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Effect of different quantities of a sugared clear fluid on gastric emptying and residual volume in children: a crossover study using magnetic resonance imaging. Schmitz A,Kellenberger C J,Lochbuehler N,Fruehauf M,Klaghofer R,Fruehauf H,Weiss M British journal of anaesthesia BACKGROUND:Gastric emptying in the first 2 h after 7 ml kg(-1) of sugared clear fluid has recently been investigated in healthy children using magnetic resonance imaging (MRI). This study aims to compare gastric volume and emptying half-life during 1 h after 3 or 7 ml kg(-1) sugared clear fluid intake. METHODS:Fourteen healthy volunteer children aged 11.1 (8.2-12.5) yr were investigated prospectively after administration of 3 and 7 ml kg(-1) diluted raspberry syrup in a randomized order, after overnight fasting (baseline). Gastric content volume (GCV(w)) was assessed with a 1.5 Tesla MRI scanner in a blinded fashion. Data are presented as median (range) and compared using the Wilcoxon test. RESULTS:Baseline GCV(w) was 0.39 (0.04-1.00) and 0.34 (0.07-0.75) before intake of 3 and 7 ml kg(-1) syrup, respectively (P=0.93). GCV(w) was 0.45 (0.04-1.55)/1.33 (0.30-2.60) ml kg(-1) 60 min after ingestion of 3/7 ml kg(-1) syrup (P=0.002). Thus GCV(w) had declined to baseline after 3 ml kg(-1) (P=0.39) but not after 7 ml kg(-1) (P=0.001) within 60 min. T(1/2) was 20 (10-62)/27 (13-43) min (P=0.73) after 3/7 ml kg(-1). CONCLUSION:In healthy volunteer children, residual GCV(w) 1 h after intake of 3 ml kg(-1) syrup is significantly smaller than that after 7 ml kg(-1) and within the range of baseline. 10.1093/bja/aer497
Canadian Pediatric Anesthesia Society statement on clear fluid fasting for elective pediatric anesthesia. Rosen David,Gamble Jonathan,Matava Clyde, Canadian journal of anaesthesia = Journal canadien d'anesthesie 10.1007/s12630-019-01382-z
Effect of pre-operative oral paracetamol on gastric residual volume and pH in young children in the context of a 1-hour clear fluid fast: a randomised controlled trial. Anaesthesia High gastric residual volume and low pH are associated with increased mortality following pulmonary aspiration in animal studies. The use of pre-operative oral paracetamol has not been investigated in younger children and infants in the context of a prescriptive 1-h clear fluid fast aimed at reducing the risk of pulmonary aspiration while improving patient experience. Children aged 1 month up to a weight of 25 kg and scheduled for elective surgery were randomly allocated to receive a prescribed 3.6 ml.kg drink of water alone (water group) or 3 ml.kg water and oral Infant Calpol® syrup (24 mg.ml concentration, equivalent volume 0.6 ml.kg , paracetamol group) 1 h before the induction of anaesthesia. Following induction, a nasogastric tube was used to aspirate gastric contents and the volume and pH were recorded. Ninety-seven children, median (IQR [range]) age 24 (12-45 [1-96]) months and weight 12.4 (9.7-16.0 [2.9-27.0]) kg, were analysed. Median time from drink to induction was 54 (45-60 [21-113]) min. There was no significant difference in gastric residual volume (p = 1) or pH (p = 0.99) between the water and the paracetamol groups. Sub-group analysis revealed no significant difference in gastric residual volume or pH for 29 children who weighed < 10 kg compared with > 10 kg. Using a prescriptive fluid regime of 3 ml.kg of water, the addition of oral paracetamol syrup did not significantly alter gastric residual volume or pH in the context of a 1-h fast in infants and young children. 10.1111/anae.15670
Preoperative fasting in children: review of existing guidelines and recent developments. Frykholm P,Schindler E,Sümpelmann R,Walker R,Weiss M British journal of anaesthesia The current guidelines for preoperative fasting recommend intervals of 6, 4, and 2 h (6-4-2) of fasting for solids, breast milk, and clear fluids, respectively. The objective is to minimize the risk of pulmonary aspiration of gastric contents, but also to prevent unnecessarily long fasting intervals. Pulmonary aspiration is rare and associated with nearly no mortality in paediatric anaesthesia. The incidence may have decreased during the last decades, judging from several audits published recently. However, several reports of very long fasting intervals have also been published, in spite of the implementation of the 6-4-2 fasting regimens. In this review, we examine the physiological basis for various fasting recommendations, the temporal relationship between fluid intake and residual gastric content, and the pathophysiological effects of preoperative fasting, and review recent publications of various attempts to reduce the incidence of prolonged fasting in children. The pros and cons of the current guidelines will be addressed, and possible strategies for a future revision will be suggested. 10.1016/j.bja.2017.11.080
