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NPO


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<b>Guidelines:</b>


Go to the [[Generalized Suggested Outline]] for information on case-specific details for each page.
[https://pubs.asahq.org/anesthesiology/article/138/2/132/137508/2023-American-Society-of-Anesthesiologists 2023 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting: Carbohydrate-containing Clear Liquids with or without Protein, Chewing Gum, and Pediatric Fasting Duration—A Modular Update of the 2017 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting*]


Go to the [[Test Page]] for examples on how to use references in the page.
[https://link.springer.com/article/10.1007/s12630-023-02509-z 2023 Canadian Pediatric Anesthesia Society Statement on fasting for elective pediatric anesthesia]


__NOTOC__ __NOEDITSECTION__
[https://pubs.asahq.org/anesthesiology/article/126/3/376/19733/Practice-Guidelines-for-Preoperative-Fasting-and 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]


[https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.15179 Guideline on anaesthesia and sedation in breastfeeding women 2020]


https://pubmed.ncbi.nlm.nih.gov/29452803/
[https://pubmed.ncbi.nlm.nih.gov/29452803/ Preoperative fasting in children: review of existing guidelines and recent developments]


https://pubs.asahq.org/anesthesiology/article/133/3/523/108227/Preoperative-Fluid-Fasting-Times-and-Postinduction
[https://pubmed.ncbi.nlm.nih.gov/34857682/ The rationale for the recommendations of the European Paediatric Fasting Guideline: Improving paediatric anaesthesia and perioperative medicine]


[https://pubmed.ncbi.nlm.nih.gov/34857683/ Pre-operative fasting in children: A guideline from the European Society of Anaesthesiology and Intensive Care]


https://www.uptodate.com/contents/preoperative-fasting-in-children-and-infants?search=preoperative-fasting-in+children_and_infants&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1  
 
[https://pubs.asahq.org/anesthesiology/article/133/3/523/108227/Preoperative-Fluid-Fasting-Times-and-Postinduction Preoperative Fluid Fasting Times and Postinduction Low Blood Pressure in Children: A Retrospective Analysis]
 
[https://www.uptodate.com/contents/preoperative-fasting-in-children-and-infants?search=preoperative-fasting-in+children_and_infants&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1 UpToDate: Preoperative fasting in children and infants]


https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2766509
https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2766509
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https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2766011
https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2766011


From PAAD https://ronlitman.substack.com/p/npo-guidelines-are-they-bubbameisters?r=g3wdr&utm_campaign=post&utm_medium=email&utm_source=copy :
[https://ronlitman.substack.com/p/npo-guidelines-are-they-bubbameisters?r=g3wdr&utm_campaign=post&utm_medium=email&utm_source=copy From PAAD]
Original article
 
[https://www.bjaed.org/article/S2058-5349(17)30168-3/fulltext Preoperative fasting in children]
 
 
[https://link.springer.com/content/pdf/10.1007/s12630-019-01382-z.pdf Canadian Pediatric Anesthesia Society statement on clear fluid fasting for elective pediatric anesthesia]
 
 
[https://pubs.asahq.org/anesthesiology/article/127/4/A15/19790/Anesthesia-amp-Breastfeeding-More-Often-Than-Not Anesthesia & Breastfeeding: More Often Than Not, They Are Compatible]
 
[https://pubs.asahq.org/anesthesiology/article/134/6/A21/115725/Ultrasound-Insights-into-Neonatal-Fasting-Get-in Ultrasound Insights into Neonatal Fasting: Get in the NP-Know]
 
[https://pubmed.ncbi.nlm.nih.gov/29624435/ ABM Clinical Protocol #15: Analgesia and Anesthesia for the Breastfeeding Mother, Revised 2017]
 
[https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.15751 The thirst for improvement: ensuring shorter and safer pre-operative fasting times in children]
 
[https://onlinelibrary.wiley.com/doi/10.1111/pan.14479 Effect of a carbohydrate lollipop on the gastric volume of fasted pediatric patients]
 
[https://pubmed.ncbi.nlm.nih.gov/36557062/ Relationship between Fasting Times and Emergence Delirium in Children Undergoing Magnetic Resonance Imaging under Sedation]
 
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4517287/ Acute Intraoperative Pulmonary Aspiration]


Jennifer J Lee, Jerri C Price, Andrew Duren, Alon Shertzer, Robert Hannum, Francis A Akita, Shuang Wang, Judy H Squires, Oliver Panzer, Jacquelin Herrera, Lena S Sun, Nicholas A Davis. Ultrasound Evaluation of Gastric Emptying Time in Healthy Term Neonates after Formula Feeding. Anesthesiology. 2021 Jun 1;134(6):845-851. PMID: 33861856
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 Mar;126(3):376-393.


