Nüchternzeiten in der Kinderanästhesie nüchtern betrachtet

Transcription

1 Nüchternzeiten in der Kinderanästhesie nüchtern betrachtet Pädiatrische Traunseeklausur Mai 2018 Gmunden (A) Prof. Dr. med. Markus Chefarzt Anästhesieabteilung, Universitäts-Kinderspital Zürich Extraordinarius für Kinderanästhesie Universität Zürich

2 Background Preanaesthetic or preoperative fasting is an universally applied principle in elective cases to minimize the risk of pulmonary aspiration of gastric content

3 Background In the early days of anaesthesia, a light breakfast was often recommended before anaesthesia Several reports of pulmonary aspiration associated with anaesthesia resulted in the implementation of various nil by mouth (NBM) from-midnight recommendations Maltby JR - Best Pract Res Clin Anaesthesiol 2006

4 Background NBM from midnight established since around 1970 Maltby JR - Best Pract Res Clin Anaesthesiol 2006

5 Background American Society of Anesthesiologists (ASA) 1998/2011 European Society of Anaesthesiology (ESA) 2011 Scandinavian Society of Anaesthesiology and Intensive Care (SSAI) in 2003 Maltby JR - Best Pract Res Clin Anaesthesiol 2006

6 Background Solids (including semi-solid food and milk-containing products) should be avoided 6 h before anaesthesia Clear fluids are allowed 2 h before anaesthesia induction Infants are usually allowed ingestion of breast milk up to 4 h before anaesthesia Maltby JR - Best Pract Res Clin Anaesthesiol 2006

7 Background New Research & Insights Children are often fasted for unnecessarily long intervals Prolonged fasting could have detrimental metabolic and behavioural effects in small children Reducing fasting intervals beyond the 2 h limit may be safe and result in a reduced risk of negative metabolic effects of fasting Frykholm P - Weiss M Br J Anaesth 2018

8 Risk of Pulmonary Aspiration Generally accepted values for children 1 pulmonary aspiration per anaesthetics Walker RWM Paediatr Anaesth 2013

9 Risk of Pulmonary Aspiration Multicentre study of specialist paediatric centres, United Kingdom h rule for fasting widespread used Incidence of Aspiration 2 and per elective cases 2.2 per emergency cases Walker RWM Paediatr Anaesth 2013

10 Risk of Pulmonary Aspiration APRICOT - Study (Anaesthesia Practice in Children Observational Trial - Study) prospective, multicentre, pan-european study > paediatric patients included Incidence of aspiration 9-10 per anaesthetics Habre W et al Lancet Respir Med 2017

11 Risk of Pulmonary Aspiration Single-centre study, USA > children included > cases Incidence of aspiration 2 per elective cases 10-fold higher incidence in emergency cases Warner MA et al Anesthesiology 1999

12 Risk of Pulmonary Aspiration The National Audit Project 4 (NAP4) Royal College of Anaesthetists and the Difficult Airway Society (United Kingdom) Major Complications of Airway Management in the UK Pulmonary aspiration was the commonest cause of death during anaesthesia in adults and accounted for 50% of anaesthesia-related deaths overall Royal College of Anaesthetists London 2011

13 Risk of Pulmonary Aspiration Pulmonary aspiration of gastric contents uncommon Devastating consequences possible No single paediatric case of perioperative aspiration-related death and no long-term sequelae from perioperative fluid aspiration has been published so far for children Under-reporting in the literature possible, because of fear from medicolegal restrictions Thomas M & Engelhardt T - Br J Anaesth 2017

14 Fasting Times and Risk of Aspiration Evidence There is no solid evidence in the form of randomized controlled trials linking the length of preoperative fasting with the risk of aspiration of gastric contents during anaesthesia

15 Fasting Times and Risk of Aspiration NORA Multicentre Trial (USA) > procedural sedations or anaesthetics in children Very low (0.007%) incidence of aspiration Similar incidence whether the children were fasted or not Patient- and anaesthetic-related issues are more likely to be responsible for an aspiration event in the elective situation Beach ML et al Anesthesiology 2016

