|Ahead of print publication
Determination of a safe time and safe protocol for oral hydration in pediatric patients following general anesthesia
Sushama Raghunath Tandale, Sunita M Khedkar, Kalpana V Kelkar, Shriaunsh Abhade, Subhadra Sinha
Department of Anaesthesia, BJGMC and SGH, Pune, Maharashtra, India
|Date of Submission||29-Nov-2019|
|Date of Decision||07-Jul-2020|
|Date of Acceptance||24-Jul-2020|
Sunita M Khedkar,
Department of Anaesthesia, BJGMC and SGH, Pune 411 001, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: The study was aimed to evaluate the safe time and safe protocol for postoperative resumption of oral hydration in pediatric patients undergoing elective nonabdominal surgery under general anesthesia. Methodology: One hundred and sixty patients (of age 6 months to 12 years) were assigned into two groups. The assessment of level of consciousness, protection of the airway (coughing and swallowing), absence of nausea and vomiting, and normal saturation were used as the safety criteria for start of postoperative oral hydration in both groups. Clear fluids in dose of 0.5–1 ml/kg were offered to them after completing 4th and 1st h of recovery in standard and experimental group, respectively. Next hour onward clear fluids was given as per the need of patients. Safety profile, safety protocol, and parental/patient satisfaction with early and delayed oral hydration were recorded. Data analysis was done using SPSS (Statistical package for social sciences) version 20:0 and P <0.05 was considered statistically significant. Results: Statistical insignificant difference was found with age, sex, weight, and the American Society of Anesthesiologists status, duration of surgery, type of surgery, type of anesthesia, fasting time, time from last intake of liquid and solid preoperatively in both the groups. None of the patients enrolled in the study experienced desaturation, moderate sedation, regurgitation, or pulmonary aspiration of gastric content. The incidence of postoperative nausea and vomiting was 7.5% and 3.75% in the standard and experimental group, respectively. Mean total volume of oral hydrating solution was 140.82 ml and 123.56 ml in standard and experimental group, respectively. Statistically significant difference (P < 0.001) was observed in parental/pediatric patient satisfaction score among two groups. Significantly shorter time to oral hydration in experimental group (71.44 min) than standard group (244.44 min) was as expected. Conclusion: Early postoperative oral hydration with clear liquid is safe and highly satisfying for parents and patients following elective nonabdominal surgery.
Keywords: General anesthesia, pediatric patients, parental or patient satisfaction score, postoperative liquid intake, postoperative nausea vomiting
|How to cite this URL:|
Tandale SR, Khedkar SM, Kelkar KV, Abhade S, Sinha S. Determination of a safe time and safe protocol for oral hydration in pediatric patients following general anesthesia. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2021 Feb 25]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=309184
| Introduction|| |
In clinical practice, postoperative oral hydration is allowed at 4th–6th h with nonabdominal surgery. There are no uniform consensuses on type of fluid, volume of fluid and time at which pediatric patient should resume oral intake following general anesthesia. Greater challenges for early postoperative resumption of oral hydration are the presence of residual neuromuscular block as well as sedation and postoperative nausea and vomiting. Concerns with residual neuromuscular blocks and sedation are risk of regurgitation and aspiration of gastric content.,
Oral fluids can be offered to healthy infants and children when they are fully awake following general anesthesia provided there are no surgical, medical, or nursing contraindications. Advantages with early oral hydration will be early and rapid return to normal diet, early mobilization, reduced thirst, and increased satisfaction. The study was aimed to evaluate the safe time and safe protocol for postoperative resumption of oral hydration in pediatric patients.
