COMMENTS
Implementation of a preoperative fasting abbreviation protocol in a tertiary pediatric center
Adriana S. Gandolfo, Priscilla F.N. Cardoso, Izabel M. Buscatti, Manoel Carlos P. Velhote, Maria Aparecida C. Bonfim, Alberto C. Helito
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Instituto da Crianca e do Adolescente, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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(D) Hazard ratio heat map of overall survival and (E) disease-free survival considering each cancer individually. Statistically significant results (Mantel-Cox test) are highlighted with blue (downregulated) or red (upregulated) borders. *<span class="elsevierStyleItalic">p</span><0.05; HR=hazard ratio</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Gabriel Arantes dos Santos, Sabrina T. Reis, Katia Ramos Moreira Leite, Miguel Srougi" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Gabriel Arantes dos" "apellidos" => "Santos" ] 1 => array:2 [ "nombre" => "Sabrina T." "apellidos" => "Reis" ] 2 => array:2 [ "nombre" => "Katia Ramos Moreira" "apellidos" => "Leite" ] 3 => array:2 [ "nombre" => "Miguel" "apellidos" => "Srougi" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1807593222002022?idApp=UINPBA00004N" "url" => "/18075932/000000760000000C/v1_202211191031/S1807593222002022/v1_202211191031/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S1807593222002009" "issn" => "18075932" "doi" => "10.6061/clinics/2021/e2991" "estado" => "S300" "fechaPublicacion" => "2021-01-01" "aid" => "200" "copyright" => "CLINICS" "documento" => "simple-article" "crossmark" => 0 "licencia" => "https://creativecommons.org/licenses/by/4.0/" "subdocumento" => "dis" "cita" => "Clinics. 2021;76C:" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:8 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">COMMENTS</span>" "titulo" => "Comments: The need to standardize use of the newly deceased in medical trainings" "tienePdf" => "en" "tieneTextoCompleto" => "en" "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Seyed Ali Enjoo" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Seyed Ali" "apellidos" => "Enjoo" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1807593222002009?idApp=UINPBA00004N" "url" => "/18075932/000000760000000C/v1_202211191031/S1807593222002009/v1_202211191031/en/main.assets" ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">COMMENTS</span>" "titulo" => "Implementation of a preoperative fasting abbreviation protocol in a tertiary pediatric center" "tieneTextoCompleto" => true "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Adriana S. Gandolfo, Priscilla F.N. Cardoso, Izabel M. Buscatti, Manoel Carlos P. Velhote, Maria Aparecida C. Bonfim, Alberto C. Helito" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Adriana S." "apellidos" => "Gandolfo" ] 1 => array:2 [ "nombre" => "Priscilla F.N." "apellidos" => "Cardoso" ] 2 => array:2 [ "nombre" => "Izabel M." "apellidos" => "Buscatti" ] 3 => array:2 [ "nombre" => "Manoel Carlos P." "apellidos" => "Velhote" ] 4 => array:2 [ "nombre" => "Maria Aparecida C." "apellidos" => "Bonfim" ] 5 => array:4 [ "nombre" => "Alberto C." "apellidos" => "Helito" "email" => array:1 [ 0 => "alberto.helito@hc.fm.usp.br" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor1" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Instituto da Crianca e do Adolescente, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR" "identificador" => "aff1" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor1" "etiqueta" => "*" "correspondencia" => "Corresponding author." ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="para10" class="elsevierStylePara elsevierViewall">Over the past two decades, the concept of preoperative fasting for pediatric patients undergoing elective surgery has been reviewed by the scientific medical community. The European Society of Anesthesiology and American Society of Anesthesiology announced a minimum of 2h of preoperative fasting time for children and adolescents and the ingestion of only clear fluids within 2h prior to procedural anesthesia (<a class="elsevierStyleCrossRef" href="#bib1">1</a>,<a class="elsevierStyleCrossRef" href="#bib2">2</a>).</p><p id="para20" class="elsevierStylePara elsevierViewall">We currently know that more than 4h of fasting may lead to unfavorable metabolic and inflammatory effects, such as increased insulin resistance, hunger, and thirst, in the pediatric population and can negatively impact a child's mental well-being. These aspects result in worse response to surgical trauma, which may lead to negative outcomes in terms of postoperative morbidity, length of hospitalization, and complications (<a class="elsevierStyleCrossRef" href="#bib2">2</a>).