Impact of liberal preoperative clear fluid fasting regimens on the risk of pulmonary aspiration in children (EUROFAST): an international prospective cohort study

Abstract

Background: Preoperative fasting regimens designed to minimise the risk of pulmonary aspiration have undergone significant changes, but unequivocal evidence of the safety of reducing clear fluid fasting has been lacking. We compared the risk of pulmonary aspiration in children using three different recommendations for clear fluid fasting.

Methods: In this prospective multicentre cohort study, centres with >1000 paediatric anaesthesia cases per year were eligible. Regurgitation events, whether they were transient or led to consequences affecting postoperative care, were reported in detail. All centres also reported the number of anaesthetised children per year and which preoperative fasting regimen they used.

Results: The 31 participating centres contributed a total of 306 900 anaesthetic procedures. The incidence of confirmed pulmonary aspiration was 1.18:10 000 in the sip-til-send group, 0.96:10 000 in the ≥1 h group, and 1.83:10 000 in the control group. There was no mortality as a result of aspiration. The 95% confidence intervals of the differences in confirmed pulmonary aspiration between the control group and the ≥1 h clear fluid fasting and the sip-til-send group were -0.344 to 3.76 and -1.48 to 3.63, respectively. Both sip-til-send and ≥1 h clear fluid fasting were statistically noninferior to ≥2 h clear fluid fasting regarding the incidence of confirmed aspiration, transient regurgitation, and regurgitation leading to escalation of care or intensive care.

Conclusions: The study provides evidence for the safety of reducing preoperative fasting time for clear fluids in children aged <16 yr from 2 h to ≤1 h.

Keywords: clear fluids; general anaesthesia; paediatric anaesthesia; preoperative fasting; pulmonary aspiration.

Fig 1

Incidence of regurgitation events categorised as transient (green), escalation of care (purple), and requiring postoperative intensive care (blue). The x-axis displays the 31 sites in order according to number of anaesthetics (largest to smallest). Each site's fasting regimen is indicated as sip-til-send (STS), ≥1 h clear fluid fasting (blank), or ≥2 h clear fluid fasting.

Fig 2

Number of events (incidence n:10 000) and 95% confidence intervals for the differences in confirmed pulmonary aspirations between sites with the ≥2 h preoperative clear fluid fasting rule (number of anaesthetics = 21 851) vs the ≥1 h rule (number of anaesthetics = 251 021) or the sip-til-send (STS) rule (number of anaesthetics = 34 028). D indicates the predefined noninferiority margin.