Editorial
Frykholm P, Disma N, Andersson H, Beck C, Bouvet L, Cercueil E, Elliott E, Hofmann J, Isserman R, Kaucane A, Kuhn F, de Queiroz Siqueira M, Rosen D, Rudolph D, Schmidt AR, Schmitz A, Stocki D, Sumpelmann R, Stricker PA, Thomas M, Veyckemans F, Afshari A. Preoperative fasting in children: guideline from the European Society of Anaesthesiology and Intensive Care. Eur J Anaesthesiol 2022; 39:4–25.


Laszlo Vutskits. Neonatal Preoperative Fasting: Time for a Change? Anesthesiology. 2021 Jun 1;134(6):823-825. PMID: 3386185
Disma N, Frykholm P, Cook-Sather SD, Lerman J. Pro-con debate: 1- vs. 2-hour fast for clear liquids before anesthesia in children. Anesth Anal 2021; 133:581-91.


My mother Sally, of blessed memory, was absolutely convinced that if I (MY) went out to play with wet hair, I would catch a cold. I have no idea where or how this old wive’s tale (in Yiddish a “bubbameister”) came from, but it was “truth” in Sally’s home until her dying day. No amount of arguing or explaining that colds came from viruses would change her mind. Which brings us to preprocedural nil per os (NPO) guidelines.  Are our fasting guidelines bubbameisters? Is it time to revisit them, and embrace more than 20 years of data demonstrating the safety of reduced fasting times?1
[https://link.springer.com/article/10.1007/s12630-023-02526-y Determining residual gastric volume in healthy children using ultrasound]


Because general anesthetics blunt or abolish protective reflexes, pre‐operative and pre-procedural fasting is employed to minimize gastric contents and in turn, decrease the risk of pulmonary aspiration (“Mendelson syndrome”).2 By and large fasting guidelines appear to have worked. Aspiration is extremely rare, however, our current concerns about aspiration may be out of proportion to the actual risk, particularly for clear liquids. Rebecca Isserman and I (LE) and our colleagues at the Children’s Hospital of Philadelphia’s published our experience with changing fasting guidelines for clear liquids to one hour.3  Making this a national guideline change is currently under discussion at the Society for Pediatric Anesthesia’s Quality and Safety Committee and at the ASA.4  Other organizations have already made this change.5, 6
[https://pubmed.ncbi.nlm.nih.gov/35881513/ Ultrasound Assessment of Gastric Fluid Volume in Children Scheduled for Elective Surgery After Clear Fluid Fasting for 1 Versus 2 Hours: A Randomized Controlled Trial]


The article by Lee et al. from Columbia University’s Morgan Stanley Children’s Hospital puts yet another nail in the NPO guideline coffin.  The most current ASA based NPO guidelines (clear fluid intake for up to 2 hours, breast milk up to 4, infant formula up to 6, and milk or solid food for up to 6-8  hours) made no substantive changes to the guidelines previously published in 1999.7,8 Much evidence of the safety of reduced fasting times has been published over the last 20 plus years. In today’s PAAD, Lee, et al, used gastric ultrasound to measure gastric emptying time in formula fed infants “to support or refute current preprocedural NPO guidelines for neonates”. Their stated goal was to “optimize patient safety and well-being in addition to patient/parental satisfaction. [Our] hypothesis is that the gastric emptying time in healthy neonates after formula feeding is less than the current guideline of 6 h of fasting.”3 
Joshi GP, Abdelmalak BB, Weigel WA, et al. 2023 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting: Carbohydrate-containing Clear Liquids with or without Protein, Chewing Gum, and Pediatric Fasting Duration-A Modular Update of the 2017 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting. Anesthesiology. Feb 1 2023;138(2):132-151. doi:10.1097/aln.0000000000004381


