Thirsting For Surgery Perioperative 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 Members Simon Whyte, MD Jordan Cheng Warren Hill Damian Duffy Trish 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 Patients 1-4 Parents 1 Benchmark quality indicator: 2-3 hrs UK RCoA & APAGBI 1 Pediatr Anesth 2011;21: Anesth Analg 2001;93: AJN 2011;111: 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 Criteria June 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”

Results n = 416 n = 214 Median: 3:29 IQR: 2:58 – 4:17 n = 202 Median: 12:36 IQR: 11:11 – 14:13

Age n = 398 n = 18

Infants n = 18

Patients 1 – 17 Years n = 398

Age Distribution n = 260

Time of Day Scheduled OR n = 297 n = 101

Morning n = 297 n = 145 Median: 3:20 IQR: 2:51–4:03 n = 152 Median: 11:50 IQR: 10:54–13:13

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 1 st peak:3.5 hrs; 50% population 2 nd 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tend towards ‘over-compliance’ 3,4 Healthcare fear of over-complicating instructions maximising OR flexibility 5 outdated concerns re fasting & aspiration risk 3 3 AJN 2011;111: Nursing Children and Young People 2011;23: J. Clin.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