1 through 14, https://links.lww.com/ALN/C935). The characteristics of randomized trials supporting recommendations for adult surgical patients included a median of 46 participants (range, 20 to 150). Pre-operative ranitidine. Simple carbohydrates included clear fruit juices or water with glucose or fructose added. Category B. Observational studies or RCTs without pertinent comparison groups may permit inference of beneficial or harmful relationships among clinical interventions and clinical outcomes. Observational studies indicate that some predisposing patient conditions (e.g., age, sex, ASA physical status, emergency surgery) may be associated with the risk of perioperative aspiration (Category B2-H evidence).15 Observational studies addressing other predisposing conditions (e.g., obesity, diabetes, esophageal reflux, smoking history) report inconsistent findings regarding risk of aspiration (Category B1-E evidence).611. Although controlled studies do not sufficiently evaluate such relationships, the reported evidence does focus on intermediate outcomes, including gastric contents (e.g., volume or pH) and nausea and vomiting, typically considered by the authors to be representative of a predicted risk of pulmonary aspiration. The task force was responsible for developing key questions; the relevant patient populations, interventions, comparators, and outcomes; and the study inclusion/exclusion criteria to guide the systematic review (see Systematic Review Protocol in the Supplemental Digital Content, https://links.lww.com/ALN/C930). Pre-operative fasting in children: A guideline from the European Society of Anaesthesiology and Intensive Care. Preoperative magnesium trisilicate in infants. A meta-analysis of three trials found a difference of 2.5ml (95% CI, 8.6 to 3.7) in residual gastric volume for protein-containing clear liquids versus fasting.49,68,91. Findings from the aggregated literature are reported in the text of the guidelines by evidence category, level, and direction and in appendix 2 (table 2). ASA members disagree and the consultants strongly disagree that proton pump inhibitors should be routinely administered before elective procedures requiring general anesthesia, regional anesthesia, or procedural sedation and analgesia in patients with no apparent increased risk for pulmonary aspiration. Preoperative carbohydrate nutrition reduces postoperative nausea and vomiting compared to preoperative fasting. However, only the findings obtained from formal surveys are reported in the current update. Menthol chewing gum on preoperative thirst management: Randomized clinical trial. Conflicts were resolved by consensus. Tests for heterogeneity of the independent studies were conducted to assure consistency among the study results. Tables 4 and 5 summarize the evidence for clinically important outcomes, and supplemental tables 7 to 10 (https://links.lww.com/ALN/C934) detail the strength-of-evidence ratings. Omeprazole reduces preoperative gastric fluid acidity and volume in children. A difference was not detected in gastric pH92,9497 (low strength of evidence, supplemental table 16, https://links.lww.com/ALN/C934). Effects of oral rehydration therapy on gastric volume and pH in patients with preanesthetic h2 antagonist. Preoperative drinking does not affect gastric contents. GRADE guidelines: 14. These practice guidelines are a modular update of the Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures. The guidance focuses on topics not addressed in the previous guideline: ingestion of carbohydrate-containing clear liquids with or without protein, chewing gum, and pediatric fasting duration. Pre-operative carbohydrate loading prior to elective caesarean delivery: A randomised controlled trial. Evaluation of gastric residual volume in fasting diabetic patients using gastric ultrasound. However, studies in children are limited, lack significant power to detect uncommon risks, and clinical controversy exists.117, There is a need for well designed, adequately powered randomized trials or large prospective cohort studies in both adults and children to evaluate uncommon adverse events and patient-reported outcomes including preoperative thirst, hunger, anxiety, and patient satisfaction. Verify patient compliance with fasting requirements at the time of their procedure. Preoperative oral carbohydrate administration to ASA IIIIV patients undergoing elective cardiac surgery. Differences were not detected in rates of nausea36,39,4345 (low strength of evidence) or patient-rated nausea (low strength of evidence). Antiemetics may be preoperatively administered to patients at increased risk of postoperative nausea and vomiting. Screening was performed independently by two methodologists. Preoperative fasting guidelines in pediatric anesthesia: Are we ready for a change? Ultrasound assessment of gastric volume in children after drinking carbohydrate-containing fluids. chewing tobacco npo guidelines. Is a 4-hour