|
 
 |
| ORIGINAL ARTICLE |
|
| Year : 2022 | Volume
: 24
| Issue : 2 | Page : 164-170 |
|
Comparison of USG-Guided gastric volume at 1 h and 2 h of giving clear fluids for elective pediatric surgeries and its effect on postoperative nausea and vomiting
N Vineela Reddy1, Sandhya Ghodke2, Ravishekar N Hiremath3, Smita M Nimbannavar4, Mahesh Krishna Kulkarni5
1 Fellow Paediatric Anaesthesia, Rainbow Children Hospital, Bangalore, Karnataka, India
2 Associate Professor and Consultant, Department of Anaesthesiology, Rainbow Children Hospital, Bangalore, India
3 Prof and Classified Specialist, Officer Commanding SHO Bangalore, Karnataka, India
4 Assistant Professor, Department of Community Medicine, Koppal Institute of Medical Sciences, New Delhi, India
5 Graded Specialist, Department of Aviation Medicine, AFMS, New Delhi, India
| Date of Submission | 31-Jan-2022 |
| Date of Decision | 02-Mar-2022 |
| Date of Acceptance | 14-Mar-2022 |
| Date of Web Publication | 10-Aug-2022 |
Correspondence Address:
Major (Dr) Sandhya Ghodke
Department of Anaesthesiology, Rainbow Children's Hospital, Marathahalli, Bengaluru, Karnataka
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jmms.jmms_17_22
Background: Preoperative fasting is a universally followed principle in patients undergoing elective surgeries to minimize the risk of pulmonary aspiration. Objectives: The main objective is to compare ultrasound (US)-guided gastric volume after encouraging clear fluids till 1 h and 2 h preoperatively. Methodology: We carried out a prospective observational study in a multispecialty children's hospital, wherein pediatric patients of American Society of Anesthesiologists (ASA) I and ASA II physical status undergoing elective surgeries and between the age group of 2 and 10 years were enrolled in the study on sample size of 60. The study tool used was US Mindray machine with a linear probe of frequency 10–12 hertz. The study was approved by hospital ethical committee. Those patients who could take clear fluids 3 ml/kg 2 h prior to surgery as per standard guidelines were placed in Group A and those who received 3 ml/kg of clear fluids till 1 h before surgery placed in Group B. US assessment of gastric volume was done in the preoperative area. Results: There is no significant difference in gastric volumes and antral cross-sectional area in both the groups. There is no significant increase in incidence of postoperative nausea and vomiting in Group B where clear fluids were encouraged till 1 h prior to surgery. Conclusion: According to the study, we can conclude that clear fluids can be encouraged till 1 h preoperatively in pediatric patients undergoing elective surgeries.
Keywords: Clear fluids, gastric volume, pediatric, USG
How to cite this article:
Reddy N V, Ghodke S, Hiremath RN, Nimbannavar SM, Kulkarni MK. Comparison of USG-Guided gastric volume at 1 h and 2 h of giving clear fluids for elective pediatric surgeries and its effect on postoperative nausea and vomiting. J Mar Med Soc 2022;24:164-70 |
How to cite this URL:
Reddy N V, Ghodke S, Hiremath RN, Nimbannavar SM, Kulkarni MK. Comparison of USG-Guided gastric volume at 1 h and 2 h of giving clear fluids for elective pediatric surgeries and its effect on postoperative nausea and vomiting. J Mar Med Soc [serial online] 2022 [cited 2023 Mar 24];24:164-70. Available from: https://www.marinemedicalsociety.in/text.asp?2022/24/2/164/353647 |
| Introduction | |  |
Preoperative fasting is a universally followed principle in patients undergoing elective surgeries to minimize the risk of pulmonary aspiration. A recent multicentric study done at specialist pediatric centers which took place in the United Kingdom revealed a very low incidence of pulmonary aspiration with incidence of 2 and 2.2 per 10,000 cases for both elective and emergency surgeries, respectively.[1] As per the current NPO (nothing by mouth) guidelines, preoperative fasting for clear fluids is 2 h.[2] The traditional 2-h clear fluid fasting time is recommended to decrease the risk of pulmonary aspiration which is based on historical adult literatures that may not be applicable to the pediatric population.[3],[4] Pulmonary aspiration is a rare event in children, with a low incidence of 0.07%–0.1%.[5] With 2-h clear fluid fasting policy, the literature suggests that this translates into 6–7-h actual duration of fasting,[6] and according to some studies, it can extend even up to 15 h.[7],[8] Fasting for prolonged periods increases thirst and irritability.[9] It can also result in detrimental physiological and metabolic effects.[10]
Liberalizing clear fluid intake has been demonstrated to have a similar risk of pulmonary aspiration with no increase in morbidity or mortality and may not be related to fasting status.
