ALATTASPreoperative Fasting & iSV Induction Final2 …medias.desar.org/Memoires-Theses/Memoires/2013/c... · Coordonnateur : Monsieur le Professeur Didier Journois Par Ahmad M. ALATTAS

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Professeur Souhayl DAHMANIChef de Service

HOPITAL ROBERT DEBREService Anesthésie-Réanimation

48, Bd Sérurier – 75935 PARIS CEDEX 19Secrétariat

Tél. : 01 40 03 22 68

Professeur Souhayl DAHMANIChef de Service

HOPITAL ROBERT DEBREService Anesthésie-Réanimation

48, Bd Sérurier – 75935 PARIS CEDEX 19Secrétariat

Tél. : 01 40 03 22 68

UNIVERSITE PIERRE ET MARIE CURIE (PARIS VIe)

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 statut volémique à l’induction chez l’enfant

Travail effectué sous la direction du Professeur Souhayl Dahmani


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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


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25-26. A Doppler probe is placed in the esophagus, and blood flow velocity profile is measured

3in the descending aorta. The blood flow velocity is integrated over time and multiplied by

aortic cross-sectional area (calculated from normograms) 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.


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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).


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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.

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).


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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

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


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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

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 correlation = 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

normograms 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 51

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 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 %)


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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 anaesthesia 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 centre observational study; patients aged 2-10 years scheduled for non-cardiac surgery. Patients received one fluid challenge after anaesthesia 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 analyses 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 anaesthesia 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: Les règles du jeun préopératoire chez l’enfant se sont allégées ces dernières années mais restent en pratique de longues durées. Cela pourrait se traduire par une hypotension, conséquence d’une hypovolémie, tout particulièrement à l’induction de l’anesthésie. L’objectif de ce travail était d’étudier la relation existante entre durée du jeun préopératoire et statut volémique à l’induction chez l’enfant.

Méthodes: 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 ont été classés en répondeurs et non répondeurs selon que le volume d’éjection systolique indexé (VESi) augmentait de 10 % ou 15 % (répondeurs) ou non (non-répondeurs). L’analyse statistique s’est faite par test non paramétrique de Mann et Whitney et par corrélation linéaire de Pearson. Les données sont exprimées en médiane [minimum – maximum].

Résultats: En considérant la réponse au remplissage comme positive pour 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 pour une augmentation du VESi de 15 % et 8 [2 – 12] heures versus 8 [2 – 12] heures ; p = 0,36 pour une augmentation du VESi de 10%. Aucune corrélation significative n’était retrouvée entre 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 déterminant le statu volémique à l’induction de l’anesthésie chez l’enfant. Toutefois, deux limites à cette étude doit être soulignées : (a) la quantité de liquide insuffisante administrée au cours de notre épreuve de remplissage pour déterminer les répondeurs et non répondeurs (b) l’absence de calcul d’effectifs à priori qui pourrait être à l’origine d’une manque de puissance de notre étude.

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ALATTASPreoperative Fasting & iSV Induction Final2 …medias.desar.org/Memoires-Theses/Memoires/2013/c... · Coordonnateur : Monsieur le Professeur Didier Journois Par Ahmad M. ALATTAS