Indeed, their hypothesis was correct. Lee, et al. “found the time to return to baseline antral cross-sectional area was 92.9 ± 42.6 min in 46 healthy full-term neonates aged 0 to 5 days. The upper range of gastric emptying time was 150 min, while the upper limit at the 99% CI was 109.8 min. There were no significant differences in gastric emptying time in subgroup analyses according to sex or mode of delivery. These findings suggest that the current fasting guidelines (6 hours) may be more stringent than necessary by more than 3 h”. They conclude: “gastric emptying time, as assessed by serial ultrasound after formula feeding in healthy full-term neonates, was determined to never exceed 2.5 h using upper range or 99% CI.” Intuitively, this makes sense and explains why babies feed about every 2.5- 3 hours!
Frykholm P, Disma N, Andersson H, et al. Pre-operative fasting in children: A guideline from the European Society of Anaesthesiology and Intensive Care. European journal of anaesthesiology. Jan 1 2022;39(1):4-25. doi:10.1097/eja.0000000000001599


The findings in this study validate the guidelines long used (without reported adverse events) at the Children’s Hospital of Philadelphia: formula fed neonates may safely feed up to 4 hours prior to anesthesia. Changing fasting guidelines will be a difficult and slow process: the bubbameister lives on in our regulatory and professional society guidelines. Until our professional societies embrace the abundance of evidence accumulated over the last 20-30 years, and put these changes into writing, individual practitioners and groups may be exposing themselves to legal risk.  On the other hand, it may be time to pick up our pitchforks and storm the castle to force these changes.  
Sarhan KA, Hasaneen H, Hasanin A, Mohammed H, Saleh R, Kamel A. Ultrasound Assessment of Gastric Fluid Volume in Children Scheduled for Elective Surgery After Clear Fluid Fasting for 1 Versus 2 Hours: A Randomized Controlled Trial. Anesthesia and analgesia. Apr 1 2023;136(4):711-718. doi:10.1213/ane.0000000000006157


What do you think?
Yaster M, Galinkin J, Schreiner M. An Introduction to the Ethical Design, Conduct, and Analysis of Pediatric Clinical Trials. In: Andropolous D, Gregory G, eds. Gregory's Pediatric Anesthesia. 6th ed. Wiley-Blackwell; 2020:56-74:chap 4.


Myron Yaster MD and Libby Elliott MD
Schmitz A, Schmidt AR. Can we use ultrasound examination of gastric content as a diagnostic test in clinical anaesthesia? Pediatric Anesthesia. 2019;29(2):112-113. doi:https://doi.org/10.1111/pan.13555


PS: In keeping with Ron Litman’s spirit and guidance before he died, I’ve (MY) tried to keep these PAADs brief, really brief. In working with Libby, Mel Brooks, and others I’ve started to include some references too. Should I continue?  What are your thoughts?
Roberts RB, Shirley MA. Reducing the risk of acid aspiration during cesarean section. Anesthesia and analgesia. Nov-Dec 1974;53(6):859-68. doi:10.1213/00000539-197453060-00010


References
DM, Rocke DA, Brock-Utne JG, Marszalek A, Engelbrecht HE. Critical volume for pulmonary acid aspiration: reappraisal in a primate model. British journal of anaesthesia. Aug 1990;65(2):248-50. doi:10.1093/bja/65.2.248


1.       Friedrich S, Meybohm P, Kranke P: Nulla Per Os (NPO) guidelines: time to revisit? Curr Opin Anaesthesiol 2020; 33: 740-745
[https://www.asahq.org/about-asa/newsroom/news-releases/2023/06/american-society-of-anesthesiologists-consensus-based-guidance-on-preoperative American Society of Anesthesiologists Consensus-Based Guidance on Preoperative Management of Patients (Adults and Children) on Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists]


2.       Mendelson CL: The aspiration of stomach contents into the lungs during obstetric anesthesia. Am J Obstet Gynecol 1946; 52: 191-205
[https://www.hindawi.com/journals/grp/2015/497176/ Contrasting Perspectives of Anesthesiologists and Gastroenterologists on the Optimal Time Interval between Bowel Preparation and Endoscopic Sedation]