The recent APRICOT study found aspiration incidence of 9.3/10,000. It appears that a liberalized clear fluid fasting regimen does not increase the incidence of pulmonary aspiration. Several studies have shown less incidence of nausea, vomiting, thirst, hunger, and anxiety if a child is allowed to drink clear fluids closer to surgery. Accordingly, children were more comfortable, better behaved, and possibly more compliant.[11] These studies also demonstrated that allowing clear fluids closer to surgery in children of age < 36 months leads to positive physiological and metabolic effects.[12] Hence, evidence suggests that clear fluids are reduced to a gastric volume of 1 mL/kg at the end of 1 h.[13]
Gastric ultrasound (US) is a valid and reliable tool for noninvasive bedside assessment of the nature and volume of gastric contents in both adults and children.[14] Several studies have suggested that the cross-sectional area of the gastric antrum can predict gastric fluid volume.[15] There is a linear correlation between the antral cross-sectional area and gastric volume, with Pearson correlation coefficients ranging from 0.6 to 0.91.[16] Through serial magnetic resonance imaging, with gastric volume of 3 mL/kg of sugar fluid, residual gastric volume was back to baseline values at 1 h after ingestion.[13] Small amounts of clear fluid can and should be offered to the child up to 1 h prior to the induction of general anesthesia while awaiting surgery.[17] The recommended maximum volume of clear fluids is 3 mL/kg. Water empties from the stomach within 30 min[18] and other clear fluids are almost gone within an hour.[19] Studies demonstrate that there is no difference in gastric volume or pH if children are starved 1 or 2 h of clear fluids.[19] If clear fluids contain glucose, then gastric emptying can be significantly quicker.[20] Decrease in fasting period decreases the incidence of dehydration and hypoglycemia and decreases perioperative morbidity. However, Cochrane database while reviewing several studies showed that prolonged withholding of oral fluids does not improve gastric pH or volume and permitting a patient to drink fluids preoperatively may even result in significantly lower gastric volumes.[10]
Guidelines on perioperative fluid management and fasting have recently been reviewed by Lambert and Carey, where they suggested that preoperative fasting should be minimized.[21] Recent guidelines by the European Society for Paediatric Anaesthesiologists (ESPA) recommend drinking clear fluids till 1 h prior to surgery. ESPA updated guidelines regarding clear fluids has also been endorsed by the Society for Paediatric Anaesthesia of Australia and New Zealand. The APRICOT study – “the Anaesthesia Practice in Children Observational Trial,” which is a pan-European multicentric study, reported that there is no single documented admission to intensive care or incidence of prolonged intubation following aspiration in children. A study by Andersson et al. reported that liberalizing the fasting period in children for clear fluids did not alter the incidence of pulmonary aspiration. The Association of Paediatric Anaesthetists of Great Britain and Ireland, the French-Language Society of Paediatric Anaesthesiologists along with ESPA, recommends clear fluid intake up to 1 h prior to elective surgery unless specific contraindications exist. Now, an official guideline of ESPA states that clear fluids can be allowed till 1 h prior to surgery. A recent study of 16000 children from the United States also showed the safety of 1-h NPO for clear fluids. Unrestricted consumption of clear fluids before anesthesia may help reduce the rate of postoperative nausea and vomiting.
There is growing evidence for role of US in qualitative and quantitative assessment of gastric contents which in turn will guide us more into modification of preoperative fasting guidelines. Thus, the main objectives of the study were to compare Ultrasound (USG) guided gastric volume at 1 h and 2 h of giving clear fluids for elective pediatric surgeries and its effect on postoperative nausea and vomiting.
