Introduction

In early procedures, fasting policies included nothing per mouth from the night before the surgery. However, contemporary usage of fasting is changed and new fasting policies are in use. In Canada, solid food is not given in the operation day and clear fluid is given until 3 hours before operation (₁). In the United States, solid food is not restricted until 6 hours before the operation and clear fluid is permitted up to 2-3 hours before the operation (₁) In the United Kingdom, solid food is forbidden after midnight and clear fluid is allowed until 3 hours before surgery (₁).

Fasting policies were changed because of surgical stresses and healing mechanisms (₂,₃,₄,₅,₆). Anxiety and healing prolongation were these types of problems detected as preoperative and postoperative problems (₂). To solve this problem, fasting for clear fluids for both children and adults are shortened (₆). In a short time, preoperative 12.5% carbohydrate drink was added to these changes but showing the safety and gastric emptying time is insufficient for this beverage (₅). Nygren et al, showed that gastric emptying for both carbohydrate drink and water before surgery did not change after surgery (₅). However, clinical trials for this purpose in children are absent. Also, gastric content and gastric pH measurements are other criteria for this beverage's safety. In a study, patients undergoing elective surgery after an overnight fasting were evaluated for gastric content and gastric pH for the groups of 400 cc carbohydrate drink according to placebo and no differences were found (₃). Most of these studies were for adults and insufficient data was available for children. To our knowledge, evaluation the gastric properties of the children has not been reported yet. In this study, we aimed to evaluate the gastric acidity differences of the children during operations.

Material and Methods

After local ethical committee approval and written informed consents, 95 male children were operated for the inguinal or penile diseases in the pediatric surgery department. Patients who did not have metabolic, genetic and gastrointestinal diseases were included in the study. Then, patients were randomly divided into three groups before their operations. All of the groups were fasted for solids from 6 hours before the operations. Only, clear liquid fasting was different in three groups. In the first group, patients fasted for 3 hours before the operation (f group). In the second group, patients fasted for 2 hours before the operation but this group drank 2 ml/kg water (w group) just before the beginning of the liquid fasting. In the third group, patients fasted for 2 hours before the operations but these patients drank 2ml/kg nutrition beverage (n group) (12.5% carbohydrates, Nutricia Preop®, Nutricia Zoetermeer, The Netherlands) just before the beginning of the liquid fasting.

Sedation Procedure

Anesthesia Management

Gastric Acidity Evaluation

Statistics

Results

Forty-two patients were operated for circumcision, 35 patients for inguinal hernia, 2 patients for hypospadias, 6 patients for hydrocele and 8 patients were operated for undescended testis. Mean age of the patients was 53.23 (± 30.66) months. In f group, there were 39 patients. In w group, there were 28 patients and in n group there were 26 patients. No vomiting or aspiration was observed during anesthesia induction or before intubation. In the beginning of the study (pH0), mean pH of f group was 2.172±1.274, w group was 2.345±0.745 and n group was 2.278±1.131 respectively. Other mean values are demonstrated in Table 1. F and p values of between the periods were 2.383 and 0.058 respectively; F and p values between the study groups were 0.017 and 0.958 respectively.

Statistically, there was no significance between study groups and between periods (Table-1). The graphical distribution of the mean values between the groups and periods were shown in Table-2.

Figure 1

Table 1:Statistical analysis in the time periods and between the groups with Repeated Measures Two Way Analysis of Variances

Figure 2

Table 2: Graphical evaluation of the periodic measurements and their differences between the groups.

Discussion

Overnight fasting depletes glucose reserves and feeding was not normal the day after the operation (₇). Baseline of this problem was “Postoperative insulin resistance” which was first reported early 1970's (₈,₉,₁₀). Postoperative insulin resistance can be simply explained as diabetes like clinical changes in a healthy non-diabetic patient after uncomplicated elective surgery (₁₁). Consequently, several anesthetic institutions took the insulin resistance into the consideration seriously and tried to prevent patients from the thirst, anxiety, preoperative discomfort and hunger. Therefore, they decreased the fasting times in their preoperative fasting guidelines (₂, ₁₂,₁₃,₁₄,₁₅). Nevertheless, decreasing the fasting time was found to be inadequate to prevent the glucose intolerance and intake of clear fluids until 2 hours before the operations was suggested to be useful. Thus, beverage containing carbohydrate in 12.5% was investigated clinical trial models. Nygren et al investigated gastric emptying and found no difference between carbohydrate drink and water on a group of healthy volunteers (₅). In another study, Hausel et al evaluate the effect of carbohydrate solution on gastric volumes and gastric acidity (₂). Two hundred fifty two adults were evaluated in their study and no differences among the groups for gastric volume and gastric acidity were found (₂).

There are insufficient studies for the patients in the pediatric age group in the English literature. In our clinical trial, we aimed to evaluate clinical difference for gastric acidity with clear fluid. We detected pH values in nutrition beverage group 2.278±1.131 which was not significantly different from other groups. We suggest that using nutrition beverage group does not change gastric acidity which means that nutritional beverages can be used within safety. We also suggest in our study that beverage had more stabile pH than other groups. The stability of the gastric acidity may be safer than other groups but our study did not aimed to measure this entity. This result might be clearer if the number of patients and time of the gastric acidities' evaluation were more than we designed in our study.

In short, we can say that we need more data for new fasting policies and nutrition drinks procedures but it seems that modern preoperative fasting policies are more physiologic than past policies for fluids in the pediatric age group and these physiologic regulations are compatible with the nutrition beverages. In our pilot study we demonstrate that nutrition solutions may the acceptable procedure in routine for children and gastric acidity is stabile in beverage group. We thought that preferring beverages in the preoperative period is useful and effective.

Acknowledgement

Correspondence to

Yeşim ŞENAYLI, Gaziosmanpaşa Üniversitesi Tıp Fakültesi, 60100, Tokat, Türkiye Tel: +90 356 212 95 00/2190 Fax: +90 356 212 94 17 e-mail: ysenayli@e-kolay.net