3.       Isserman R, Elliott E, Subramanyam R, Kraus B, Sutherland T, Madu C, Stricker PA: Quality improvement project to reduce pediatric clear liquid fasting times prior to anesthesia. Paediatr Anaesth 2019; 29: 698-704
[https://aspenjournals.onlinelibrary.wiley.com/doi/10.1002/jpen.2556 Pre-Procedural Fasting Policies for Patients Receiving Tube Feeding: A National Survey]


4.       Vutskits L, Davidson A: Fluid Fasting in Children: Solid Science? Anesthesiology 2020; 133: 493-494
[https://www.bjanaesthesia.org/article/S0007-0912(23)00563-9/fulltext Incidence of adverse respiratory events after adjustment of clear fluid fasting recommendations to 1 h: a prospective, observational, multi-institutional cohort study]


5.       Green SM, Leroy PL, Roback MG, Irwin MG, Andolfatto G, Babl FE, Barbi E, Costa LR, Absalom A, Carlson DW, Krauss BS, Roelofse J, Yuen VM, Alcaino E, Costa PS, Mason KP: An international multidisciplinary consensus statement on fasting before procedural sedation in adults and children. Anaesthesia 2020; 75: 374-385
[https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.16117 Pre-operative gastric ultrasound in patients at risk of pulmonary aspiration: a prospective observational cohort study]


6.       Thomas, M; Morrison, C; Newton, R; Schindler, E. Consensus statement on clear fluids fasting for elective pediatric general anesthesia. Pediatric Anesthesia 2018, 28(5): 411-414
[https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/anae.16190 Editorial: Point-of-care gastric ultrasound: food for thought]


7.       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(3): 376-393
[https://pubs.asahq.org/monitor/article/88/4/19/139952/Perioperative-Tube-Feedings-Common-Questions Perioperative Tube Feedings – Common Questions]


8.      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: a report by the American Society of Anesthesiologist Task Force on Preoperative Fasting. Anesthesiology. 1999 Mar;90(3):896-905.
[https://journals.lww.com/anesthesia-analgesia/fulltext/2024/04000/preoperative_renin_angiotensin_system_antagonists.12.aspx Preoperative Renin-Angiotensin System Antagonists Intake and Blood Pressure Responses During Ambulatory Surgical Procedures: A Prospective Cohort Study]

Latest revision as of 17:24, 16 April 2024

This is a Stub Notice. This page has not been completed. You can work on this page by signing in and going to the Edit tab. Thanks for helping to make PedsAnesthesia.Net Wiki useful.

Go to the Main Page to see the Topic Outline.

Go to the Generalized Suggested Outline for information on case-specific details for each page.

Go to the Test Page for examples on how to use references in the page.


Relevant Article Depot:


NPO

Guidelines:

2023 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting: Carbohydrate-containing Clear Liquids with or without Protein, Chewing Gum, and Pediatric Fasting Duration—A Modular Update of the 2017 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting*

2023 Canadian Pediatric Anesthesia Society Statement on fasting for elective pediatric anesthesia

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

Guideline on anaesthesia and sedation in breastfeeding women 2020

Preoperative fasting in children: review of existing guidelines and recent developments

The rationale for the recommendations of the European Paediatric Fasting Guideline: Improving paediatric anaesthesia and perioperative medicine

Pre-operative fasting in children: A guideline from the European Society of Anaesthesiology and Intensive Care


Preoperative Fluid Fasting Times and Postinduction Low Blood Pressure in Children: A Retrospective Analysis

UpToDate: Preoperative fasting in children and infants

https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2766509

https://bjanaesthesia.org/article/S0007-0912(21)00111-2/fulltext

https://link.springer.com/article/10.1007/s12630-019-01382-z

https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2766011

From PAAD

Preoperative fasting in children


Canadian Pediatric Anesthesia Society statement on clear fluid fasting for elective pediatric anesthesia


Anesthesia & Breastfeeding: More Often Than Not, They Are Compatible

Ultrasound Insights into Neonatal Fasting: Get in the NP-Know

ABM Clinical Protocol #15: Analgesia and Anesthesia for the Breastfeeding Mother, Revised 2017

The thirst for improvement: ensuring shorter and safer pre-operative fasting times in children

Effect of a carbohydrate lollipop on the gastric volume of fasted pediatric patients

Relationship between Fasting Times and Emergence Delirium in Children Undergoing Magnetic Resonance Imaging under Sedation

Acute Intraoperative Pulmonary Aspiration

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 Mar;126(3):376-393.