| Methodology | | |
We carried out a prospective observational study in the Department of Anaesthesiology at a multispecialty children's hospital, Bangalore, India, from June 2019 to May 2020. Pediatric patients of American Society of Anesthesiologists (ASA) I and ASA II physical status undergoing elective surgeries and between the age group of 2 and 10 years were enrolled in the study. Children with cerebral palsy child, history of gastroesophageal reflux disease, obesity, trauma, emergency surgeries, and history of esophageal and gastric surgeries were excluded from the study. Sample size was calculated. By considering expected prevalence (P) would be 4%[22] and as per records, in a year, approximately 1200 children are being admitted to the hospital, P of 0.05 and d would be sample error (5%), sample size came out to be 60. The study tool used was US Mindray machine with a linear probe of frequency 10-12 hertz. The study was approved by hospital ethical committee. Written informed consent was taken from the parents prior to the study. Preanesthesia checkup was done to all children enrolled in the study. All were admitted 1 day prior to surgery to make sure fasting guidelines followed strictly. Patients were randomly observed under two groups [[Figure 1], consort diagram]. Those patients who could take clear fluids in the form of water (3 ml/kg) 2 h prior to surgery as per standard guidelines were placed in Group A and those who received 3 ml/kg of clear fluids (in the form of water) till 1 h before surgery placed in Group B. US assessment of gastric volume was done in the preoperative area. For children who were not cooperative, injection midazolam 0.05 mg/kg was given as premedication and the assessment was done. The operative time for all surgeries was <2 h. None of our patients had any aspiration, so nasogastric tube placement was not required intraoperatively.
| Results | | |
From the data, it can be inferred that most of the children (27) are in the age group of 2–4 years. In Group B, the male and female ratio of children is 50% each, whereas in Group A, the male and female ratio is 56.7% and 43.3%, respectively. From the data, it can be inferred that most of the children's (37) weight is between 10 and 20 kg.
Impact of demographic variables on cross-sectional area for Group A [Table 1] and [Table 2] | Table 1: Impact of demographic variables on cross-sectional area for Group A and Group B
Click here to view |
 | Table 2: Post hoc tests - multiple comparisons for dependent variable of CSA in Group A
Click here to view |
One-way analysis of variance analysis was used to assess the impact of demographic variables at 95% confidence level. Here, as per the results, age and gender do not have any impact on cross-sectional area when clear fluids were given 2 h before surgery. However, impact of weight on cross-sectional area has been seen. Probability value for weight is 0.00, which is <0.05. Further to this, Games–Howell test has been used to assess which category weight has an impact on cross-sectional area for Group A. As per the result, it can be concluded that children with the weight of more than 30 kg have impact on cross-sectional area.
Impact of demographic variables on gastric volume for Group A [Table 3] and [Table 4] | Table 3: Impact of demographic variables on gastric volume for Group A and Group B
Click here to view |
 | Table 4: Post hoc tests - multiple comparisons of Group A (age) and Group B (age and weight)
Click here to view |
Gender does not have any impact on gastric volume. However, the impact of age and weight on gastric volume has been seen. Probability value for age is 0.000 and weight is 0.002. Both these values are <0.05. Further to this, Games–Howell test has been used to assess which category of age and weight has an impact on GV for Group A. As per the result, it can be concluded that children with the age group of 8–10 and children with all weight have impact on gastric volume.
Impact of demographic variables on postoperative nausea and vomiting for Group A [Table 5] | Table 5: Impact of demographic variables on postoperative nausea and vomiting for Group A
Click here to view |
Age and gender do not have any impact on postoperative nausea and vomiting, when clear fluids were given 2 h before surgery. However, impact of weight on postoperative nausea and vomiting has been seen. Probability value for weight is 0.023, which is <0.05. Further to this, Games–Howell test has been used to assess which category weight has an impact on postoperative nausea and vomiting for Group A. As per the result, it can be concluded that children with all weight have impact on postoperative nausea and vomiting.
Impact of demographic variables on cross-sectional area for Group B
Age, gender, and weight do not have any impact on cross-sectional area when clear fluid was given 1 h before surgery. Probability value for all these demographics is >0.05, hence it can be concluded that there is no impact of demographic variable on cross-sectional area in Group B.
Impact of demographic variables on gastric volume for Group B
Gender does not have any impact on gastric volume when clear fluid has been given 1 h before. However, impact of age and weight on gastric volume has been seen. Probability value for age and weight is 0.000. Both these values are <0.05. Further to this, Games–Howell test has been used to assess which category of age and weight has an impact on gastric volume for Group B. As per the result, it can be concluded that children with the age group of 8–10 years and children with all weight have impact on gastric volume.
