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UNIVERSITE PIERRE ET MARIE CURIE(PARIS VI)
ACADEMIE DE PARISAnnée 2012-2013
MEMOIRE
pour l'obtention du DES
d'Anesthésie-Réanimation
C:oordonnateur : Monsieur le Professeur Didier Journois
par
Ahmad NI. ALATTAS
Présenté et soutenu le 16 Avril 2013
Effet du jeun préopératoire sur le statu volémique àl'induction chez l'enfant
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Travail effectué sous la direction du Professeur Souhayl Dahmani
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UNIVERSITE PIERRE ET MARIE CURIE
(PARIS VI)
ACADEMIE DE PARIS
Année 2012-2013
MEMOIRE
pour l’obtention du DES
d’Anesthésie-Réanimation
Coordonnateur : Monsieur le Professeur Didier Journois
par
Ahmad M. ALATTAS
Présenté et soutenu le 16 Avril 2013
Effet du jeun préopératoire sur le statu volémique à
l’induction chez l’enfant
Travail effectué sous la direction du Professeur Souhayl Dahmani
[ins%tut-‐anesthesie-‐reanima%
on.org]. Do
cumen
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s Licen
se Crea%
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mon
s (by-‐nc-‐sa).
Introduction
In modern anesthesia, Fasting guidelines were set to balance different goals such
as, minimizing pulmonary aspiration risk, assuring patient/parent satisfaction, facilitate
vascular access, improve hemodynamic conditions, maintain plasma glucose levels and last
but not least it may improve recovery. Same guidelines of pre-operative fasting came out as
recommendation from several societies like ADARPEF and ASA (Table 1). Nowadays most
centers are trying to follow these guidelines or at least have already implemented it already as
local protocol. And on the other hand, adherence to fasting advices may be affected by
parents’ recall and understanding 1. Either way, failure of respecting fasting guide lines or
over fasting to match parents comfort can increase aspiration risk as well as hypovolemic
state after general anesthesia induction. To compensate state of hypovolemia, optimal fluid
therapy found to be an alleviating factor of perioperative mortality and morbidity in adult
populations 2-4
.
Intraoperative fluid therapy remains challenging in children due to the lack of
validation of indexes in this population. Until recently, optimal therapy relied on Holliday
and Segar’s or Berry’s formula 5-9
, urine output monitoring, central venous pressure and
classical hemodynamic parameters namely heart rate and systemic blood pressure variations.
Many static and dynamic hemodynamic indexes have been validated and are now available
for fluid balance optimization in adults 10-17
. Non-invasive ultrasound measured
hemodynamic parameters have been recently validated in children. The first and most
accurate is peak aortic velocity 18-20
. More recent reports have described using esophageal
ultrasound measured stroke volume as a marker of fluid requirements during pediatric
surgery 21-25
. Trans-esophageal Doppler (TED) probes can be used in children > 3 kg and
have been validated against pulmonary artery thermodilution , Fick and dye dilution methods
25-26. A Doppler probe is placed in the esophagus, and blood flow velocity profile is measured
in the descending aorta. The blood flow velocity is integrated over time and multiplied by
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aortic cross-sectional area (calculated from nomograms) to determine stroke volume and
cardiac output.
In current study, using (TED) as perioperative device to obtain Stroke volume index
(SVI), we investigated the volemic state of a cohort of patients and try to correlate the
magnitude of hypovolemia to the duration of preoperative fasting. Our hypothesis is that this
duration might cause fluid deficit and contraction of intravascular space.
[ins%tut-‐anesthesie-‐reanima%
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Material and Methods
This is a prospective single center observational study, and was approved by our
IRB (Comité d’Evaluation de l’Ethique des Projets de Recherche Biomédicale - CEERB –
Paris Nord). Written consent was waived by the institutional ethics committee because
perioperative care during this study was part of standard care delivered to patients in our
institution (Clinical Trials Directive; 2001/20/EC issue from the European Network of
Centers for pharmaco-epidemiology and pharmaco-vigilance). However, parents were
informed (orally and using specific forms) and oral consent was obtained from all patients.