A liberalized fasting guideline for formula-fed infants does not increase average gastric fluid volume before elective surgery. Greeley William J,Cook-Sather Scott D,Harris Kathleen A,Chiavacci Rosetta,Gallagher Paul R,Schreiner Mark S Anesthesia and analgesia UNLABELLED:Recommended preoperative fasting intervals for infant formula vary from 4 to 8 h. We conducted a prospective, randomized, observer-blinded trial of 97 ASA physical status I and II infants scheduled for elective surgery to determine whether average gastric fluid volume (GFV) recovered from infants formula-fasted for 4 h (liberalized fast, Group L) differed from that recovered from infants allowed clear liquids up until 2 h, but fasted 8 h for formula and solids (traditional fast, Group T). In Group L, 31 of 39 subjects followed protocol and ingested formula 4-6 h before surgery. In Group T, 36 of 58 subjects followed protocol, taking clear liquids 2-5 h before the induction of anesthesia. Thirty subjects had prolonged fasts and were included only in a secondary intent-to-treat analysis. Respective mean age (5.7 +/- 2.3 versus 6.4 +/- 2.4 mo; range, 0.7-10.5 mo), weight (7.5 +/- 1.8 versus 7.5 +/- 1.1 kg), and volume of last feed (4.9 +/- 2.2 versus 4.0 +/- 2.3 oz.) did not vary between Groups L and T. GFV (L: 0.19 +/- 0.38 versus T: 0.16 +/- 0.30 mL/kg) and gastric fluid pH (L: 2.5 +/- 0.5 versus T: 2.9 +/- 1.3) did not vary. For all subjects, GFV (mL/kg) increased with age (Spearman correlation coefficient = +0.23, P = 0.03). Infant irritability and hunger and parent satisfaction were similar between groups. We conclude that average GFV after either a 4- to 6-h fast for infant formula or 2-h fast after clear liquids is small and not significantly different between groups. On the basis of these findings, clinicians may consider liberalizing formula feedings to 4 h before surgery in selected infants. IMPLICATIONS:Healthy infants aged < or =10.5 mo may drink formula up to 4 h before surgery without increasing gastric fluid volume compared with infants allowed clear liquids up to 2 h and formula 8 h before surgery. 10.1213/01.ANE.0000055807.31411.8B
Fluid Fasting in Children: Solid Science? Vutskits Laszlo,Davidson Andrew Anesthesiology 10.1097/ALN.0000000000003406
Determinants of liquid gastric emptying: comparisons between milk and isocalorically adjusted clear fluids. Okabe T,Terashima H,Sakamoto A British journal of anaesthesia BACKGROUND:Although current preoperative fasting guidelines apply restrictions to drinks containing milk because of delayed gastric emptying, the safe volume of milk that can be consumed up to 2 h before surgery on a theoretical basis has not yet been defined. We aimed to determine whether delayed gastric emptying depended mainly on the total amount of calories irrespective of compositional differences between milk and clear fluids. METHODS:We prepared five beverages with a uniform volume (500 ml) and step-wise increments in calories (0, 220, and 330 kcal), comprised mainly of non-human milk, pulpless orange juice, water, and gum syrup. The gastric emptying rate of each beverage was determined by ultrasound measurements of the gastric antral cross-sectional area after their ingestion by eight healthy fasting volunteers. RESULTS:The emptying rates of 500 ml of orange juice and 330 ml of non-human milk with 170 ml of water (both were 220 kcal) from the stomach were similar. Furthermore, 450 ml of orange juice with 50 ml of gum syrup and 500 ml of non-human milk (both were 330 kcal) left the stomach at similar rates. The 220 kcal beverages emptied faster than the 330 kcal beverages. CONCLUSIONS:There were no significant differences in liquid gastric emptying after drinking equal volumes of either orange juice or milk as long as both had the same amount of calories. Liquid gastric emptying depends chiefly on the total caloric content. CLINICAL TRIAL REGISTRATION:UMIN000012537. 10.1093/bja/aeu338
Ultrasound assessment of gastric emptying time after a standardised light breakfast in healthy children: A prospective observational study. Beck Christiane E,Witt Lars,Albrecht Lisa,Dennhardt Nils,Böthig Dietmar,Sümpelmann Robert European journal of anaesthesiology OBJECTIVES:Current guidelines recommend 6 h of fasting for solids before anaesthesia. However, prolonged fasting may lead to discomfort, hunger, thirst, misbehaviour and lipolysis. To prevent this, a more liberal fasting regimen has been empirically implemented in our children's hospital, allowing a shorter fasting time of 4 h for a standardised light breakfast. AIM:The aim of this study was to determine the gastric emptying time after a standardised light breakfast in healthy children. DESIGN:A prospective observational noninterventional study. METHODS:After fasting overnight, the children had a standardised light breakfast. Before and afterwards, ultrasound examinations of the gastric antrum were performed hourly to determine the gastric antral area (GAA), which is a surrogate parameter for gastric volume in children in the right lateral position (RLP). Demographic data and fasting times are presented as mean ± SD (range) and GAA as median (interquartile range). RESULTS:Twenty-two children aged 7.8 (2.5 to 13.6) years volunteered for this study. After fasting overnight [735 ± 120 (467 to 930) min], the initial GAA was 3.06 (2.35 to 4.03) cm in RLP. After the light breakfast, GAA in RLP initially increased and decreased subsequently. After 4 h, GAA in RLP was lower than the initial value (median of differences -0.54, 95% confidence interval -1.00 to -0.07, P < 0.05). Correlation between GAA in RLP and fasting time was significant (r = -0.62, P < 0.0001). Using a linear regression model, the calculated mean gastric emptying time after the standardised light breakfast was 211 min for GAA = 3.06 cm. CONCLUSION:The study showed a mean gastric emptying time of less than 4 h after a standardised light breakfast in children. These results encourage our current clinical practice and support the efforts towards a more liberal fasting regimen for light meals in paediatric anaesthesia. TRIAL REGISTRATION:German Registry of Clinical Studies (DRKS-ID: DRKS 00013893). 10.1097/EJA.0000000000000874
