Clinical Study

Ear, Nose & Throat Journal

2022, Vol. 0(0) 1–6
Effect of fasting time before anesthesia on © The Author(s) 2022
Article reuse guidelines:
postoperative complications in children sagepub.com/journals-permissions
DOI: 10.1177/01455613221078344
journals.sagepub.com/home/ear
undergoing adenotonsillectomy

Yonghao Huang, MD1 , Junhu Tai, MD2 , and Yongshan Nan, MD, PhD1

Abstract
Objectives: Although the guidelines clearly recommend the fasting time of children before anesthesia, it is usually difficult to
control. For pediatric patients, prolonged fasting time before surgery will lead to dehydration and hypoglycemia. Ad-
enotonsillectomy is one of the most common operations in pediatric patients, but its complications are not rare. The purpose of
this study is to analyze the relationship between preoperative fasting time and postoperative complications in children un-
dergoing adenotonsillectomy. Methods: The medical and surgical records of 480 pediatric patients who underwent ad-
enotonsillectomy were analyzed retrospectively. They were divided into three groups, including adenoidectomy group,
tonsillectomy group, and adenotonsillectomy group. Logistic regression analysis was used to analyze the effect of preoperative
fasting time on postoperative complications and hospital stay in pediatric patients of the three groups. Results: The post-
operative bleeding rate in the adenoidectomy group (5.16%) was lower than tonsillectomy group and adenoidectomy group (P <
.001). Logistic regression analysis showed that the fasting time was positively correlated with the vomiting and pain in ad-
enoidectomy group, tonsillectomy group, and adenotonsillectomy group. And, the postoperative hospital stay was also
positively correlated with fasting time in three groups. Conclusion: The prolonged fasting time before otolaryngology surgery
in children is related to the occurrence of postoperative complications like vomiting and pain, and also to the increase of
postoperative hospital stay.

Keywords
Pediatric, fasting, anesthesiology, adenotonsillectomy, complications

Introduction children to arrange the operation in advance, which makes it

more difficult to control the preoperative fasting time.
The most common explanation for preoperative fasting is to Prolonged preoperative fasting may affect the operation
allow sufficient time for gastric emptying, so as to prevent the and postoperative recovery process of patients. The reduction
contents of the stomach from being inhaled into the trachea of body fluid may bring various intraoperative complications,
during general anesthesia. The American Society of Anes- such as increased blood loss, electrolyte imbalance, and hy-
thesiology (ASA) recommends that children fast for 2 hours of poglycemia. Other clinical problems may include physical
clear liquid, 4 hours of breast milk, and 6 hours of solid food or
formula milk before general anesthesia.1 Although there are
clear recommendations in the guidelines, usually, most pe- 1
Department of Anesthesiology, Yanbian University Hospital, Yanji, PR China
diatric patients are required to preoperative fasting at midnight 2
Department of Otorhinolaryngology-Head & Neck Surgery, College of
on the day of surgery. Our hospital recommends that parents Medicine, Korea University, Seoul, Korea
give children clear liquid in the morning, but many parents
Corresponding Author:
will forget or give the wrong drink, resulting in prolonged Yongshan Nan, Department of Anesthesiology, Yanbian University
preoperative waiting time. Moreover, the rearrangement and Hospital, 1327 Juzijie, Yanji 133000, PR China.
cancellation of the operation list will also make it possible for Email: [email protected]

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2 Ear, Nose & Throat Journal 0(0)

