Preoperative Fasting in Preventing Complications in Children

Clinical bottom line

Young children and adolescents are required to undergo preoperative fasting prior to general anesthesia. This is similar to the fasting required by adults before surgical operation procedures. Various scholars and medical professionals have argued that preoperative fasting minimizes the risks associated with regurgitation in the course of operations. In the recent past new evidence from medical research suggests that this practice should shift from total fasting policies to more flexible routines. This paper systematically evaluates the influence of various preoperative fasting regimes in relation to the reduction of perioperative complications.¹

• A Medline review identified 25 studies, which were relevant to the research topic. A total of 47 randomized control trials, which included 2543 children were reported to be potentially at risk of regurgitation. Only a single case of regurgitation and aspiration was observed. Children allowed to take liquids 120 minutes before the operation were observed not to develop high gastric or low pH figures. Evidence associated with the preoperative consumption of milk was scanty. The quantity of liquids allowed in the preoperative period did not reveal any adverse effects on intraoperative gastric levels.¹
• A Medline review which had 19 randomized control trials with a sample population of about 1274 children suggested that children who were allowed to take fluids up to 2 hours before the surgical operations, reported higher gastric volumes and lower incidence of gastric pH prior to operations. A total of 19 randomized controls trials were evaluated, and only 2 suggested that an observation of regurgitation was reported. Only a single case of regurgitation was recorded in which the patient was allowed to take fluids just 2 hours before the operation. A minimum of 4 studies observed that children did not regurgitate and aspirate when they were under anesthesia. This means that big multi-center surveys will be needed to illustrate the disparities on the impact of fasting regimens.²
• In a CINAHL review, a randomized control trial was carried out to describe how preoperative fasting advice provided to child patients impacted on the anxiety and parental knowledge. The study also sought to investigate the impact of the counseling on ambulatory tonsillectomy. The sample of the study was made up of parents of children aged between 4 and 10 years scheduled for ambulatory tonsillectomy. The study had a total of 124 participants in the sample population. The control group did not receive any counseling. The study revealed that counseling relieved anxiety in parents and the patient significantly.³
• A CINAHL review shows a randomized study conducted to evaluate the effects of preoperative and postoperative fasting. The study had a target sample of 12 children aged between 2-10 years. The probability of postoperative bleeding was a general concern for parents. The patients had recently undergone tonsillectomy.⁴
• A CINAHL review of a randomized trial. The trail investigated the effect of face-to-face counseling in relation to perioperative complications. A total of 116 families with children diagnosed with ambulatory tonsillectomy took part in the study. In the intervention group, the score was generally low within the immediate 24 hours after the operation. However, it increased in the control group.⁵
• A Cochrane review of a study conducted on 56 women to assess the safety of preoperative fasting at least 2 hours before surgical procedures begin. A total of 50 respondents completed the survey. No signs of regurgitation or aspiration were identified during anesthesia. The median range of RGV was 6 (0-80) mL.⁶
• In a Cochrane review, a randomized control trial was conducted on 22 patients admitted surgery. The study revealed that preoperative feeding contained an endogenous breakdown of lipids. It also reduced the oxidation of amino acids.⁷
• A review of a randomized clinical trial from Cochrane, which had 116 respondents from the parents of children scheduled for ambulatory tonsillectomy.⁸
• A Cochrane review of a clinical trial survey which includes 80 children aged between 1 and 10 years. The respondents were divided into eight groups of 10 each. Blood sugar was generally high in patients who consumed NLF and HCD. The only exception was the HCD-4 group. There were no distinct disparities in the prealbumin in the blood.⁹
• A PubMed review of a randomized control trial to the authenticity of relaxed fasting regimes. It was noted that the general occurrence of aspiration is relatively low particularly in pediatric patients. The study had a sample of 100 patients comprised of children below the age of 8 years. The results indicate that 16% of the control group experienced at least a single case of vomiting. The study group recorded 18%. However, this score did not illustrate any fundamental differences between the two groups.¹⁰
• A PubMed review of a randomized control trial to investigate the effect and degree of safety with regard to the preoperative administration of fluids compared to fasting. A total of 221 respondents took part in the study. The average preoperative clinical condition of respondents in groups B and C was predominantly better compared to A. An increase in insulin resistance was relatively high in group A.¹¹
• A PubMed review which compared the influence of preoperative ingestion of carbohydrates. This was compared to insulin resistance prior to surgical procedures. The characteristics of patients did not vary from one group to the other. A total of 21 females took part in the study. An estimated 70% and 27.3% of the control and study population witnessed an occurrence of vomiting. The serum glucose and insulin levels attributed to the control group were far much higher compared to the study group.¹²
• A DARE review of a randomized clinical trial carried out in a health institution. It was composed of patients going through ophthalmologic surgery. The study had 123 patients and 109 were randomly allocated to two groups. Respondents who drank 200ml approximately 2 hours prior to surgery relatively did not experience hunger. Neither were they thirsty prior to and after the operation.¹³
• A DARE review of the liberalized guidelines provided in reference to preoperative fasting. This is a single randomized study on 42 patients who were asked to evaluate the occurrence of 12 signs of discomfort before and after operations. The fasting lasted for 11.3 hours for the LTNPO group. For the STNPO group, it was 10.9 hours. However the period of fasting in relation to liquids was relatively short for the STNPO group at 4.5 hours. For the LTNPO group, it was 11.3 hours. The study observed a relatively low occurrence of feeling cold prior to operation. It also realized low cases of thirst postoperatively. However, no fundamental disparities were witnessed between the groups in regard to blood pressure and gastric volumes.¹⁴
• A DARE review of a randomized trial aimed at assessing the effectiveness of the administration of fluids in the morning before surgery. This is in an effort to minimize the long preoperative fasting imposed by surgery. Informed consent was obtained from parents so that 116 children could be enrolled in the survey. The patients were scheduled for orthopedic operations. The sample was divided into two groups. The fasting time varied between 4.8 to 2.1 hours. In the group which received a glass of juice, more patients were observed to be generally irritated and dehydrated. No high levels of glucose in the blood stream were attributed to any group.¹⁵

