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Clear fluids fasting for elective paediatric anaesthesia

The European Society of Anaesthesiology consensus statement

Disma, Nicola; Thomas, Mark; Afshari, Arash; Veyckemans, Francis; De Hert, Stefan

European Journal of Anaesthesiology (EJA): March 2019 - Volume 36 - Issue 3 - p 173–174
doi: 10.1097/EJA.0000000000000914
Editorial
Free

From the Department of Paediatric Anaesthesia, Istituto Giannina Gaslini, Genoa, Italy (ND), Department of Anaesthesia, Great Ormond Street Hospital, London, UK (MT), Department of Paediatric & Obstetric Anaesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (AA), Département d’Anesthésie, Réanimation pédiatrique Hôpital Jeanne de Flandre, CHU de Lille, Lille, France (FV) and Department of Anaesthesiology & Perioperative Medicine, Ghent University Hospital, Ghent University, Ghent, Belgium (SDH)

Correspondence to Nicola Disma, MD, Department of Paediatric Anaesthesia, Istituto Giannina Gaslini, Via G. Gaslini 5, 16100 Genoa, Italy E-mail: nicoladisma@icloud.com

Guidelines for the management of pre-operative paediatric clear fluid fasting historically recommend a minimum of 2 h. In particular, the published guideline from European Society of Anaesthesiology (ESA) in 2011, dedicated a section to peri-operative fasting in children and infants.1 This guideline stated that: ‘Children should be encouraged to drink clear fluids (including water, pulp-free juice and tea or coffee without milk) up to 2 h before elective surgery’, with an evidence level 1++ and a recommendation grade A.

Similarly, the American Society of Anaesthesiology (ASA) published their updated guidelines in 2017.2 ASA guidelines stated that ‘clear fluids may be ingested for up to 2 h before procedures requiring general anesthesia, regional anesthesia, or procedural sedation and analgesia’, with category A1-E evidence on gastric volume and category A2-B evidence demonstrating children are more thirsty and hungry when fasted in excess of 4 h.

These recommendations, as others, were based on published reviews and meta-analyses of randomised controlled trials, primarily aimed at minimising the risk of pulmonary aspiration of gastric contents. However, pulmonary aspiration is a very rare event (less than 3 to 4/10 000),3,4 and harm resulting from clear fluid aspiration in children is rarer still.4 It is also known that the stomach of a healthy child empties clear fluids within 30 min after intake (or even faster if fluids contain glucose), that gastric pH does not change 1 h after water intake, and that age does not affect the speed of gastric emptying.5,6

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The new evidence and the need for a new statement

The recently published APRICOT study,7 performed on a population of more than 30 000 children undergoing anaesthesia, showed that the risk of aspiration was approximately 9/10 000, and none of these children suffered significant clinical consequences, in terms of increased morbidity or mortality. Likewise, more liberalised clear fluid fasting regimes in other large cohorts of children, have shown no increase in the incidence of pulmonary aspiration.8,9 Furthermore, although gastric volume is a poor surrogate for the risk of aspiration, the gastric pH and residual volumes do not differ whether clear fluid fasting is 1 or 2 h in children.10

Moreover, the traditional 2-h clear fasting policy results in actual duration of fasting ranging from 6 to 15 h.11 Shortening the fasting regimen to 1 h, or even less with a liberalised regimen, reduces the duration of fasting with positive impact on children's psychology, metabolism and hemodynamic tolerance to the induction of anaesthesia, without increasing risks.12,13

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A recently endorsed statement

Based on the above new evidence, the European Society for Paediatric Anaesthesiology (http://www.euroespa.com/news/consensus-statement-on-clear-fluids-fasting-for-elective-pediatirc-general-anesthesia/), L’Association Des Anesthesistes-Reanimateurs Pediatriques d’Expression Francaise and the Association of Paediatric Anaesthetists of Great Britain and Ireland (https://www.apagbi.org.uk/sites/default/files/paragraphs/files/Fasting%20Consensus%20statement%20signatures%20Word.pdf) endorsed a new statement that advocates reducing the fasting time for clear fluids from 2 to 1 h.14

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The new statement on clear fluid fasting in children

Following the above initiative, and supported by the recent scientific advancements, the ESA endorses the new consensus statement for good clinical practice. The new statement can be considered applicable to all ages unless contraindicated by specific medical conditions or surgical reasons. The type and volume of fluids are deliberately not included in this statement, as they might be specified or defined by the national scientific societies and/or local institutional policies. The statement represents a global achievement and can be used as an update of the previously published guidelines on clear fluids fasting regimen in children.

