thirsting for surgery perioperative fluid fasting at bc children’s hospital “too much of a good...
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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
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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
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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
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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
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Study Purpose
• What is the current “state of play”?
• Assess actual clear fluid fasting times for our patients
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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”
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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
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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
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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
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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
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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
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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
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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
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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
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Implications for Practice
• Change conversation in phone room• different education?• prescribed fluid time?
• Case by case discussion
• Establish benchmarks for ongoing audit
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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