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.