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Reduced Preoperative Fasting in Children
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.ORCID iD: 0000-0002-1462-0513
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Preoperative fasting is recommended in order to reduce the risk of perioperative pulmonary aspiration. However, preoperative fasting may have negative effects on patient wellbeing and homeostasis. In this thesis, more lenient regimens for preoperative fasting in elective paediatric patients were assessed, with the aim to further improve preoperative fasting regimens.

Paper I investigated if paediatric patients allowed to drink clear fluids until called to surgery, had an increased risk of pulmonary aspiration. The incidence of perioperative pulmonary aspiration in children allowed free clear fluids until called to surgery was 3 in 10 000, as compared to 1-10 in 10 000 in previous studies where longer fasting intervals were studied. Hence, no increase of incidence for pulmonary aspiration was found.

Paper II investigated actual fasting times for clear fluids when applying two-hour fasting for clear fluids, and zero-hour fasting for clear fluids. When applying two-hour fasting, children were fasted median four hours for clear fluids. After transitioning to zero-hour fasting, median fasting time decreased to one hour, and the incidence of children fasting for more than six hours decreased from 35 % to 6 %. Abandoning the time limit for clear fluids significantly reduced the proportion of patients fasting for extended periods.

Paper III assessed gastric content volume after a light breakfast in children scheduled for elective general anaesthesia. Patients were examined with gastric ultrasound four hours after a light breakfast. Of the 20 patients included in the study, 15 had an empty stomach, 4 had clear fluids < 0.5 ml kg-1 and one had solid content in the stomach. A light breakfast preoperatively might be safe, but amount and caloric restriction is needed to avoid the risk of perioperative pulmonary aspiration.

Paper IV investigated preoperative weight loss, glucose level and ketone bodies in paediatric patients presenting for elective surgery. The outcomes were tested for correlation to preoperative fasting times. Of the 43 children enrolled in the study, three had weight loss of more than 5 %, five children presented with blood glucose level < 3.3 mmol l-1, and 11 children presented with ketone bodies > 0.6 mmol l-1. There was no correlation between fasting time, and the respective outcomes. Even with a lenient fasting regimen, there is risk of mild preoperative dehydration, hypoglycaemia and ketogenesis.

In conclusion, the results obtained in the present thesis supports the shift to more lenient preoperative fasting regimens for clear fluids in elective paediatric patients.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2019. , p. 62
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1600
Keywords [en]
Fasting, Children, Preoperative, Pulmonary Aspiration
National Category
Anesthesiology and Intensive Care
Research subject
Anaesthesiology and Intensive Care
Identifiers
URN: urn:nbn:se:uu:diva-394232ISBN: 978-91-513-0764-0 (print)OAI: oai:DiVA.org:uu-394232DiVA, id: diva2:1358031
Public defence
2019-11-22, Martin H:son Holmdahl-salen, Akademiska Sjukhuset, ingång 100, Uppsala, 09:00 (English)
Opponent
Supervisors
Available from: 2019-10-30 Created: 2019-10-06 Last updated: 2019-11-12
List of papers
1. Low incidence of pulmonary aspiration in children allowed intake of clear fluids until called to the operating suite
Open this publication in new window or tab >>Low incidence of pulmonary aspiration in children allowed intake of clear fluids until called to the operating suite
2015 (English)In: Pediatric Anaesthesia, ISSN 1155-5645, E-ISSN 1460-9592, Vol. 25, no 8, p. 770-777Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: International guidelines recommend 2 h of clear fluid fasting prior to general anesthesia. The pediatric anesthesia unit of Uppsala University Hospital has been implementing a more liberal fasting regime for more than a decade; thus, children scheduled for elective procedures are allowed to drink clear fluids until called to the operating suite.

AIM: To determine the incidence of perioperative pulmonary aspiration in pediatric patients allowed unlimited intake of clear fluids prior to general anesthesia.

METHOD: Elective pediatric procedures between January 2008 and December 2013 were examined retrospectively by reviewing anesthesia charts and discharge notes in the electronic medical record system. All notes from the care event and available chest x-rays were examined for cases showing vomiting, regurgitation, and/or aspiration. Pulmonary aspiration was defined as radiological findings consistent with aspiration and/or postoperative symptoms of respiratory distress after vomiting during anesthesia.

RESULTS: Of the 10 015 pediatric anesthetics included, aspiration occurred in three (0.03% or 3 in 10 000) cases. No case required cancellation of the surgical procedure, intensive care or ventilation support, and no deaths attributable to aspiration were found. Pulmonary aspiration was suspected, but not confirmed by radiology or continuing symptoms, in an additional 14 cases.

CONCLUSION: Shortened fasting times may improve the perioperative experience for parents and children with a low risk of aspiration.

National Category
Pediatrics Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:uu:diva-256491 (URN)10.1111/pan.12667 (DOI)000357730600003 ()25940831 (PubMedID)
Available from: 2015-06-24 Created: 2015-06-24 Last updated: 2019-10-06Bibliographically approved
2. Introducing the 6-4-0 fasting regimen and the incidence of prolonged preoperative fasting in children
Open this publication in new window or tab >>Introducing the 6-4-0 fasting regimen and the incidence of prolonged preoperative fasting in children
2018 (English)In: Pediatric Anaesthesia, ISSN 1155-5645, E-ISSN 1460-9592, Vol. 28, no 1, p. 46-52Article in journal (Refereed) Published
Abstract [en]

Background

Children often starve for longer than recommended by current preoperative fasting guidelines.