| Methodology|| |
This interventional study was conducted after approval from Hospital Ethics Committee, departmental permission, and informed parental consent. The study was registered in the clinical trial registry of India (CTRI/2018/05/013883;www.ctri.in). One hundred and sixty pediatric patients of age between 6 months to 12 years, the American Society of Anesthesiologists (ASA) Status I-II, undergoing elective nonabdominal surgery under general anesthesia were included prospectively between November 2017 and September 2018. Patients were randomized to respective groups by lottery method.Participants were allotted to groups by selfpick up of chits from the box containing 200 chits(100 for each group). Exclusion criteria included patients with gastrointestinal disorder and anticipated delay in gastric emptying, patients undergoing oropharyngeal surgery, thoracic surgery and neurosurgery, patients with known allergy to drugs used in study, requirement of perioperative inotropes infusion and ASA Status >II. History of prior postoperative nausea or vomiting and motion sickness, if any among relatives or in patient, was recorded. Time since consumption of last oral solid and liquid intake was also recorded. All pediatric patients were premedicated with standard doses of glycopyrrolate, ondansetron, and fentanyl. General anesthesia was induced with appropriate dose of propofol and nondepolarizing muscle relaxant followed by endotracheal intubation with appropriate size of endotracheal tube. Central neuraxial block and/or peripheral nerve blocks were administered for analgesia whenever indicated. Total doses of nondepolarizing muscle relaxant and fentanyl administered during surgery was recorded. At the end of surgery, neuromuscular block was reversed with appropriate doses of neostigmine and glycopyrrolate followed by extubation of trachea after adequate neuromuscular and clinical recovery (presence of cough reflex, spontaneous limb movements, eye opening on verbal command, and touch). Patients were monitored in recovery room throughout the study procedure.
In recovery room, the child was assessed and documented for level of consciousness, protective airway reflexes, oxygen saturation, and presence of nausea and vomiting on a scale in recovery room every 15 min after 4 h in standard group and every 15 min after 1 h in experimental group till completion of 4 h since their first oral intake. Patients in standard group had received postoperative oral hydration after 4 h and experimental group had received postoperative oral hydration after 1 h.
Clear fluid was offered to pediatric patients when they were conscious, had intact protective airway reflexes (coughing and swallowing reflex), normal saturation, and absence of nausea and vomiting in a dose of 0.5–1 ml/kg after completion of 4th h of recovery and if required was repeated once during 5th h. Clear fluids were offered again on demand after 5th h, following well acceptance of initial fluid in standard group as per their need. Clear fluid was offered to pediatric patients when they were conscious, had intact protective airway reflexes (coughing and swallowing reflex), normal saturation, and absence of nausea and vomiting in a dose of 0.5–1 ml/kg after completion of 1st h of recovery and if required was repeated once during 2nd h. Clear fluids were offered again on demand after the 2nd h, following well acceptance of initial fluid in experimental group as per their need. Patients in both the groups were observed every 15 min till completion of 4 h in recovery period after start of their first postoperative oral hydration. If child would have refused to drink after offering clear fluid, he/she would have been given whenever they demand in postoperative period. Type and volume of oral hydration fluid administered to pediatric patients were recorded. Adverse events, if any postoperatively such as desaturation, moderate sedation, regurgitation, or pulmonary aspiration of gastric content were also recorded. Parental/patients satisfaction score was also recorded with postoperative oral hydration.
Modified scoring system was used to assess postoperative vomiting as follows:
- 0: No vomiting
- 1: Retching (attempt to vomit without expulsion of stomach content)
- 2: Single episode of vomiting during a 30 min period
- 3: Continuous retching or two or more episodes of vomiting during a 30 min period.
The level of consciousness was assessed as follows:
- Child is conscious, alert, talks, verbalizes thirst, sustained eye opening, has consistent answers and is oriented
- Drowsy, wakes up after verbal command, makes eye contact and has understandable verbal response, going back to sleep after the end of stimulus.
Reflexes of airway protection was assessed as follows,
- I-Coughs to verbal command, breathes in and uses the thoracic and abdominal muscles, expelling high air flow.
Presence of cough during extubation
II-Swallows voluntarily or with verbal command or presence of sucking
- I-Does not cough with verbal command.
The absence of cough during extubation
II-Does not swallow with verbal command or absence of sucking
Parental or pediatric patient satisfaction was recorded using a verbal numerical scale from 0 to 10, with 0 meaning not satisfied to 10 being most satisfied.