This study was part of a work assessing Pleth Variability Index (PVI) accuracy in predicting
fluid responsiveness in anesthetized children, recently accepted in Pediatric Anesthesia
journal 26 Jan2013.
Inclusion criteria
Patients were included if they fulfilled the following criteria: age between 2 and 10
years, ASA status 1 or 2, undergoing open surgeries including abdominal, urological,
gynecologic or orthopedic in supine or lithotomy position. All procedures had a planned
duration exceed 45 minutes.
Patients were excluded if they were undergoing laparoscopic surgery, operated upon
in a prone or lateral position, presented with known renal failure, esophageal abnormalities
(ulceration, stenosis), previous esophageal or thoracic surgery that might influence the
anatomical relationship between the aorta and the esophagus, rectal abnormalities
(contraindicating rectal temperature probe insertion), undergoing emergent surgery or had
known cardiac or vascular disease (heart failure, hypertension).
Intraoperative anesthesia management
All patients were pre-medicated using oral Hydroxyzine 2 mg.kg-1
given 60 to
120 minutes before surgery. Anesthesia was performed according to local protocols.
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Monitoring included heart rate (HR), non-invasive blood pressure, arterial saturation with the
sensor placed on a finger on the opposite side of the blood pressure cuff, end tidal CO2
(ETCO2), gas analysis (Sevoflurane, O2 and N2O concentrations), airway volumes and
pressures and rectal temperature measurement. All patients underwent three minutes pre-
oxygenation. Induction was performed using Sevoflurane (6 % in a mixture of O2/N2O
50%/50%) and an intravenous cannula inserted. Tracheal intubation was performed following
the administration of Sufentanil (0.2 µg.kg-1
) and Atracurium (0.5 mg.kg-1
). Hypnosis was
maintained using Sevoflurane (0.8 to 1 age adjusted MAC) in a mixture of O2/N2O
50%/50%. Ventilation was performed using pressure control without end-expiratory pressure.
End tidal CO2 concentration was maintained between 30 and 35 mmHg. Analgesia was
administered as Sufentanil boluses (0.1 µg.kg-1
when HR or mean arterial pressure (MAP)
increased by 20% of baseline). Paralysis was achieved using a non-depolarizing
neuromuscular blocking drug (Atracurium 0.2 mg.kg-1
) where indicated by adductor pollicis
monitoring. Patients were actively warmed from entry into theatre until exit. Temperature
was monitored using a rectal probe so as to facilitate esophageal Doppler monitoring. Thirty
minutes before the end of surgery, patients received an intravenous bolus of Paracetamol (15
mg.kg-1
) and Ketoprofen (1 mg.kg-1
). No ketamine was administered. At the end of surgery,
regional analgesia was performed when indicated, consisting of either caudal (single bolus)
or epidural analgesia (a bolus and a postoperative patient or nurse controlled regional
analgesia). Prevention of postoperative nausea and vomiting was administered following
induction: intravenous Dexamethasone (0.15 mg.kg-1
) and Ondonsetron (0.1 mg.kg-1
).
Intraoperative fluid management
Intravenous fluid maintenance is standardized in our institution. Ringer’s Lactate is
used for patients weighing more than 30 kg and Ringers lactate and 1 % glucose (B66,
product of the Assistance Publique Hôpitaux de Paris, Paris, France) in those weighing less
than 30 kg 33, 34
. Fluids are administered according to Holliday and Segar formulae with
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compensation for preoperative fasting determined by the hour of last oral liquid intake. After
intubation, a pediatric Trans Esophageal Doppler TED probe was inserted and connected to a
CardioQR device (Deltex Medical, Chicester, England). Probe position was adjusted to
obtain the best aortic contour waveform. As recommended by our local guidelines, a fluid
challenge was performed systematically 10 minutes after intubation, before the beginning of
the surgery, where 10 ml.kg-1
of normal saline solution was infused over 15 minutes using a
calibrated pump. According to local guidelines, fluid challenges were monitored by: stroke
volume index variation (SVI: a decrease of more than 15 % of SVI in comparison to its value
after preincision fluid challenge), classical hemodynamic parameters (increased heart rate,
decreased mean arterial pressure), decreased urine output (when the bladder was catheterized)
or intraoperative surgical circumstances such as bleeding or prolonged abdominal surgery,
and according to the judgment of the anesthesiologist caring the patient.
