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Planned Peri-Extubation Fasting in Critically Ill Children: An International Survey of Practice
Tomasz Nabialek1, Lyvonne N Tume2, Eloise Cercueil3
1Pediatric Intensive Care, Royal Children's Hospital, Melbourne, VIC, Australia.
Insights
Pediatric intensive care units (PICUs) show varied fasting practices around extubation, with no clear evidence guiding duration. Shorter fasting times may be safe, but awareness of gastric ultrasound is low.
Area of Science:
- Pediatric critical care medicine
- Clinical nutrition
- Gastroenterology
Background:
- Cumulative energy/protein deficit in pediatric intensive care units (PICUs) is linked to poorer outcomes.
- Enteral nutrition is preferred, but feeding interruptions, especially peri-extubation fasting, can compromise delivery.
- Current evidence to guide peri-extubation fasting duration in PICU is lacking.
Purpose of the Study:
- To investigate current pediatric intensive care unit (PICU) fasting practices around extubation.
- To explore the rationales behind these varied fasting protocols.
Main Methods:
- A cross-sectional electronic survey was distributed to the European Pediatric Intensive Care Society (ESPNIC) membership.
- Experienced clinicians (nurses, dietitians, doctors) described their unit's fasting practices before and after extubation.
Main Results:
- Responses from 122 PICUs internationally revealed significant variability in fasting durations, often based on anesthesia guidelines.
- Practices ranged from no fasting in low-risk patients to withholding feeding for all.
- Fasting post-extubation also varied, with many units withholding oral or gastric/jejunal nutrition for over 5 hours; 37% initiated oral feeding based on patient demand.
Conclusions:
- The wide variation in practices suggests that shorter fasting times may be safe.
- Reducing unnecessary fasting and accelerating extubation could be aided by methods like gastric point-of-care ultrasonography (POCUS).
- Awareness and utilization of POCUS for assessing gastric emptiness remain low among surveyed PICUs.
Introduction:
Cumulative energy/protein deficit is associated with impaired outcomes in pediatric intensive care Units (PICU). Enteral nutrition is the preferred mode, but its delivery may be compromised by periods of feeding interruptions around procedures, with peri-extubation fasting the most common procedure. Currently, there is no evidence to guide the duration of the peri-extubation fasting in PICU. Therefore, we aimed to explore current PICU fasting practices around the time of extubation and the rationales supporting them.
Materials And Methods:
A cross sectional electronic survey was disseminated via the European Pediatric Intensive Care Society (ESPNIC) membership. Experienced senior nurses, dieticians or doctors were invited to complete the survey on behalf of their unit, and to describe their practice on PICU fasting prior to and after extubation.
Results:
We received responses from 122 PICUs internationally, mostly from Europe. The survey confirmed that fasting practices are often extrapolated from guidelines for fasting prior to elective anesthesia. However, there were striking differences in the duration of fasting times, with some units not fasting at all (in patients considered to be low risk), while others withheld feeding for all patients. Fasting following extubation also showed large variations in practice: 46 (38%) and 26 (21%) of PICUs withheld oral and gastric/jejunal nutrition more than 5 h, respectively, and 45 (37%) started oral feeding based on child demand. The risk of vomiting/aspiration and reducing nutritional deficit were the main reasons for fasting children [78 (64%)] or reducing fasting times [57 (47%)] respectively.
Discussion:
This variability in practices suggests that shorter fasting times might be safe. Shortening the duration of unnecessary fasting, as well as accelerating the extubation process could potentially be achieved by using other methods of assessing gastric emptiness, such as gastric point of care ultrasonography (POCUS). Yet only half of the units were aware of this technique, and very few used it.
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