- Department of Pediatrics, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - M G Roback
- University of Colorado School of Medicine, Aurora, CO, USA
| | - M G Irwin
- Department of Anaesthesiology, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - G Andolfatto
- University of British, Columbia Department of Emergency Medicine, Lions Gate Hospital, North Vancouver, BC, Canada
| | - F E Babl
- Department of Emergency Medicine, Royal Children's Hospital, Parkville, Vic., Australia
| | - E Barbi
- Department of Pediatrics, Institute for Maternal and Child Health-IRCCS 'Burlo Garofolo', Trieste, Italy
| | - L R Costa
- Department of Pediatric Dentistry, Federal University of Goias, Goiania-Goias, Brazil
| | - A Absalom
- Department of Anaesthesia, University of Groningen, University Medical Center Groningen, the Netherlands
| | - D W Carlson
- Department of Pediatrics, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - B S Krauss
- Department of Pediatrics, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - J Roelofse
- Departments of Anaesthesia, University of the Western Cape, Stellenbosch University, Tygerberg, Republic of South Africa
| | - V M Yuen
- Department of Anaesthesiology, Hong Kong Children's Hospital and Queen Mary Hospital, University of Hong Kong, Hong Kong
| | - E Alcaino
- Department of Paediatric Dentistry, University of Sydney, Westmead Centre for Oral Health, Sydney, NSW, Australia
| | - P S Costa
- Department of Pediatrics, Federal University of Goias, Goiania-Goias, Brazil
| | - K P Mason
- Department of Anesthesia, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
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19
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Isserman R, Elliott E, Subramanyam R, Kraus B, Sutherland T, Madu C, Stricker PA. Quality improvement project to reduce pediatric clear liquid fasting times prior to anesthesia. Paediatr Anaesth 2019; 29:698-704. [PMID: 31070840 DOI: 10.1111/pan.13661] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 04/29/2019] [Accepted: 05/05/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Unnecessarily long preprocedural fasting can cause suffering and distress for children and their families. Institutional fasting policies are designed to consistently achieve minimum fasting times, often without regard to the extent to which actual fasting times exceed these minimums. Children at our hospital frequently experienced clear liquid fasting times far in excess of required minimums. AIMS The aim of this study was to utilize quality improvement methodology to reduce excess fasting times, with a goal of achieving experienced clear liquid fasting times ≤4 hours for 60% of our patients. METHODS This quality improvement project was conducted between July 2017 and August 2018. A multidisciplinary team performed a series of Plan-Do-Study-Act cycles focused on children undergoing elective procedures at a large children's hospital. Key drivers for clear liquid fasting times and relevant balancing measures were identified. Data were analyzed using control charts and statistical process control methods. RESULTS Approximately 16 000 children were involved in this project. Over the course of the project, the percentage of children with goal clear liquid fasting times improved from the baseline of 20%-63%, with a change in the mean fasting time from 9 hours to 6 hours. There were no significant effects on balancing measures (case delays/cancellations and clinically significant aspiration events). CONCLUSION Using quality improvement methodology, we safely improved the duration of preoperative fasting experienced by our patients. Our results provide additional data supporting the safety of more permissive 1-hour clear liquid fasting minimums. We suggest other institutions pursue similar efforts to improve patient and family experience.
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Affiliation(s)
- Rebecca Isserman
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia (CHOP), University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Elizabeth Elliott
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia (CHOP), University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Rajeev Subramanyam
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia (CHOP), University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Blair Kraus
- The Center for Healthcare Quality and Analytics, Children's Hospital of Philadelphia (CHOP), Philadelphia, Pennsylvania
| | - Tori Sutherland
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia (CHOP), University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Chinonyerem Madu
- The Center for Healthcare Quality and Analytics, Children's Hospital of Philadelphia (CHOP), Philadelphia, Pennsylvania
| | - Paul A Stricker
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia (CHOP), University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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20
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21
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Azad AM, Al Madi HA, Abdull Wahab SF, Shokoohi H, Kang YJ, Liteplo AS. Gastric ultrasonography in evaluating NPO status of pediatric patients in the emergency department. Am J Emerg Med 2019; 37:355-356. [DOI: 10.1016/j.ajem.2018.06.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 06/06/2018] [Indexed: 11/25/2022] Open
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22
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Green SM, Mason KP, Krauss BS. Pulmonary aspiration during procedural sedation: a comprehensive systematic review. Br J Anaesth 2018; 118:344-354. [PMID: 28186265 DOI: 10.1093/bja/aex004] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background Although pulmonary aspiration complicating operative general anaesthesia has been extensively studied, little is known regarding aspiration during procedural sedation. Methods We performed a comprehensive, systematic review to identify and catalogue published instances of aspiration involving procedural sedation in patients of all ages. We sought to report descriptively the circumstances, nature, and outcomes of these events. Results Of 1249 records identified by our search, we found 35 articles describing one or more occurrences of pulmonary aspiration during procedural sedation. Of the 292 occurrences during gastrointestinal endoscopy, there were eight deaths. Of the 34 unique occurrences for procedures other than endoscopy, there was a single death in a moribund patient, full recovery in 31, and unknown recovery status in two. We found no occurrences of aspiration in non-fasted patients receiving procedures other than endoscopy. Conclusions This first systematic review of pulmonary aspiration during procedural sedation identified few occurrences outside of gastrointestinal endoscopy, with full recovery typical. Although diligent caution remains warranted, our data indicate that aspiration during procedural sedation appears rare, idiosyncratic, and typically benign.
