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Anesthesiology:
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Adequate Preoperative Fasting and Aspiration: Factors Affecting Regurgitation

Salem, M Ramez M.D.*; Gaucher, Donald M.D.; Joseph, Ninos J. B.S.

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To the Editor:—

Kawabata et al.1 reported a case of unanticipated vomiting and pulmonary aspiration after induction of anesthesia in a formula-fed 4-month-old female infant who weighed 6.26 kg scheduled for elective cheiloplasty. Anesthesia was induced with sevoflurane and nitrous oxide in 33% oxygen. The anesthesiologist tried to maintain spontaneous respirations but, abruptly, mask ventilation could not be performed. Arterial oxygen saturation decreased to 28% and formula was found in the patient's mouth. The authors argue that despite surveys and the American Society of Anesthesiologists practice guidelines' recommended 4-h fasting time,2–4 the risk of aspiration remains and suggested that further studies and discussions are needed for a consensus on fasting time for formula-fed infants. Several comments related to the case appear warranted.
First, this case demonstrates that despite more than 4 h of fasting, residual formula can still be present in some infants. Not surprisingly, studies have shown that a completely empty stomach is often not achieved after the recommended fasting time.5,6
Second, although the authors claim that their patient vomited, it appears from their own description that the action was regurgitation rather than vomiting. Various factors can play a role in inducing regurgitation in infants.7 Airway obstruction during spontaneous breathing during anesthetic induction may cause regurgitation by increasing pleuroperitoneal pressure differences (thus increasing the intragastric-esophageal pressure difference) and by raising the intragastric pressure as a result of the “over action” of the diaphragm.7,8 Positive airway pressure (in excess of 20 cm H2O) may result in intermittent opening of the cricopharyngeal sphincter and the gastroesophageal junction with a subsequent increase in intragastric pressure.7,8 The resting intragastric pressure can be higher in infants9 (as compared with adults) because of the relatively small size of the stomach, encroachment of some abdominal organs, previous air swallowing during crying, and strenuous diaphragmatic breathing.7,9 In addition, a mild from of relaxation of the gastroesophageal junction may exist in the first 6 months of age. Once gastric contents are forced up into the esophagus, they may readily find their way into the pharynx because of the short esophagus in the infant.7,9,10
Third, although inhalation induction using 30–35% oxygen is commonly practiced in infants and children, it is time to seriously consider “preoxygenation” to increase oxygen reserves and thereby delay the onset of arterial oxygen desaturation in case airway obstruction occurs.11–14 Infants are at an increased risk of hypoxemia because of their small functional residual capacity and increased oxygen consumption.15 The value of preoxygenation in pediatric patients has been recently discussed in a number of reports15–17 and certainly can be easily achieved.11–17
In conclusion, despite what appears to be an adequate preoperative fasting, the anesthesiologist should proceed with the assumption that the stomach is not completely empty. It behooves the anesthesiologist to take into consideration the factors that may induce regurgitation during induction and specifically avoiding and immediately correcting airway obstruction. Finally, preoxygenation before induction should be practiced.
M. Ramez Salem, M.D.,*
Donald Gaucher, M.D.
Ninos J. Joseph, B.S.
* Advocate Illinois Masonic Medical Center and University of Illinois College of Medicine, Chicago, Illinois. ramez.salem-md@advocatehealth.com
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References

1. Kawabata T, Tokumine J, Nakamura S, Sugahara K: Unanticipated vomiting and pulmonary aspiration at anesthesia induction in a formula-fed 4-month-old infant. Anesthesiology 2004; 100:1330–1

2. Emerson BM, Wrigley R, Newton M: Preoperative fasting for paediatric anaesthesia: A survey of current practice. Anaesthesia 1998; 53:326–30

3. Ferrari LR, Rooney FM, Rockoff AM: Preoperative fasting practices in pediatrics. Anesthesiology 1999; 90:978–80

4. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application of healthy patients undergoing elective procedures. A report by the American Society of Anesthesiologists Task Force on Preoperative Fasting. Anesthesiology 1999; 90:896–905

5. Cook-Sather SD, Harris KA, Chiavacci R, Gallagher PR, Schreiner MS: A liberalized fasting guideline for formula-fed infants does not increase average gastric fluid volume before elective surgery. Anesth Analg 2003; 96:965–9

6. Schreiner MS, Triebwasser A, Keon TP: Ingestion of liquids compared with preoperative fasting in pediatric outpatients. Anesthesiology 1990; 72:593–7

7. Salem MR, Wong AY, Collins VJ: The pediatric patient with a full stomach. Anesthesiology 1973; 39:535–40

8. Stevens JH: Anesthetic problems of intestinal obstruction in adults. Br J Anaesth 1964; 36:438–50

9. Salem MR, Wong AY, Lin YH: The effect of suxamethonium on the intragastric pressure in infants and children. Br J Anaesth 1972; 44:166–70

10. Salem MR, Wong AY, Fizzotti GF: Efficacy of cricoid pressure in preventing aspiration of gastric contents in paediatric patients. Br J Anaesth 1972; 44:401–4

11. Videira RL, Neto PP, do Amaral RV, Freeman JA: Preoxygenation in children: for how long? Acta Anaesthesiol Scand 1992; 36:109–11

12. Kinouchi K, Fukumitsu K, Tashiro C, Takauchi Y, Ohashi Y, Nishida T: Duration of apnoea in anaesthetized children required for desaturation of haemoglobin to 95%: Comparison of three different breathing gases. Paediatr Anaesth 1995; 5:115–9

13. Xue FS, Luo LK, Tong SY, Liao X, Deng XM, An G: Study of the safe threshold of apneic period in children during anesthesia induction. J Clin Anesth 1996; 8:568–74

14. Morrison JE Jr, Collier E, Friesen RH, Logan L: Preoxygenation before laryngoscopy in children: How long is enough? Paediatr Anaesth 1998; 8:293–8

15. Morrison JE Jr: Children at increased risk of hypoxia. Anesthesiology 2000; 92:1844

16. Videira RL: Preoxygenation in children: Why not? Anesthesiology 2000; 92:1844–5

17. Salem MR, Joseph NJ, Villa EM, Wafai Y, El-Orbany MI: Preoxygenation in children: Comparison of tidal volume and deep breathing techniques. Anesthesiology 2001; 95:A1247

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