Data analysis was done using SPSS (Statistical package for social sciences) version 20:0. its a statistical software used for analysis of data. Qualitative data variables expressed by using frequency and percentage (%). Quantitative data variables expressed using mean and standard deviation Unpaired t–test used to compare the quantitative data variables in two independent groups. Chi-square test used to compare the qualitative data variables in two independent groups. P <0.05 was considered as statistically significant.
| Results|| |
A total of 181 children fulfilled the inclusion criteria. Of these, 21 parents refused to participate in clinical trial, thus 160 patients were included in the statistical analysis. Demographic characteristics, surgical procedures, and anesthesia data of the patients in standard and experimental group are summarized in [Table 1]. There was statistically insignificant difference among the two groups as regards age, weight, gender, ASA status, and positive history of prior postoperative nausea vomiting or motion sickness in relatives, duration of surgery, surgical procedure, and anesthesia data.
Relevant drugs used during general anaesthesia such as fentanyl and vecuronium are summarized in [Table 2]. Propofol (3 mg/kg) and ondansetron (0.1 mg/kg) were used in all patients. Statistically insignificant observation was noted among the two groups with respect to fentanyl (P < 0.642) and vecuronium (P < 0.303).
|Table 2: Mean dose of fentanyl and vecuronium throughout procedure in both groups|
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All surgical procedures were completed without any complications. None of the patients enrolled in the study experienced desaturation, moderate sedation, regurgitation, or pulmonary aspiration of gastric content. Incidence of postoperative nausea and vomiting was 7.5% (6 out of 80) and 3.75% (3 out of 80) in the standard and experimental group, respectively. None of the vomiting episode was prior to the administration of oral hydrating solution. Fasting time, time since last intake of liquid, time since the last intake of solid and parental/pediatric patient satisfaction score are summarized in [Table 3]. There was statistically insignificant difference as regards fasting time, time from the last intake of liquid and solid preoperatively and statistically significant difference as regards parental/pediatric patient satisfaction score among two groups.
|Table 3: Mean±standard deviation fasting time (min), time from last intake of liquid (min), time from last intake of solid (min) and parental satisfaction score in both groups|
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As expected there was significantly shorter time to oral hydration in experimental group (71.44 min) than standard group (244.44 min).
The mean volume of oral rehydrating solution at the end of 2nd h and 4th h in experimental group and at the end of 5th h and 8th h in standard group is summarized in [Table 4]. Mean total volume of oral hydrating solution in standard group was 140.82 ml and in experimental group was 123.56 ml. Type of oral hydrating solution was frooti, mineral water, coconut water, frooti plus mineral water and mineral water plus coconut water in 33.75%, 31.25%, 27.5%, 7.5%, and 0% in experimental group and 18.75%, 7.5%, 40%, 31.25%, and 2.5% in standard group.
|Table 4: Total volume of oral hydrating solution in standard and experimental group|
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| Discussion|| |
In this study, we investigated the safe protocol for early oral hydration after emergence from general anesthesia and its association with postoperative nausea and vomiting as well as risk of regurgitation. We have also evaluated the parental/pediatric patient's satisfaction with early oral hydration. Results of the present study demonstrated that early postoperative oral hydration with clear liquid on demand, in awake pediatric patient with presence of cough and swallowing reflex following elective non abdominal surgery is safe and highly satisfying for parents/pediatric patients.
Early oral hydration following general anesthesia is not practiced routinely as it is thought to be associated with risk of regurgitation, postoperative nausea and vomiting, and abdominal distension. These complications are distressing to parents/patients and associated with increased total stay in hospital and cost of health-care resources utilization. Clinical practice guidelines on perioperative fasting in adults and children, laid by royal college of nursing clearly recommends oral fluids to healthy infants and children when they are fully awake following anesthesia, providing there are no medical, surgical or nursing contraindications. They also state that, clinician should consider giving clear fluids or breast milk before introducing other oral intake and importantly, children and infants undergoing day surgery should not be required to drink as part of the discharge criteria. These recommendations are also supported firmly by European society of anesthesiology who suggests that adults and children should be allowed to resume drinking as soon as they wish after elective surgery. However, fluid intake should not be insisted upon before allowing discharge from a day or ambulatory surgery facility.