Collected Data
The following variables were recorded immediately before and after each fluid
challenge: stroke volume index (SVI, mean of three measurements), heart rate (HR), systolic
blood pressure, diastolic blood pressure, mean arterial pressure, respiratory rate, peak airway
pressure, Tidal volume, arterial hemoglobin saturation, ETCO2, expired Sevoflurane
concentration and rectal temperature. In addition, demographic data (age, weight), the
surgery performed, and the durations of surgery and anesthesia were recorded.
Statistical analysis:
Descriptive statistics were displayed as median [minimum – maximum] or number
[percentage]. Discrete variables were compared using Chi² test or exact test of Fisher.
Continuous variables were considered as normally distributed when sample size exceeded 30
measurements and paired Student’s t test was used. Otherwise, variables were compared
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using the Wilcoxon signed-rank test. The Bonferroni correction was applied for multiple
comparisons. A value of p less than 0.05 was considered the threshold to reject the null
hypothesis. Statistical analyses were performed using SPSS 20.0 software (IBM Company,
Chicago, Illinois, USA) and MedCalc 12.3 (MedCalc, MedCalc Software, Mariakerke,
Belgium).
The power calculation for this study was computed for assessing the accuracy of
PVI in predicting fluid challenge response assuming an area under ROC of 0.85, an alpha of
0.05 and beta of 0.2 and 50% of patients would be fluid responsive. Results indicate that
Forty patients were necessary and we empirically decided to include 50 patients in that study.
However, the power sample calculation for the duration of the preoperative fasting leading to
a difference in response to a fluid challenge during anesthesia induction was not computed
for the current analysis.
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Results
Fifty four eligible patients were included. All patients received one fluid challenge
after induction of anesthesia (termed preincision fluid challenge in the current study). The
population is described in (table 2). Surgery included abdominal surgeries (nephrectomy,
spleenectomy and stoma closures), urological surgeries (hypospadias and urological tract
surgery) and orthopedic surgeries (osteotomy: femoral and tibial osteotomy with or without
tenoplasty). As planned, fifty four fluid challenge (one per patient) were administered after
intubation (preincision). 77.6 % of these challenges were administered under neuromuscular
blockade (52.4 % in responders and 47.6 % in non-responders, p = 0.09).
Considering a response to fluid challenge as an increase in SVI of more than 15 %, 25 (46.3
%) fluid challenges elicited a response and 29 (53.7%) did not. Hemodynamic, respiratory,
anesthetic gas and temperature parameters are described for all preincision fluid challenges in
(tables 3). While if considering a response of fluid challenge as an increase of SVI of more
than 10 %, there were 35 (64.8 %) responders and 19 (35.2 %) non-responders to fluid
challenges.
Comparison of duration of preoperative fasting in responders and non-responders challenges
did not found a statistical difference nor when considering a 15 % increase in SVI as a
response to the fluid challenge (duration of preoperative fasting 8 [3 – 12] hours versus 8 [2 –
12]hours, in responders and non-responders, respectively; p = 0.937) neither when a 10 %
increase in SVI defined the response to fluid challenge (duration of preoperative fasting 8 [2
– 12] hours versus 8 [2 – 12]hours, in responders and non-responders, respectively; p =
0.681). Moreover, no statistical correlation was found between duration of preoperative
fasting and percentage changes in SVI during fluid challenges (pearson correlationr = 0.13, p
= 0.36)
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Discussion
Our study can be summarized as the following : in our sample of children aged
from 2-10 years scheduled for non-cardiac surgery performed in supine position, no
significant difference in duration of preoperative fasting period was found between
responders to a fluid bolus and non-responders.
