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Starvation Therapy For Surgical Procedures in Children? :

August 9, 2016

Among children having surgery, how compliant are pre- and postoperative fasting times with evidence-based guideline

Yes, that title is a bit harsh, but I meant to capture your attention. The description of surgical fasting guidelines in this study reminds me of the bad old days of extended NPO periods for infant gastroenteritis management - it doesn't make sense in today's medical world, and it may be harmful. The real problem lies in how practice change can be implemented.

Source: Brunet-Wood K, Simons M, Evasiuk A, et al. Surgical fasting guidelines in children: are we putting them into practice? J Pediatr Surg. 2016; 51:1298-302. doi:10.1016/j.jpedsurg.2016.04.006. See AAP Grand Rounds commentary by Dr. Corey Iqbal (subscription required).

PICO Question: Among children having surgery, how compliant are pre- and postoperative fasting times with evidence-based guidelines?

Question type: Descriptive

Study design: Prospective cohort

These investigators, from a single hospital, looked at duration of fasting for children before and after scheduled surgical procedures. They found poor adherence to published guidelines (American, Canadian, and European anesthesiology societies). The guidelines are based on high-quality evidence, including a Cochrane review. This looked like a great start to a quality improvement project, but the study left me hanging, wanting for more details and plans for corrective actions.

First of all, the study took place in a single hospital over a very short time period, only 5 weeks. The authors acknowledged that this may limit generalizability of results. Even more curious is the fact that this 5-week period was in early 2012, and the study is just now being published. There are a lot of reasons why studies don't get published, or get published late, but I would think that a 4-year lag is a bit long. A journal editor should have requested newer information to be included. It would have been nice to compare the 2012 data with information collected in 2015 or 2016. As this study stands, I can't tell what bearing it might have on this hospital's present practice.

That significant fact notwithstanding, I searched in vain for some details that could lead to a system intervention. For example, probably most clinicians involved in inpatient care have noticed the order "NPO post midnight" to be very common. However, this one size doesn't fit all, it really depends on when the following day the procedure is scheduled. Also, essentially none of the guidelines state that a child must have nothing by mouth for as long as 7 hours, which is about the minimum time period implied by the midnight term. Knowing how frequently this type of generic order is used would go a long way towards finding root causes to target in improving practice.

Knowledge translation is perhaps the biggest hurdle in reaping the rewards of evidence-based medicine. Often, clinical trials are designed without thinking about implementation of new practice. Thankfully, comparative effectiveness research and pragmatic trials are becoming more common.

In the meantime, I hope that pediatric surgeons and anesthesiologists will read this study and become motivated to look at their own institutions' practices to lessen unnecessary withholding of nutrition in children undergoing surgical procedures.

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