Pro-Con Debate: 1- vs 2-Hour Fast for Clear Liquids Before Anesthesia in Children.

Perioperative fasting guidelines are designed to minimize the risk of pulmonary aspiration of gastrointestinal contents. The current recommendations from the American Society of Anesthesiologists (ASA) and the European Society of Anaesthesiology and Intensive Care (ESAIC) are for a minimum 2-hour fast after ingestion of clear liquids before general anesthesia, regional anesthesia, or procedural sedation and analgesia. Nonetheless, in children, fasting guidelines also have consequences as regards to child and parent satisfaction, hemodynamic stability, the ability to achieve vascular access, and perioperative energy balance. Despite the fact that current guidelines recommend a relatively short fasting time for clear fluids of 2 hours, the actual duration of fasting time can be significantly longer. This may be the result of deficiencies in communication regarding the duration of the ongoing fasting interval as the schedule changes in a busy operating room as well as to poor parent and patient adherence to the 2-hour guidelines. Prolonged fasting can result in children arriving in the operating room for an elective procedure being thirsty, hungry, and generally in an uncomfortable state. Furthermore, prolonged fasting may adversely affect hemodynamic stability and can result in parental dissatisfaction with the perioperative experience. In this PRO and CON presentation, the authors debate the premise that reducing the nominal minimum fasting time from 2 hours to 1 hour can reduce the incidence of prolonged fasting and provide significant benefits to children, with no increased risks.

Gastric Ultrasound Assessing Gastric Emptying of Preoperative Carbohydrate Drinks: A Randomized Controlled Noninferiority Study.

BACKGROUND: Tools for the evaluation of gastric emptying have evolved over time. The purpose of this study was to show that the risk of pulmonary aspiration is not increased with carbohydrate drink, by demonstrating that the gastric antral cross-sectional area (CSA) of the NO-NPO group is either equivalent to or less than that of the NPO (nil per os) group. METHODS: Sixty-four patients scheduled for elective laparoscopic benign gynecologic surgery were enrolled and randomly assigned to the NPO group (n = 32) or the NO-NPO group (n = 32). After having a regular meal until midnight before surgery, the NPO group fasted until surgery, while the NO-NPO group ingested 400 mL of a carbohydrate drink at midnight and freely up to 2 hours before anesthesia. The primary outcome was the gastric antral CSA by gastric ultrasound in right lateral decubitus position (RLDP). Noninferiority was defined as a mean difference of CSA <2.8 cm2. Secondary outcomes included CSA in supine position, gastric volume (GV), GV per weight (GV/kg), GV/kg >1.5 mL/kg, and Perlas grade. RESULTS: CSA in RLDP was not different between the NPO group (6.25 ± 3.79 cm2) and the NO-NPO group (6.21 ± 2.48 cm2; P = .959). The mean difference of CSA in RLDP (NO-NPO group - NPO group) was 0.04 (95% confidence interval [CI], -1.56 to 1.64), which was within the noninferiority margin of 2.8 cm2. CSA was not different between the 2 groups (4.17 ± 2.34 cm2 in NPO group versus 4.28 ± 1.23 cm2 in NO-NPO group; P = .828). GV in NPO group (70 ± 56 mL) was not different from NO-NPO group (66 ± 36 mL; mean difference, 3.66; 95% CI, -20 to 27; P = .756). GV/kg in the NPO group (1.25 ± 1.00 mL/kg) was not different from the NO-NPO group (1.17 ± 0.67 mL/kg; P = .694). The incidence of GV/kg > 1.5 mL/kg was not different between NPO (31.3%) and NO-NPO group (21.9%; P = .768). The median (interquartile range) of the Perlas grade was 1 (0-1) in NPO group and 0.5 (0-1) in NO-NPO group (P = .871). CONCLUSIONS: Preoperative carbohydrates ingested up to 2 hours before anesthesia do not delay gastric emptying compared to midnight fasting, as evaluated with gastric ultrasound.

Nulla Per Os (NPO) guidelines: time to revisit?