</p><p id="para30" class="elsevierStylePara elsevierViewall">A prospective, multicenter, randomized study that evaluated 1200 children found that blood glucose levels at the time of anesthesia were significantly higher in all groups that received up to 15 ml/kg of a 10% carbohydrate solution 2h before anesthesia compared with the 6 h preoperative fasting group (control group). Other relevant findings included no residual gastric volume in the groups receiving oral glucose administration up to 10 ml/kg and a significantly higher crying ratio in the control group than in the other three groups (<a class="elsevierStyleCrossRef" href="#bib3">3</a>). Aguilar-Nascimento et al. reported better metabolic and inflammatory responses by reducing the preoperative fasting time in preschool children up to 2h (<a class="elsevierStyleCrossRef" href="#bib4">4</a>).</p><p id="para40" class="elsevierStylePara elsevierViewall">Furthermore, in a multicenter study that enrolled over 30,000 children in Europe, pulmonary aspiration was observed in only 0.1% of the patients and was not associated with an increase in morbidity and mortality in this population (<a class="elsevierStyleCrossRef" href="#bib5">5</a>).</p><p id="para50" class="elsevierStylePara elsevierViewall">Recently, a new proposal advocating the reduction of fasting time for clear fluids from 2h to 1h was introduced (<a class="elsevierStyleCrossRef" href="#bib6">6</a>,<a class="elsevierStyleCrossRef" href="#bib7">7</a>). Previous studies have shown promising results in shortening the clear fluid-fasting regimen in children. Indeed, there was no increase in the incidence of bronchial aspiration and no difference between gastric residual volumes when the clear fluid fasting time was 1h or 2h. Moreover, changing the fasting period from 2h to 1h reduced the median clear fluid fasting period from 4h to 1h and raised the number of children subjected to fasting times less than 4h by up to 72% (<a class="elsevierStyleCrossRefs" href="#bib8">8-13</a>).</p><p id="para60" class="elsevierStylePara elsevierViewall">At our institution, an analysis of fasting time indicators showed that almost half of the day hospital surgical patients had a fasting time longer than 12h. Apprehension towards surgery suspension by caregivers and the fear of clinical complications by health teams may be potential reasons for this finding. Based on this, we proposed the adoption of an institutional protocol for preoperative fasting abbreviations. The main objective of the protocol was awareness among health teams, patients, and caregivers about the safety and benefits of shortening the fasting period that children and adolescents were subjected to before elective surgery.</p><p id="para70" class="elsevierStylePara elsevierViewall">A committee of professionals was created, including medical teams, nurses, and nutritionists from the Pediatric Day Hospital Unit, Pediatric Surgery Unit, and Anesthesiology Unit. The protocol was as follows: <span class="elsevierStyleBold">1.</span> clear liquids were prescribed in the hospital up to 2h before elective surgery, with respect to the exclusion criteria (<a class="elsevierStyleCrossRef" href="#tbl1">Table 1</a>); <span class="elsevierStyleBold">2.</span> caregivers were provided an orientation about the possibility of offering different kinds of food on the same day of the procedure, respecting safe intervals, such as light meals up to 8h prior to hospital arrival, formula up to 6h prior to hospital arrival, breast milk up to 4h prior to hospital arrival, and clear liquids (gelatin and coconut water) up to 2h prior to hospital arrival; and <span class="elsevierStyleBold">3.</span> sending text messages for guidance, the day before the procedure. Since 2016, the committee has periodically audited the protocol based on current indicators and recent literature.</p><elsevierMultimedia ident="tbl1"></elsevierMultimedia><p id="para80" class="elsevierStylePara elsevierViewall">The protocol was implemented in July 2016. The first departments that adopted the protocol were the Pediatric Day Hospital Unit and Pediatric Surgery Unit. Then, it was adopted by all units of the Children and Adolescents' Institute, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), and by other institutes in our tertiary hospital complex. After protocol implementation, there was a statistically significant reduction in preoperative fasting time: >6h (256 [94.1%] patients before protocol <span class="elsevierStyleItalic">versus</span> 473 [60.8%] after protocol); >10h (194 [71.3%] patients before protocol <span class="elsevierStyleItalic">versus</span> 233 [29.9%] after protocol); and >12h (129 [47.4%] patients before protocol <span class="elsevierStyleItalic">versus</span> 111 [14.3%] after protocol) (<span class="elsevierStyleItalic">p</span><0.001 for all), without the occurrence of adverse events, such as bronchopulmonary aspiration with clinical repercussion and/or related morbidities or even suspension of surgeries. Indeed, at the Pediatric Day Hospital Unit, there were fewer episodes of symptomatic hypoglycemia, dehydration, and the need for a venous line for treatment. The standard procedure for general anesthesia in children in our hospital is inhalation induction. Venous puncture prior to operatory room arrival is unusual and may cause discomfort to patients or caregivers. <a class="elsevierStyleCrossRef" href="#tbl2">Table 2</a> compares the fasting time and venous puncture indicators before and after protocol implementation.