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Affiliation(s)
- S M Green
- Department of Emergency Medicine, Loma Linda University Medical Center and Children's Hospital, Loma Linda, CA, USA
| | - K P Mason
- Department of Anesthesia, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - B S Krauss
- Division of Emergency Medicine, Boston Children's Hospital and the Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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23
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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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24
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Thomas M, Morrison C, Newton R, Schindler E. Consensus statement on clear fluids fasting for elective pediatric general anesthesia. Paediatr Anaesth 2018; 28:411-414. [PMID: 29700894 DOI: 10.1111/pan.13370] [Citation(s) in RCA: 102] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/26/2018] [Indexed: 02/06/2023]
Abstract
Pediatric anesthetic guidelines for the management of preoperative fasting of clear fluids are currently 2 hours. The traditional 2 hours clear fluid fasting time was recommended to decrease the risk of pulmonary aspiration and is not in keeping with current literature. It appears that a liberalized clear fluid fasting regime does not affect the incidence of pulmonary aspiration and in those who do aspirate, the sequelae are not usually severe or long-lasting. With a 2-hour clear fasting policy, the literature suggests that this translates into 6-7 hours actual duration of fasting with several studies up to 15 hours. Fasting for prolonged periods increases thirst and irritability and results in detrimental physiological and metabolic effects. With a 1-hour clear fluid policy, there is no increased risk of pulmonary aspiration and studies demonstrate the stomach is empty. There is less nausea and vomiting, thirst, hunger, and anxiety, if allowed a drink closer to surgery. Children appear more comfortable, better behaved and possibly more compliant. In children less than 36 months this has positive physiological and metabolic effects. It is practical to allow children to drink until 1 hour prior to anesthesia on the day of surgery. In this joint consensus statement, the Association of Paediatric Anaesthetists of Great Britain and Ireland, the European Society for Paediatric Anaesthesiology, and L'Association Des Anesthésistes-Réanimateurs Pédiatriques d'Expression Française agree that, based on the current convincing evidence base, unless there is a clear contraindication, it is safe and recommended for all children able to take clear fluids, to be allowed and encouraged to have them up to 1 hour before elective general anesthesia.
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Affiliation(s)
- Mark Thomas
- Department of Anaesthesia, Great Ormond Street Hospital, London, UK
| | - Christa Morrison
- Department of Anaesthesia, Great Ormond Street Hospital, London, UK
| | - Richard Newton
- Department of Anaesthesia, Royal Sussex County Hospital, Brighton, UK
| | - Ehrenfried Schindler
- Department of Paediatric Anaesthesia, Asklepios Klinik Sankt Augustin, Sankt Augustin, Germany
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25
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Eisler L, Huang G, Lee KEM, Busse JA, Sun M, Lin AY, Sun LS, Ing C. Identification of perioperative pulmonary aspiration in children using quality assurance and hospital administrative billing data. Paediatr Anaesth 2018; 28:218-225. [PMID: 29341336 PMCID: PMC6427906 DOI: 10.1111/pan.13319] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/14/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Perioperative aspiration is a rare but potentially devastating complication, occurring in 1-10 per 10 000 anesthetics based on studies of quality assurance databases. Quality assurance reporting is known to underestimate the incidence of adverse outcomes, but few large studies use supplementary data sources. This study aims to identify the incidence of and risk factors for perioperative aspiration in children using quality assurance data supplemented by administrative billing records, and to examine the utility of billing data as a supplementary data source. METHODS Aspiration events for children receiving anesthesia at a tertiary care pediatric hospital between 2008 and 2014 were identified using (i) a perioperative quality assurance database and (ii) hospital administrative billing records with International Classification of Diseases, Ninth Revision Clinical Modification coded diagnoses of aspiration. Records were subject to review by pediatric anesthesiologists. Following identification of all aspiration events, the incidence of perioperative aspiration was calculated and risk factors were assessed. RESULTS 47 272 anesthetic cases were evaluated over 7 years. The quality assurance database identified 20 cases of perioperative aspiration occurring in surgical inpatients, same-day admissions, and outpatients. Using hospital administrative data (which excludes outpatients with shorter than a 24-hour stay), 9 cases of perioperative aspiration were identified of which 6 had not been found through quality assurance data. Overall, International Classification of Diseases, Ninth Revision coding demonstrated a positive predictive value of 94.5% for any aspiration event; however, positive predictive value was <4% for perioperative aspiration. A total incidence of 5.5 perioperative aspirations per 10 000 (95% CI: 3.7-8.0 per 10 000) anesthetics was found. CONCLUSION Quality assurance data offer an efficient way to measure the incidence of rare events, but may underestimate perioperative complications. International Classification of Diseases, Ninth Revision codes for aspiration used as a secondary data source were nonspecific for perioperative aspiration, but when combined with record review yielded a 30% increase in identified cases of aspiration over quality assurance data alone. The use of administrative data therefore holds potential for supplementing quality assurance studies of rare complications.