fast necessary? Outcomes: adverse effects of fasting (preoperative hunger, thirst, and nausea) and pulmonary aspiration. Residual gastric volume evaluation with ultrasonography after ingestion of carbohydrate- or carbohydrate plus glutamine-enriched beverages: A randomized, crossover clinical trial with healthy volunteers. Alcoholic beverages should be avoided within 8 hours of the scheduled arrival time. These evidence categories are further divided into evidence levels. Comparison of different non-pharmacological preoperative preparations on gastric fluid volume and acidity: A randomized controlled trial. Preoperative oral carbohydrate reduces postoperative insulin resistance by activating amp-activated protein kinase after colorectal surgery. An updated report by the ASA task force on preoperative fasting and use of pharmacologic agents to reduce the risk of pulmonary aspiration, which was adopted by the ASA in 2016 and published in 2017.1 The 2017 guideline did not address whether one type of clear liquid, such as water or carbohydrate-containing clear liquids (with and without protein), is more beneficial. Individuals can improve their health and reduce their risk of contracting these and other diseases by quitting chewing tobacco. The consultants and ASA members strongly agree that a review of pertinent medical records, a physical examination, and patient survey or interview should be performed as part of the preoperative evaluation. Almost all adult study participants had an ASA Physical Status I or II (92%). Drinking carbohydrate-containing clear liquids resulted in lower hunger ratings than did noncaloric clear liquids (moderate strength of evidence).23,24,26,39,41,7275 Differences were not evident for patient ratings of thirst23,24,26,39,41,72,73,7577 (low strength of evidence) and nausea23,24,26,73 (low strength of evidence) or in rates of preoperative thirst78 and nausea23,24,26,39,73,79 (both very low strength of evidence). A carbohydrate-rich beverage prior to surgery prevents surgery-induced immunodepression: a randomized, controlled, clinical trial. An updated report by the American Society of Anesthesiologists task force on preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration. An acceptable significance level was set at P< 0.01 (one-tailed). chewing tobacco npo guidelines. Consider both the amount and type of foods ingested when determining an appropriate fasting period. Patients drinking protein-containing clear liquids until 2h before their procedures experienced less hunger compared to fasting (table 4) and less hunger and thirst compared to drinking other clear liquids (table 5). Furthermore, it would be necessary to update related policies, printed literature, and wall posters/charts to ensure that patients are receiving consistent messages and instructions from all medical personnel. Welcome! The authors declare no competing interests. The purposes of these guidelines are to provide direction for clinical practice related to preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration and to reduce the severity of complications related to perioperative pulmonary aspiration. A new histamine H2-receptor antagonist. Safety and efficacy of oral rehydration therapy until 2h before surgery: A multicenter randomized controlled trial. Consistent with the 2017 ASA guideline intended population,1 healthy individuals are defined as those without coexisting diseases or conditions that may increase the risk for aspiration, including esophageal disorders such as significant uncontrolled reflux disease, hiatal hernia, Zenkers diverticulum, achalasia, stricture; previous gastric surgery (for example, gastric bypass); gastroparesis; diabetes mellitus88,89; opioid use; gastrointestinal obstruction or acute intraabdominal processes; pregnancy; obesity; and emergency procedures.24 Anesthesiologists should recognize that these conditions can increase the likelihood of regurgitation and pulmonary aspiration and should modify these guidelines based upon their clinical judgment. Shortened preanesthetic fasting interval in pediatric cardiac surgical patients. The guidelines do not apply to patients who undergo procedures with no anesthesia or only local anesthesia when upper airway protective reflexes are not impaired and when no risk factors for pulmonary aspiration are apparent. Smoking and gastric juice volume in outpatients. They also may serve as a resource for other health care professionals who advise or care for patients who receive anesthesia care during procedures. The impact of preoperative carbohydrate loading on patients with type II diabetes in an enhanced recovery after surgery protocol. They provide basic recommendations for anesthesia care that are supported by synthesis and analysis of the current literature, expert and practitioner opinion, public comment, and clinical feasibility data. Placebo-controlled RCTs are equivocal regarding the efficacy of glycopyrrolate to reduce gastric volume or acidity (Category A2-E evidence),83,102 and two nonrandomized placebo-controlled comparative studies report equivocal findings the efficacy of atropine on gastric volume and acidity (Category B1-E evidence).103,104. Meta-analysis of placebo-controlled RCTs indicate that metoclopramide is effective in reducing gastric volume and pH during the perioperative period (Category A1-B evidence).5560 The literature is insufficient to evaluate the effect of metoclopramide on the perioperative incidence of pulmonary aspiration.