</p><elsevierMultimedia ident="tbl2"></elsevierMultimedia><p id="para90" class="elsevierStylePara elsevierViewall">The presented data confirm the importance and beneficial impact of the fasting time abbreviation protocol in pediatric healthcare. As a result of the shorted fasting periods, feelings of anxiety, fear, pain, sadness, hunger, thirst, discomfort, and malaise were minimized. They also favor faster post-surgical recuperation.</p><p id="para100" class="elsevierStylePara elsevierViewall">As the protocol continues to evolve, the committee continuously seeks areas for improvement. Our next step would be shortening the clear liquid fasting period to 1h, in accordance with the latest scientific trends (<a class="elsevierStyleCrossRef" href="#bib6">6</a>,<a class="elsevierStyleCrossRef" href="#bib7">7</a>,<a class="elsevierStyleCrossRef" href="#bib13">13</a>).</p><p id="para110" class="elsevierStylePara elsevierViewall">Thus, this protocol provides better patient outcomes and the opportunity for shared decision-making with patients and caregivers at our health facility.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:1 [ "nota" => "<p class="elsevierStyleNotepara" id="cenpara10">No potential conflict of interest was reported.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "tbl1" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients undergoing pharmacological treatment for gastroesophageal reflux disease (or previous treatment in the last 12 months) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients using drugs that delay gastric emptying (cyclosporine, opioids, amitriptyline, calcium channel blockers, octreotide, chlorpromazine, and promethazine) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients with neurological diseases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients diagnosed with peritonitis, intestinal obstruction, diabetes, severe obesity, significant gastrointestinal bleeding, or pregnancy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients in maintenance fluid therapy or parenteral nutrition \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients on peritoneal dialysis or chronic hemodialysis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients preparing for a positron emission tomography and computed tomography scan \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spara10" class="elsevierStyleSimplePara elsevierViewall">Exclusion criteria for clear liquid prescription after hospital admission.</p>" ] ] 1 => array:7 [ "identificador" => "tbl2" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spara30" class="elsevierStyleSimplePara elsevierViewall">Results are presented as median (minimum value-maximum value) or numbers (%). Data were compared using a Mann-Whitney test and chi-squared test.</p>" "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variables, n=1050 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Before protocol (n=272) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">After protocol (n=778) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-value \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Demographic data \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Age, months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">46.8 (0-235) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">58.5 (1-273) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.027 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Male sex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">201 (73.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">550 (70.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.352 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Comorbidities \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">101 (37.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">357 (45.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.015 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Preoperative fasting time \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>>6 hours \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">256 (94.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">473 (60.