Speakers
Prof. Peter FRYKHOLM
Consultant
Paediatric Section Department of Anaesthesiology and Intensive Care
Uppsala University Hospital
Present employment
My main work is as Consultant at the Paediatric Section Department of Anaesthesiology and Intensive Care, Uppsala University Hospital, Sweden. I was head of the Paediatric Anaesthesia unit from 2013 to the beginning of 2016. Presently I hold a part time senior research position which is combined with clinical work at the Paediatric Section. Uppsala University Hospital is the oldest of the seven academic hospitals in Sweden, and a tertiary referral centre covering about 2 million people from middle and northern Sweden. The hospital is also a national centre for e.g. craniosynostosis surgery, endocrine oncology, burns and pelvic trauma.
My key research interests are improving perioperative paediatric anaesthesia practice with special focus on preoperative fasting. I am the head of the ESAIC task force for preoperative fasting in children which has published a new European guideline and continues with multicentre collaborative projects such as the EUROFAST audit. In the past, I have studied cerebral ischaemia, optimisation of ventilation during anaesthesia and intensive care and the physiology and implementation of jet ventilation. I have also put some effort into airway management and vascular access, having co-authored national guidelines and reviews on these topics.
Affiliations
ESPA – European Society for Paediatric Anaesthesiology (Board member 2018 until present,
Honorary treasurer since 2020)
SSAI - Scandinavian Society for Anaesthesiology and Intensive Care (member)
ESAIC - European Society for Anaesthesiology (member)
IARS - International Anesthesia Research Society (member)
SFAI – Swedish Society for Anaesthesiology and Intensive Care (member)
SFAI working groups for vascular access and airway management
SAFETOTS – board member since 2020
Previous studies and employment
I studied Medicine at Uppsala University from 1985 – 1991, going on to internship and residency at Gävle-Sandviken County Hospital. I also studied History, Musicology and the Philosophy of Science. I moved back to Uppsala University Hospital in 2000, given the opportunity to subspecialise in paediatric anaesthesia. In parallel, I completed my thesis on Cerebral Ischaemia at the Department of Neuroscience.
In 2004 I very much enjoyed a clinical fellowship at PICU, Starship Children’s Hospital, Auckland, New Zealand. I regularly do volunteer work as a paediatric anaesthetist for Operation Smile. Over the years, I have also worked part-time as a musician; presently on a very limited scale (mostly Doric;-) in world music.
Ensuring adequate preoperative fasting before general anesthesia is one of the fundamental measures to decrease the risk of pulmonary aspiration due to regurgitation of gastric contents during anesthesia. Nil-per-os from midnight was the paradigm after Robert Mendelsohn published a case series of obstetric patients, pointing to aspiration of solids leading to airway obstruction. He also revealed a mechanism for chemical pneumonitis after aspiration of gastric juices. But fasting from midnight led to very long fasting times, and it became obvious that especially small children suffered from fasting 12 hours or more. In 1999, the ASA issued the first guideline on preoperative fasting including the recommendations of at least 6 hours after a light meal, 4 hours after breast milk and 2 hours after clear fluid ingestion. In January 2022, the ESAIC published a new guideline, further reducing the minimum fasting times for breast milk and clear fluids.
Why not stick to the old 6–4–2 regimen? Can reducing the minimum clear fluid fasting time from 2 to 1 h really make a difference for real world fasting times? The main reason for the change was the growing number of studies showing that real world fasting times are not even close to 2 h for clear fluids. On the contrary, mean clear fluid fasting times ranging from 8 to 15 h have been reported. It has proven to be surprisingly difficult to reduce fasting times when implementing the 6–4–2 regimen. With a 1 h limit, it is much easier to safely permit clear fluid intake on the morning of surgery. Two quality improvement projects on both sides of the Atlantic reached strikingly similar conclusions: it was not possible to reach the goal of reducing the risk of prolonged fasting until the clear fluid limit was reduced to 1 h. But how about the risk of aspiration? A problem is that noninferiority studies assessing the risk of aspiration require a massive number of participants. In my talk I will discuss the reasons for change and tentative future studies to increase the understanding of safe limits for preoperative fasting.
