Preoperative Fasting in Children. The Evolution of Recommendations and Guidelines, and the Underlying Evidence
- Author: sciencedirect.com
- Full Title: Preoperative Fasting in Children. The Evolution of Recommendations and Guidelines, and the Underlying Evidence
- Category: #articles
- Document Tags: ../../../Knowledge/Medicine/Paediatrics part 2
- Summary: This text discusses the evolution of preoperative fasting guidelines for children in pediatric anesthesia. Recommendations on fasting have only seen minor changes over the past three decades, with studies showing a low incidence of pulmonary aspiration in children. Current evidence suggests that the duration of clear fluid fasting may not significantly impact the risk of pulmonary aspiration in pediatric patients.
- URL: https://www.sciencedirect.com/science/article/pii/S152168962400017X
Highlights
- Case reports of asphyxiation due to vomiting were available during the 19th century with Sir Joseph Lister publishing the first recommendation for preoperative fasting in 1883 (View Highlight)
New highlights added June 15, 2024 at 2:39 PM
- The guidelines included recommendations for preoperative fasting after a large meal of solids (8 h), a light meal (6 h), breast milk (4 h), and clear fluids (2 h), commonly abbreviated to the 6-4-2 rule. (View Highlight)
- the ESAIC guideline introduced the concept of encouraging intake of clear fluids at 2 h before anesthesia, and breast milk or formula at 4 h before anesthesia in infants <6 months of age (View Highlight)
New highlights added June 15, 2024 at 4:03 PM
- Fasting overnight does very little harm to healthy older children and only leads to clinically insignificant changes in blood glucose and ketone bodies, blood pressure, or difficulties of intravenous insertion during anesthesia (View Highlight)
- modern fasting rule aims to prevent unnecessarily prolonged fasting (View Highlight)
- Several studies of the incidence of pulmonary aspiration of gastric contents in children have been published; the incidence ranges from 0.6 to 12 in 10,000 (View Highlight)
- pulmonary aspiration of gastric content in healthy children does not lead to mortality (View Highlight)
- the majority of aspiration incidents do not lead to patient harm (View Highlight)
- Children are more likely to experience negative outcomes due to hypoxia caused by inadequate anesthesia technique and failure to oxygenate and ventilate (View Highlight)
- The real threat in children is hypoxia rather than aspiration (View Highlight)
- Gastric fluid content has been cited as a risk factor for pulmonary aspiration based on a remark in a paper by Roberts and Shirley (1974) [30]. Gastric fluid (0.4 ml kg-1) with a pH of 1.26, directly instilled into the left bronchus via a tracheostomy in a single Rhesus monkey led to inflammation. Extrapolation from this single laboratory experiment resulted in the suggestion that pregnant women are at risk if gastric fluid content exceeds 25 ml. This ‘fact’ was uncritically accepted until 1998, when Schreiner pointed out that 30–60% of patients would be at increased risk of aspiration if the 0.4 ml kg−1 were to be valid in humans (View Highlight)
- the suggested ‘critical gastric volume’ increased from 0.4 ml kg−1 to 0.8 ml kg−1, then further to 1.25 ml kg−1, to presently the often quoted volume 1.5 ml kg−1 based on the method of measuring – laboratory, nasogastric suctioning and finally gastric ultrasound (View Highlight)
- regurgitation of gastric content also depends on several other factors including lower esophageal sphincter pressure (varying among patients and according to the anesthetic drug administered), on the anesthesia team making sure that the anesthesia level is deep enough to avoid coughing and straining, on the occurrence of difficult airway, and finally the experience level of the anesthesiologist (View Highlight)
- Preoperative fasting for solids is ever important, but clear fluids can be ingested closer to induction than previously thought (View Highlight)