Preoperative FastingPharmacologic Agents.docx
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Preoperative FastingPharmacologic Agents.docx
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PreoperativeFastingPharmacologicAgents
PracticeGuidelinesforPreoperativeFastingandtheUseofPharmacologicAgentstoReducetheRiskofPulmonaryAspiration:
ApplicationtoHealthyPatientsUndergoingElectiveProcedures
AnUpdatedReportbytheAmericanSocietyofAnesthesiologistsCommitteeonStandardsandPracticeParameters
PRACTICEGuidelinesaresystematicallydevelopedrecommendationsthatassistthepractitionerandpatientinmakingdecisionsabouthealthcare.Theserecommendationsmaybeadopted,modified,orrejectedaccordingtoclinicalneedsandconstraintsandarenotintendedtoreplacelocalinstitutionalpolicies.Inaddition,PracticeGuidelinesdevelopedbytheAmericanSocietyofAnesthesiologists(ASA)arenotintendedasstandardsorabsoluterequirements,andtheirusecannotguaranteeanyspecificoutcome.PracticeGuidelinesaresubjecttorevisionaswarrantedbyheevolutionofmedicalknowledge,technology,andpractice.Theyprovidebasicrecommendationsthataresupportedbyasynthesisandanalysisofthecurrentliterature,expertandpractitioneropinion,openforumcommentary,andclinicalfeasibilitydata.
ThisupdateincludesdatapublishedsincethePracticeGuidelinesforPreoperativeFastingandtheUseofPharmacologicAgentstoReducetheRiskofPulmonaryAspirationwereadoptedbytheASAin1998andpublishedin1999.*
Methodology
DefinitionofPreoperativeFastingandPulmonaryAspiration
FortheseGuidelines,preoperativefastingisdefinedasaprescribedperiodoftimebeforeaprocedurewhenpatientsarenotallowedtheoralintakeofliquidsorsolids.Perioperativepulmonaryaspirationisdefinedasaspirationofgastriccontentsoccurringafterinductionofanesthesia,duringaprocedure,orintheimmediateperiodaftersurgery.
PurposesoftheGuidelines
ThepurposesoftheseGuidelinesareto
(1)enhancethequalityandefficiencyofanesthesiacare,
(2)stimulateevaluationofclinicalpractices,and(3)reducetheseverityofcomplicationsrelatedtoperioperativepulmonaryaspirationofgastriccontents.
Enhancementsinthequalityandefficiencyofanesthesiacareinclude,butarenotlimitedto,thecost-effectiveuseofperioperativepreventivemedication,increasedpatientsatisfaction,avoidanceofdelaysandcancellations,decreasedriskofdehydrationorhypoglycemiafromprolongedfasting,andtheminimizationofperioperativemorbidity.
Clinicalpracticesinclude,butarenotlimitedto,withholdingsolidsandliquidsforspecifiedtimeperiodsbeforesurgery,andprescribingpharmacologicagentstoreducegastricvolumeandacidity.
Complicationsofaspirationinclude,butarenotlimitedto,aspirationpneumonia,respiratorydisabilities,andrelatedmorbidities.
Focus
TheseGuidelinesfocusonpreoperativefastingrecommendations,aswellasrecommendationsregardingtheadministrationofpharmacologicagentstomodifythevolumeandacidityofgastriccontentsduringproceduresinwhichupperairwayprotectivereflexesmaybeimpaired.Preventionofperioperativepulmonaryaspirationispartofthelargerprocessofpreoperativeevaluationandpreparationofthepatient.
AirwaymanagementtechniquesthatareintendedtoreducetheoccurrenceofpulmonaryaspirationarenotthefocusoftheseGuidelines.Forexample,arapid-sequenceinduction/trachealintubationtechniqueoranawaketrachealintubationtechniquemaybeusefultopreventthisproblemduringthedeliveryofanesthesiacare.Inaddition,theseGuidelinesdonotaddresstheselectionofanesthetictechnique.
TheintendedpatientpopulationfortheseGuidelinesislimitedtohealthypatientsofallagesundergoingelectiveprocedures.TheseGuidelinesdonotapplytopatientswhoundergoprocedureswithnoanesthesiaoronlylocalanesthesiawhenupperairwayprotectivereflexesarenotimpaired,andwhennoriskfactorsforpulmonaryaspirationareapparent.TheseGuidelinesarealsonotintendedforwomeninlabor.
TheseGuidelinesmaynotapplyto,ormayneedtobemodifiedfor
(1)patientswithcoexistingdiseasesorconditionsthatcanaffectgastricemptyingorfluidvolume(e.g.,pregnancy,obesity,diabetes,hiatalhernia,gastroesophagealrefluxdisease,ileusorbowelobstruction,emergencycare,enteraltubefeeding)and
(2)patientsinwhomairwaymanagementmightbedifficult.Anesthesiologistsandotheranesthesiaprovidersshouldrecognizethattheseconditionscanincreasethelikelihoodofregurgitationandpulmonaryaspiration.Additionaloralternativepreventivestrategiesmaybeappropriateforsuchpatients.
