The edition · Anaesthesiology
Clear fluids under two hours before anaesthesia showed no rise in aspiration in children
Across 580,000 children, aspiration was about 3 in 10,000 whether fasting was liberal or conventional. Plus a ketamine signal for delirium, and why good epidurals may run hot.
The edition in brief
A meta-analysis of 33 studies and about 580,000 children found pulmonary aspiration in about 0.03% under both liberal (under 2 hours) and conventional (2 hours or more) clear fluid fasting, with no difference in risk (RR 0.77, 0.40–1.47); certainty was very low, but the numbers support shorter fasts. A meta-analysis of 25 trials found perioperative ketamine (RR 0.69) and esketamine (RR 0.58) were associated with less postoperative delirium, mainly at higher doses and in major surgery, though trial sequential analysis judged the evidence inconclusive and dizziness rose. In 952 nulliparous women with labour epidurals, lower pain scores were associated with more intrapartum fever (13% overall), consistent with a sympathetic-block mechanism. A regression discontinuity study of 7,270 older adults found no clear benefit from routine echocardiography at age 75 on intraoperative hypotension or outcomes, with wide intervals. The pearl covers non-drug delirium prevention.
Ketamine and esketamine were linked to less delirium, but the evidence is not yet settled
Ketamine may reduce delirium, but the evidence is inconclusive; do not add it for that purpose alone.
Better labour epidural analgesia was associated with more intrapartum fever
Consider the epidural itself in a comfortable labouring woman with fever, but always assess for infection.
Routine echocardiography at 75 showed no clear benefit before non-cardiac surgery
Order preoperative echocardiography for clinical indications, not because a patient has reached 75.
Delirium prevention starts with the basics
Identify delirium risk preoperatively, avoid deliriogenic drugs and hand over the risk to the ward.
Shorter clear fluid fasts in children showed no rise in aspiration
Consider allowing clear fluids up to 1 hour before anaesthesia in healthy children, and audit real fasting times.
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