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>>10 hours \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">194 (71.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">233 (29.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>>12 hours \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">129 (47.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">111 (14.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Venous punction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">41 (15.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 (1.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spara20" class="elsevierStyleSimplePara elsevierViewall">Demographic data, preoperative fasting time, and the need for a venous line before elective surgery for Pediatric Day Hospital Unit patients.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "REFERENCES" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "cebibsec10" "bibliografiaReferencia" => array:13 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => """ I Smith \n \t\t\t\t\t\t\t\t """ 1 => """ P Kranke \n \t\t\t\t\t\t\t\t """ 2 => """ I Murat \n \t\t\t\t\t\t\t\t """ 3 => """ A Smith \n 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Are you thirsty? - Fasting times in elective outpatient pediatric patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => """ T Engelhardt \n \t\t\t\t\t\t\t\t """ 1 => """ G Wilson \n \t\t\t\t\t\t\t\t """ 2 => """ L Horne \n \t\t\t\t\t\t\t\t """ 3 => """ M Weiss \n \t\t\t\t\t\t\t\t """ 4 => """ A Schmitz \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:2 [ 0 => array:2 [ "doi" => "10.1111/j.1460-9592.2011.03573.x" "Revista" => array:7 [ "tituloSerie" => "Paediatr Anaesth" "fecha" => "2011" "volumen" => "21" "numero" => "9" "paginaInicial" => "964" "paginaFinal" => "968" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21489044" "web" => "Medline" ] ] ] ] 1 => array:2 [ "doi" => "10.1111/j.1460-9592.2011.03573.x" "WWW" => array:1 [ "link" => "https://doi.org/10.1111/j.1460-9592.2011.03573.x" ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib12" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Low incidence of pulmonary aspiration in children allowed intake of clear fluids until called to the operating suite" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => """ H Andersson \n \t\t\t\t\t\t\t\t """ 1 => """ B Zarén \n \t\t\t\t\t\t\t\t """ 2 => """ P Frykholm \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:2 [ 0 => array:2 [ "doi" => "10.1111/pan.12667" "Revista" => array:7 [ "tituloSerie" => "Paediatr Anaesth" "fecha" => "2015" "volumen" => "25" "numero" => "8" "paginaInicial" => "770" "paginaFinal" => "777" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25940831" "web" => "Medline" ] ] ] ] 1 => array:2 [ "doi" => "10.1111/pan.12667" "WWW" => array:1 [ "link" => "https://doi.org/10.1111/pan.12667" ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib13" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Preoperative fasting guidelines in pediatric anesthesia: are we ready for a change?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => """ H Andersson \n \t\t\t\t\t\t\t\t """ 1 => """ A Schmitz \n \t\t\t\t\t\t\t\t """ 2 => """ P Frykholm \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:2 [ 0 => array:2 [ "doi" => "10.1097/ACO.0000000000000582" "Revista" => array:7 [ "tituloSerie" => "Curr Opin Anaesthesiol" "fecha" => "2018" "volumen" => "31" "numero" => "3" "paginaInicial" => "342" "paginaFinal" => "348" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29443724" "web" => "Medline" ] ] ] ] 1 => array:2 [ "doi" => "10.1097/ACO.0000000000000582" "WWW" => array:1 [ "link" => "https://doi.org/10.1097/ACO.0000000000000582" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/18075932/000000760000000C/v1_202211191031/S1807593222002010/v1_202211191031/en/main.assets" "Apartado" => null "PDF" => "https://static.elsevier.es/multimedia/18075932/000000760000000C/v1_202211191031/S1807593222002010/v1_202211191031/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1807593222002010?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 0 | 3 |
| 2024 October | 30 | 47 | 77 |
| 2024 September | 32 | 32 | 64 |
| 2024 August | 32 | 35 | 67 |
| 2024 July | 33 | 27 | 60 |
| 2024 June | 24 | 30 | 54 |
| 2024 May | 39 | 28 | 67 |
| 2024 April | 40 | 21 | 61 |
| 2024 March | 26 | 18 | 44 |
| 2024 February | 36 | 27 | 63 |
| 2024 January | 31 | 17 | 48 |
| 2023 December | 28 | 27 | 55 |
| 2023 November | 32 | 26 | 58 |
| 2023 October | 63 | 41 | 104 |
| 2023 September | 33 | 26 | 59 |
| 2023 August | 33 | 4 | 37 |
| 2023 July | 49 | 21 | 70 |
| 2023 June | 47 | 12 | 59 |
| 2023 May | 48 | 1 | 49 |
| 2023 April | 43 | 1 | 44 |
| 2023 March | 33 | 11 | 44 |
| 2023 February | 9 | 1 | 10 |
| 2023 January | 6 | 6 | 12 |
| 2022 December | 14 | 6 | 20 |
| 2022 November | 10 | 3 | 13 |
Show all