Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology.

Eur J Anaesthesiol. 2011 Aug;28(8):556-69

Authors: Smith I, Kranke P, Murat I, Smith A, O'Sullivan G, Søreide E, Spies C, in't Veld B,

Abstract
This guideline aims to provide an overview of the present knowledge on aspects of perioperative fasting with assessment of the quality of the evidence. A systematic search was conducted in electronic databases to identify trials published between 1950 and late 2009 concerned with preoperative fasting, early resumption of oral intake and the effects of oral carbohydrate mixtures on gastric emptying and postoperative recovery. One study on preoperative fasting which had not been included in previous reviews and a further 13 studies published since the most recent review were identified. The searches also identified 20 potentially relevant studies of oral carbohydrates and 53 on early resumption of oral intake. Publications were classified in terms of their evidence level, scientific validity and clinical relevance. The Scottish Intercollegiate Guidelines Network scoring system for assessing level of evidence and grade of recommendations was used. The key recommendations are that adults and children should be encouraged to drink clear fluids up to 2 h before elective surgery (including caesarean section) and all but one member of the guidelines group consider that tea or coffee with milk added (up to about one fifth of the total volume) are still clear fluids. Solid food should be prohibited for 6 h before elective surgery in adults and children, although patients should not have their operation cancelled or delayed just because they are chewing gum, sucking a boiled sweet or smoking immediately prior to induction of anaesthesia. These recommendations also apply to patients with obesity, gastro-oesophageal reflux and diabetes and pregnant women not in labour. There is insufficient evidence to recommend the routine use of antacids, metoclopramide or H2-receptor antagonists before elective surgery in non-obstetric patients, but an H2-receptor antagonist should be given before elective caesarean section, with an intravenous H2-receptor antagonist given prior to emergency caesarean section, supplemented with 30 ml of 0.3 mol l(-1) sodium citrate if general anaesthesia is planned. Infants should be fed before elective surgery. Breast milk is safe up to 4 h and other milks up to 6 h. Thereafter, clear fluids should be given as in adults. The guidelines also consider the safety and possible benefits of preoperative carbohydrates and offer advice on the postoperative resumption of oral intake.

PMID: 21712716 [PubMed - indexed for MEDLINE]

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Ultrasound-guided external jugular vein cannulation for central venous access by inexperienced trainees.

Eur J Anaesthesiol. 2010 Mar;27(3):300-3

Authors: Mitre CI, Golea A, Acalovschi I, Mocan T, Caea AM, Ruţă C, Mariana M

BACKGROUND AND OBJECTIVE: The insertion of central venous catheters via the external jugular vein (EJV) is not always practical because of the relatively frequent failure rate; thus, the internal jugular approach is generally used. Data from the literature suggest that ultrasound-guided catheterization of the internal jugular vein is superior to the surface anatomy landmark technique and, therefore, should be the method of choice. We evaluated the value of ultrasound guidance in the learning process of central venous cannulation via EJV by similarly inexperienced trainees. METHODS: In this prospective randomized study, 60 patients were assigned to two groups: group SA (surface anatomy; n = 30) underwent insertion of the central venous catheter using landmark guidance and group US (ultrasound; n = 30) underwent insertion using ultrasound guidance. In all patients, catheter insertion through the right EJV was performed by trainees in their second year of training. Ultrasound guidance was carried out by the same ultrasound specialist. The following parameters were evaluated in all patients: the number of successful punctures of the right EJV, the total number of attempts and the time to vein puncture; the number of successful insertions of the central venous catheter, the number of attempts and the duration of catheterization (from puncture of EJV to external fixation of the catheter); and the incidence of complications. The study was approved by the institutional ethics committee, and all patients gave written informed consent. Data were expressed as mean +/- SD. Student's t-test, Mann-Whitney test and chi2-test were used for analysis and P < 0.05 was considered statistically significant. The power of the study was 85%. RESULTS: The EJV puncture was successful in 24 out of 30 (80%) patients from group SA and in 22 out of 30 (73%) patients from group US (P = NS). There were no statistically significant differences between the groups regarding the mean time to perform the vein puncture and the number of attempts. The insertion of the central venous catheter was performed successfully in 10 (33%) patients from group SA and six (20%) patients from group US. The success rate of central cannulation via the EJV approach was 10 out of 24 (42%) in group SA and six out of 22 (27%) in group US (P = NS). The total time for insertion and the number of attempts were similar in both groups (P = NS). Local haematoma occurred in 11 patients in group SA and in three patients in group US (P = NS). CONCLUSION: Our results demonstrate no significant differences between the conventional surface anatomy landmark technique and the ultrasound-guided technique for the insertion of a central venous catheter via EJV by inexperienced trainees.

PMID: 19935072 [PubMed - indexed for MEDLINE]