Reviewing "Nil Per Os" Guidance for Clear Fluids in Children Before Anesthesia: Survey of the Pediatric Anesthesia Leadership Council.

Background: Several international pediatric anesthesia societies have endorsed a change in the traditional nil per os (NPO) cutoff of clear fluids (CF) from 2 hours to 1 hour. These recommendations were compiled from large-scale outcomes, gastric ultrasound, and quality improvement studies. The American Society of Anesthesiologists (ASA) recently published their updated guidelines. Despite the lack of prospective randomized studies with conclusive outcomes, several major children's health systems in North America have already implemented or are modifying their institutional guidelines for CF. The objectives of this survey were to evaluate the current practices, changing trends, perceived benefits, and barriers in reducing the NPO times for CF in children presenting for anesthesia.

Methods: After approval from the Penn State University Institutional Review Board, an electronic survey of the Pediatric Anesthesia Leadership Council (PALC, consortium of Pediatric Anesthesiology Chairs and Division Chiefs across the United States) members was conducted by the Society for Pediatric Anesthesia Quality and Safety Committee (SPA-QS) NPO Clears Task Force between June 2023 and October 2023. Inclusion criteria were PALC membership and single response from each institution.

Results: A total of 88 member institutions were represented by the PALC group. The final response rate was 75 of 88 (85.2%) from across 33 states. Eighty-eight percent of the respondents belonged to a tertiary pediatric center, and 94.7% belonged to an academic setting. At the time of the survey, 8 out of 75 (10.6%) responding institutions followed 1-hour CF cutoff, 7 (9.3%) were in the process of changing to 1-hour and 60 (80%) followed a 2-hour cutoff. 55(73%) respondents actively encouraged CF up to the time they had to be NPO. 46.7% of the respondents reported significant issues (hypoglycemia, dehydration, difficulty in establishing intravenous access, patient and parental dissatisfaction) with prolonged fasting in children. The survey responses included multiple comments in favor of changing guidelines to 1 hour for CF in healthy young children. The overarching concern for implementation of 1-hour cutoff for CF was the potential medicolegal ramification of a policy change in the absence of an official statement from national professional societies.

Conclusions: The survey demonstrates growing trends toward implementing the reduced NPO time for CF to 1 hour nationally. Based on the current ASA guidelines, the SPA-QS committee recommends close attention to NPO times and strongly encourages CF consumption up to the recommended cutoff time. It appears reasonable to follow a 1-hour cutoff for CF as deemed appropriate by the attending anesthesiologist or the institution.