Frykholm P, Disma N, Andersson H, Beck C, Bouvet L, Cercueil E, Elliott E, Hofmann J, Isserman R, Kaucane A, Kuhn F, de Queiroz Siqueira M, Rosen D, Rudolph D, Schmidt AR, Schmitz A, Stocki D, Sumpelmann R, Stricker PA, Thomas M, Veyckemans F, Afshari A. Preoperative fasting in children: guideline from the European Society of Anaesthesiology and Intensive Care. Eur J Anaesthesiol 2022; 39:4–25.

Disma N, Frykholm P, Cook-Sather SD, Lerman J. Pro-con debate: 1- vs. 2-hour fast for clear liquids before anesthesia in children. Anesth Anal 2021; 133:581-91.

Determining residual gastric volume in healthy children using ultrasound

Ultrasound Assessment of Gastric Fluid Volume in Children Scheduled for Elective Surgery After Clear Fluid Fasting for 1 Versus 2 Hours: A Randomized Controlled Trial

Joshi GP, Abdelmalak BB, Weigel WA, et al. 2023 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting: Carbohydrate-containing Clear Liquids with or without Protein, Chewing Gum, and Pediatric Fasting Duration-A Modular Update of the 2017 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting. Anesthesiology. Feb 1 2023;138(2):132-151. doi:10.1097/aln.0000000000004381

Frykholm P, Disma N, Andersson H, et al. Pre-operative fasting in children: A guideline from the European Society of Anaesthesiology and Intensive Care. European journal of anaesthesiology. Jan 1 2022;39(1):4-25. doi:10.1097/eja.0000000000001599

Sarhan KA, Hasaneen H, Hasanin A, Mohammed H, Saleh R, Kamel A. Ultrasound Assessment of Gastric Fluid Volume in Children Scheduled for Elective Surgery After Clear Fluid Fasting for 1 Versus 2 Hours: A Randomized Controlled Trial. Anesthesia and analgesia. Apr 1 2023;136(4):711-718. doi:10.1213/ane.0000000000006157

Yaster M, Galinkin J, Schreiner M. An Introduction to the Ethical Design, Conduct, and Analysis of Pediatric Clinical Trials. In: Andropolous D, Gregory G, eds. Gregory's Pediatric Anesthesia. 6th ed. Wiley-Blackwell; 2020:56-74:chap 4.

Schmitz A, Schmidt AR. Can we use ultrasound examination of gastric content as a diagnostic test in clinical anaesthesia? Pediatric Anesthesia. 2019;29(2):112-113. doi:https://doi.org/10.1111/pan.13555

Roberts RB, Shirley MA. Reducing the risk of acid aspiration during cesarean section. Anesthesia and analgesia. Nov-Dec 1974;53(6):859-68. doi:10.1213/00000539-197453060-00010

DM, Rocke DA, Brock-Utne JG, Marszalek A, Engelbrecht HE. Critical volume for pulmonary acid aspiration: reappraisal in a primate model. British journal of anaesthesia. Aug 1990;65(2):248-50. doi:10.1093/bja/65.2.248

American Society of Anesthesiologists Consensus-Based Guidance on Preoperative Management of Patients (Adults and Children) on Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists

Contrasting Perspectives of Anesthesiologists and Gastroenterologists on the Optimal Time Interval between Bowel Preparation and Endoscopic Sedation

Pre-Procedural Fasting Policies for Patients Receiving Tube Feeding: A National Survey

Incidence of adverse respiratory events after adjustment of clear fluid fasting recommendations to 1 h: a prospective, observational, multi-institutional cohort study

Pre-operative gastric ultrasound in patients at risk of pulmonary aspiration: a prospective observational cohort study

Editorial: Point-of-care gastric ultrasound: food for thought

Perioperative Tube Feedings – Common Questions

Preoperative Renin-Angiotensin System Antagonists Intake and Blood Pressure Responses During Ambulatory Surgical Procedures: A Prospective Cohort Study

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