PURPOSE OF REVIEW: Preoperative fasting guidelines are generalized to elective procedures and usually do not distinguish between the ambulatory and inpatient setting. Prevalence of aspiration is low while prolonged preoperative fasting is common clinical reality. Recently, changes in preoperative fasting guidelines have been widely discussed. RECENT FINDINGS: Rates of prolonged clear fluid fasting (>4 h) prior to surgery are reported in up to 80% of patients with mean fasting duration of up to 16 h and beyond. Prolonged fasting may result in adverse effects such as intraoperative hemodynamic instability, postoperative delirium, patient discomfort, and extended hospital length of stay. Liberal approaches allowing clear fluids up to 1 h prior to anesthesia or until premedication/call to the operating room have shown no increase in adverse events among children. Various anesthesia societies now encourage clear fluid intake up to 1 h prior to pediatric elective anesthesia. Similar reports in the adult cohort are scarce. SUMMARY: Allowing sips of water until call to the operating room may help reducing prolonged preoperative fasting and improving patient comfort while keeping a flexibility in operating room schedule. The feasibility and safety of a liberal clear fluid fasting regimen among adults undergoing elective anesthesia needs to be evaluated in future studies.

Práctica actual de la inducción de secuencia rápida en adultos: una encuesta nacional entre anestesiólogos en España / Current practice of rapid sequence induction in adults: a national survey among anesthesiologists in Spain

ANTECEDENTES: La inducción de secuencia rápida (ISR) en adultos ha experimentadcambios en los últimos años debido a los avances farmacológicos y tecnológicos. El objetivo de esta encuesta fue evaluar la práctica actual entre los anestesiólogos españoles. MÉTODOS: Se envió un cuestionario con 31 preguntas referentes a la práctica de la ISR a anestesiólogos de hospitales del Servicio Nacional de Salud de España. Las diferencias en las respuestas relacionadas con el tipo de hospital o experiencia se compararon para todos los datos utilizando el Chi-cuadrado y la prueba exacta de Fisher. RESULTADOS: Aproximadamente el 15,89% de los anestesiólogos españoles participaron en la encuesta (1.002 cuestionarios). Los resultados muestran una gran heterogeneidad en la mayoría de los aspectos de la ISR. El citrato sódico es administrado por menos del 20% de los participantes. El 64% de los encuestados coloca una sonda nasogástrica en pacientes con obstrucción intestinal. El residuo gástrico se evalúa con ultrasonidos en un 6%. Una cuarta parte de los encuestados controla la eficacia de la preoxigenación con la ETO2 y el 22% utiliza la insuflación nasal de oxígeno con gafas nasales o THRIVE. El 62% de los encuestados aplica presión cricoidea, pero solo se libera en un 50% cuando aparece dificultad en la intubación. Hasta el 40% de los anestesiólogos refirieron haber tenido algún caso de aspiración a pesar de aplicar presión cricoidea. El propofol fue el hipnótico más utilizado (97,6%), mientras que no hubo una diferencia clara en la preferencia del relajante neuromuscular (ratio suxametonio versus rocuronio de aproximadamente 1:1). Solo el 44% de los encuestados calcula la dosis de sugammadex necesaria para una reversión de emergencia del rocuronio. CONCLUSIONES: La encuesta demostró una variación significativa en la práctica de la ISR, similar a la de otros países. Se necesitan estudios prospectivos de calidad para estandarizar la práctica clínica

BACKGROUND: Rapid sequence induction (RSI) in adults has undergone changes in recent years due to pharmacological and technological advances. The objective of this survey was to evaluate current practice among Spanish anesthesiologists. METHODS: A 31-item questionnaire regarding RSI practice was sent to anesthesiologists working in Spanish public hospitals. Differences in responses according to the type of hospital or experience of the respondent were compared for all data using the chi-square and Fisher's exact test. RESULTS: Approximately 15.89% of Spanish anesthesiologists participated in the survey (1002 questionnaires). The results show considerable heterogeneity in most aspects of RSI. Less than 20% of respondents administer sodium citrate. Sixty-four percent place a nasogastric tube in patients with intestinal obstruction. Gastric residue is assessed by ultrasound in 6% of cases. Only 25% of respondents measure ETO2 to check the effectiveness of preoxygenation, and 22% use nasal oxygen insufflation with nasal prongs or THRIVE. Sixty two percent of respondents apply cricoid pressure, but only 50% release the pressure when encountering intubation difficulty. Up to 40% of respondents reported cases of aspiration despite applying cricoid pressure. Propofol was the most commonly used hypnotic (97.6%), but there was no clear preference in the choice of neuromuscular relaxant (suxamethonium versus rocuronium ratio of approximately 1:1). Only 44% of respondents calculated the dose of sugammadex that would be required for emergency reversal of rocuronium. CONCLUSIONS: The survey showed significant variation in RSI practice, similar to that of other countries. Quality prospective studies are needed to standardize clinical practice

Predictive factors for gastrostomy at time of diagnosis and impact on survival in patients with amyotrophic lateral sclerosis.