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Consensus statement of the European Society of Anaesthesiology

‘It is safe and recommended for all children able to take clear fluids, to be allowed and encouraged to have them up to 1 h before elective general anaesthesia’.

In accordance with the above statement, there is an urgent need to update the published paediatric pre-operative fasting guidelines in a collaborative manner. We acknowledge that publishing state of the art scientific guidelines is a time and effort consuming endeavour and that very few societies have policies for fast-track guidelines and statements. Thus, this statement could act as a stimulus for future collaborative guidelines in paediatric anaesthesia.

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Acknowledgements relating to this article

Assistance with the Editorial: none.

Financial support and sponsorship: none.

Conflict of interest: none.

Comment from the Editor: this Editorial was checked and accepted by the Editors, but was not sent for external peer-review. FV is an associate editor of the European Journal of Anaesthesiology.

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References

1. Smith I, Kranke P, Murat I, et al. European Society of Anaesthesiology. Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 2011; 28:556–569.
2. [No authors listed]. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures an updated report by the American Society of Anesthesiologists task force on preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration. Anesthesiology 2017; 126:376–393.
3. Tan Z, Lee S. Pulmonary aspiration under GA: a 13-year audit in a tertiary pediatric unit. Pediatr Anesth 2016; 26:547–552.
4. Kelly C, Walker R. Perioperative pulmonary aspiration is infrequent and low risk in pediatric anesthetic practice. Pediatr Anesth 2015; 25:36–43.
5. Okabe T, Terashima H, Sakamoto A. Determinants of liquid gastric emptying: comparisons between milk and isoclorically adjusted clear fluids. Br J Anaesth 2015; 114:77–82.
6. Bonner JJ, Vajjah P, Abduljalil K, et al. Does age affect gastric emptying time? A model-based meta-analysis of data from premature neonates through to adults. Biopharm Drug Dispos 2015; 36:245–257.
7. Habre W, Disma N, Virag K, et al. Incidence of severe critical events in paediatric anaesthesia (APRICOT): a prospective multicentre observational study in 261 hospitals in Europe. Lancet 2017; 5:412–425.
8. Andersson H, Hellström PM, Frykholm P. Introducing the 6-4-0 fasting regimen and the incidence of prolonged preoperative fasting in children. Paediatr Anaesth 2018; 28:46–52.
9. Newton RJG, Stuart GM, Willdridge DJ, et al. Using quality improvement methods to reduce clear fluid fasting times in children on a preoperative ward. Paediatr Anaesth 2017; 27:793–800.
10. Schmidt A, Buehler P, Seglias L, et al. Gastric pH and residual volume after 1 and 2 h fasting time for clear fluids in children. Br J Anaesth 2015; 114:477–482.
11. Engelhardt T, Wilson G, Horne L, et al. Are you hungry? Are you thirsty? – Fasting times in elective outpatient pediatric patients. Pediatr Anesth 2011; 21:964–968.
12. Andersson H, Zaren B, Frykholm P. Low incidence of pulmonary aspiration in children allowed intake of clear fluids until called to the operating suite. Pediatr Anesth 2015; 25:770–777.
13. Frykholm P, Schindler E, Sümpelmann R, et al. Preoperative fasting in children: review of existing guidelines and recent developments. Br J Anaesth 2018; 120:469–474.
14. Thomas M, Morrison C, Newton R, et al. Consensus statement on clear fluids fasting for elective pediatric general anesthesia. Paediatr Anaesth 2018; 28:411–414.
© 2019 European Society of Anaesthesiology