Optimized preoperative fasting times decrease ketone body concentration and stabilize mean arterial blood pressure during induction of anesthesia in children younger than 36 months: a prospective observational cohort study

Dennhardt, Nils; Beck, Christiane; Huber, Dirk; Sander, Bjoern; Boehne, Martin; Boethig, Dietmar; Leffler, Andreas; Sümpelmann, Robert

doi:10.1111/pan.12943

Cited by 104 publications

(135 citation statements)

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“…Large meals were defined as main meals not restricted in quantity and contents, and light meals as cereals, toast or dairy products other than breast milk or formula milk. In accordance with the study by Dennhardt et al prolonged fasting was defined as a deviation from present fasting guidelines of more than 2 hours. Regurgitation was defined as findings of gastric contents outside the airway without respiratory symptoms thereafter.…”

Section: Methodsmentioning

confidence: 91%

“…Prolonged fasting before anesthesia is still common in children . Shortened fasting times may improve the metabolic and hemodynamic condition during induction of anesthesia and the perioperative experience for parents and children with a low risk of aspiration and simplify perioperative management. As a consequence, some centers have reduced the fasting requirements for clear fluids to 1 hour and for light meals to 4 hours .…”

Section: Introductionmentioning

confidence: 99%

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Real fasting times and incidence of pulmonary aspiration in children: Results of a German prospective multicenter observational study

Beck

Rudolp

Becke‐Jakob

et al. 2019

Pediatric Anesthesia

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Background Prolonged fasting before anesthesia is still common in children. Shortened fasting times may improve the metabolic and hemodynamic condition during induction of anesthesia and the perioperative experience for parents and children and simplify perioperative management. As a consequence, some centers in Germany have reduced fasting requirements, but the national guidelines are still unchanged. Aims This prospective multicenter observational study was initiated by the Scientific Working Group for Pediatric Anesthesia of the German Society of Anesthesiology and Intensive Care Medicine to evaluate real fasting times and the incidence of pulmonary aspiration before a possible revision of national fasting guidelines. Methods After the Ethics Committee's approval, at least 3000 children were planned to be enrolled for this analysis. Patient demographics, real fasting times, anesthetic and surgical procedures and occurrence of regurgitation or pulmonary aspiration were documented using a standardized case report form. Results were presented as median [interquartile range] (range) or incidence (percentage). Results At ten pediatric centers, 3324 children were included between October 2018 and May 2019. The real fasting times for large meals were 14 [12.2‐15.6] (0.5‐24) hours, for light meals 9 [5.6‐13.3] (0.25‐28.3) hours, for formula milk 5.8 [4.5‐7.4] (0.9‐24) hours, for breast milk 4.8 [4.2‐6.3] (1.3‐25.3) hours and for clear fluids 2.7 [1.5‐6] (0.03‐22.8) hours. Prolonged fasting (deviation from guideline >2 hours) was reported for large meals in 88.3%, for light meals in 54.7%, for formula milk in 44.4%, for breast milk in 25.8% and for clear fluids in 34.2%. Eleven cases (0.33%) of regurgitation, four cases (0.12%) of suspected pulmonary aspiration and two cases (0.06%) of confirmed pulmonary aspiration were reported; all of them could be extubated after the end of the procedure and recovered without any incidents. Conclusion This study shows that prolonged fasting is still common in pediatric anesthesia in Germany that pulmonary aspiration with postoperative respiratory distress is rare and that improvements to current local fasting regimens and national fasting guidelines are urgently needed.

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Section: Methodsmentioning

confidence: 91%

Section: Introductionmentioning

confidence: 99%

Real fasting times and incidence of pulmonary aspiration in children: Results of a German prospective multicenter observational study

Beck

Rudolp

Becke‐Jakob

et al. 2019

Pediatric Anesthesia

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“…Despite these findings, observational studies show that excessive fasting remains common practice at children's hospitals and that optimized preoperative fasting times closely following the current guidelines (6‐4‐2‐rule) are effective in decreasing the ketone body concentration and stabilizing arterial blood pressure, particularly in young children . Other studies have found no differences in the gastric contents 4 or 6 hours after a light meal, and no increased incidence of pulmonary aspiration was observed after clear fluids were given less than 2 hours preoperatively …”

Section: Choosing Wisely In Pediatric Anesthesia: 10 Dos and Don′tsmentioning

confidence: 99%

Choosing Wisely in pediatric anesthesia: An interpretation from the German Scientific Working Group of Paediatric Anaesthesia (WAKKA)