Aims

We studied the effects of implementing a more lenient fasting regimen on the duration of clear fluid fasting, as well as the incidence of extended fasting in children.

Methods

Preoperative duration of clear fluid fasting was recorded for patients scheduled for procedures in a unit applying the standard 6-4-2 fasting regimen. This group was compared with a cohort in the same unit 1year after transitioning to a 6-4-0 fasting regimen. The latter includes no limitations on clear fluid intake until the child is called to theater. A third cohort from a unit in which the 6-4-0 fasting regimen has been implemented for over a decade was also studied for comparison.

Results

Patients fasting according to the 6-4-2 fasting regimen (n=66) had a median fasting time for clear fluids of 4.0h and a 33.3% incidence of fasting more than 6h. After transitioning to the 6-4-0 fasting regimen (n=64), median duration of fasting for clear fluids decreased to 1.0h, and the incidence of fasting more than 6h decreased to 6.3%. In the second unit (n=73), median fasting time was 2.2h and the proportion of patients fasting more than 6h was 21.9%.

Conclusion

The introduction and implementation of the 6-4-0 fasting regimen reduces median fluid fasting duration and the number of children subjected to extended fasting.

Keywords
anesthesia, children, fasting, fluids, preoperative
National Category
Anesthesiology and Intensive Care Pediatrics
Identifiers
urn:nbn:se:uu:diva-343890 (URN)10.1111/pan.13282 (DOI)000417604600008 ()29168341 (PubMedID)
Available from: 2018-03-05 Created: 2018-03-05 Last updated: 2019-10-06Bibliographically approved
3. Gastric content assessed with gastric ultrasound in paediatric patients prescribed a light breakfast prior to general anaesthesia. A prospective observational study.
Open this publication in new window or tab >>Gastric content assessed with gastric ultrasound in paediatric patients prescribed a light breakfast prior to general anaesthesia. A prospective observational study.
(English)In: Article in journal (Other academic) Accepted
Abstract [en]

Background:

A light breakfast has been found to empty from the stomach within four hours in healthy volunteers.

Aim

The aim of this study was to investigate if a light breakfast of yoghurt or gruel empties from the stomach within four 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 four hours prior to induction. They were subsequently examined with gastric ultrasound within four hours of ingestion. In case of gastric contents, the gastric antral area was measured, and gastric content volume 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 gastric content volume in this patient was calculated to 2.1 ml kg-1. The patient with solids present had ingested 25 ml kg-1 of gruel four hours prior to assessment. The planned procedure was therefore delayed one hour. There were no cases of pulmonary aspiration or vomiting.

Conclusion:

A light breakfast four hours prior to induction may be considered, but there is need for further studies on safe limits for the volume ingested.

Keywords
Ultrasound, General anesthesia, child < Age
National Category
Anesthesiology and Intensive Care
Research subject
Anaesthesiology and Intensive Care
Identifiers
urn:nbn:se:uu:diva-394230 (URN)
Available from: 2019-10-05 Created: 2019-10-05 Last updated: 2019-10-10
4. Preoperative weight loss, hypoglycaemia and ketosis in elective paediatric patients, preliminary results from a prospective observational study
Open this publication in new window or tab >>Preoperative weight loss, hypoglycaemia and ketosis in elective paediatric patients, preliminary results from a prospective observational study
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background

New paediatric fasting guidelines allow free clear fluids up until one hour prior to surgery. At the paediatric anaesthesia department of Uppsala University Hospital, children are fasted six hours for solids, four hours for breast milk and are allowed free clear fluids up until called to theatre. Preoperative fasting is necessary to avoid perioperative pulmonary aspiration. However, extended fasting times have detrimental effects for fluid homeostasis and may cause hypoglycaemia and ketone bodies.

Aim

The aim of the current study was to investigate if preoperative weight loss, glucose level and ketone bodies were related to preoperative fasting times.

Methods

Paediatric patients aged 0-72 months were included in this prospective, observational study. All children included were instructed to fast from midnight for solids, four hours for breast milk or semi-solids and from when they are called to theatre for clear fluids. Fasting times were registered, and patient weight was measured in the evening prior to surgery, and before induction. Blood glucose and ketone body levels were measured before induction. Multiple regression was used to determine how fasting time affected the outcomes weight change, blood glucose level and ketone bodies, respectively.

Results

43 patients were enrolled. Three children had a weight loss of more than 5 %, five children presented with blood glucose level < 3.3 mmol l-1, and 11 children presented with ketone bodies > 0.6 mmol l-1. There was no correlation between fasting time and the respective outcomes.

Conclusion

Even with a lenient preoperative fasting regimen, mild dehydration or hypoglycaemia may occur. This methodology may be used in further studies of the effects of preoperative fasting in settings where dehydration may be more significant.

Keywords
General Anesthesia, child < Age, Dehydration, Fasting, Hypoglycaemia, Ketosis
National Category
Anesthesiology and Intensive Care
Research subject
Anaesthesiology and Intensive Care; Anaesthesiology and Intensive Care
Identifiers
urn:nbn:se:uu:diva-394231 (URN)
Available from: 2019-10-05 Created: 2019-10-05 Last updated: 2019-10-06

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