signs and symptoms such as hunger, thirst, discomfort, drowsi- Statistical analysis
ness, and coma.2 For pediatric patients, prolonged fasting time
before operation will soon bring the symptoms of dehydration and Statistical analyses were conducted using SPSS version 20.0.
hypoglycemia,3 which is a common cause of anxiety and pain for Values for continuous variables were represented as mean
patients and their families before operation.4 Adenotonsillectomy standard deviation, and those for categorical variables were
is one of the most common surgical operations in pediatric pa- described using number and percentage. Student’s t-test was
tients. Although it is a relatively common operation, it puts for- used to analyze difference between two groups for continuous
ward high requirements for surgeons and anesthesiologists.5 The variable, and chi-square analysis was performed for cate-
development of surgical techniques and equipment and anesthesia gorical variables. Logistic regression analysis was performed
has reduced the risk of adenotonsillectomy, but this does not mean to evaluate the effect of preoperative fasting time on various
that there are no potential adverse events; the complications of postoperative complications and hospital stay.
adenotonsillectomy are not rare and sometimes serious enough to
cause death.6
Results
The purpose of this paper is to analyze the relationship
between preoperative fasting time, postoperative complications in Baseline characteristics of study population
pediatric patients undergoing adenotonsillectomy, so as to deter-
mine whether fasting time is related to the occurrence of com- A total of 480 cases of pediatric patients with otolaryngology
plications in pediatric patients undergoing adenotonsillectomy, were enrolled in the study, including 155 patients in the ad-
and to provide evidence for the preoperative fasting time rec- enoidectomy group, 120 patients in the tonsillectomy group,
ommended by the ASA in the perioperative environment. and 205 patients in the adenotonsillectomy group. The mean
age of the population was 5.96 ±2.53, girls account for 41.7% of
the total, and the median preoperative fasting time of the whole
Patients and methods group was 565. Compared with the adenotonsillectomy group
(39.02%) and the tonsillectomy group (37.5%), the postoper-
Subjects ative bleeding rate in the adenoidectomy group (5.16%) was
This study reviewed 480 children under general anesthesia who lower than that in the other two groups (P < .001). There was no
underwent surgery of adenotonsillectomy by surgeons in our hospital significant difference in age, gender, BMI, duration of illness,
from October 2018 to June 2021. Children under 14 years of age with fasting time, intraoperative parameters such as anesthesia time,
ASA grade 1 or 2, non-emergency, no gastrointestinal absorption operation time, intraoperative bleeding, and recovery time,
problems, and no obesity were included in the study. Special pop- postoperative parameters such as vomiting, pain, cough, and
ulations with specific fasting guidance or patients with non-standard postoperative hospital stay between the three groups (Table 1).
fasting guidance given by their doctors and patients with known
metabolic or endocrine disorders were excluded from the study. The The effect of fasting time on postoperative
start time of fasting is uniformly informed by the hospital to the
complications in three groups
parents of the children as midnight. If the time of fasting is more than
12 hours or less than two hours, the patients will be excluded. This Logistic regression analysis was used to evaluate the relationship
research project was carried out following the Declaration of Helsinki between fasting time and postoperative complications. For post-
by the World Medical Association and was approved by the Research operative vomiting, the fasting time in the adenoidectomy group
Ethics Committee. All participants provided informed consent. (adjusted odds ratio = 2.99, P = .004), tonsillectomy group (adjusted
odds ratio = 3.85, P = .003), and the adenotonsillectomy group
(adjusted odds ratio = 3.83, P < .001) were positively correlated with
Data collection
the occurrence of vomiting (Table 2). For postoperative pain, the
We collected information from medical and surgical records, fasting time in the adenoidectomy group (adjusted odds ratio =
including age, gender, Body mass index (BMI), duration of 13.33, P < .001), tonsillectomy group (adjusted odds ratio = 6.02, P
illness, preoperative fasting time, anesthesia time, operation < .001), and the adenotonsillectomy group (adjusted odds ratio =
time, intraoperative bleeding, recovery time, various post- 4.07, P < .001) were also positively correlated with the occurrence of
operative complications such as vomiting and cough, and the pain (Table 3). But for postoperative cough and bleeding, there was
postoperative hospital stay. no significant difference between the fasting time and the occurrence
of complications in the three groups (Tables 4 and 5).
Grouping
The relationship between fasting time and
The pediatric patients were divided into three groups, in-
postoperative hospital stay in three groups
cluding adenoidectomy group, tonsillectomy group, and ad-
enotonsillectomy group. Fasting time was divided into two The results of logistic regression showed that the preopera-
groups according to the median. tive fasting time in the adenoidectomy group (adjusted odds
Huang et al. 3

Table 1. Baseline characteristics of participants.

