Randomized trial comparing overnight preoperative fasting period Vs oral administration of apple juice at 06:00-06:30 am in pediatric orthopedic surgical patients. Ingestion of liquids compared with preoperative fasting in pediatric outpatients. The effect of pre-operative intake of oral water and ranitidine on gastric fluid volume and pH in children undergoing elective surgery. The effect of preoperative apple juice on gastric contents, thirst, and hunger in children. The effect of different pre-operative feeding regimens on plasma glucose and gastric volume and pH in infancy. Unlimited clear fluid ingestion by infants up to 2 hours before surgery is safe. Clear fluids three hours before surgery do not affect the gastric fluid contents of children. [Possibility of rice porridge for preoperative feeding in children]. Large volumes of apple juice preoperatively do not affect gastric pH and volume in children. Shortened preanesthetic fasting interval in pediatric cardiac surgical patients. [Preoperative fasting in pediatrics]. Effects of duration of fasting on gastric fluid pH and volume in healthy children. Gastric residual volume in infants and children following a 3-hour fast. Efficacy, duration, and absorption of a paediatric oral liquid preparation of ranitidine hydrochloride. Effects of 2-, 4- and 12-hour fasting intervals on preoperative gastric fluid pH and volume, and plasma glucose and lipid homeostasis in children. Paediatric glucose homeostasis during anaesthesia. Ingestion of clear fluids is safe for adolescents up to 3 h before anaesthesia. Effect of oral liquids and ranitidine on gastric fluid volume and pH in children undergoing outpatient surgery. Benefits of oral administration of an electrolyte solution interrupting a prolonged preoperatory fasting period in pediatric patients.
We aimed to evaluate the efficacy of clear liquids orally administered at 06:00-06:30 am on the morning of surgery to reduce prolonged preoperative fasting periods.
                After obtaining informed parental consent, 100 children undergoing scheduled orthopedic surgical procedures, ASA I-II, were randomly allocated to two groups. In group 1, children underwent the typical overnight preoperative period and patients in group 2 received a commercial brand of apple juice (glucose 28 g in 250 ml) at 06:00-06:30 am on the day of surgery. Patients <3 years old received 15 ml.kg(-1) and older children 10 ml.kg(-1) to a maximum volume of 250 ml. All patients underwent overnight fasting for milk and solids.
                Fasting time was 4.8 +/- 2.1 h (ranging from 3 to 11 h) in the group receiving apple juice at 06:00-06:30 am and 13.2 +/- 3.3 h (ranging from 5 to 19 h) in the overnight-fasting group (P < 0.05; 95% CI: -9.6 to -7.4 h). More patients were irritable (odds ratio, OR 4.5; 95% CI: 1.9-10.8) and dehydrated (OR 21.6; 95% CI: 5.9-79.0) in the overnight-fasting group. Glucose levels <2.7 mmol.l(-1) (50 mg.dl(-1)) were not reported in any case.
                A 15 ml.kg(-1) of apple juice for patients of <3 years of age or 10 ml.kg(-1) for older children, at 06:00-06:30 am of the surgical morning is a simple procedure to prevent dehydration and to produce positive behavior in low-risk, pediatric surgical patients. The preoperative fast is often an unpleasant preoperative experience that might be alleviated by allowing children to drink clear liquids. The authors compared gastric fluid volume and pH in two groups of children, one of whom was permitted clear liquids until 2 h before surgery (study group) and the other followed routine preoperative fasting orders (control group). The study group was not limited in the quantity of clear liquid allowed with the exception that the last intake prior to surgery was limited to 8 ounces. The study group (n = 53) averaged 5.9 +/- 5 yr and weighed 23.6 +/- 17 kg, while the control group averaged 7.3 +/- 4.6 yr and weighed 29 +/- 17.7 kg (P = NS). Gastric contents were aspirated following induction of anesthesia. Gastric fluid volume averaged 0.44 +/- 0.51 ml/kg for study group and 0.57 +/- 0.51 ml/kg in the control group (P = 0.12). Of the study patients, 48% had a measured gastric fluid volume greater than or equal to 0.4 ml/kg compared with 58% of the control patients (P = 0.77). Eighty three patients had sufficient gastric fluid for pH determination; of these 34/35 (97%) in the study group and 44/48 (92%) in the control group had a gastric fluid pH less than or equal to 2.5. Using a linear analog scale parents rated the children in the study group to be less irritable (P less than 0.001) and to have had a better overall preoperative experience (P less than 0.01) compared with the control patients.