Gastric emptying of milk in infants and children up to 5 years of age: normative data and influencing factors. Kwatra Neha S,Shalaby-Rana Eglal,Andrich Mary P,Tsai Jason,Rice Amy L,Ghelani Sunil J,Spottswood Stephanie E,Majd Massoud Pediatric radiology BACKGROUND:Gastric emptying scintigraphy is widely used in infants and children, but there is a lack of age-specific normative data. OBJECTIVE:The objectives of this retrospective study were: 1) to establish a range of gastric emptying of milk or formula as a surrogate for normal gastric emptying in infants and young children ≤5 years of age, and 2) to investigate the effects of patient age, feeding volume, feeding route and gastroesophageal reflux on gastric emptying. MATERIALS AND METHODS:The reports of 5,136 gastric emptying studies of children ≤5 years of age performed at Children's National Medical Center from January 1990 to August 2012 were reviewed. Demographic data, 1-h and 3-h gastric emptying values and gastroesophageal reflux status of all patients were stored in a database. Using stringent inclusion and exclusion criteria, the studies of patients as similar to healthy children as possible were selected for this study. RESULTS:The study group included 2,273 children (57% male) ages 0-59 months (median: 4.6 months). The median 1-h gastric emptying was 43% (interquartile range [IQR] 34-54%). The median 3-h gastric emptying was 91% (IQR 79-98%). Sixty-one percent of patients with 1-h gastric emptying value of <50% had 3-h gastric emptying ≥80%. Gastric emptying was significantly faster in children ≤6 months as compared with all older age groups. In each age group, the median gastric emptying decreased with increasing feeding volume. Gastric emptying was significantly faster in patients fed via combined nasogastric tube and oral routes as compared with those fed exclusively orally. There was no significant difference in gastric emptying of children with and without gastroesophageal reflux. CONCLUSION:Although there are statistically significant differences in gastric emptying based on age, volume and route of feeding, the data suggest that overall normal liquid gastric emptying in infants and children ≤5 years of age is ≥80% at 3 h. One-hour emptying measurements are not reliable for detecting delayed gastric emptying. 10.1007/s00247-020-04614-3
Ultrasound assessment of gastric emptying time after intake of clear fluids in children scheduled for general anesthesia-A prospective observational study. Beck Christiane E,Chandrakumar Thurgkai,Sümpelmann Robert,Nickel Katja,Keil Oliver,Heiderich Sebastian,Boethig Dietmar,Witt Lars,Dennhardt Nils Paediatric anaesthesia BACKGROUND:While many clinics have changed their local regimen toward a more liberal policy regarding clear fluid fasting for general anesthesia, there is a lack of studies evaluating gastric emptying time in a clinical setting. AIMS:Based on this and before implementation of a more liberal preoperative clear fluid fasting policy for children, we studied gastric emptying time of clear fluids in children and hypothesized that the mean gastric emptying time would be 1 hour. METHODS:Between March and December 2019, children scheduled for general anesthesia at our University Children's Hospital were enrolled in this prospective observational study. After overnight fasting, gastric emptying was examined by sonographic measurements of the gastric antral area before and 5, 15, 30, 45, and 60 minutes after intake of water or fruit juice. RESULTS:Twenty-six children were enrolled in this study, and 24 aged 11 (range 4-17) years were included for statistical analysis. The median ingested fluid volume was 4.7 (range 1.8-11.8) mL kg . The gastric antral area of the children initially increased and subsequently decreased after intake of clear fluids and correlated significantly with fasting time (r = -0.55, P < .0001). After 1 hour, the gastric antral area had returned to the baseline level in 20 children but not in four children with a fluid intake >5 mL kg . There was no difference in the gastric antral area between water and fruit juice. Using a linear regression model, the calculated mean gastric emptying time of clear fluids was 52 minutes. CONCLUSION:This study showed that the gastric emptying time of children after intake up to 5 mL kg clear fluids was <1 hour in a clinical setting. These results support the more liberal fasting regimen favoring a 1-hour fasting time and suggest 5 mL kg as an upper limit for clear fluids (eg, water, sugared water or tea or diluted fruit juice) from 2 hours to 1 hour before induction of anesthesia in children. 10.1111/pan.14029