Global trend on reducing clear fluids fasting time in children: declaration of the Pediatric Anesthesia Committee and the scenario in Brazil

According to the Preoperative Fasting Guidelines of American Society of Anesthesiologists updated in 2017, the recommendation for clear fluids fasting in children is 2 h.¹ These orientations were made based on systematic reviews of literature, considering the primary objective of reducing pulmonary aspiration, although this risk is known to be very low in healthy children,² and the harm resulted from aspiration of clear liquid is very rare.³

The APRICOT study² demonstrated a risk of aspiration of 9.3/10 000, and none of these children presented serious complications. A recent study from Children's Hospital of Philadelphia⁴ applied a quality improvement methodology to decrease fasting time in children admitted for outpatient procedures. Their main objective was to reduce clear fluids fasting time to less then 4 h allowing children to have clear liquids up to 30 min of arrival at the hospital. They improved their clear fluids fasting time of less then 4 h from 20% to 63% without any event of surgery cancelation or pulmonary aspiration. Considering the American Society of Anesthesiologists guidelines, this study was the first in the USA to allow 1-h clear fluids fasting in children.

For the anesthesiologists who have their majority of practice with children, is not uncommon to face patients with very long fasting time, often up to 6-15 h, besides proper preoperative orientation for 2 h clear fluids fasting time. In Brazil, mainly in hospital when both adults and children are treated, this time could be longer, which could impair the perioperative quality.

Based on this reasoning and evidences, the European Society for Paediatric Anaesthesiology (ESPA), along with L’Association Des Anesthesistes-Reanimateurs Pediatriques d’Expression Francaise and the Association of Paediatric Anaesthetists of Great Britain and Ireland endorsed a new consensus statement reducing clear fluids fasting from 2 to 1 h.⁵

According to the new ESPA consensus statement,⁵ it is recommended to offer 3 mL.kg^-1 (predicted weight) of clear fluids. A practical way would be offering 55 mL to children from 1 to 5 years old, 140 mL to children 6-12 and 250 mL to those older than 12. Contraindications should be on the discretion of the anesthesiologist and/or surgical team, such as gastro-esophageal reflux, renal failure, cerebral palsy, enteropathies, diabetes mellitus and/or surgical contraindications.

The ESPA consensus statement⁵ was published in February 2018 and endorsed by European Society of Anaesthesiology and SPANZA (Society for Paediatric Anaesthesia of New Zealand and Australia) in March 2019.^3,6 In April 2019 the Canadian Society of Pediatric Anesthesia stated, “Pediatric patients should be encouraged and allowed to ingest clear fluids up to 1 h before elective anesthesia or sedation”, endorsing the European new consensus statement.⁷

Since the Brazilian Society of Anesthesiology does not have specific guidelines, each hospital or anesthesia department defined their fasting time policy according to current literature. The American Society of Anesthesiologists has not yet pronounced about these new consensus statements in Europe, Canada, and Australia/New Zealand maintain their recommendations of 2 h clear fluids fasting time.

We believe that is necessary to be aware of such changes and choose either to be conservative and wait for a large multicenter observational study to solidify this new statement or endorse these important societies which already lowered the clear fluids fasting time from 2 to 1 h.

References

• ¹
  Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiology. 2017;126:376-393.
• ²
  Habre W, Disma N, Virag K, et al. Incidence of severe critical events in paediatric anaesthesia (APRICOT): a prospective multicentre observational study in 261 hospitals in Europe. Lancet Respir Med. 2017;5:412-25.
• ³
  Disma N, Thomas M, Afshari A, et al. Clear fluids fasting for elective paediatric anaesthesia: the European Society of Anaesthesiology consensus statement. Eur J Anaesthesiol. 2019;36:173-4.
• ⁴
  Isserman R, Elliott E, Subramanyam R, et al. Quality improvement project to reduce pediatric clear liquid fasting times prior to anesthesia. Paediatr Anaesth. 2019;29:698-704.
• ⁵
  Thomas M, Morrison C, Newton R, et al. Consensus statement on clear fluids fasting for elective pediatric general anesthesia. Paediatr Anaesth. 2018;28:411-4.
• ⁶
  Linscott D. SPANZA endorses 1-hour clear fluid fasting consensus statement. Paediatr Anaesth. 2019;29:292.
• ⁷
  Rosen D, Gamble J, Matava C. Canadian Pediatric Anesthesia Society statement on clear fluid fasting for elective pediatric anesthesia. Can J Anaesth. 2019;66:991-2.

Publication Dates

• Publication in this collection
  10 Oct 2019
• Date of issue
  Jul-Aug 2019

History

• Published
  10 July 2019