(ABSTRACT TRUNCATED AT 250 WORDS) The effect of pre-operative intake of oral water and ranitidine on gastric fluid volume and pH was studied in 75 children of American Society of Anesthetists (ASA) grade I and grade II undergoing elective surgery. Group I patients fasted from midnight and acted as control. Group II patients received 5 ml/kg plain water orally 3 hours before surgery. Group III children received 5 ml/kg of plain water and 2 mg/kg of ranitidine orally 3 hours before surgery. Mean volume of gastric aspirate was comparable in all 3 groups (p > 0.05). Mean pH was significantly higher in ranitidine treated patients (5.12 +/- 1.73) as compared to non-ranitidine treated patients (2.26 +/- 0.57 and 2.53 +/ 0.79 in group I and group II respectively). Number of patients at risk (pH < or = 2.5 and volume > or = 0.4 ml/kg) was not significantly different in group I and group II. Mean thirst and behaviour scores were significantly higher in fluid treated patients (groups II and III) as compared to control (p < 0.01). To conclude, administration of pre-operative water (5 ml/kg) along with ranitidine (2 mg/kg) favourably modifies gastric fluid volume and pH, improves patient behaviour and minimises the number of patients at risk of aspiration pneumonitis, should the child aspirate. The effect of 3 ml.kg-1 of apple juice given 2.6 +/- 0.4 hours preoperatively was investigated in 80 healthy children of ages five to ten years in this prospective, randomized, single blind study. The children who drank apple juice preoperatively had decreased gastric volume, thirst, and hunger (p less than 0.05). The gastric volume in the control group was 0.43 +/- 0.46 ml.kg-1 and in the patients who received apple juice the gastric volume was 0.24 +/- 0.31 ml.kg-1. The gastric pH was not significantly different, with the control group's gastric pH being 1.7 +/- 0.6 and the treated group's pH was 2.2 +/- 1.2. Further studies of the effects of different volumes and timing of preoperative clear fluids are indicated in paediatric patients. The effects of four different pre-operative feeding regimens were studied in 123 children below the age of one year presenting for surgery. Plasma glucose concentrations, blood acid-base values, gastric volume and gastric pH were measured before and after induction of anaesthesia. No patient was found to be hypoglycaemic and there were no significant differences in plasma glucose concentration and acid-base values between the groups. No correlation was demonstrated between the age and weight of the patients and the duration of fasting and the plasma glucose concentration. There was a significant elevation of plasma glucose concentration in all four groups after induction of anaesthesia (P less than 0.001) compared with the pre-induction level which is a reflection of the stress of blood sampling and induction of anaesthesia. Infants less than three months of age in the milk-feed group had a significantly higher gastric volume with low pH (P less than 0.05) signifying a potentially greater risk of pulmonary acid aspiration. The practice of timing the last pre-operative feed in infancy according to the infant's normal feeding pattern does not appear to increase the risk factors for pulmonary aspiration, if milk is avoided. nan This prospective, randomized, single-blind study of 121 healthy children aged 2 to 12 yr investigated the effect of clear fluids on gastric contents. Gastric fluid volume and pH were measured immediately following the induction of general anaesthesia and were not significantly affected by the ingestion of unlimited clear fluids up to three hours preoperatively. After a prolonged fast (mean fast 14 hr), gastric fluid volume was 0.39 +/- 0.37 ml.kg-1 and gastric pH was 1.7 +/- 0.4; after unlimited clear fluids (203 +/- 109 ml) up to three hours before surgery gastric fluid volume was 0.34 +/- 0.28 ml.kg-1 and gastric pH was 1.8 +/- 0.7 (mean +/- SD). Gastric fluid volume (ml.kg-1) increased in both the control and study groups as age increased, P less than 0.005. It is concluded that drinking clear fluid up to three hours before scheduled surgery does not have a measurable effect on gastric volume and pH of healthy children of ages 2 to 12 yr. To determine the effect of rice porridge feeding before elective surgery on preoperative gastric fluid pH, volume and starvation, a prospective study was undertaken in pediatric patients. Twenty healthy children ranged in age from 5 to 12 years were allocated randomly to either a fasted or rice porridge group. The children of fasted group (control group) were allowed to take solid food until midnight before the operation. The rice porridge group (study group) patients received a small amount of rice porridge 5 hours 30 minutes before the induction of anesthesia. The patients of both groups were permitted to take clear fluid until 5 hours before the induction of anesthesia. After the induction of anesthesia, gastric fluid