Discussion
Previous studies have shown that paediatric patients who have undergone adenotonsillectomy/tonsillectomy can experience significant functional limitation and pain(5). Few studies have focused on the interaction between perioperative factors and functional limitations that occur post-tonsillectomy. Perioperative factors such as prolonged periods of fasting for all patients and especially children may result in dehydration and discomfort(6). In fact, many studies have shown that minimising fasting may enhance recovery in multiple types of surgeries(7,8). Shorter fasting guidelines have been advocated by the European, Canadian and American anaesthetic societies(9,10,11). With current fasting guidelines, there has been no increase in the incidence of aspiration(12).
The children in both groups of our study were similar in gender, age and weight. Fasting was prolonged in both groups, but fasting times for clear liquids were reduced in the group that had been given anaesthetic instructions by the anaesthetic team by almost 10 hours. The fasting times were unexpectedly prolonged in both groups. A major impetus for this project, was the need to quantify the duration of fasting.
The PPPM has been used as a measure of pain in paediatric populations and previous research has identified that a PPPM of >6 correlated with significant pain(13). Lower PPPM scores on the day of surgery were associated with the group that had fasting minimised. The difference was not seen in the following days after surgery and PPPM scores were similar in both groups. Causation cannot be established, but the results suggest that further investigation may be warranted. Other literature suggests that a possible mechanism may be the blunting of the catabolic response to surgical trauma may make patients less vulnerable to postoperative complications(15). Enhanced recovery after surgery protocols have emphasised the consumption of carbohydrate drinks 2 hours before surgery to retain anabolic homeostasis(16). These protocols are currently used in major head and neck surgery, colorectal surgery, breast reconstruction, total joint replacement and cardiac surgery(17,18,19). Carbohydrate loading has been shown to reduce insulin resistance in orthopaedic surgery(20,21). In total hip replacement some small studies have been shown to show positive effects on pain and nausea(22).
There were several limitations to this study. Firstly, the patient, parent/caregiver and the anaesthetist were not blinded to the administration of juice. Like any other non-blinded study, this trial also suffers from the same concerns of investigator(anaesthetist) bias. Complete blinding of the patient and anaesthetist would have been impossible due to the nature of the intervention and safety of the anaesthetic induction including appropriate pre-operative history taking by the anaesthetist.
The consultant anaesthetist performed the PPPM interview. This may have created a reporting bias. However, this was minimised by ensuring that all PPPM interviews abided to the specific questionnaire provided.
In addition, the PPPM is a 3rd party assessment of a subjective experience, and self-report is the ideal measure of post-operative pain. However, since parents and caregivers are the advocates for the patients in hospital and they control administration of pain medication to their children at home, it remains especially important that they accurately assess their children’s pain. Other limitations include the fact that our study was limited to tonsillectomies(+/-adenoidectomy)without prolonged hospitalisations. The findings may not translate to other types or surgeries and patient populations.
Knowledge translation of current evidence is needed to reduce fasting times in children undergoing surgical procedures. The effort to minimise unnecessary preoperative fasting in paediatric anaesthesia is in evolution. This project showed that there may be improved return to normal activity for patients following tonsillectomy with closer adherence to international guidelines of fasting. Study results revealed inconsistencies between practice and guideline recommendations, as well as opportunities for improvement to minimise fasting in paediatric patients prior to surgery.
Data availability statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.