Characteristics of the evidence

The evidence summary provided here was obtained from a literature review of sources not more than 5 years old from medical and health databases. These evidences in the summary have been specifically obtained from 5 different databases namely Cochrane, DARE, Medline, CINAHL, and PubMed. The 15 sources used in this summary are:

• A Medline review of 47 randomized control trials which had a sample of 2543 patients.¹
• A Medline review of 19 randomized control trials with a sample population of 1274 children.²
• A CINAHL review of a randomized control trial with 124 respondents.³
• A CINAHL review of trail conducted of 12 children who had undergone tonsillectomy, aged between 2 to 10 years.⁴
• A CINAHL randomized control trial review with a target sample of 116 respondents. It revealed that the VAS scores were higher in the control group.⁵
• A Cochrane review of a randomized study having a sample of 56; however, only 50 completed the trial.⁶
• A Cochrane review of a clinical RCT of 22 patients scheduled for surgery.⁷
• A Cochrane review of a clinical study, which had 116 respondents.⁸
• A Cochrane review of a randomized control trial of 80 children suffering from inguinoscrotal disorders.⁹
• A PubMed review of a randomized control trial comprising of 100 respondents below the age of 8 years.¹⁰
• A PubMed review of a RCT study which included 221 respondents divided into three groups.¹¹
• A PubMed review of the effect of preoperative ingestion of carbohydrates, conducted on 21 females.¹²
• A DARE review of a RCT with 123 patients but only 109 were assigned to the two groups.¹³
• A DARE randomized control trial review conducted on 42 patients with regard to the liberalization of national regulations on preoperative fasting.¹⁴
• A DARE review of a randomized control trial study that had a sample population of 116 respondents divided into two groups.¹⁵

Best practice recommendations

• It is safe for children to take clear fluids at least 2 hours before surgical procedures.
• The review of evidence from various studies indicates that the consumption of fluids several hours before surgical procedures does not in any way increase the probability of aspiration and regurgitation in the course of a surgery. However, preoperative comfort is observed in relation to thirst and hunger.
• No evidence suggests that children who are not allowed to take fluids for a period longer than 6 hours prior to operations actually benefit in relation to intraoperative gastric pH and volume.
• Children who are over-weight, suffering from diabetes and other stomach ailment are more predisposed to regurgitation and aspiration.