As clinical appreciation of the volemic status is known to be unreliable in
anesthetized ventilated children 30
minimally invasive tools that could predict patient
responsiveness to volume expansion or fluid challenges would be extremely useful. In our
methods of conducting this study we choose to use Trans Esophageal Doppler (TED) for
several reasons, non-invasive, user-friendly monitor allowing measurement of CO and
effective management of haemodynamic instability. Tibby and colleagues 24
established
nomograms on the entire pediatric population, from neonates to older children, showing
satisfactory correlation with thermodilution measures. They concluded that TED provides a
clinically accurate estimate of CO across the entire pediatric age range and is able to follow
changes in CO. In addition, First study to evaluate the use of TED measurements in neonates
and young infants in the intraoperative setting was conducted by Raux et al 22
.
An SVI increase of more than 10 or 15 % defined fluid responsiveness was
previously described and validated in both adult and children populations 21-25, 29
and that is
to assure a detectable volume expansion augmentation, allowing a standardized definition
whatever the fluid challenge indication 22
. Fluid challenge boluses were 10 ml.Kg-1, following
recommendations for hypovolemia in children practiced in our university hospital center as
local protocol based mainly but not only on Holliday and Segar works8, keeping in mind
uncertainty of whether there is a real state of hypovolemia 31
. Boluses of 10 ml.Kg-1
were
preferred to 20 ml.Kg-1 so as to avoid excessive intraoperative fluid administration, which has
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been found to impair perioperative outcomes in adult patients 32
. In addition, Concerning the
volume expansive effect of crystalloids a recent study has addressed a revised crystalloid-to-
colloid volume ratio of 1.8 (and even low to 1.4) instead of 3 or 4 classically considered as a
rational for colloids use 40
. In contrast, despite the more rapid interstitial diffusion of
crystalloid solutions in comparison to colloids, it has been recently found that 50 % to 70 %
of the infused volume remains in the plasma compartment after crystalloid infusion 41
.
However, one of the important limitations of our methodology stills the hypothetical
insufficient bolus of normal saline given during the fluid challenge that might underestimate
the true incidence of hypovolemic patients.
The privilege of crystalloid on colloid in our center protocol does go with recent
researches which found an increasing evidence of their harmful effect on human body despite
its capability of producing some volume expanding effect. Some of these harmful effects
were found with solutions such as Hydroxyethyl starch HES which are not localized only to
the circulatory system but are known to deposit in the skin, liver, muscle, spleen, endothelial
cells, and kidneys of patients who receive these products as well marked hemostatic side
effects 35-36-41-42
. Although producers are still promoting for new achievements regarding
patient safety margin but unfortunately conclusion of randomized trials does not support at
all their promotion efforts 37-38
. In fact, toxic effects of HES solutions on renal function have
been well documented in experimental and clinical studies, a meta-analysis of randomized
trials by Zarychanski et al 39
. The same author and his team has concluded in a recent
Systematic Review and Meta-analysis, that there is no association between reduced
mortality and the use of HES, compared with other resuscitation solutions. Moreover, even
after exclusion of 7 trials performed by an investigator whose research has been retracted
because of scientific misconduct, HES was associated with a significant increased risk of
mortality and acute kidney injury. published in JAMA, February 20, 2013 27
. In infants and
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toddlers changes in thrombelastographic parameters and routine coagulation tests after 15
ml.kg-1
were significantly more pronounced following HES 130 40
.
Our study found that duration of preoperative fasting did not influence the volemia
status of patients, given our criteria to define this state. Although many reports still found an
impressive gap between recommended duration of preoperative fasting and its real duration
in the clinical setting, this problem has to be reconsidered in the management of fluid intakes.
Studies have mainly found that preoperative fasting does play an important role in
modern patients’ safety, quality and efficiency of anesthesia care. Despite the endless debate
supported by recent evidences trying to investigate preoperative fasting truth and myth and
their impacts in modern practice, strict adherence to modern guide lines is considered to some
extent a difficult task to follow by both patients and medical care providers although one of
the main goals of recent guidelines is assuring optimal patients’ comfort specially children.
