Liberal fluid fasting: impact on gastric pH and residual volume in healthy children undergoing general anaesthesia for elective surgery

Schmidt, Alexander R.; Buehler, Philipp K.; Both, Christian P.; Wiener, Renda Soylemez; Klaghofer, Richard; Hersberger, Martin; Weiß, Markus; Schmitz, A.

doi:10.1016/j.bja.2018.02.065

Cited by 34 publications

(66 citation statements)

References 25 publications

(28 reference statements)

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“…2,15 Encouraging fluid intake until premedication decreases fasting times, but this practice must be weighed against the risk of increased gastric residual volumes if fasting times are 30 min or shorter. 16,17 Our findings complement earlier studies that examined the effects of prolonged fasting in anesthetized children. Higher mean arterial pressures were observed after induction of anesthesia in a cohort of "optimized fasting management" children with fasting times that were significantly shorter than a preoptimization group.…”

Section: Discussionsupporting

confidence: 84%

Preoperative Fluid Fasting Times and Postinduction Low Blood Pressure in Children

Simpao

Nelson

et al. 2020

Anesthesiology

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Background Children are required to fast before elective general anesthesia. This study hypothesized that prolonged fasting causes volume depletion that manifests as low blood pressure. This study aimed to assess the association between fluid fasting duration and postinduction low blood pressure. Methods A retrospective cohort study was performed of 15,543 anesthetized children without preinduction venous access who underwent elective surgery from 2016 to 2017 at Children’s Hospital of Philadelphia. Low blood pressure was defined as systolic blood pressure lower than 2 standard deviations below the mean (approximately the 2.5th percentile) for sex- and age-specific reference values. Two epochs were assessed: epoch 1 was from induction to completion of anesthesia preparation, and epoch 2 was during surgical preparation. Results In epoch 1, the incidence of low systolic blood pressure was 5.2% (697 of 13,497), and no association was observed with the fluid fasting time groups: less than 4 h (4.6%, 141 of 3,081), 4 to 8 h (6.0%, 219 of 3,652), 8 to 12 h (4.9%, 124 of 2,526), and more than 12 h (5.0%, 213 of 4,238). In epoch 2, the incidence of low systolic blood pressure was 6.9% (889 of 12,917) and varied across the fasting groups: less than 4 h (5.6%, 162 of 2,918), 4 to 8 h (8.1%, 285 of 3,531), 8 to 12 h (5.9%, 143 of 2,423), and more than 12 h (7.4%, 299 of 4,045); after adjusting for confounders, fasting 4 to 8 h (adjusted odds ratio, 1.33; 95% CI, 1.07 to 1.64; P = 0.009) and greater than 12 h (adjusted odds ratio, 1.28; 95% CI, 1.04 to 1.57; P = 0.018) were associated with significantly higher odds of low systolic blood pressure compared with the group who fasted less than 4 h, whereas the increased odds of low systolic blood pressure associated with fasting 8 to 12 h (adjusted odds ratio, 1.11; 95% CI, 0.87 to 1.42; P = 0.391) was nonsignificant. Conclusions Longer durations of clear fluid fasting in anesthetized children were associated with increased risk of postinduction low blood pressure during surgical preparation, although this association appeared nonlinear. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

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Section: Discussionsupporting

confidence: 84%

Preoperative Fluid Fasting Times and Postinduction Low Blood Pressure in Children

Simpao

Nelson

et al. 2020

Anesthesiology

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“…This project was undertaken as a Quality Improvement Initiative and as such does not constitute human subjects research. Safety considerations were addressed by implementing policies consistent with published evidence and guidelines, and through the balancing measures described above.…”

Section: Methodsmentioning

confidence: 99%

“…The current American Society of Anesthesiologists (ASA) practice guidelines recommend preoperative clear liquid fasting times (CLFT) of at least 2 hours prior to general anesthesia in healthy individuals . An emerging body of evidence suggests that more liberal CLFT can safely be employed; as a result, the major European pediatric anesthesia societies published a consensus statement recommending that healthy children be allowed to drink clear liquids up to 1 hour before elective anesthesia . This statement has since been endorsed by the Society for Paediatric Anesthesia in New Zealand and Australia, and echoed by the European Society for Anaesthesiology …”

Section: Introductionmentioning

confidence: 99%

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

Isserman

Elliott

Subramanyam

et al. 2019

Pediatric Anesthesia

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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. K E Y W O R D S patient safety, patient satisfaction, pediatric anesthesia, perioperative aspiration, perioperative fasting, perioperative guidelines | 699 ISSERMAN Et Al.

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“…The cutoff value of 1.5 mL kg −1 to indicate a full stomach is based on normal fasting volumes in healthy patients but has no proven link to the risk of pulmonary aspiration. In a recent study, Schmidt et al reported 5.1% of patients allowed clear fluids until premedication to have gastric fluid volume >4 mL kg −1 , compared to no patients in a 2‐hour fasting group. If GCV is a risk factor for pulmonary aspiration, this means that children allowed liberal intake of clear fluids until premedication run a higher risk for perioperative pulmonary aspiration.…”

Section: Discussionmentioning

confidence: 99%

Gastric content assessed with gastric ultrasound in paediatric patients prescribed a light breakfast prior to general anaesthesia: A prospective observational study

Andersson

Frykholm

2019

Pediatric Anesthesia

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Background A light breakfast has been found to empty from the stomach within 4 hours in healthy volunteers. Aim The aim of this study was to investigate whether a light breakfast of yoghurt or gruel empties from the stomach within 4 hours, in children scheduled for general anaesthesia. Method In this observational cohort study, children aged 1‐6 years scheduled for elective general anaesthesia were prescribed free intake of yoghurt or gruel 4 hours prior to induction. They were subsequently examined with gastric ultrasound within 4 hours of ingestion. In case of gastric contents, the gastric antral area was measured, and gastric content volume (GCV) was calculated. Results Twenty children were included in the study and the ingested amount of gruel or yoghurt ranged 2.5‐25 mL kg−1. In 15 cases, the stomach was empty with juxtaposed walls and no further measurements were made. In four cases, there was fluid present in the stomach, but the calculated gastric contents were <0.5 mL kg−1. One patient had solids in the stomach, and GCV in this patient was calculated to 2.1 mL kg−1. The patient with solids present had ingested 25 mL kg−1 of gruel 4 hours prior to assessment. The planned procedure was therefore delayed 1 hour. There were no cases of pulmonary aspiration or vomiting. Conclusion A light breakfast 4 hours prior to induction may be considered, but there is need for further studies on safe limits for the volume ingested.

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Liberal fluid fasting: impact on gastric pH and residual volume in healthy children undergoing general anaesthesia for elective surgery

Abstract: NCT02603094.

Cited by 34 publications

References 25 publications

Preoperative Fluid Fasting Times and Postinduction Low Blood Pressure in Children

Preoperative Fluid Fasting Times and Postinduction Low Blood Pressure in Children

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

Gastric content assessed with gastric ultrasound in paediatric patients prescribed a light breakfast prior to general anaesthesia: A prospective observational study

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