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Affiliation(s)
- Lisa Eisler
- Anesthesiology, Columbia University, New York, NY, USA
| | - Grace Huang
- Anesthesiology, Columbia University, New York, NY, USA
| | - Ka-Eun M. Lee
- Anesthesiology, Columbia University, New York, NY, USA
| | | | - Ming Sun
- Biostatistics, Mailman School of Public Health, New York, NY, USA
| | - Albert Y. Lin
- Anesthesiology, Columbia University, New York, NY, USA
| | - Lena S. Sun
- Anesthesiology and Pediatrics, Columbia University, New York, NY, USA
| | - Caleb Ing
- Anesthesiology, Columbia University, New York, NY, USA,Epidemiology, Mailman School of Public Health, New York, NY, USA
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26
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Gagey AC, de Queiroz Siqueira M, Monard C, Combet S, Cogniat B, Desgranges FP, Robinson P, Chassard D, Bouvet L. The effect of pre-operative gastric ultrasound examination on the choice of general anaesthetic induction technique for non-elective paediatric surgery. A prospective cohort study. Anaesthesia 2017; 73:304-312. [DOI: 10.1111/anae.14179] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2017] [Indexed: 01/01/2023]
Affiliation(s)
- A.-C. Gagey
- Department of Anaesthesia and Intensive Care; Hôpital Femme Mère Enfant; Bron France
| | | | - C. Monard
- Department of Anaesthesia and Intensive Care; Hôpital Femme Mère Enfant; Bron France
| | - S. Combet
- Department of Anaesthesia and Intensive Care; Hôpital Femme Mère Enfant; Bron France
| | - B. Cogniat
- Department of Anaesthesia and Intensive Care; Hôpital Femme Mère Enfant; Bron France
| | - F.-P. Desgranges
- Department of Anaesthesia and Intensive Care; Hôpital Femme Mère Enfant; Bron France
- Department of Anaesthesia; Université Claude Bernard Lyon 1; Villeurbanne France
| | - P. Robinson
- Department of Clinical Research; Hospices Civils de Lyon, Lyon France
| | - D. Chassard
- Department of Anaesthesia and Intensive Care; Hôpital Femme Mère Enfant; Bron France
- Department of Anaesthesia; Université Claude Bernard Lyon 1; Villeurbanne France
| | - L. Bouvet
- Department of Anaesthesia and Intensive Care; Hôpital Femme Mère Enfant; Bron France
- Université Claude Bernard Lyon 1; INSERM, LabTAU UMR1032; Lyon France
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27
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28
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Newton RJG, Stuart GM, Willdridge DJ, Thomas M. Using quality improvement methods to reduce clear fluid fasting times in children on a preoperative ward. Paediatr Anaesth 2017; 27:793-800. [PMID: 28675597 DOI: 10.1111/pan.13174] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2017] [Indexed: 01/02/2023]
Abstract
OBJECTIVES We applied quality improvement (QI) methodology to identify the different aspects of why children fasted for prolonged periods in our institution. Our aim was for 75% of all children to be fasted for clear fluid for less than 4 hours. BACKGROUND Prolonged fasting in children can increase thirst and irritability and have adverse effects on haemodynamic stability on induction. By reducing this, children may be less irritable, more comfortable and more physiologically stable, improving the preoperative experience for both children and carers. METHODS We conducted a QI project from January 2014 until August 2016 at a large tertiary pediatric teaching hospital. Baseline data and the magnitude of the problem were obtained from pilot studies. This allowed us to build a key driver diagram, a process map and conduct a failure mode and effects analysis. Using a framework of Plan-Do-Study-Act cycles our key interventions primarily focused on reducing confusion over procedure start times, giving parents accurate information, empowering staff and reducing variation by allowing children to drink on arrival (up to one hour) before surgery. RESULTS Prior to this project, using the 6,4,2 fasting rule for solids, breast milk, and clear fluids, respectively, 19% of children were fasted for fluid for less than 4 hours, mean fluid fasting time was 6.3 hours (SD 4.48). At the conclusion 72% of patients received a drink within 4 hours, mean fluid fasting reduced to 3.1 hours (SD 2.33). The secondary measures of aspiration (4.14:10 000) and cancellations have not increased since starting this project. CONCLUSIONS By using established QI methodology we reduced the mean fluid fasting time for day admissions at our hospital to 3.1 hours and increased the proportion of children fasting for less than 4 hours from 19% to 72%.
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Affiliation(s)
| | - Grant M Stuart
- Department of Anaesthesia, Great Ormond Street Hospital, London, UK
| | | | - Mark Thomas
- Department of Anaesthesia, Great Ormond Street Hospital, London, UK
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Thomas M, Engelhardt T. Think drink! Current fasting guidelines are outdated. Br J Anaesth 2017; 118:291-293. [DOI: 10.1093/bja/aew450] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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