Study population

Variable Adenotonsillectomy group Tonsillectomy group Adenoidectomy group P-value

Subjects 205 120 155

Age (year) 6.07 ± 2.46 5.92 ± 2.58 5.83 ± 2.58 .649
Gender
Girl 82 (40.00%) 51 (42.50%) 67 (43.23%) .809
Boy 123 (60.00%) 69 (57.50%) 88 (56.77%)
BMI(kg/m2) 20.52 ± 5.70 20.53 ± 5.83 20.26 ± 8.59 .924
Duration of illness (year) 1.41 ± 1.17 1.57 ± 1.40 1.48 ± 1.24 .57
Fasting time (minute) 606.24 ± 110.40 592.60 ± 106.27 579.79 ± 114.89 .081
Anesthesia time (minute) 36.59 ± 16.41 36.67 ± 14.32 37.54 ± 18.10 .848
Operation time (minute) 26.52 ± 13.97 26.48 ± 11.84 27.03 ± 15.56 .928
Intraoperative bleeding (ml) 9.57 ± 4.86 9.38 ± 4.83 9.56 ± 5.40 .937
Recovery time (minute) 9.80 ± 4.09 9.77 ± 3.37 9.83 ± 3.75 .99
Postoperative complications
Vomiting, n (%) .645
No 121 (59.02%) 77 (64.17%) 93 (60.00%)
Yes 84 (40.98%) 43 (35.83%) 62 (40.00%)
Pain, n (%) .08
No 127 (61.95%) 72 (60.00%) 117 (75.48%)
Yes 78 (38.05%) 48 (40.00%) 38 (24.52%)
Cough, n (%) .571
No 112 (54.63%) 62 (51.67%) 76 (49.03%)
Yes 93 (45.37%) 58 (48.33%) 79 (50.97%)
Postoperative bleeding, n (%) <.001
No 125 (60.98%) 75 (62.50%) 147 (94.84%)
Yes 80 (39.02%) 45 (37.50%) 8 (5.16%)
Postoperative hospital stays (day) 4.30 ± .99 4.23 ± .95 3.91 ± 1.08 0.1

Table 2. Logistic regression analysis of fasting time and vomiting in three groups.

Variable Category No vomiting Vomiting COR (95%CI) AOR (95%CI) P

Fasting time in adenoidectomy group (minute) ≤565 69 (74.19%) 31 (50.00%) 1 1 .004

>565 24 (25.81%) 31 (50.00%) 2.87 (1.46–5.68) 2.99 (1.48–6.02)
Fasting time in tonsillectomy group (minute) ≤ 565 45 (58.44%) 12 (27.91%) 1 1 .003
>565 32 (41.56%) 31 (72.09%) 3.63 (1.62–8.13) 3.85 (1.69–8.78)
Fasting time in adenotonsillectomy group (minute) ≤ 565 67 (55.37%) 21 (25.00%) 1 1 <.001
>565 54 (44.63%) 63 (75.00%) 3.72 (2.02–6.85) 3.83 (2.06–7.13)
COR: crude odds ratio; AOR: adjusted odds ratio; CI: confidence interval.

Table 3. Logistic regression analysis of fasting time and pain in three groups.

Variable Category No pain Pain COR (95%CI) AOR (95%CI) P

Fasting time in adenoidectomy group (minute) ≤565 91 (77.78%) 9 (23.68%) 1 1 <.001

>565 26 (22.22%) 29 (76.32%) 11.28 (4.75–26.8) 13.33 (5.19–34.21)
Fasting time in tonsillectomy group (minute) ≤ 565 46 (63.89%) 11 (22.92%) 1 1 <.001
>565 26 (36.11%) 37 (77.08%) 5.95 (2.6–13.61) 6.02 (2.62–13.87)
Fasting time in adenotonsillectomy group (minute) ≤ 565 70 (55.12%) 18 (23.08%) 1 1 <.001
>565 57 (44.88%) 60 (76.92%) 4.09 (2.18–7.7) 4.07 (2.16–7.68)

COR: crude odds ratio; AOR: adjusted odds ratio; CI: confidence interval.
4 Ear, Nose & Throat Journal 0(0)

Table 4. Logistic regression analysis of fasting time and cough in three groups.