Poor recall of fasting advice by the parents may have contributed to poor compliance, and
this could be linked with the evidence that elevated stress levels and distractions caused by
their hungry or thirsty children may influence their ability to appreciate and subsequently
retain the information presented to them. Cantellow et al stated “The majority of parents do
not understand the reasons for preoperative fasting” and advice to encourage sufficient
patients-anesthetists communication regarding this issue according to a questioner survey
over 120 parents1. Another prospective study of Engelhardt et al found children presenting
for elective outpatient surgery are suffering from a considerable amount of pre-operative
discomfort because of excessive fasting 43
. Not to forget mentioning some of every day “last
minute” changes in operational programs or non-convinced anesthetists to follow less strict
fasting or more liberal guidelines ending with either over fasting or a full stomach and hence
increasing the risk of aspiration. One of the main consideration which has stimulate recent
re-analysis of modern fasting guidelines is the risk of aspiration after anesthesia induction
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and that’s was based on a large body of evidence even back to the 80’s alleviating this epical
obsession to nearly not existence 44-46
. Fluids permitted in the preoperative period does not
appear to impact children’s intra gastric volume or pH 28
even to overweight and obese
cases47
. Although increased gastric contents increase the risk of aspiration pneumonia, there
is no known gastric fluid volume that places a particular patient at clinically relevant risk or
eliminates all risk. There are numerous benefits when children ingest clear fluids at least 2
hours before anesthesia, including as discussed earlier: improved patient and parental
satisfaction, increased gastric pH, decreased risk of hypoglycemia, and improved
homeostasis. In the last guidelines from the European Society of Anaesthesiology 2011,
drinking carbohydrate-rich fluids before elective surgery found to improves subjective well-
being, reduces thirst and hunger and reduces postoperative insulin resistance (evidence level
1++, recommendation grade A) in their rational they mentioned the result of a placebo-
controlled randomized trial of 252 patients undergoing elective gastrointestinal surgery, it
was shown that the intake of carbohydrate-rich clear fluid until 2 h before the operation led to
less thirst, restlessness, weakness and concentration problems as compared to placebo 48-49
.
Additionally patients undergoing open colorectal surgery also had reduced postoperative
insulin resistance after preoperative oral carbohydrates, as well as reduced thirst and hunger
50.
However, duration of preoperative fasting must not be taken in account in managing
intraoperative fluid intakes. This has already been largely documented in adult patient.
Moreover, large body of evidences are now available in adult population favoring the rational
administration of perioperative fluid according to hemodynamic goals termed the “goal
directed therapy”. These strategies has been found to decrease both perioperative mortality
and morbidity. Such strategies might also produce same results in children and must be
considered as a priority for our future investigation. However, such a strategy that relies on
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optimizing cardiac output is actually facing many challenges especially considering the tools
to be used. Static parameters such as cardiac output of dynamic ones such as pulse pressure
variation necessitate a central venous access or arterial line are considered invasive for
routine use. Derived from studies performed in adult patients, non-invasive ultrasound
haemodynamic parameters have been recently validated in children. The first one, and the
most accurate, consists on peak aortic velocity 17-19
. More recently, reports have emphasized
the use of trans esophageal Doppler in monitoring stroke volume as a marker of fluid needs
during pediatric surgery 20-24
. However, these two techniques necessitate specific devices and
specialized training. Recently, the Plethysmogaphic Variability Index (PVI), a new totally
non-invasive, widely available and easy-to use dynamic parameter, has been validated for
guiding fluid administration and preload responsiveness in adult patients 4-6,25-27
. Pediatric
studies concerning PVI have found controversial results, with one study exhibiting a negative
result in a sample of infants and children and the other a positive result during intraoperative
cardiac surgery 17,28
. Consequently, more studies are mandatory to assess the accuracy of PVI
in the pediatric setting.
Our study suffers some limitations, first the bolus given after induction might be
insufficient to assess the responsiveness to the fluid bolus and assess the voleamic status of
patients. Second, our study did not compute an a priori sample to be included, while data
were taken from another study. Assuming an alpha risk of 5 % and a Beta risk of 20 %. and
given an observed response to fluid loading in 43 patients (when considering a response as 15
% in SVI), for patient with a duration of liquid preoperative fasting period of more than 3
hours; 788, 188 patients had to be included in a comparative study in order to found a
difference of incidence of responders of 10% or 20 %, respectively.
In conclusion, although respecting pre-operative fasting guide lines is important to
assure patient safety and optimal preparation especially in children by providing comfort and
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avoiding hunger stress, reducing risk of nausea and inhalation risk till normoglycemia and
having accessible intravascular access, in our series we did not find any hypovolemic effects
of preoperative fasting.
