Thirsting For SurgeryPerioperative Fluid Fasting at BC Children’s Hospital

“Too Much of a Good Thing?”

Simon Whyte, MD; Jordan Cheng; Warren Hill; Damian Duffy; Trish Page

Acknowledgements

This project was funded by the iACT Trainee Clinical Investigator Award

through the Child and Family Research Institute.

Team MembersSimon Whyte, MD

Jordan ChengWarren Hill

Damian DuffyTrish Page

What do we know?

• Fasting is required

• ASA: 2 hr for clear fluids

• BCCH Anesthesia: 2 hrs

• Pre-operative phone call protocol is 3 hrs

• OR has a dynamic schedule

• Excessive fasting is not benign

Prolonged Fluid Fasting

Why does it matter?Physiological impact• Dehydration• Hypoglycemia• Hypotension

Psychological impact• Patients1-4

• Parents1

Benchmark quality indicator: 2-3 hrs• UK RCoA & APAGBI

1 Pediatr Anesth 2011;21:964-8 2 Anesth Analg 2001;93:1344-50 3 AJN 2011;111:38-434 Nursing Children and Young People 2011;23:14-19

Study Purpose

• What is the current “state of play”?

• Assess actual clear fluid fasting times for our patients

Methodology

Inclusion CriteriaJune 14 - July 13, 2012

age 0 – 17 yrs

received SDCU pre-op fasting instructions

returned to SDCU during JC’s work hours

Fasting time = procedure room entry - last reported clear fluid intake time

> 4h interval = “over-fasted”

Distribution of Clear Liquid Fasting

0

10

20

30

40

50

60

70

80

90

0 2 4 6 8 10 12 14 16 18 20 22 24

Hours Fasted From Clear Liquids

Nu

mb

er

of C

ase

s

Results

n = 416

n = 214

Median: 3:29

IQR: 2:58 – 4:17

n = 202

Median: 12:36

IQR: 11:11 – 14:13

Infants

0

1

2

3

4

5

6

7

8

9

10

0 2 4 6 8 10 12 14 16 18 20 22 24

Hours Fasted From Clear Liquids

Nu

mb

er

of C

ase

s

Infants

n = 18

Patients Older Than One Year

0

10

20

30

40

50

60

70

80

90

0 2 4 6 8 10 12 14 16 18 20 22 24

Hours Fasted From Clear Liquids

Nu

mb

er

of C

ase

s

Patients 1 – 17 Years

n = 398

Age Distribution of Patients Who Fasted Over Four Hours

0

10

20

30

40

50

60

0 2 4 6 8 10 12 14 16 18

Age

Nu

mb

er

of C

ase

s

Age Distribution

n = 260

AM Surgeries

0

10

20

30

40

50

60

70

0 2 4 6 8 10 12 14 16 18 20 22 24

Hours Fasted From Clear Liquids

Nu

mb

er

of C

ase

s

Morning

n = 297

n = 145

Median: 3:20

IQR: 2:51–4:03

n = 152

Median: 11:50

IQR: 10:54–13:13

PM Surgeries

0

5

10

15

20

25

0 2 4 6 8 10 12 14 16 18 20 22 24

Hours Fasted From Clear Liquids

Nu

mb

er

of C

ase

s

Afternoon

n = 101

n = 51

Median: 3:36

IQR: 3:11-4:21

n = 50

Median: 14:54

IQR: 13:30–16:36

Summary of Results

Bimodal distribution• 1st peak: 3.5 hrs; 50% population• 2nd peak: 12.5 hrs; 50% population

65% clear fluid fast >4 hrs

Patients <3 yrs are most challenging

Not uncommon results

Reasons For Findings?

Parental• parents’ historical experience w anesthesia• tend towards ‘over-compliance’3,4

Healthcare• fear of over-complicating instructions• maximising OR flexibility5

• outdated concerns re fasting & aspiration risk3

3 AJN 2011;111:38-43 4 Nursing Children and Young People 2011;23:14-195. J. Clin. Anesth 2000;12:48-51

Implications for Practice

• Change conversation in phone room• different education?• prescribed fluid time?

• Case by case discussion

• Establish benchmarks for ongoing audit

Conclusions

• Two thirds of patients experience prolonged fasting• 30% < 3yr

• Literature suggests specific actions to mitigate

• Practice change will take effort

• Auditing needs to be continued on an ongoing basis