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Introducing the 6-4-0 fasting regimen and the incidence of prolonged preoperative fasting in children
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Gastroenterology/Hepatology.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
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.

Place, publisher, year, edition, pages
2018. Vol. 28, no 1, p. 46-52
Keywords [en]
anesthesia, children, fasting, fluids, preoperative
National Category
Anesthesiology and Intensive Care Pediatrics
Identifiers
URN: urn:nbn:se:uu:diva-343890DOI: 10.1111/pan.13282ISI: 000417604600008PubMedID: 29168341OAI: oai:DiVA.org:uu-343890DiVA, id: diva2:1187656
Available from: 2018-03-05 Created: 2018-03-05 Last updated: 2019-10-06Bibliographically approved
In thesis
1. Reduced Preoperative Fasting in Children
Open this publication in new window or tab >>Reduced Preoperative Fasting in Children
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
Fasting, Children, Preoperative, Pulmonary Aspiration
National Category
Anesthesiology and Intensive Care
Research subject
Anaesthesiology and Intensive Care
Identifiers
urn:nbn:se:uu:diva-394232 (URN)978-91-513-0764-0 (ISBN)
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

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Andersson, HannaHellström, Per M.Frykholm, Peter

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