Variable Category No cough Cough COR (95%CI) AOR (95%CI) P

Fasting time in adenoidectomy group (minute) ≤565 52 (68.42%) 48 (60.76%) 1 1 .407

>565 24 (31.58%) 31 (39.24%) 1.4 (.72–2.71) 1.4 (.7–2.82)
Fasting time in tonsillectomy group (minute) ≤565 37 (59.68%) 20 (34.48%) 1 1 .513
>565 25 (40.32%) 38 (65.52%) 1.81 (.84–2.91) 1.83 (.85–2.95)
Fasting time in adenotonsillectomy group (minute) ≤565 56 (50.00%) 32 (34.41%) 1 1 .353
>565 56 (50.00%) 61 (65.59%) 1.91 (.88–3.36) 1.96 (.92–3.49)
COR: crude odds ratio; AOR: adjusted odds ratio; CI: confidence interval.

Table 5. Logistic regression analysis of fasting time and postoperative bleeding in three groups.

Variable Category No bleeding Bleeding COR (95%CI) AOR (95%CI) P

Fasting time in adenoidectomy group (minute) ≤565 95 (64.63%) 5 (62.50%) 1 1 1

>565 52 (35.37%) 3 (37.50%) 1.1 (.25–4.77) 1.02 (.23–4.46)
Fasting time in tonsillectomy group (minute) ≤565 38 (50.67%) 19 (42.22%) 1 1 .479
>565 37 (49.33%) 26 (57.78%) 1.41 (.67–2.96) 1.41 (.67–2.97)
Fasting time in adenotonsillectomy group (minute) ≤565 60 (48.00%) 28 (35.00%) 1 1 .091
>565 65 (52.00%) 52 (65.00%) 1.71 (.96–3.06) 1.66 (.93–2.98)
COR: crude odds ratio; AOR: adjusted odds ratio; CI: confidence interval.

Table 6. Logistic regression analysis of fasting time and postoperative hospital stay in three groups.

Postoperative hospital Postoperative hospital

Variable Category stays (≤ 4 days) stays (>4 days) COR (95%CI) AOR (95%CI) P

Fasting time in ≤565 76 (72.38%) 24 (48.00%) 1 1 .005

adenoidectomy group >565 29 (27.62%) 26 (52.00%) 2.84 (1.41–5.72) 3.38 (1.59–7.19)
(minute)
Fasting time in ≤565 55 (71.43%) 2 (4.65%) 1 1 <.001
tonsillectomy group >565 22 (28.57%) 41 (95.35%) 51.25 (11.4–230.37) 63.93 (13.42–304.48)
(minute)
Fasting time in ≤565 85 (69.11%) 3 (3.66%) 1 1 <.001
adenotonsillectomy >565 38 (30.89%) 79 (96.34%) 58.9 (17.48–198.46) 62.61 (18.33–213.86)
group (minute)

COR: crude odds ratio; AOR: adjusted odds ratio; CI: confidence interval.

ratio = 3.38, P = .005), tonsillectomy group (adjusted odds arrangement of operating room. However, even in the United
ratio = 63.93, P < .001), and the adenotonsillectomy group States and other developed countries, long-term preoperative
(adjusted odds ratio = 62.61, P < .001) were positively cor- fasting is still common.7
related with the postoperative hospital stay (Table 6). Prolonged preoperative fasting may lead to low blood
volume and metabolic imbalance, which may increase the
possibility of adverse events, including arterial hypotension,
Discussion
venous access difficulties, and hypoglycemic events.8 Sur-
This retrospective study analyzed the relationship between gical trauma, a large number of secretions in the mouth and
fasting time and postoperative complications in children with nose, and reactive postoperative edema are the causes of
otolaryngology. The main finding is that the longer the fasting postoperative complications. After adenotonsillectomy, the
time, the more likely the children are to have complications most common early postoperative complications in children
such as vomiting and pain, and the postoperative hospital stay are cough and bleeding, followed by pain, vomiting, and
will be prolonged accordingly. We found that the actual dehydration; infection and cardiac complications are rare.9
preoperative fasting time of children in our hospital was much Postoperative vomiting is a common complication in pe-
longer than that recommended by the ASA, which may be due diatric anesthesia. Various independent risk factors are related
to the medical staff, patients and their families, or the to the occurrence of vomiting, which often occurs in
Huang et al. 5