16 Fasting Times and Risk of Aspiration Patient Related Factors Full stomach, bowel obstruction, abdominal pain Diabetes Trauma or drug therapy with reduced gastric emptying Royal College of Anaesthetists London 2011

17 Fasting Times and Risk of Aspiration Anaesthetists Related Factors Choice of airway management Light or inadequate anaesthesia Inadequate muscle paralysis Anaesthetists rather than gastric content are the risk! Warner MA et al Anesthesiology 1999

18 Physiology of Gastric Emptying Techniques of investigations Scintigraphy (radionuclide method) Aspiration of gastric contents by a nasogastric tube Pharmacokinetic studies Magnetic resonance imaging (MRI) Ultrasound imaging (US) Hellstroem PM et al - Best Pract Res Clin Anaesthesiol 2006

19 Physiology of Gastric Emptying Gastric Content Volume «Nothing to Do with Pulmonary Aspiration» Surrogate Parameter for Risk of Pulmonary Aspiration

20 Physiology of Gastric Emptying Gastric Emptying Kinetics Gastric emptying of solids may be described as zero-order elimination (constant rate) Gastric emptying of fluids follows a first-order kinetics (exponentially) Hellstroem PM et al - Best Pract Res Clin Anaesthesiol 2006

21 Physiology of Gastric Emptying Consequences A very large meal will take a long time to be completely eliminated from the stomach. It is likely that a last drink before surgery will pass through the gastric ventricle within less than 1 h Hellstroem PM et al - Best Pract Res Clin Anaesthesiol 2006

22 Practice of Gastric Emptying University Children s Hospital

23 Practice of Gastric Emptying Fasting Times and Gastric Content Gastric content volume (GCV) using MRI: Clinical observational trial Elective MRI including upper abdominal region in deep propofol sedation 68 children aged (2.8) years Schmitz at al - Paediatr Anaesth 2011

24 Practice of Gastric Emptying Fasting Times and Gastric Content Schmitz at al - Paediatr Anaesth 2011

25 Practice of Gastric Emptying Gastric Emptying of Clear Fluids (MRI) 2 h-follow up after 7 ml/kg (raspberry syrup, 135 kj/100 ml) 16 school children Aged (9.2) years Schmitz A et al Br J Anaesth 2011

26 Practice of Gastric Emptying Schmitz A et al Br J Anaesth 2011

27 Practice of Gastric Emptying Gastric Emptying of Clear Fluids (MRI) Crossover: 3 vs. 7 ml/kg (1 h follow-up) (raspberry syrup, 135 kj/100 ml) 14 school children Age (11.1) years Schmitz A et al Br J Anaesth 2012

28 Practice of Gastric Emptying Schmitz A et al Br J Anaesth 2012

29 Practice of Gastric Emptying Conclusion A larger amount of fluid (7 ml/kg) is not completely eliminated after a 1 h interval Repeated (even hourly) small amounts instead of a large single volume of clear fluid could safely be offered to the child waiting for surgery Orlay G and Smith K Anaesth Intensive Care 2015

30 Practice of Gastric Emptying Gastric Emptying of Clear Fluids (OR) 1h versus 2h for clear fluid fasting Elective surgery with tracheal intubation Aspiration by gastric tube n = 131, ASA 1 & 2, aged 1-16,2 (7.5) yrs Schmidt AR et al Br J Anaesth 2014

31 Practice of Gastric Emptying Schmidt AR et al Br J Anaesth 2014

32 Practice of Gastric Emptying Schmidt AR et al Br J Anaesth 2014

33 Practice of Gastric Emptying Gastric Emptying of Light Solids (MRI) Crossover: 4h vs 6h & clear fluid 2h (6 hours follow-up) 18 school children Age (9.0) years Schmidt A et al Acta Anaesthesiol Scand 2012