Impact of clear fluids 1 or 2 h before anesthesia [Table 6]
Paired t-test has been used to evaluate the impact of liquid fluid 1 or 2 h before anesthesia at 95% confidence level. Here, mean for Pair 1 (cross-sectional area) 1 and 2 h of clear fluids before anesthesia is 0.72 and 0.70, respectively, and their standard deviation is 0.560 and 0.535, respectively. Mean for Pair 2 (gastric volume) 1 and 2 h of liquid fluid before anesthesia is 4.71 and 4.37, respectively, and their standard deviation is 4.293 and 4.245, respectively. Correlation between the pairs is not significant. Probability value of Pair 1 (cross-sectional area) is 0.708 and Pair 2 (gastric volume) is 0.319. Both these values are >0.05, hence it can be concluded that there is no correlation between Group A and Group B. As regards, with paired t-test at 95% confidence level, results are not significant. Hence, it can be concluded that if clear fluid has been given 1 h before anesthesia, then also there is no significant impact on children's behavior with the age group of <8 years.
| Discussion | | |
Our study showed that age and gender do not have any impact on cross-sectional area when clear fluids were given 2 h before surgery. However, weight has an impact on cross-sectional area in Group A. Probability for weight is 0.00 which is <0.05. From this, we can be concluded that weight of >30 kg has impact on cross-sectional area. Furthermore, as per our study, gender does not have any impact on gastric volume. However, weight and age have impact on gastric volume. Probability for age is 0.000 and weight is 0.002 which is <0.05. Thus, it can be concluded that children with age group of 8–10 years (with all weights) have impact on gastric volume. In Group A, age and gender do not have any impact on postoperative nausea and vomiting. However, weight has an impact on postoperative nausea and vomiting in Group A. Probability for weight is 0.0023 which is <0.05. Thus, it can be concluded that children with all weight have impact on postoperative nausea and vomiting.
Probability of impact of demographic variables on cross-sectional area is >0.05 in Group B. Hence, it can be concluded that in Group B, age, gender, and weight do not have any influence on cross-sectional area. Furthermore, in Group B, gender does not have any influence on gastric volume. However, impact of age and weight on gastric volume in Group B has been seen. Probability for age and weight is 0.000 which is <0.05. Hence, it can be concluded that children of age group 8–10 years and with all weight have impact on gastric volume. No patient in Group B had postoperative nausea and vomiting. Mean cross-sectional area of clear fluids given 1 h before is 0.72 and clear fluids given 2 h before is 0.70. Mean gastric volume of clear fluids given 1 h before is 4.71 and of clear fluids given 2 h before is 4.37. Correlation between the pairs is not significant. Probability value for cross-sectional area is 0.708 and for gastric volume is 0.319. Both these values are >0.05. Hence, it can be concluded that there is no correlation between the two groups.
Our study correlates with the current concept of liberalizing clear fluids till 1 h before procedure as studied by Rai and Toms[23] published in 2019. A study also correlates with the guidelines by the Association of Paediatric Anaesthetists by Great Britain and Ireland and ESPA.[24]
This study also correlates with a study done by Schmidt et al.[25] in 2018 which showed that there was no significant difference in gastric volumes if clear fluids given till premedication. Our study also correlates with a study done by Schmidt et al. which proves that 1-h clear fluid does not alter gastric volume significantly compared with 2-h fasting. This also correlates with a study done by Brady et al.[10] in 2009 that clear fluids preoperatively did not result in a clinically important difference in children's gastric volume or pH.
