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Preoperative fasting in children: is there room for improvement?

How long do your patients fast prior to surgery? Do they align with your institution’s fasting policy? Are they even close? Are your patients fasting longer than they need to because they do not understand their preoperative instructions and do not want their procedure canceled? The day of surgery can be long, confusing, and stressful for children and their families. We are all familiar with the scenario of a hungry and cranky child who has had nothing to eat or drink since dinnertime the day before and her frustrated parents. Would this scenario be improved with a cup of juice on arrival to the preoperative check-in? Would such a simple intervention translate to more stable hemodynamics and easier venous access? In this issue, Newton and colleagues begin to answer some of these questions, and more importantly, they show us how to investigate this in our patient populations. Aspiration of gastric contents in otherwise healthy fasting children is a rare occurrence. The most recent American Society of Anesthesiologists practice guidelines for preoperative fasting recommend the provision of clear liquids up to 2 hours prior to anesthetic induction in most children undergoing elective surgery. Although there is compelling evidence based on a surrogate of aspiration risk (gastric fluid volume) that 1-hour clear fluid fasting times are likely also safe, we know through both personal experience and published research that children often fast longer than necessary. In addition to the discomfort and dissatisfaction prolonged fasting creates for children and their families, these children are more prone to hemodynamic instability on induction, a sequence of events that can be prevented with preoperative fluid optimization. Thus, there remains a chasm between evidence and practice for preoperative fasting. Where such chasms exist, physicians have increasingly turned to quality improvement (QI) methodologies to integrate evidence-based medicine into clinical practice. The balance between risks and benefits of fasting times in the preoperative arena is very real and needs to take into consideration clinical experience and evidence. Both clinical research and QI share the goal of improving patient care and outcomes. Although research provides facts, data, and foundational knowledge, QI methodology is dynamic, adaptable, and addresses the granular real-world obstacles faced when implementing practice changes to improve patient care. Newton et al. have shown us how they tackled the preoperative fasting question using QI methodology. They first delineated the problem of preoperative fasting at their institution. Despite having a 2-hour clear fasting fluid policy, they found that only 19% of children received clear fluids within 4 hours of induction with a mean clear fluid fast time of 6.3 hours. We suspect that this type of discrepancy would be present at many tertiary pediatric institutions. They then created a multidisciplinary team that included nurses, anesthetists, a dietician, administrators, and a data analyst. This team set about trying to solve this common clinical problem through structured Plan-Do-Study-Act cycles with sequential changes in patient education, preoperative phone calls, and, finally, administration of an age-based volume of clear fluids following arrival at the hospital. These changes ultimately resulted in a remarkable improvement, more than tripling the number of children receiving a clear fluid within 4 hours of induction (72%), combined with a reduction of the mean clear fluid fasting time by more than half (3.1 hours). For the pediatric anesthesia community, this work is valuable both for the new clinical evidence it contains and the example it provides about how to put this type of change into practice. Rather than evaluating the effect of implementing a 1-hour clear fluid fasting rule in the context of hypothesis-driven research, we instead have a potentially more useful report that includes outcome data on the safety of an envelope-pushing fasting policy in over 6800 patients. Although the nuances of implementation would likely be different at other institutions, the QI framework presented appears broadly applicable. Of note, Newton and colleagues do not report on surrogate end points or outcomes. Instead, the authors focus on clinical outcomes that matter: actual fasting times and aspiration events. The absence of an increased risk of aspiration events in the context of a shortened 1-hour clear fluid fasting time is consistent with a recent large population study of aspiration events in pediatric patients undergoing procedural sedation/anesthesia where aspiration was rare (0.7 events per 10 000) and was not increased in patients who were not nil per os. What remains to be seen is whether 1-hour clear fluid fasting practices lead to improvements in patient/ family satisfaction, compliance with induction, hemodynamic stability, and vascular access. So what’s a pediatric anesthesiologist to do? Here in the US, do we follow published practice guidelines, which recommend that children be fasted for 2 hours for clear liquids, or do we implement something similar to what Newton and colleagues have done, while continuing to track the safety of this practice? Based on our read of the data, we would argue for the latter. Change begins when we acknowledge that there is a problem. The data presented in this issue of the journal add to the rising tide of evidence that it is time to reevaluate our clear fluid fasting practices. In the era of the electronic health record, we should know how long our patients fast, and if there is a problem, we owe it to our patients to address it. Our colleagues at Great Ormond Street DOI: 10.1111/pan.13166