otolaryngology surgery, including tonsillectomy and ad- stay in three groups, which was corresponding to the results of
enoidectomy.10 Our results showed that the fasting time of the complications.
three groups was positively correlated with the occurrence of Shortening the fasting time before operation can improve
vomiting. This is consistent with Urits et al,11 who pointed out the metabolism and hemodynamics during anesthesia.19 It can
that preoperative fasting is a factor that may affect the oc- also relieve patients’ preoperative anxiety, especially in
currence of postoperative vomiting especially in pediatric children.20 In order to protect pediatric patients from long
anesthesia. We do not provide antiemetic drugs to patient preoperative fasting time, freer fasting programs and better
conventionally, which may be different from most developed interdisciplinary cooperation need to be considered.21
countries. In subsequent studies, we need to consider the
changes after giving antiemetic drugs.
Conclusion
Pain after tonsillectomy is very common, inflammation and
stimulation of nerve endings, pharyngeal muscle spasm, and Preoperative fasting time is related to the occurrence of
preoperative anxiety may be one of the causes.12 And it is well postoperative complications, such as vomiting and pain. In
known that the preoperative anxiety increases with the in- addition, the preoperative fasting time also leads to the ex-
crease of the preoperative fasting time. Our results also show tension of postoperative hospital stay. Although the standards
that the fasting time in three groups is positively correlated of our hospitals are different from those in most developed
with the occurrence of postoperative pain. Postoperative pain countries, they are indeed common in developing countries.
assessment in children is difficult to complete and depends on Our results may lead more people to consider improving
physiological, behavioral, and self-report methods.13 But preoperative fasting strategies in order to prevent postoper-
because this is a retrospective study, it can only judge whether ative complications in children’s otolaryngology better.
children have postoperative pain through medical records, Medical staff should communicate more with children’s
which is one of the limitations of this study. We will stan- parents to formulate a more optimized fasting program that
dardize the pain score in the follow-up study. meets the standards.
Endotracheal tube may cause cough during anesthesia
recovery after otolaryngology surgery in children, which Acknowledgment
usually lasts for several hours to several days.14 However, no This research was supported by the Yanbian University Hospital.
study has reported whether the fasting time will lead to the
occurrence of postoperative cough. A large sample statistical Author contributions
article from Korea15 reported that adenotonsillectomy did not
change the risk of upper respiratory tract infection in children. Writing—original draft preparation: Yonghao Huang and Junhu Tai
Our results show that although the incidence of postoperative Review and editing: Yongshan Nan
cough is about 50%, the fasting time has no effect on its Supervision: Yongshan Nan
occurrence. All authors have read and agreed to the published version of the
In terms of bleeding reporting, some people will define any manuscript.
small or large bleeding after tonsillectomy as bleeding, while
others will only strictly define bleeding as large bleeding Declaration of conflicting interests
that needs to be returned to the operating room for control.16 The author(s) declared no potential conflicts of interest with respect to
In the medical records retrospectively analyzed in this the research, authorship, and/or publication of this article.
study, whether a small amount or a large amount of bleeding
is defined as postoperative bleeding, this may result in a Funding
high postoperative bleeding rate. Our results showed that
The author(s) received no financial support for the research, au-
although the probability of postoperative bleeding in ad-
thorship, and/or publication of this article.
enotonsillectomy group and tonsillectomy group was
higher than that in adenoidectomy group, the fasting time of
the three groups was not related to postoperative bleeding. Ethical approval
The results of Spektor et al17 pointed out that age and The data collection was approved by the medical ethics committees of
history of recurrent tonsillitis were related to the occurrence the Yanbian University Hospital
of bleeding after tonsillectomy in children, but there was no
study on the relationship between preoperative fasting time Informed consent
and postoperative bleeding. Further research studies are
Written informed consent was obtained for each participant.
needed to find out the specific causes.
Postoperative complications will lead to prolonged post-
operative hospital stay and increased medical expenses.18 Our ORCID iDs
statistical results showed that there was a positive correlation Yonghao Huang  https://orcid.org/0000-0001-9351-741X
between preoperative fasting time and postoperative hospital Junhu Tai  https://orcid.org/0000-0003-1491-9889
6 Ear, Nose & Throat Journal 0(0)

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