Difference of ketone levels between diurnal and nocturnal fasting in children: an observational study
Introduction: Children are susceptible to developing preoperative ketonemia, which can be affected by changes in the circadian rhythm and counter-regulatory hormones. It is unclear whether ketonemia depends on the timing of fasting.
Objective: To assess the effect of preoperative fasting time (diurnal vs. night) on the preoperative concentration of ketone bodies in children.
Methods: We conducted a prospective-observational clinical study between September 2020 and March 2021, including children under 48 months of age scheduled for elective surgery. Two groups were identified based on fasting time, as follows: diurnal fasting (group A, n = 40) and nocturnal fasting (group B, n = 52). Demographic data, duration of fasting, time of excess fasting, type of food intake, the concentration of ketone bodies and capillary blood glucose, level of anxiety, and dehydration were analyzed in both groups.
Results: Diurnal fasting was associated with higher incidence of ketonemia compared with nocturnal fasting (Group A: 62.5% [95% CI 48.1-82.0]; group B: 38,5% [95% CI 26.5-52.5], P=0.02). Most of the patients exceeded the duration of fasting recommended by preoperative fasting guidelines (95.6%). The type of food eaten before surgery was significantly associated with the presence of ketonemia (P=0.01).
Conclusions: Preoperative ketonemia is relatively common in patients under 48 months of age, especially among those who undergo diurnal fasting compared to nocturnal fasting.
Laffel L. Ketone bodies: a review of physiology, pathophysiology and application of monitoring to diabetes. Diabetes Metab Res Rev. 1999;15:412–26. doi: https://doi.org/10.1002/(sici)1520-7560(199911/12)15:6<412::aid-dmrr72>3.0.co;2-8
Chaussain JL, Georges P, Olive G, Job JC. Glycemic response to 24-hour fast in normal children and children with ketotic hypoglycemia: II. Hormonal and metabolic changes. J Pediatr. 1974;85(6):776–81. doi: https://doi.org/10.1016/s0022-3476(74)80339-2
Poggiogalle E, Jamshed H, Peterson CM. Circadian regulation of glucose, lipid, and energy metabolism in humans. Metabolism. 2018;84:11–27. doi: https://doi.org/10.1016/j.metabol.2017.11.017
Berghmans JM, Poley MJ, van der Ende J, Weber F, Van de Velde M, Adriaenssens P, et al. A Visual Analog Scale to assess anxiety in children during anesthesia induction (VAS-I): Results supporting its validity in a sample of daycare surgery patients. Paediatr Anaesth. 2017;27(9):955–61. doi: https://doi.org/10.1111/pan.13206
Steiner MJ, Dewalt D a. Is this child dehydrated ? JAMA. 2004;291(22):2746–54. doi: https://doi.org/10.1001/jama.291.22.2746
Chiu RW, Ho CS, Tong SF, Ng KF, Lam CW. Evaluation of a new handheld biosensor for point-of-care testing of whole blood beta-hydroxybutyrate concentration. Hong Kong Med J. 2002;8(3):172–6. PMID: 12055361.
Donohoe PB, Kessler R, Beattie TF. Exploring the clinical utility of blood ketone levels in the emergency department assessment of paediatric patients. Emerg Med J. 2006;23(10):783–7. doi: https://doi.org/10.1136/emj.2006.035758
Dennhardt N, Beck C, Huber D, Nickel K, Sander B, Witt LH, et al. Impact of preoperative fasting times on blood glucose concentration, ketone bodies and acid-base balance in children younger than 36 months: A prospective observational study. Eur J Anaesthesiol. 2015; doi: https://doi.org/10.1097/EJA.0000000000000330
Bougneres PF, Lemmel C, Ferre P, Bier DM. Ketone body transport in the human neonate and infant. J Clin Invest. 1986;77(1):42–8. doi: https://doi.org/10.1172/JCI112299
Morimoto Y, Sugimura M, Hanamoto H, Niwa H. Risk factors for hyperketonemia in cleft lip and palate infants during general anesthesia. J Oral Maxillofac Surg. 2012;70(6):1449–55. doi: http://dx.doi.org/10.1016/j.joms.2011.03.049
S Niiya 1, T Nakamura, T Hara, M Miyako MF. The effect of calories of preoperative oral intake on the glucose metabolic response in children. Masui Japanese J Anesthesiol. 1999;48(4):362–7. PMID: 10339932
Krauchi K, Wirz-Justice A. Circadian rhythm of heat production, heart rate, and skin and core temperature under unmasking conditions in men. Am J Physiol - Regul Integr Comp Physiol. 1994;267(3 36-3). doi: https://doi.org/10.1152/ajpregu.1994.267.3.R819