References

Brady M, Kinn S, Ness V, O’Rourke K, Randhawa N, Stuart P. Preoperative fasting for preventing perioperative complications in children. The Cochrane Database of Systematic Reviews [serial on the Internet]. (2009), [2013]; 14(4):38-51.

Robertson-Malt S, Winters A, Ewing S, Jackson D, Kiame G. Preoperative fasting for preventing perioperative complications in children. Australian Nursing Journal [serial on the Internet]. (2008), [2013]; 15(9):29-31.

Klemetti S, Kinnunen I, Suominen T, Antila H, Vahlberg T, Leino-Kilpi H, et al. The effect of preoperative nutritional face-to-face counseling about child’s fasting on parental knowledge, preoperative need-for-information, and anxiety, in pediatric ambulatory tonsillectomy. Patient Education & Counseling [serial on the Internet]. (2010), [2013]; 80(1):64-70.

Klemetti S, Suominen T. Fasting in paediatric ambulatory surgery. International Journal of Nursing Practice [serial on the Internet]. (2008), [2013]; 14(1):47-56.

Klemetti S, Kinnunen I, Suominen T, Antila H, Vahlberg T, Leino-Kilpi H, et al. The effect of preoperative fasting on postoperative thirst, hunger and oral intake in paediatric ambulatory tonsillectomy. Journal of Clinical Nursing [serial on the Internet]. (2010), [2013]; 19(3-4):341-350.

Dock-Nascimento D B, Aguilar-Nascimento J E D, Caporossi C, Magalhães M S, Faria R, Caporossi F S, & Waitzberg D L. Safety of oral glutamine in the abbreviation of preoperative fasting; a double-blind, controlled, randomized clinical trial. Nutr Hosp. 2011; 26(1):86-90.

Schricker T, Meterissian S, Lattermann R, Adegoke O A, Marliss E B, Mazza L, & Wykes L. Anticatabolic effects of avoiding preoperative fasting by intravenous hypocaloric nutrition: a randomized clinical trial. Annals of surgery. 2008; 248(6): 1051-1059.

Klemetti S, Kinnunen I, Suominen T, Antila H, Vahlberg T, Grenman R, & Leino-Kilpi H. The effect of preoperative fasting on postoperative pain, nausea and vomiting in pediatric ambulatory tonsillectomy. International journal of pediatric otorhinolaryngology. 2009; 73(2):263-273.

Yurtcu M, Gunel E, Sahin T K, & Sivrikaya A. Effects of fasting and preoperative feeding in children. World journal of gastroenterology: WJG. 2009; 15(39):4919.

Shabana A M, Ghanem M A, Elsarraf W M R. Preoperative fasting regimen for clear fluids in healthy children, changing perspective. A randomized controlled single blinded study. Egyptian Journal of Anaesthesia. 2009; 25(2):83-86.

Kaška M, Grosmanová, T Á, Havel E, Hyšpler R, Petrová Z, Brtko, M & Sluka, M. The impact and safety of preoperative oral or intravenous carbohydrate administration versus fasting in colorectal surgery–a randomized controlled trial. Wiener klinische Wochenschrift. 2010; 122(1-2):23-30.

Faria M S, de Aguilar-Nascimento J E, Pimenta O S, Alvarenga Jr L C, Dock-Nascimento D B & Slhessarenko N. Preoperative fasting of 2 hours minimizes insulin resistance and organic response to trauma after video-cholecystectomy: a randomized, controlled, clinical trial. World journal of surgery. 2009; 33(6):1158-1164.

Bopp C, Hofer S, Klein A, Weigand M A, Martin E & Gust R. A liberal preoperative fasting regimen improves patient comfort and satisfaction with anesthesia care in day-stay minor surgery. Minerva anestesiologica. 2011; 77(7):680-682.

Meisner M, Ernhofer U & Schmidt J. Liberalisation of preoperative fasting guidelines: effects on patient comfort and clinical practicability during elective laparoscopic surgery of the lower abdomen. Zentralblatt für Chirurgie. 2008; 133(05):479-485.

Klemetti S, Kinnunen I, Suominen T, Antila H, Vahlberg T, Leino-Kilp H, et al. Active preoperative nutrition is safely implemented by the parents in pediatric ambulatory tonsillectomy. Ambulatory Surgery [serial on the Internet]. 2010; 16(3):75-79.