BACKGROUND: Gastrostomy is recommended in patients with Amyotrophic Lateral Sclerosis (ALS) in the presence of weight loss over 10% as compared to usual weight, repeated aspirations or meal time duration longer than 45 min. Currently, the impact of gastrostomy on survival of ALS patients is not clear. AIMS: i) to describe diagnosis factors associated with the indication for gastrostomy ii) to evaluate survival of ALS patients with gastrostomy indication according to their acceptance of feeding tube placement. METHODS: Patients with ALS were included and followed in the ALS referral centre of Limoges's teaching hospital between 2006 and 2017. Neurological, nutritional and respiratory status was assessed prospectively from diagnosis to death. Statistical analysis was performed using Mann-Whitney test, Chi2 tests, Cox model and multivariate logistic regression. RESULTS: Two hundred and eighty-five patients were included. Among the 182 for whom gastrostomy was indicated, 63.7% accepted the placement. The median time was 7.3 months [IQR: 3.2-15.0] and 2.7 months [IQR: 0.9-5.8] respectively from diagnosis to indication and from indication to placement. Weight loss >5% significantly increased the risk of death by 17% (p < 0.0001). At time of diagnosis, bulbar onset, a loss of one point in the body mass index or on the bulbar functional scale were all positively associated with indication for gastrostomy (aOR = 10.0 [95%CI: 1.96-25.0]; p = 0.002, aOR = 1.17 [95%CI: 1.02-1.36]; p = 0.025 and aOR = 1.19 [95%CI: 1.06-1.32]; p = 0.002, respectively). However, gastrostomy placement did not have any impact on survival (aHR = 1.25 [95%CI: 0.88-1.79]; p = 0.22). CONCLUSION: Both neurological and nutritional criteria were associated with an indication for gastrostomy at diagnosis. Gastrostomy placement had no impact on survival. The study of earlier gastrostomy placement might be of interest in further prospective studies.

An international survey about rapid sequence intubation of 10,003 anaesthetists and 16 airway experts.

Pulmonary aspiration of gastric content is a significant cause of anaesthesia-related morbidity and mortality. High-quality prospective randomised evidence to support prevention strategies, such as rapid sequence intubation, is difficult to generate due to well-described practical, ethical and methodological barriers. We aimed to generate an understanding of worldwide practice through surveying clinically practicing anaesthetists and airway experts. Our survey was designed to assess the influence of: departmental standards; patient factors; socio-economic factors; training; and supervision. We surveyed 10,003 anaesthetists who responded to an invitation to participate on LinkedIn. We then surveyed 16 international airway experts on the same content. When asked about a hypothetical patient with intestinal obstruction, respondents expressed preferences for [OR (95%CI)]: the head-up or -down position 4.26 (3.98-4.55), p < 0.001; nasogastric tube insertion 29.5 (26.9-32.3), p < 0.001; and the use of cricoid force 2.80 (2.62-3.00), p < 0.001, as compared with a hypothetical patient without intestinal obstruction also requiring rapid sequence intubation. Respondents from lower income countries were more likely to prefer [OR (95%CI]: the supine position 2.33 (2.00-2.63), p < 0.001; nasogastric tube insertion 1.29 (1.09-1.51), p = 0.002; and cricoid force application 2.54 (2.09-3.09), p < 0.001 as compared with respondents from higher income countries for a hypothetical patient with intestinal obstruction. This survey, which we believe is the largest of its kind, demonstrates that preferences for positioning, nasogastric tube use and cricoid force application during rapid sequence intubation vary substantially. Achieving agreed consensus may yield better training in the principles of rapid sequence intubation.

An international multidisciplinary consensus statement on fasting before procedural sedation in adults and children.

The multidisciplinary International Committee for the Advancement of Procedural Sedation presents the first fasting and aspiration prevention recommendations specific to procedural sedation, based on an extensive review of the literature. These were developed using Delphi methodology and assessment of the robustness of the available evidence. The literature evidence is clear that fasting, as currently practiced, often substantially exceeds recommended time thresholds and has known adverse consequences, for example, irritability, dehydration and hypoglycaemia. Fasting does not guarantee an empty stomach, and there is no observed association between aspiration and compliance with common fasting guidelines. The probability of clinically important aspiration during procedural sedation is negligible. In the post-1984 literature there are no published reports of aspiration-associated mortality in children, no reports of death in healthy adults (ASA physical status 1 or 2) and just nine reported deaths in adults of ASA physical status 3 or above. Current concerns about aspiration are out of proportion to the actual risk. Given the lower observed frequency of aspiration and mortality than during general anaesthesia, and the theoretical basis for assuming a lesser risk, fasting strategies in procedural sedation can reasonably be less restrictive. We present a consensus-derived algorithm in which each patient is first risk-stratified during their pre-sedation assessment, using evidence-based factors relating to patient characteristics, comorbidities, the nature of the procedure and the nature of the anticipated sedation technique. Graded fasting precautions for liquids and solids are then recommended for elective procedures based upon this categorisation of negligible, mild or moderate aspiration risk. This consensus statement can serve as a resource to practitioners and policymakers who perform and oversee procedural sedation in patients of all ages, worldwide.