Bass J, Takahashi JS. Circadian integration of metabolism and energetics. Science. 2010;330(6009):1349–54. doi: https://doi.org/10.1126/science.1195027
Nygren J, Thorell A, Ljungqvist O. Preoperative oral carbohydrate therapy. Curr Opin Anaesthesiol. 2015;28(3):364–9. doi: https://doi.org/10.1097/ACO.0000000000000192
Tudor-Drobjewski BA, Marhofer P, Kimberger O, Huber WD, Roth G, Triffterer L. Randomised controlled trial comparing preoperative carbohydrate loading with standard fasting in paediatric anaesthesia. Br J Anaesth. 2018;121(3):656–61. doi: https://doi.org/10.1016/j.bja.2018.04.040
Castillo-Zamora C, Castillo-Peralta LA, Nava-Ocampo AA. Randomized trial comparing overnight preoperative fasting period Vs oral administration of apple juice at 06:00-06:30 AM in pediatric orthopedic surgical patients. Paediatr Anaesth. 2005;15(8):638–42. doi: https://doi.org/10.1111/j.1460-9592.2005.01517.x
Habre W, Disma N, Virag K, Becke K, Hansen TG, Jöhr M, et al. Incidence of severe critical events in paediatric anaesthesia (APRICOT): a prospective multicentre observational study in 261 hospitals in Europe. Lancet Respir Med. 2017;5(5):412–25. doi: http://dx.doi.org/10.1016/S2213-2600(17)30116-9
Beach ML, Cohen DM, Gallagher SM, Cravero JP. Major Adverse Events and Relationship to Nil per Os Status in Pediatric Sedation/Anesthesia Outside the Operating Room: A Report of the Pediatric Sedation Research Consortium. Anesthesiology. 2016;124(1):80–8. doi: https://doi.org/10.1097/ALN.0000000000000933
Brady MC, Kinn S, Ness V, O’Rourke K, Randhawa N, Stuart P. Preoperative fasting for preventing perioperative complications in children. Cochrane Database Syst Rev. 2009;(4). doi:http://doi.wiley.com/10.1002/14651858.CD005285.pub2
Van De Putte P, Vernieuwe L, Jerjir A, Verschueren L, Tacken M, Perlas A. When fasted is not empty: A retrospective cohort study of gastric content in fasted surgical patients. Br J Anaesth. 2017;118(3):363–71. doi: https://doi.org/10.1093/bja/aew435
Beck CE, Rudolp D, Becke-Jakob K, Schindler E, Etspüler A, Trapp A, et al. Real fasting times and incidence of pulmonary aspiration in children: Results of a German prospective multicenter observational study. Paediatr Anaesth. 2019;29(10):1040–5. doi: https://doi.org/10.1111/pan.13725
Karan S, Indu B, Divya J. Parent´s perception and factors affecting compliance with preoperative fasting instructions in children undergoing day care surgery: A prospective observational study. Indian J Anaesth. 2019;49(4):257–62. doi: https://doi.org/10.4103/ija.IJA_794_19
Newton RJG, Stuart GM, Willdridge DJ, Thomas M. Using quality improvement methods to reduce clear fluid fasting times in children on a preoperative ward. Paediatr Anaesth. 2017;27(8):793–800. doi: https://doi.org/10.1111/pan.13174
Andersson H, Hellström PM, Frykholm P. Introducing the 6-4-0 fasting regimen and the incidence of prolonged preoperative fasting in children. Paediatr Anaesth. 2018;28(1):46–52. doi: https://doi.org/10.1111/pan.13282
Thomas M, Morrison C, Newton R, Schindler E. Consensus statement on clear fluids fasting for elective pediatirc general anesthesia. Paediatric Anaesthesia. 2018. doi: https://doi.org/10.1111/pan.13370
Beck CE, Rudolph D, Mahn C, Etspüler A, Korf M, Lüthke M, et al. Impact of clear fluid fasting on pulmonary aspiration in children undergoing general anesthesia: Results of the German prospective multicenter observational (NiKs) study. Paediatr Anaesth. 2020;30(8):892–9. doi: https://doi.org/10.1111/pan.13948
Frykholm P, Disma N, Andersson H, Beck C, Bouvet L, Cercueil E,et al. Pre-operative fasting in children: A guideline from the European Society of Anaesthesiology and Intensive Care. Eur J Anaesthesiol. 2022;39(1):4-25. doi: https://doi.org/10.1097/EJA.0000000000001599.
Al-Robeye AM, Barnard AN, Bew S. Thirsty work: Exploring children’s experiences of preoperative fasting. Paediatr Anaesth. 2020;30(1):43–9. doi: https://doi.org/10.1111/pan.13759
Copyright (c) 2023 Sociedad Colombiana de Anestesiología y Reanimación (S.C.A.R.E.)
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
This document does not have Crossref citations yet.