***. Additional fasting time (e.g., 8 or more hours) may be needed in cases of patient intake of fried foods, fatty foods, or meat. Nonrandomized comparative studies assessing the impact of ingesting breast milk before a procedure are equivocal for gastric volume or pH when compared with the ingestion or clear liquids or infant formula (Category B1-E evidence).4446. Investigation of preoperative fasting times in children. Simple or complex carbohydratecontaining clear liquids appear to reduce hunger compared with noncaloric clear liquids. Safe pre-operative fasting times after milk or clear fluid in children. Ultrasound assessment of gastric emptying time after intake of clear fluids in children scheduled for general anesthesia: A prospective observational study. Effects of preoperative oral carbohydrates on quality of recovery in laparoscopic cholecystectomy: A randomized, double blind, placebo-controlled trial. Home. Aspiration was not reported in any of the included studies (randomized controlled trials32,43,49,5255,64 or nonrandomized designs90). Effects of preoperative oral carbohydrate supplementation on postoperative metabolic stress response of patients undergoing elective abdominal surgery. Preoperative oral fluids: is a five-hour fast justified prior to elective surgery? The body of evidence included 22 adult surgical studies (20 randomized controlled trials,32,43,49,5255,57,64,68,73,76,80,85,91,148152 1 nonrandomized trial,90 and 1 retrospective cohort165), 7 adult nonsurgical studies (1 randomized controlled trial167 and 6 crossover studies170,171,173176), and 1 pediatric nonsurgical study104 comparing the effects of drinking protein-containing clear liquids with fasting or noncaloric clear liquids. Accepted for publication October 26, 2016. When these fasting guidelines are not followed, compare the risks and benefits of proceeding, with consideration given to the amount and type of liquids or solids ingested. Single-dose oral omeprazole for reduction of gastric residual acidity in adults for outpatient surgery. The impact of oral carbohydrate-rich supplement taken two hours before caesarean delivery on maternal and neonatal perioperative outcomesA randomized clinical trial. 8,827. (Chair). Both the consultants and ASA members disagree that gastrointestinal stimulants should be routinely administered before elective procedures requiring general anesthesia, regional anesthesia, or procedural sedation and analgesia in patients with no apparent increased risk for pulmonary aspiration. None of the studies received industry support, and 1 study noted author conflict of interest. Protection against pulmonary acid aspiration with ranitidine. A randomized crossover study of the effects of glutamine and lipid on the gastric emptying time of a preoperative carbohydrate drink. Finally, there is a need for education of patients, their caregivers, and healthcare providers regarding avoidance of preoperative fasting beyond the recommended durations and the detrimental effects of prolonged fasting. Gastric fluid volume and pH after fentanyl, enflurane, or halothane-nitrous oxide anesthesia with or without atropine or glycopyrrolate. Association of nausea and length of stay with carbohydrate loading prior to total joint arthroplasty. Do preoperative oral carbohydrates improve postoperative outcomes in patients undergoing coronary artery bypass grafts? Preoperative fasting abbreviation (enhanced recovery after surgery protocol) and effects on the metabolism of patients undergoing gynecological surgeries under spinal anesthesia: A randomized clinical trial. The previous update was developed by an ASA-appointed Task Force of ten members, including anesthesiologists in both private and academic practice from various geographic areas of the United States and consulting methodologists from the ASA Committee on Standards and Practice Parameters. 8,061. Ultrasonographic evaluation of gastric emptying after ingesting carbohydrate-rich drink in young children: A randomized crossover study. A preliminary study using real-time ultrasound. Supplemental tables 13 and 14 (https://links.lww.com/ALN/C934) detail the strength-of-evidence ratings. All protein-containing clear liquids in the trials included carbohydrates, precluding assessment of liquids containing only protein. Tobacco Use and Cessation. Influence of preoperative fasting time on maternal and neonatal blood glucose level in elective caesarean section under subarachnoid block. 