34 Practice of Gastric Emptying Schmidt A et al Acta Anaesthesiol Scand 2012

35 Practice of Gastric Emptying Schmidt A et al Acta Anaesthesiol Scand 2012

36 Practice of Gastric Emptying Schmidt A et al Acta Anaesthesiol Scand 2012

37 Prolonged Preoperative Fasting h Fasting Recommendation and the reality Engelhardt T et al Paediatr Anaesth 2011

38 Prolonged Preoperative Fasting Engelhardt T et al Paediatr Anaesth 2011

39 Prolonged Preoperative Fasting WHY? Fear of pulmonary aspiration Guidelines ignored, misunderstood by medical staff Misunderstanding by patients/parents Not waking up children early for drinking / eating Organisational delay Thomas DKM Br J Anaesth 1974

40 Prolonged Preoperative Fasting Hungry and Thirsty Elective dental treatment (n=1350) Are you hungry? Are you thirsty : 56 % very hungry or starving - 27 % very thirsty Engelhardt T et al Paediatr Anaesth 2011

41 Prolonged Preoperative Fasting Higher metabolic rate and reduced glycogen stores in small children when compared with adults 28% incidence of hypoglycaemia in toddlers Prolonged fasting is associated with ketoacidosis, especially in children less than 36 months old. Dennhardt N et al Paediatr Anaesth 2016

42 Prolonged Preoperative Fasting Physiological Consequences of Prolonged Preoperative Fasting Observational clinical study 100 children < 36 months for elective surgery Mean fasting time: 7.8 ± 4.5 h ( h) Difference to guidelines: 54 % > 2 h Dennhardt N et al - Eur J Anaesthesiol 2015

43 Prolonged Preoperative Fasting Physiological Consequences of Prolonged Preoperative Fasting Dennhardt N et al - Eur J Anaesthesiol 2015

44 New Strategies to Reduce the Incidence of Prolonged Fasting Standard habits versus optimized strategies Clinical cohort study N = 2 x 50 Children < 36 months Dennhardt N et al Paediatr Anaesth 2016

45 New Strategies to Reduce the Incidence of Prolonged Fasting Standard habits versus optimized strategies Staff & parents better informed Children encouraged to eat & drink as long as possible Fasting times adapted in case of re-scheduling Dennhardt N et al Paediatr Anaesth 2016

46 New Strategies to Reduce the Incidence of Prolonged Fasting Standard habits versus optimized strategies Results OPT vs. OLD (= Standard) Mean fasting time 6.0 ± 1.9 h vs. 7.8 ± 4.5 h Dennhardt N et al Paediatr Anaesth 2016

47 New Strategies to Reduce the Incidence of Prolonged Fasting Standard habits versus optimized strategies Dennhardt N et al Paediatr Anaesth 2016

48 New Strategies to Reduce the Incidence of Prolonged Fasting Unlimited Intake of Clear Fluids until Called to the OR 30 min between calling and induction of anaesthesia Effective fasting time for clear fluids: 1.7 hours Pulmonary aspiration in 3 cases / n = / 0 16 yrs Aspiration incidence: 1 per 3338 cases H. Andersson, B. Zarén, P. Frykholm Paediatr Anaesth 2015

49 New Strategies to Reduce the Incidence of Prolonged Fasting Limited clear fluids every hour before surgery Repeated (even hourly) small amounts instead of a large single volume of clear fluid could safely be offered to the child waiting for surgery Orlay G and Smith K Anaesth Intensive Care 2015

50 New Strategies to Reduce the Incidence of Prolonged Fasting Clear Fluids until 1 hr to Anaesthesia Induction Quality-improvement programme (GOSH London) 1 h clear fluid fasting time Increase of children fasting less than 4 h from 19% to 72% Newton RJG - Paediatr Anaesth 2017

51 Preoperative Fasting - Quo vadis? Frykholm P Br J Anaesth 2018

52 Preoperative Fasting - Quo vadis? ESPA / APA Paediatr Anaesth 2018 in press

53 Let them drink!

54 Nüchternzeiten in der Kinderanästhesie nüchtern betrachtet Besten Dank für Ihre Aufmerksamkeit