was aspirated through an orogastric tube. The mean gastric fluid volume was 0.43 +/- 0.32 ml.kg-1 in the control group and 0.5 +/- 0.6 ml.kg-1 in the study group. The mean gastric fluid pH was 1.43 +/- 0.27 ml.kg-1 in the control group and 1.89 +/- 0.75 ml.kg-1 in the study group. There were no significant differences between the two groups concerning the gastric fluid volume and pH. The patient of the study group complained of less hunger. Preoperative rice porridge feeding is a possible preoperative feeding for pediatric patients. The effect on gastric pH and volume of 0, 6 and 10 ml.kg-1, of apple juice given 2.5 hours before surgery to children aged five to ten years was investigated in this prospective, randomized, single-blind study. Gastric contents were aspirated after induction of anaesthesia, and the volume measured. The pH of the gastric aspirate was then assessed using pH paper. Neither gastric volume nor pH immediately following the induction of general anaesthesia were significantly different among the three groups. Gastric volumes after 0, 6 and 10 ml.kg-1, of juice averaged (mean +/- SD) 0.45 +/- 0.31, 0.66 +/- 0.79 and 0.71 +/- 0.76 ml.kg-1, respectively; gastric pH averaged 1.7 +/- 0.6, 1.7 +/- 0.6 and 1.8 +/- 0.8, respectively. On the basis of questions asked immediately before induction of anaesthesia, patients who drank 6 ml.kg-1 of apple juice had decreased thirst and were less irritable and upset before anaesthesia than those who had not (P less than 0.05). It is concluded that drinking large volumes of clear apple juice 2.5 hours before scheduled surgery does not have a measurable effect on gastric volume and pH and may offer benefits such as improved patient comfort. The recent liberalization of preoperative feeding orders in healthy pediatric outpatients prompts the question of whether this applies to children about to have cardiac surgery. The authors compared gastric fluid volume and pH in two groups of children undergoing elective cardiac surgery, one of which was not only permitted ad libitum clear liquids but was mandated to drink clear liquids 2-3 h before induction of anesthesia (study group). The other group followed routine inpatient preoperative fasting orders (control group). The study group (n = 44) averaged 3.1 +/- 4.1 yr and weighed 15.3 +/- 16.3 kg; the control group averaged 3.3 +/- 3.9 yr and weighed 14.3 +/- 12.1 kg (P = 0.82, 0.73, respectively). Aspiration of residual gastric fluid volume was attempted in all patients after induction of anesthesia. Gastric fluid volume averaged 0.6 +/- 0.9 mL/kg in the study group and 0.4 +/- 0.6 mL/kg in the control group (P = 0.13). Of the study patients, 41% had a measured gastric volume greater than or equal to 0.4 mL/kg compared with 32% of the control patients (P = 0.50). Of the 42 patients who had residual gastric fluid aspirated, pH determinations were completed on 37 aspirates; of these 19 of 20 (95%) in the study group and 14 of 17 (82%) in the control group had a gastric pH less than or equal to 2.5. Using a linear analogue scale, parents rated children in the study group to be more comfortable, less hungry, and less thirsty compared with the control patients (P = 0.004, 0.002, 0.0001, respectively).(ABSTRACT TRUNCATED AT 250 WORDS) nan To determine the effects of duration of fasting before elective surgery on gastric fluid pH and volume in children, a prospective, randomized, blinded study of 100 unpremedicated children, aged 1-14 yr, was undertaken. Each child was given 2 mL/kg of water orally and then fasted 2, 4, or 6 h preoperatively. After induction of anesthesia and tracheal intubation, gastric fluid was aspirated through a large-bore, multiorifice orogastric tube. Gastric fluid pH was measured using a calibrated PHM62 radiometer. Gastric fluid volume was the total volume of fluid aspirated from the stomach. The duration of fasting was between 2.0 and 8.5 h. We found that neither gastric fluid pH nor gastric fluid volume correlated with the duration of fasting. The mean (+/- SD) gastric fluid pH was 1.80 +/- 0.79 and the mean (+/- SD) gastric fluid volume was 0.56 +/- 0.39 mL/kg. Gastric fluid pH was less than 2.5 and volume greater than 0.4 mL/kg in 53% of children. We conclude that healthy children may receive 2 mL/kg of water up to 2 h before elective surgery without decreasing gastric fluid pH or increasing gastric fluid volume beyond values obtained after fasting for 6 h. The effect of a 3-hour versus a 10-hour preoperative fasting interval on the gastric residual volume and gastric pH of pediatric patients was evaluated. Forty-four healthy infants, 1 month to 5 years of age, were randomly assigned to one of two groups. The 3-hour nil per os (NPO) group consisted of 19 infants kept NPO for 3 hours following ingestion of up to 4 ounces of 5% dextrose in water (D5W). The control group consisted of 25 infants who remained NPO an average of 10 hours prior to surgery. Gastric residual volume was calculated using the dye-dilution technique. After the dye marker was injected into the stomach, complete aspiration of the stomach (including the volume of dye marker plus residual gastric contents) was attempted as another method to measure gastric residual volume. There were no significant differences in gastric residual volume between the 3-hour and the 10-hour NPO groups using either the dye-dilution or aspiration methods. However, there were significant differences between the two measuring techniques. Gastric residual volume was significantly greater in volume when measured by the dye-dilution technique than it was when measured by the aspiration technique in both the 10-hour (p less than 0.009) and the 3-hour (p less than 0.0009) NPO groups. Complete aspiration of a known volume of fluid injected through the orogastric tube was not possible in 23 of the 44 (52.4%) infants. Mean gastric pH was less than 2.0 in both groups.(ABSTRACT TRUNCATED AT 250 WORDS) The objectives of this study were to assess the clinical efficacy of a new oral ranitidine liquid preparation in reducing gastric acidity and volume, to determine the degree of absorption of the drug, and to determine the duration of drug effect. Eighty preoperative children between the ages of one and six years were enrolled in each of three centres. Each subject was allocated to one of the following groups: Group A - apple juice, 5 ml.kg-1 plus placebo liquid; Group B - apple juice, 5 ml.kg-1 plus ranitidine hydrochloride 2 mg.kg-1; Group C - water, 5 ml and placebo liquid; or Group D - water, 5 ml and ranitidine liquid 2 mg.kg-1. All study agents were administered at least two hours before surgery along with a dye marker, sulfobromophthalein 1 ml (50 mg.ml-1). Following induction of anaesthesia, gastric fluid was aspirated, and analyzed for pH, volume, and sulfobromophthalein content (as an index of the ingested fluids). A serum sample was also drawn and analyzed for ranitidine content by high performance liquid chromatography. Groups B and D had fewer subjects with pH below 2.5 and gastric volume > 0.4 ml.kg-1. The duration of reduced volume and acidity was shown to be greatest from two to four hours after drug administration. Thirty-three percent of subjects receiving oral ranitidine, 2 mg.kg-1 hydrochloride as a single dose demonstrated no measurable effect on gastric pH and volume; 28 of those subjects had adequate ranitidine serum levels. We evaluated 105 randomly-selected unpremedicated children aged 1-14 years to determine the effects of a 2-, 4- and 12-h preoperative fasting interval on the preoperative gastric fluid pH and volume, and plasma glucose and lipid homeostasis. Each child undergoing elective surgery ingested a large volume (approximately 10 ml/kg b.w.) of apple juice and then fasted for 2, 4 or 12 h before the estimated induction of anaesthesia. After induction of anaesthesia, gastric fluid was aspirated through a large-bore, multiorifice orogastric tube. Plasma concentrations of glucose, total ketone bodies, non-esterified fatty acid (NEFA), triglycerides, and cortisol were measured at the time of induction to evaluate the fasting interval effects on preoperative plasma glucose and lipid homeostasis. There were no significant differences between the three groups in either gastric fluid volume or pH. In addition, there were no significant differences between the groups with respect to the proportion with a pH < 2.5 and volume > 0.4 ml/kg b.w. Neither plasma concentrations of glucose, triglycerides, nor cortisol at the time of anaesthetic induction differed between the three groups. Both 4 and 12 h nil per os (NPO) caused an increase in lipolysis, which was presumably a compensatory mechanism to maintain normoglycaemia. The plasma NEFA and total ketone bodies concentrations were therefore significantly higher in these two fasting intervals than in 2 h NPO. These data suggest that a 2-h NPO, after a large volume of ingested apple juice, may offer additional benefits by preventing an increase in lipolysis during the fasting interval without either increasing the volume of gastric fluid or decreasing the gastric pH.