Adequate recovery of protective cough reflex is essential to permit safe resumption of oral hydration postoperatively as it protects the lungs from inhalation of foreign particles and clears the airways of retained secretions. Residual sedation after propofol use does not seem to adversely affect the cough reflex. Awake, phonating child with flexion of both arms and legs and persistent head lift for more than 5 s implies adequate neuromuscular recovery from neuromuscular blocking agents and sedative agents by clinical criteria. In our study, oral hydrating fluid was offered to pediatric patients when they were conscious, had intact protective cough reflex, were able to swallow, with normal saturation and in absence of nausea and vomiting. These all criteria make a safe protocol for postoperative resumption of oral hydration following general anesthesia.
All pediatric patients in both groups received IV propofol as an induction agent and IV ondansetron as prophylactic antiemetic. Both the groups did not reveal any statistical difference with use of fentanyl and atracurium which are implicated in postoperative nausea and vomiting and postoperative residual muscle weakness., With regards to timing of oral intake after general anesthesia, Cheng et al. reports that, in children who have undergone minor surgery, oral intake can begin 1 h after emergence from anesthesia, because gastric motility has returned to normal by this time. In our study, the first oral hydration time in standard and experimental group was 244.44 and 71.44 min, respectively.
In our study, incidence of postoperative nausea and vomiting was high in standard group compared to experimental group. Radke et al. investigated the effects of postoperative fasting on vomiting in children undergoing outpatient surgery and he found that incidence of vomiting was higher in group which was fasted for 6 h (22%) than group which was allowed for oral intake as per their need (15%), hence he concluded that postoperative fasting did not reduce the incidence of vomiting after general anesthesia in children when compared with a liberal regimen. Mercan et al. compared the incidence of vomiting in children with first oral intake at first versus 2nd h after emergence from general anesthesia following hernia repair and orchiopexy and he also did not notice any increased incidence of vomiting with oral intake at 1st h than 2nd h after emergence. Y O Atalay sedated 180 children for magnetic resonance imaging whom were assigned into three groups. He allowed the patients to drink as much clear fluids they want prior to discharge in Group I, 1 h after the patients met the discharge criteria in Group II and 2 h after the patients met the discharge criteria in Group II. He did not notice any nausea or vomiting in either the recovery or post discharge period in any group. Chauvin et al. evaluated the role of early postoperative feeding on the use of opioids and incidence of postoperative vomiting. He stated that oral intake before the administration of an opioid analgesic allowed reduction in incidence of postoperative vomiting from 23.93% in control group to 11.40% in liberal group. Guo et al. compared early (just after emergence) versus delayed (4 h after emergence) oral hydration in adult patients undergoing nongastrointestinal surgery with general anesthesia and he found that early oral intake group had a similar incidence (22%) of vomiting compared with the delayed oral intake group (20%). Our results are comparable with them.
Schreiner et al. observed that the incidence of vomiting was increased in children who were forced to drink before discharge as compared with children who drink on their will. Several studies have reported that mandatory food intake after surgery has been shown to increase nausea and vomiting.,,, In our study, oral hydrating fluid was offered after meeting the clinical criteria for safe feeding and was given to pediatric patients on demand.
Xiaorong et al. evaluated thirst scales before and after oral hydration in two groups of adult patients undergoing non gastrointestinal surgery namely with early oral hydration (when patient recovered from general anesthesia) and delayed oral hydration (4 h after general anesthesia). The study showed that patients in early oral hydration group had significantly decreased thirst scales after hydration and higher patient satisfaction. In our study, the parental satisfaction was highest in experimental group (9.79) than standard group (7.36) which was statistically highly significant.
Strength of our study is we have used novel approach for early postoperative hydration, both in terms of volume and time. The assessment of level of consciousness, protection of the airway (coughing and swallowing), absence of nausea and vomiting and normal saturation were used as the safety criteria for start of early postoperative oral hydration. Limitation of our study was that, we relied on subjective monitoring for reversal of neuromuscular blockade by clinical criteria. Because the evaluation of neuromuscular blockade with objective neuromuscular monitoring is of limited value in pediatric patients as the data is difficult to reproduce in children due to its standardization of test with adult population.
Results of the present study demonstrated that early postoperative oral hydration with clear liquid is safe and highly satisfying for patients and parents following elective nonabdominal surgery. Protocol for administering fluid should include presence of cough and swallowing reflex, presence of consciousness, normal saturation, and absence of nausea and vomiting.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]