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TABLE 1
Ingested material Minimum fast (hr)
Clear liquids 2 Breast milk 4 Infant formula 6 Non-human milk 6
Light meal 6
Other meal >8
Table 1: Summary of Preoperative Fasting Recommendations according to an Updated Report
by ASA 51
TABLE 2:
DATA Median [min – max] or N (%)
Age (years) 4 [2 – 10]
Weight (Kg) 19.5 [11 – 45]
Duration of surgery (minutes) 125 [45 – 320]
Duration of liquid preoperative fasting (hours) 8 [2 – 12]
First hour fluid intake (ml.Kg-1) 31 [18 – 47]
Total operative fluid intake : - ml.Kg-1 - ml.Kg-1.h-1
51 [30 - 106] 21 [11 – 44]
Surgery Abdominal Surgery Orthopedic Surgery Urological Surgery
9 (17 %) 23 (42 %) 22 (41 %)
Table 2: Demographic description of the study population, fluid intakes and surgeries performed.
Data are expressed as median [min – max] or Percentage.
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Responders and Non-
responders Responders Non-responders
N =54 N=25 N=29
Before FC After FC
P
(before
Vs After
FC)
Before
FC After FC
P
(before
Vs After
FC)
Before
FC After FC
P
(before
Vs After
FC)
Temperature (°C) 36.5 [35.8-
37.5]
36.4[35.6-
37.4] <0.0001
36.4
[35.9-
37.1]
36.4 [35.6-
37.4] 0.012
36.5
[35.8-
37.5]
36.4
[35.6-
37.1]
<0.0001
Respiratory
frequency
(cycle/min)
17.5 [14-26] 17.5 [14-
26] 1
17 [14-
26] 17 [14-26] 1
18 [14-
26] 18 [14-26] 1
Peak Airway
Pressure (cmH2O) 16 [12-19] 16 [12-21] 0.5
16 [12-
19] 16 [12-21] 0.6
16 [12-
18] 15 [12-19] 0.56
Tidal volume
(ml/Kg) 9.4 [8 – 12]
9.5 [8 –
12] 0.63
9.4 [8 –
12]
9.4 [8 –
12] 0.73
9.5 [8 –
12]
9.5 [8 –
12] 0.5
Expiratory
Sevoflurane
concentration (%)
2.4 [1.9-2.8] 2.4 [2-2.8] 0.43 2.4
[1.9-
2.8]
2.4 [2-2.6] 0.8 2.4 [2-
2.8]
2.4 [2.1-
2.8] 0.22
Heart rate
(beat per minute)
109.5 [58-
142]
108 [62-
145] 0.9
110
[67-
134]
106 [66-
124] 0.22
109
[58-
142]
112 [62-
145] 0.9
Sa02 (%) 99 [98-100] 99 [98-
100] 0.24
99[98-
100] 99[98-100] 0.8
99 [98-
100]
99 [98-
100] 0.052
Mean Arterial
Pressure (mmHg)
62.7 [38.7-
82.7]
62.5 [47.3-
80.0] 0.005
62.7[42
.3-
82.7]
63.3[54.7-
80.0] 0.015
63
[38.7-
77.7]
61.7
[47.3-
78.3]
0.16
End-Tidal CO2
concentration
(mmHg)
33 [29-36] 33 [30-37] 0.22 33 [29-
35] 33 [31-37] 0.047
33 [29-
36] 33 [30-36] 0.67
Stroke volume
index (SVI : ml.m-
2)
27.5 [15-46] 33.5 [20-
51] <0.0001
25 [15-
41] 35 [28-50] <0.0001
29 [19-
46] 33 [20-51] <0.0001
Table 3: Temperature, Arterial Hemoglobin oxygen saturation (SaO2), expiratory sevoflurane
concentration (expressed as percentage), ventilatory and hemodynamic parameters before and after
fluid challenges (FC) in overall, responder and non-responder challenges, for the overall period of the
study. Data are expressed as median [min – max]. Comparisons of data were performed using paired
Student T test (N ≥ 30) or paired Wilcoxon signed-rank test (N < 30). Bonferronin correction for
multiple comparisons (6 per variable) decreased the threshold for significance to 0.008. Comparison
between parameters before and after fluid challenges are displayed as P; comparison of parameters
between responders and non-responders are displayed in bold and as *: p < 0.05, **: p < 0.01; ***: p <
0.001.