Nil per os guidelines: what is changing, what is not, and what should?

Preoperative nil per os (NPO) guidelines have been in existence since the recognition of the risk of perioperative aspiration. These guidelines aim at reducing the risk for gastric content aspiration to the lowest possible, to avoid associated morbidity, unplanned hospital and/or an intensive care admission. Thus, such guidelines are not only considered for patients having major surgeries, but more so in those having ambulatory surgery including those performed at non-operating room anesthesia locations. NPO guidelines have always been controversial due to the paucity of data in support of one recommendation versus another and have seen multiple changes and updates by the issuing national anesthesiology societies as new evidence emerges. At the present time, they have become increasingly permissive, such that the ingestion of clear fluids is now encouraged up to two hours before elective surgery. This has added more fuel to the already heated controversies regarding NPO guidelines and contributed to the experienced variability among different local NPO policies adopted by different clinicians. In this article, we attempt to discuss many of these controversies, including the relationship between NPO duration and the risk of aspiration, NPO and the choice of airway device, NPO and operating room efficiency and NPO for procedural sedation.

[A Process-Oriented Approach at Current Recommendations for Obstetric Anesthesia and Postoperative Monitoring After C-Section]. / Geburtshilfliche Anästhesie und postoperative Überwachung.

The known guidelines before a planned operation on aspiration, fasting and preoperative risk evaluation also apply in obstetrics. Extended measures are only justified under concrete anamnestic or specific symptoms. Neuraxial anesthesia techniques should be offered to the mother as early as possible, as waiting for a certain opening of the cervix is not justified. Catheter procedures offer numerous advantages and are useful for possible emergency situations. Low-dose local anesthetic concentrations in combination with an opioid are still recommended. The benefit of pencil-point spinal needles in minimizing the risk of post-puncture headache has been demonstrated. Predictable emergencies are airway emergencies, hemorrhagic emergencies and cardiopulmonary resuscitation with emergency cesarean if appropriate (> 20 SSW).

[Rapid Sequence Induction]. / Rapid Sequence Induction.

A Rapid Sequence Induction and Intubation (RSI oder RSII) is a standard technique for emergency airway management and anaesthesia. The aim of an RSI is to prevent aspiration by fast endotracheal intubation without the use of facemask ventilation.Today, only few European countries have specific guidelines for RSI. During daily practice, head-up positioning is standard and provides some advantages as compared to other positions. A gastric tube should be left in place; it is not necessary to remove it. If no gastric tube is in place, it can be positioned after intubation. An opioid should be administered prior to RSI since it may reduce the dosage of the hypnotic drug and, therefore, side effects, too.

A multicentre prospective cohort study of the accuracy of conventional landmark technique for cricoid localisation using ultrasound scanning.

Cricoid pressure is employed during rapid sequence induction to reduce the risk of pulmonary aspiration. Correct application of cricoid pressure depends on knowledge of neck anatomy and precise identification of surface landmarks. Inaccurate localisation of the cricoid cartilage during rapid sequence induction risks incomplete oesophageal occlusion, with potential for pulmonary aspiration of gastric contents. It may also compromise the laryngeal view for the anaesthetist. Accurate localisation of the cricoid cartilage therefore has relevance for the safe conduct of rapid sequence induction. We conducted a multicentre, prospective cohort study to determine the accuracy of cricoid cartilage identification in 100 patients. The cranio-caudal midpoint of the cricoid cartilage was identified by a qualified anaesthetic assistant using the conventional landmark technique and marked. While maintaining the patient in the same position, a second mark was made by identifying the midpoint of the cricoid cartilage using ultrasound scanning. The mean (SD) distance between the two marks was 2.07 (8.49) mm. In 41% of patients the midpoint was incorrectly identified by a margin greater than 5 mm. This error was uniformly distributed both above and below the midpoint of the cricoid cartilage. The Pearson correlation coefficient of this error with respect to body mass index was 0.062 (p = 0.539) and with age was -0.020 (p = 0.843). There were also no significant differences in error between male and female patients. Identification of cricoid position using a landmark technique has a high degree of variability and has little correlation with age, sex or body mass index. These findings have significant implications for the safe application of cricoid pressure in the context of rapid sequence induction.

