The edition · Anaesthesiology
Clear fluids under two hours before anaesthesia in children: aspiration stayed at 3 in 10,000
A meta-analysis of 580,197 children finds no difference in aspiration between liberal and conventional fasting. Also: age-triggered preoperative echo, ketamine for delirium, and why a very comfortable epidural may run hot.
The edition in brief
A meta-analysis of 33 studies (580,197 children) found pulmonary aspiration in 0.03% under both liberal (under two hours) and conventional (two hours or more) clear fluid fasting policies, with no difference in risk (RR 0.77, 95% CI 0.40 to 1.47) and similar vomiting rates. Certainty was very low, but the absolute risk is very small and supports shorter clear fluid fasts. A regression discontinuity analysis of 7,270 older adults at one institution found that routine echocardiography triggered by age 75 did not clearly reduce intraoperative hypotension or improve outcomes; estimates were imprecise. A meta-analysis of 25 randomised trials (3,344 patients) found perioperative ketamine (RR 0.69) and esketamine (RR 0.58) associated with less postoperative delirium, mainly at higher doses and after major surgery, but trial sequential analysis judged the evidence inconclusive and dizziness rose. In a multicentre observational study of 952 nulliparous women, lower pain scores during epidural labour analgesia were associated with more intrapartum hyperthermia, supporting a sympathetic-block mechanism. The pearl covers fever in labour with an epidural.
Echo at 75 by policy did not clearly change perioperative outcomes
Base preoperative echocardiography on clinical indications rather than age alone.
Ketamine and esketamine may cut postoperative delirium, at a dizziness cost
Treat the ketamine-delirium signal as unproven; keep to established delirium prevention.
The more comfortable the labour epidural, the more often fever followed
Monitor temperature in labour epidurals, especially with very dense blocks, and still assess fever for infection.
Fever in labour with an epidural: still look for infection
Assess every intrapartum fever for infection, even when an epidural is a likely cause.
Shorter clear fluid fasts in children: no rise in aspiration across 580,000 patients
Consider a one-hour clear fluid fast for healthy children; aspiration was rare and no more common than with two hours.
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