(ABSTRACT TRUNCATED AT 250 WORDS) The perioperative blood glucose regulatory response was compared in 20 healthy children (aged 1-5 yr) presenting for minor surgery and allocated randomly to either a fasted or a glucose group. All children received a milk feed at midnight. The fasted group received no oral intake thereafter, whereas the glucose group received 5% dextrose water 10 ml kg-1 orally about 4 h before operation. The mean plasma glucose concentrations in the two groups were similar before operation and were within normal limits. The pattern of change in the concentrations of plasma glucose, insulin, cortisol, growth hormone and glucagon were also similar between the two groups. Ten percent of patients in the fasted group and 33% in the glucose group had gastric aspirates in excess of 0.4 ml kg-1. The pH of all gastric samples was less than 2.5. The results suggest that healthy preschool children were able to maintain glucose homeostasis after 8 h of fasting. Feeding within 4-6 h before surgery may increase the risk of pulmonary aspiration. We have studied the effect of ingestion of unlimited clear fluids by adolescents up to 3 h before anaesthesia to determine the effect this fluid ingestion would have on thirst, hunger and gastric contents at induction of anaesthesia. We studied prospectively 152 adolescents (ages 13-19 yr) undergoing elective surgery. Fifty percent of the patients had nothing by mouth after midnight. The other 50% were instructed to ingest unlimited clear fluids up to 3 h before surgery. On arrival in the operating room, subjects were asked to assess thirst and hunger with a linear analogue scale of 0-10 (0 corresponding to no thirst or no hunger). After induction of anaesthesia, gastric contents were aspirated via a 16-French gauge orogastric tube. Gastric fluid volume (GV) was measured with a syringe and gastric pH (GpH) was assessed with Merck pH strips. GV, GpH and subject hunger were unaffected by ingestion of clear fluids. Subject thirst was reduced by clear fluids. It is concluded that unlimited clear fluid ingestion by healthy adolescents up to 3 h before operation decreases thirst and does not affect gastric contents. Eighty-eight children (mean age 5.6 yr, range 1-14 yr) about to undergo elective outpatient surgery were randomly assigned to four groups. All children were given phenolsulfonphthalein (PSP) orally 2-3 h before the scheduled time of surgery as a marker dye to assess gastric emptying. Immediately after receiving PSP they were given: group A--liquids, up to 5 ml/kg + placebo (glucose water 0.2 ml/kg); group B--liquids, up to 5 ml/kg + ranitidine 2 mg/kg in glucose water 0.2 ml/kg; group C--placebo only; group D--ranitidine only. Gastric contents were aspirated after induction of anesthesia. Mean volume (range) in ml/kg of aspirated gastric fluid in each group was: group A--0.34 (0-1.0); group B--0.17 (0.07); group C--0.25 (0-1.1); group D--0.16 (0-0.6). The pH mean (range) value was: group A--1.83 (0.9-3.6); group B--4.76 (2.0-7.7); group C--2.10 (1.2-4.1); group D--3.97 (1.3-7.3). PSP could not be detected in the gastric samples from children in whom the ingestion-sampling interval was more than 2.25 h. In comparison with prolonged starvation, administration of oral liquids without ranitidine 2-3 h preoperatively did not produce a significant increase in mean volume of gastric aspirate, and there was no increase in the number of patients with gastric aspirate greater than 0.4 ml/kg. Administration of ranitidine with or without fluids resulted in a decrease in both volume and acidity of gastric contents. The aim of this study was to evaluate the benefits of an oral isosmolar solution of electrolytes (ISE) administered to interrupt a prolonged fasting period in children undergoing an elective surgical procedure under general anesthesia.
                Forty unpremedicated children aged 3 to 12 years, ASA I, undergoing a surgical procedure requiring general anesthesia were assigned randomly to 1 of 2 groups. Group 1 consisted of patients with an overnight fasting period for milk and solids of at least 8 hours. In group 2, patients under a similar fasting period received a volume of 4 mL/kg of an oral ISE 3 hours before completing the fasting period. After anesthetic induction, blood glucose level (BGL) was quantified, and patients underwent an endoscopic examination to obtain the gastric content to determine the residual gastric volume (RGV) and pH levels.
                In group 1, the RGV was 0.78 +/- 0.44 mL/kg, pH was 1.75 +/- 0.38, and BGL was 86.4 +/- 14.5. In group 2, the RGV was 0.40 +/- 0.29 mL/kg, pH was 3.18 +/- 0.61, and BGL was 85.1 +/- 12.6. Only RGV and pH were significantly different between groups.
                A prolonged fasting period interrupted with oral ISE administration resulted in an RGV of low risk, without counterbalancing a potential fasting-induced hypoglycemia.
There is no evidence that children who are denied oral fluids for more than six hours preoperatively benefit in terms of intraoperative gastric volume and pH compared with children permitted unlimited fluids up to two hours preoperatively. Children permitted fluids have a more comfortable preoperative experience in terms of thirst and hunger. This evidence applies only to children who are considered to be at normal risk of aspiration/regurgitation during anaesthesia.