Gastro-Oesophageal Reflux and Aspiration: Does Laparoscopic Fundoplication Significantly Decrease Pulmonary Aspiration?

PURPOSE: Pulmonary aspiration of gastric refluxate is one of the indications for anti-reflux surgery. Effectiveness of surgery in preventing pulmonary aspiration post-operatively has not been previously tested. The aim of this project is to assess effectiveness of anti-reflux surgery on preventing pulmonary aspiration of gastric refluxate. METHODS: Retrospective analysis of prospectively populated database of patients with confirmed aspiration of gastric refluxate on scintigraphy. Patients that have undergone anti-reflux surgery between 01/01/2014 and 31/12/2015 and had scintigraphy post-operatively were included. Objective data such as resolution of aspiration, degree of proximal aero-digestive contamination, surgical complications and oesophageal dysmotility as well as patient quality of life data were analysed. RESULTS: Inclusion criteria were satisfied by 39 patients (11 male and 28 female). Pulmonary aspiration was prevented in 24 out of 39 patients (61.5%) post-operatively. Significant reduction of isotope contamination of upper oesophagus supine and upright (p = 0.002) and pharynx supine and upright (p = 0.027) was confirmed on scintigraphy post-operatively. Severe oesophageal dysmotility was strongly associated with continued aspiration post-operatively OR 15.3 (95% CI 2.459-95.194; p = 0.02). Majority (24/31, 77%) of patients were satisfied or very satisfied with surgery, whilst 7/31 (23%) were dissatisfied. Pre-operative GIQLI scores were low (mean 89.77, SD 20.5), modest improvements at 6 months (mean 98.4, SD 21.97) and deterioration at 12 months (mean 88.41, SD 28.07) were not significant (p = 0.07). CONCLUSION: Surgery is partially effective in reversing pulmonary aspiration of gastric refluxate on short-term follow-up. Severe oesophageal dysmotility is a predictor of inferior control of aspiration with surgery.

Pulmonary aspiration in adjustable gastric banding carriers undergoing a second surgical procedure. Considerations on personal experience and review of the literature.

BACKGROUND: The observation of a relatively high number of pulmonary aspirations (PA) among gastric band (GB) carriers undergoing a second surgery, prompted us to modify our strategy for GB patients candidate to further operation under general anesthesia. MATERIAL OF STUDY AND RESULTS: In January 2013, following the occurrence of PA at the induction of general anesthesia in 1 GB carrier undergoing a further operation, we reviewed our Data Base between January 2005 and 2013, to explore the rate of pulmonary aspiration in patients GB carriers undergoing a second surgery. Considering the rate (3/172 - 1.7%) too high in comparison with non-GB carriers, we decided to deflate the banding before any further surgery planned under general anesthesia. We then retrospectively reviewed the occurrence of PA after having changed the protocol. Since February 2013, through December 2016, 81 GB carriers underwent a second surgery and not a single episode of PA occurred (0/81). DISCUSSION: The occurrence of PA in patients with GB seems greater than in non-GB patients. Larger series should be examined to assess the incidence of PA among this specific population. Awareness of the increased risk is important to general anesthesiologists and surgeons, considering the increasing number of GB carriers who may be in need of surgery. Our result after adopting the deflation policy, even though not statistically significant, seems highly suggestive. CONCLUSION: We believe that, considering the potentially severe consequences of PA, the gastric band should be deflated before any planned procedure requiring general anesthesia. Further data are needed. KEY WORDS: Adjustable gastric banding, Aspiration Pneumonia, Bariatric surgery, Morbid obesity, Pulmonary Aspiration.

Ultrasonographic gastric volume before unplanned surgery.

We aimed to measure gastric antral cross-sectional area with ultrasound and estimate the gastric volume of 300 patients before unplanned surgery, fasted for at least six hours. Measurements were successfully recorded in 263 semi-recumbent patients. The median (IQR [range]) area was 333 (241-472 [28-1803]) mm2 and the mean (SD) estimated volume was 45.8 (34.0) ml. The area exceeded 410 mm2 in 92/263 (35%) measurements. Body mass index and morphine administration were associated with larger gastric areas on multivariable linear regression analysis, with beta coefficient (95%CI) 0.02 (0.01-0.04), p = 0.01, 0.23 (0.01-0.46), p = 0.04, respectively. Fasting time was not associated with gastric area and therefore could not substitute for ultrasound measurements in this cohort.