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SUMMARYAbstention from food and drink prior to anesthesia remains a corner stone in safe practice. It is thought that fasting (NPO from midnight) reduces the risk of regurgitation and aspiration of gastric contents during surgery. Because such rigid guidelines in children caused fussy, more thirsty, more irritable and possibly hypoglycemic patients, studies documenting no increase in gastric fluid volume with liberalization of clear liquid up to 2 hours. This provides a more human approach for both children and their parents without increasing the risk of pulmonary aspiration of gastric contents.Since, there may be a discrepancy between conclusion based on scientific studies and the current routine practice which may be due to a degree of uncertainty in evaluating the evidence, fear of litigation and difficulty in discarding old habits. The present study is intended to provide a scientific evidence on the benefit of permitted clear fluids up to 2 hours before surgery for healthy patients scheduled for elective procedures without adverse outcome and the possibility of increased comfort in the perioperative period. The introduction of liberalized fasting guidelines has been supported by re-appraisal of older data and more recent scientific studies.In the current randomized controlled study, 80 pediatric patients were studied for all children, milk and solids were administered until midnight on the day before surgery. Just prior to the fasting period, the patients were instructed to ingest unlimited amount of apple juice. The patients divided into four equal groups according to the duration of fasting (n = 20).· Group I: 2 hours nothing per oral (NPO).· Group II: 4 hours NPO.· Group III: 6 hours NPO.· Group IV: 8 hours NPO (standard fast)Each group divided into 2 subgroups according to their age:A: 3-6 years.B: 7-12 yearsas hemodynamic measurement differs between 2 age groups.The parents of the children or the children themselves were requested before entering the operating room to comment on thirst, hunger and irritability. Measurement of these parameters were carried out using linear analogue scale (0-10 cm). In all cases 10 was considered to be the best possible score and 0 the worst.Age, weight, ASA physical status, duration of fasting and amount of ingested clear fluid (apple juice) were identified and recorded.Heart rate, systolic, diastolic, mean blood pressure were recorded preinduction, post induction, every 10 minute intraoperative and postoperative.Blood glucose level were identified immediately post induction (after loss of eye lash reflex), after surgical incision and postoperative.Gastric fluid was collected by another person (blind technique), gastric fluid volume and pH were measured and recorded.The quality of induction were assessed by laryngospasm coughing, regurgitation or aspiration.Analysis of the study results revealed no significant difference in the mean values of gastric fluid volume and pH between the groups.There was no significant difference in the incidence of the risk of aspiration between the groups.There was no significant difference between the four groups as regard to post induction blood glucose level but there is significant increase in mean values of blood glucose level after surgical incision and postoperative in the four groups.There was no significant difference between the four groups as regard to the heart rate, systolic, diastolic and mean blood pressure.The children permitted clear fluids up to 2 hours before surgery were less thirsty, less hungry and less irritable than other groups.CONCLUSIONFrom the present study, we conclude that, the children allowed drinking unlimited clear fluid up to 2 hours before surgery are not at a clinically significant risk of increased volume or decreased pH than children of other groups. In addition, children permitted a clear drink 2 hours preoperatively were found to be less thirsty, less hungry and better behaved than children of other groups. So, through this study, we urge the clinicians to permit the children to drink clear fluids up to two hours preoperatively and it must be prescribed (not just allowed), making it part of routine premedication.It should be remembered however that this evidence only applies to healthy children scheduled for elective surgery who are not considered to be at increased risk of aspiration during anesthesia.RECOMMENDATIONThis study may be starting point for further investigation as:- The effect of different duration of fasting on the same parameters musty be evaluated in age group (1 month to 2 years).- Studies on special situation as diabetic, obese or emergency cases must be done.- Studies on the best choice of clear fluid and premedication that can decrease gastric fluid volume and increase gastric pH must be encouraged.- The effect of intraoperative infusion of different concentration of glucose (1%, 2.5% or 5%) and the rate of infusion must be evaluated to avoid hypoglycemia or hyperglycemia.- A survey study on the outcome of revised fasting guidelines must be encouraged to conduct large prospective investigation to scientifically decide. This issue lead us to pediatric anesthesia care that is both safe and human.
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