TABLE 3
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Abstract
Introduction: preoperative fasting is nowadays trending to be more liberal than ever, but still
today practice can be affected by several factors ending with trending results of over fasting
hours. Some of these consequences might be manifested as marked hypotensive or
hypovolemic state after anesthesia induction. The objective of the study was to investigate the
volemic state of a cohort of patients and try to correlate the magnitude of hypovolemia to the
duration of preoperative fasting. Our hypothesis is that this duration might cause fluid deficit
and contraction of intravascular space.
Method: This is a prospective single center observational study, patients aged 2-10 years
scheduled for non-cardiac surgery. Patients received one fluid challenge after anesthesia
induction (10 ml.kg-1
of normal saline solution infused over 15 minutes) according to a
standardized local guidelines, patients were classified as responders and non-responders, if
their indexed stroke volume (SVI) increased by more than 15% or 10 %. Statistical analysis
were performed using the Mann & Whetney test and the Pearson correlation. Data are
expressed as median [ranges].
Results: Fifty four patients were eligible for the study aged between 2-10 years, so a total of
54 fluid challenges were given. Considering a 15 % increase in SVI as a response to the fluid
challenge (duration of preoperative fasting 8 [3 – 12] hours versus 8 [2 – 12] hours, in
responders and non-responders, respectively; p = 0.937) neither when a 10 % increase in SVI
defined the response to fluid challenge (duration of preoperative fasting 8 [2 – 12] hours
versus 8 [2 – 12]hours, in responders and non-responders, respectively; p = 0.681). No
statistical correlation was found between duration of preoperative fasting and percentage
changes in SVI during fluid challenges (pearson correlation r = 0.13, p = 0.36)
Discussion: Our study suggests no effect of duration of preoperative fasting on volemic state
during induction of anesthesia in children aged 2 to 10 years. Study limitation could be :
(a) insufficient fluid challenge volume given to assess the responsiveness and assess the
volemic status of patients (b) the absence of a priori sample needed to reject the null
hypothesis.
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Résumé
Introduction: Le jeun préopératoire c’est relativement moins durci ces dernières années. Mais
reste en pratique de longue durée. Cela pourrait se traduire par une hypotension, conséquence
d’une hypovolémie à l’induction. L’objectif de cette étude était d’étudier la relation existante
entre durée du jeun préopératoire et statu volémique à l’induction.
Method: Après accord du comité d’éthique, des patients âgés de 2 à 10 ans programmés pour
une chirurgie non cardiaque ont été inclus. Les patients ont reçu un bolus de sérum
physiologique (10 ml.kg-1
en 15 minutes) et les patients ont été classés en répondeurs et non
répondeurs selon que le volume d’éjection systolique indexé (VESi) augmentait de 10 % ou
15 %. L’analyse statistique s’est faite par test non paramétrique de Mann et Whitney et par
corrélation linéaire de Pearson. Les données sont exprimées ne médiane [min – max].
Results: En considérant la réponse au remplissage comme positive quand à une augmentation
du VESi de 15 % ou 10 %, les durées de jeun préopératoire étaient similaires (8 [3 – 12]
heures versus 8 [2 – 12] heures; p = 0,937 et 8 [2 – 12] heures versus 8 [2 – 12] heures ; p =
0,36). Aucune corrélation significative n’était retrouvée en tre la durée du jeun et le
pourcentage de variation du VESi (r = 0,13, p = 0,36).
Discussion: Notre étude suggère que la durée du jeun préopératoire n’est pas un facteur
determinant le statu volémique des patients à l’induction de l’anesthésie chez l’enfant.
Toutefois, une limite à cette étude doit être soulignée : la quantité de liquide insuffisante
réalisée au cours de notre bolus post-induction pour déterminer les répondeurs et non
répondeurs.