Becke

Eich

Höhne

et al. 2018

Pediatric Anesthesia

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Inspired by the Choosing Wisely initiative, a group of pediatric anesthesiologists representing the German Working Group on Paediatric Anaesthesia (WAKKA) coined and agreed upon 10 concise positive ("dos") or negative ("don'ts") evidence-based recommendations. (i) In infants and children with robust indications for surgical, interventional, or diagnostic procedures, anesthesia or sedation should not be avoided or delayed due to the potential neurotoxicity associated with the exposure to anesthetics. (ii) In children without relevant preexisting illnesses (ie, ASA status I/II) who are scheduled for elective minor or medium-risk surgical procedures, no routine blood tests should be performed. (iii) Parental presence during the induction of anesthesia should be an option for children whenever possible. (iv) Perioperative fasting should be safe and child-friendly with shorter real fasting times and more liberal postoperative drinking and enteral feeding. (v) Perioperative fluid therapy should be safe and effective with physiologically composed balanced electrolyte solutions to maintain a normal extracellular fluid volume; addition of 1%-2.5% glucose to avoid lipolysis, hypoglycemia, and hyperglycemia, and colloids as needed to maintain a normal blood volume. (vi) To achieve safe and successful airway management, the locally accepted airway algorithm and continued teaching and training of basic and alternative techniques of ventilation and endotracheal intubation are required. (vii) Ultrasound and imaging systems (eg, transillumination) should be available for achieving central venous access and challenging peripheral venous and arterial access. (viii) Perioperative disturbances of the patient's homeostasis, such as hypotension, hypocapnia, hypothermia, hypoglycemia, hyponatremia, and severe anemia, should not be ignored and should be prevented or treated immediately. (ix) Pediatric patients with an elevated perioperative risk, eg, preterm and term neonates, infants, and critically ill children, should be treated at institutions where all caregivers have sufficient expertise and continuous clinical exposure to such patients. (x) A strategy for preventing postoperative vomiting, emergence delirium, and acute pain should be a part of every anesthetic procedure.

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“…Despite the guidelines, fasting periods are often exceeded in pediatrics [5]. Long periods of fasting in children, however, may lead to symptoms of dehydration or discomfort [6], thus exceeding the fasting time may be more harmful than useful. Current guidelines recommend a fasting time of 2 h for clear fluids, 4 h for breast milk, and 6 h for other milk and solids before induction of deep sedation or general anesthesia [7].…”

Section: Discussionmentioning

confidence: 99%

“…In addition, the rigid approach to fasting has led to orders of nil per os after midnight leading to considerably long fasting time of up to 15 hours [8]. In addition to the discomfort of fasting, a fasting state poses the body under significant metabolic stress decreasing its ability to deal with stress, and with depletion of glycogen stores lean body mass is sacrificed to meet the metabolic demands [6]. …”

Section: Discussionmentioning

confidence: 99%

Preoperative Fasting Guidelines in Children: Should They Be Revised?

Kafrouni

Ojaimi

2018

Case Reports in Anesthesiology

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Children presenting with ingestion of foreign bodies need gastroscopy as a primary management modality. A controversy lies regarding guidelines for preoperative fasting among children with low risk of aspiration and intraoperative complications. This case report represents cases of children who ingested foreign bodies and underwent fasting at different times preoperatively. With mounting evidence questioning the benefits of long durations of fasting in decreasing the risk of aspiration and with studies showing that fasting for more than 2 hours after ingestion of clear fluid does not significantly alter gastric pH or volume, these incidental findings raise the question of whether it is safe to keep children NPO, for a shorter duration before the administration of anesthesia. In addition, this report shows that current guidelines are in need of revision.

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Optimized preoperative fasting times decrease ketone body concentration and stabilize mean arterial blood pressure during induction of anesthesia in children younger than 36 months: a prospective observational cohort study

Abstract: Optimized fasting times improve the metabolic and hemodynamic condition during induction of anesthesia in children younger than 36 months of age.

Cited by 104 publications

References 23 publications

Real fasting times and incidence of pulmonary aspiration in children: Results of a German prospective multicenter observational study

Real fasting times and incidence of pulmonary aspiration in children: Results of a German prospective multicenter observational study

Choosing Wisely in pediatric anesthesia: An interpretation from the German Scientific Working Group of Paediatric Anaesthesia (WAKKA)

Preoperative Fasting Guidelines in Children: Should They Be Revised?

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