| Conclusion | | |
As per our study, we conclude that clear fluids can be encouraged till 1 h prior to all elective pediatric surgeries. There is no significant difference in cross-sectional area and gastric volume even if clear fluids are given 1 h prior to surgery than compared to prior 2 h. Our study also showed that clear fluids given 1 h prior to all elective pediatric surgeries decrease the incidence of postoperative nausea and vomiting.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Walker RW. Pulmonary aspiration in pediatric anesthetic practice in the UK: A prospective survey of specialist pediatric centers over a one-year period. Paediatr Anaesth 2013;23:702-11.  |
| 2. | American Society of Anesthesiologists Committee. 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 Committee on Standards and Practice Parameters. Anesthesiology 2011;114:495-511. |
| 3. | Mendelson CL. The aspiration of stomach contents into the lungs during obstetric anesthesia. Am J Obstet Gynecol 1946;52:191-205. |
| 4. | Roberts RB, Shirley MA. Reducing the risk of acid aspiration during cesarean section. Anesth Analg 1974;53:859-68. |
| 5. | Kelly CJ, Walker RW. Perioperative pulmonary aspiration is infrequent and low risk in pediatric anesthetic practice. Paediatr Anaesth 2015;25:36-43. |
| 6. | Andersson H, Zarén B, Frykholm P. Low incidence of pulmonary aspiration in children allowed intake of clear fluids until called to the operating suite. Paediatr Anaesth 2015;25:770-7. |
| 7. | Newton RJ, Stuart GM, Willdridge DJ, Thomas M. Using quality improvement methods to reduce clear fluid fasting times in children on a preoperative ward. Paediatr Anaesth 2017;27:793-800. |
| 8. | Buller Y, Sims C. Prolonged fasting of children before anaesthesia is common in private practice. Anaesth Intensive Care 2016;44:107-10. |
| 9. | Abebe WA, Rukewe A, Bekele NA, Stoffel M, Dichabeng MN, Shifa JZ. Preoperative fasting times in elective surgical patients at a referral Hospital in Botswana. Pan Afr Med J 2016;23:102. |
| 10. | Brady M, Kinn S, Stuart P. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev. 2003;(4):CD004423. |
| 11. | Malmud LS, Fisher RS, Knight LC, Rock E. Scintigraphic evaluation of gastric emptying. Semin Nucl Med 1982;12:116-25. |
| 12. | Splinter WM, Stewart JA, Muir JG. The effect of preoperative apple juice on gastric contents, thirst, and hunger in children. Can J Anaesth 1989;36:55-8. |
| 13. | Schmitz A, Kellenberger CJ, Liamlahi R, Studhalter M, Weiss M. Gastric emptying after overnight fasting and clear fluid intake: A prospective investigation using serial magnetic resonance imaging in healthy children. Br J Anaesth 2011;107:425-9. |
| 14. | Perlas A, Davis L, Khan M, Mitsakakis N, Chan VW. Gastric sonography in the fasted surgical patient: A prospective descriptive study. Anesth Analg 2011;113:93-7. |
| 15. | Perlas A, Chan VW, Lupu CM, Mitsakakis N, Hanbidge A. Ultrasound assessment of gastric content and volume. Anesthesiology 2009;111:82-9. |
| 16. | Perlas A, Mitsakakis N, Liu L, Cino M, Haldipur N, Davis L, et al. Validation of a mathematical model for ultrasound assessment of gastric volume by gastroscopic examination. Anesth Analg 2013;116:357-63. |
| 17. | Frykholm P, Schindler E, Sümpelmann R, Walker R, Weiss M. Preoperative fasting in children: Review of existing guidelines and recent developments. Br J Anaesth 2018;120:469-74. |
| 18. | Okabe T, Terashima H, Sakamoto A. Determinants of liquid gastric emptying: Comparisons between milk and isocalorically adjusted clear fluids. Br J Anaesth 2015;114:77-82. |
| 19. | Schmidt AR, Buehler P, Seglias L, Stark T, Brotschi B, Renner T, et al. Gastric pH and residual volume after 1 and 2 h fasting time for clear fluids in children†. Br J Anaesth 2015;114:477-82. |
| 20. | Dennhardt N, Beck C, Huber D, Sander B, Boehne M, Boethig D, et al. Optimized preoperative fasting times decrease ketone body concentration and stabilize mean arterial blood pressure during induction of anesthesia in children younger than 36 months: A prospective observational cohort study. Paediatr Anaesth 2016;26:838-43. |
| 21. | Lambert E, Carey S. Practice guideline recommendations on perioperative fasting: A systematic review. JPEN J Parenter Enteral Nutr 2016;40:1158-65. |
| 22. | Pourhoseingholi MA, Vahedi M, Rahimzadeh M. Sample size calculation in medical studies. Gastroenterol Hepatol Bed Bench 2013;6:14-7. |
| 23. | Rai E, Toms AS. Operative fasting guidelines and postoperative feeding in paediatric anaesthesia-Current concepts. Indian J Anaesth 2019;63:707-12. [ PUBMED] [Full text] |
| 24. | |
| 25. | Schmidt AR, Buehler KP, Both C, Wiener R, Klaghofer R, Hersberger M, et al. Liberal fluid fasting: Impact on gastric pH and residual volume in healthy children undergoing general anaesthesia for elective surgery. Br J Anaesth 2018;121:647-55. |
[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
|
Search Pubmed for