Application
TheseGuidelinesareintendedforusebyanesthesiologistsandotheranesthesiaproviders.Theyalsomayserveasaresourceforotherhealthcareprofessionalswhoadviseorcareforpatientswhoreceiveanesthesiacareduringprocedures.Anesthesiacareduringproceduresreferstogeneralanesthesia,regionalanesthesia,orsedation/analgesia(i.e.,monitoredanesthesiacare).ThroughouttheseGuidelines,preoperativeshouldbeconsideredsynonymouswithpreprocedural,asthelattertermisoftenusedtodescribeproceduresthatarenotconsideredoperations.
TaskForceMembersandConsultants
TheoriginalGuidelinesweredevelopedbyaTaskForceof10members,includinganesthesiologistsinbothprivateandacademicpracticefromvariousgeographicareasofNorthAmerica,andaconsultingmethodologistfromtheASACommitteeonStandardsandPracticeParameters.
TheTaskForcedevelopedtheoriginalGuidelinesbymeansofasix-stepprocess.First,theyreachedconsensusonthecriteriaforevidence.Second,originalpublishedresearchstudiesfrompeer-reviewedjournalsrelevanttopreoperativefastingwerereviewedandevaluated.Third,expertconsultantswereasked
(1)toparticipateinopinionsurveysontheeffectivenessofvariouspreoperativefastingmanagementrecommendationsand
(2)toreviewandcommentonadraftoftheGuidelines.Fourth,theTaskForceheldopenforumsatanationalmeetingtosolicitinputonthedraftrecommendations.Fifth,expertconsultantsweresurveyedtoassesstheiropinionsonthefeasibilityofimplementingtheGuidelines.Sixth,allavailableinformationwasusedtobuildconsensuswithintheTaskForcetofinalizetheGuidelinerecommendations(appendix1).
In2009,theASACommitteeonStandardsandPracticeParametersrequestedthatscientificevidencefortheseGuidelinesbeupdated.ThisupdateconsistsofanevaluationofliteraturethatincludesnewstudiesobtainedafterpublicationoftheoriginalGuidelines,newsurveysofexpertconsultants,andasurveyofarandomlyselectedsampleofactiveASAmembers.
AvailabilityandStrengthofEvidence
PreparationofthisupdateusedthesamemethodologicprocessaswasusedintheoriginalGuidelinestoobtainnewevidencefromtwoprincipalsources:
scientificevidenceandopinion-basedevidence(appendix2).Theprotocolforreportingeachsourceofevidenceisdescribedbelow.
ScientificEvidence
Studyfindingsfrompublishedscientificliteraturewereaggregatedandarereportedinsummaryformbyevidencecategory,asdescribedbelow.Allliterature(e.g.,randomizedcontrolledtrials,observationalstudies,casereports)relevanttoeachtopicwasconsideredwhenevaluatingthefindings.However,forreportingpurposesinthisdocument,onlythehighestlevelofevidence(i.e.,level1,2,or3withincategoryA,B,orC)isincludedinthesummary.
CategoryA:
SupportiveLiterature
Randomizedcontrolledtrialsreportstatisticallysignificant(P<0.01)differencesbetweenclinicalinterventionsforaspecifiedclinicaloutcome.
Level1.Theliteraturecontainsmultiplerandomizedcontrolledtrials.Aggregatedfindingsaresupportedbymeta-analysis.‡
Level2.Theliteraturecontainsmultiplerandomizedcontrolledtrials,butthereisaninsufficientnumberofstudiestoconductaviablemeta-analysisforthepurposeoftheseGuidelines.
Level3.Theliteraturecontainsasinglerandomizedcontrolledtrial.
CategoryB:
SuggestiveLiterature
Informationfromobservationalstudiespermitsinferenceofbeneficialorharmfulrelationshipsamongclinicalinterventionsandclinicaloutcomes.
Level1.Theliteraturecontainsobservationalcomparisons(e.g.,cohort,case-controlresearchdesigns)ofclinicalinterventionsorconditionsandindicatesstatisticallysignificantdifferencesbetweenclinicalinterventionsforaspecifiedclinicaloutcome.
Level2.Theliteraturecontainsnoncomparativeobservationalstudieswithassociative(e.g.,relativerisk,correlation)ordescriptivestatistics.
Level3.Theliteraturecontainscasereports.
CategoryC:
EquivocalLiterature
Theliteraturecannotdeterminewhethertherearebeneficialorharmfulrelationshipsamongclinicalinterventionsandclinicaloutcomes.
Level1.Meta-analysisdidnotfindsignificantdifferencesamonggroupsorconditions.
Level2.Thenumberofstudiesisinsufficienttoconductmeta-analysis,and
(1)randomizedcontrolledtrialshavenotfoundsignificantdifferencesamonggroupsorconditions,or
(2)randomizedcontrolledtrialsreportinconsistentfindings.
Level3.Observationalstudiesreportinconsistentfindingsordonotpermitinferenceofbeneficialorharmfulrelationships.
CategoryD:
InsufficientEvidencefromLiterature
Thelackofscientificevidenceintheliteratureisdescribedusingthetermsdefinedbelow.
Silent.Noidentifiedstudiesaddressthespecifiedrelationshipsamonginterventionsandoutcomes.
Inadequate.Theavailableliteraturecannotbeusedtoassessrelationshipsamongclinicalinterventionsandclinicaloutcomes.Theliteratureeitherdoesnotmeetthecriteriaforcontentasdefinedinthe“Focus”oftheGuidelinesordoesnotpermitaclearinterpretationoffindingsdue
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