1,3 Reproductive and Developmental Risks Effect of preoperative intravenous carbohydrate loading on preoperative discomfort in elective surgery patients. Pulmonary aspiration of gastric contents is a rare but potentially life-threatening complication. When relevant, decision-informative, and practicable, pairwise and network random-effects meta-analyses of randomized controlled trials were conducted.10,11 Nonrandomized studies were considered in the assessment of harms when there was infrequent reporting of harms in randomized controlled trials. The lack of sufficient scientific evidence in the literature may occur when the evidence is either unavailable (i.e., no pertinent studies found) or inadequate. Preoperative carbohydrate loading and intraoperative goal-directed fluid therapy for elderly patients undergoing open gastrointestinal surgery: A prospective randomized controlled trial. The guideline task force included anesthesiologists, epidemiology-trained methodologists, and a patient representative, who was chosen from contacts of the task force and who had experience as a patient. All meta-analyses are conducted by the ASA methodology group. Cimetidine for prophylaxis of aspiration pneumonitis: comparison of intramuscular and oral dosage schedules. RCTs report equivocal findings for gastric volume and acidity when histamine-2 receptor antagonists (i.e., cimetidine, ranitidine) are combined with gastrointestinal stimulants (i.e., metoclopramide) compared with either drug alone (Category A2-E evidence).56,5860,105107 RCTs comparing histamine-2 receptor antagonists or metoclopramide with sodium citrate report equivocal findings for gastric volume and acidity (Category A2-E evidence).57,106. Eligible studies included randomized and nonrandomized trials, quasiexperimental, cohort (prospective and retrospective), and case-control designs. When an equal number of categorically distinct responses are obtained, the median value is determined by calculating the arithmetic mean of the two middle values. A double-blind comparison of cimetidine and ranitidine as prophylaxis against gastric aspiration syndrome. A randomized placebo controlled trial of preoperative carbohydrate drinks and early postoperative nutritional supplement drinks in colorectal surgery. Patient positioning such that a magnet cannot be used (prone, lateral, severe obesity, etc.). Anesthesiology 2023; 138:132151 doi: https://doi.org/10.1097/ALN.0000000000004381. About the Guidelines The Guidelines Committee has established several task forces to elaborate guidelines on the related subject. Evidence categories refer specifically to the strength and quality of the research design of the studies. A Tool to Screen Patients for Obstructive Sleep Apnea, ACE (Anesthesiology Continuing Education), One-hour Clear Liquid Fasting in Pediatric Patients, Appendix: Study and Patient Characteristics, https://doi.org/10.1097/ALN.0000000000004381, https://CRAN.R-project.org/package=netmeta, https://CRAN.R-project.org/package=metasens, https://gdt.gradepro.org/app/handbook/handbook.html, 2023 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting: Carbohydrate-containing Clear Liquids with or without Protein, Chewing Gum, and Pediatric Fasting DurationA Modular Update of the 2017 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting, 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: A Report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade, 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway, Add Chewing Gum to 6-Hour Fasting Guidelines. Responses to atropine, glycopyrrolate, and riopan of gastric fluid pH and volume in adult patients. Effect of routine preoperative fasting on residual gastric volume and acid in patients undergoing myomectomy. Site Management asa npo guidelines 2020 chewing tobacco Download PDF 2 MB. The consultants and ASA members both strongly agree that, when antacids are indicated for selected patients, only nonparticulate antacids should be used. The incidence and outcome of perioperative pulmonary aspiration in a university hospital: A 4-year retrospective analysis. Safe pre-operative fasting times after milk or clear fluid in children. Preoperative fasting of 2 hours minimizes insulin resistance and organic response to trauma after video-cholecystectomy: A randomized, controlled, clinical trial. Are you hungry? The effect of shortening the pre-operative fluid fast on postoperative morbidity. Safety and benefit of pre-operative oral carbohydrate in infants: A multi-center study in China. Procedures in which upper airway protective reflexes may be impaired. Industry support was reported in 16 trials, and author conflict of interest was reported in 12 (10%) studies. Large volumes of apple juice preoperatively do not affect gastric pH and volume in children. General variance-based effect-size estimates or combined probability tests were obtained for continuous outcome measures, and Mantel-Haenszel odds ratios were obtained for dichotomous outcome measures. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints, and are not intended to replace local institutional policies. Support was provided by the American Society of Anesthesiologists (Schaumburg, Illinois) and developed under the direction of the Committee on Practice Parameters, Karen B. Domino, M.D., M.P.H. Although the literature is insufficient to evaluate the influence of preoperatively adding milk or milk products to clear liquids (e.g., tea or coffee) on either pulmonary aspiration, gastric volume, pH, or gastric emptying, some studies with healthy volunteer subjects have reported equivocal findings for gastric volume and gastric emptying when these products are added to clear liquids.5254. Anesthesia care during procedures refers to general anesthesia, regional anesthesia, or procedural sedation and analgesia. appropriate fasting period. Support was provided solely from institutional and/or departmental sources. Prolonged fasting has well described adverse consequences. Society for Ambulatory Anesthesia 12th Annual Meeting, Orlando, Florida, 1997. These studies were combined with 133 pre-2010 articles used in the previous update, resulting in a total of 175 articles found acceptable as evidence for these guidelines. Medications that block gastric acid secretion may be preoperatively administered to patients at increased risk of pulmonary aspiration. Assessment of gastric emptying of maltodextrin, coffee with milk and orange juice during labour at term using point of care ultrasound: A non-inferiority randomised clinical trial. I'm now going for no booze or caffeine for Lent. In adults, evidence comparing fasting with chewing gum was inconsistent with respect to patient-rated hunger92 or thirst92,93 (very low strength of evidence). These guidelines are intended for use by anesthesiologists and other anesthesia providers. The ASA members disagree and the consultants strongly disagree that preoperative anticholinergics should be routinely administered before elective procedures requiring general anesthesia, regional anesthesia, or procedural sedation and analgesia to decrease the risk of pulmonary aspiration. Meta-analyses from other sources are reviewed but not included as evidence in this document. See the Tobacco and Nicotine CessationGuideline for additional information. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. All other recommendations from the 2017 guideline still apply. Anesthesiology, V 126 No 3 376 March 2017: Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures An Updated Report by the American Society of Anesthesiologists Task According to the American Society of Anesthesiologists (ASA) Preoperative Fasting Guidelines for Healthy Patients of All Ages, it is recommended that all patients abstain from drinking clear liquids 2 hours prior to elective surgery. If I take food in through an enteral or nasogastric tube (e.g., gastric/stomach tube, enteral/jejunostomy tube, etc.) Comparison of the Effect of Pre-operative Single Oral Dose of Tramadol and Famotidine on Gastric Secretions pH and Volume in Patients Scheduled for Laparoscopic Cholecystectomy. Determinants of liquid gastric emptying: comparisons between milk and isocalorically adjusted clear fluids. Comparative trial of the effect of ranitidine and cimetidine on gastric secretion in fasting patients at induction of anaesthesia. When warranted, the Task Force may add educational information or cautionary notes based on this information. Guidelines to the practice of anesthesia Revised edition 2022. Effect of the preoperative administration of water on gastric volume and pH. asa npo guidelines 2020 chewing tobacco asa npo guidelines 2020 chewing tobacco vo 9 Thng Su, 2022 vo 9 Thng Su, 2022 Clinical and metabolic results of fasting abbreviation with carbohydrates in coronary artery bypass graft surgery. For adults undergoing elective procedures with general anesthesia, regional anesthesia, or procedural sedation, what are the benefits and harms of carbohydrate-containing clear liquids ingested until 2h before the procedure compared with fasting and noncaloric clear liquids? 11 (Technical Guideline for Sample Handling of Smokeless Tobacco and Smokeless Tobacco Products) to describe the appropriate storage and preparation of tobacco. How to perform a meta-analysis with R: A practical tutorial. In 2015, the ASA Committee on Standards and Practice Parameters requested that the updated guidelines published in 2011 be re-evaluated. Impact of enhanced recovery after surgery with preoperative whey protein-infused carbohydrate loading and postoperative early oral feeding among surgical gynecologic cancer patients: An open-labelled randomized controlled trial. First, the Task Force reached consensus on the criteria for evidence. Comparators of interest include, Carbohydrate- and protein-containing clear liquids alone and in combination. Rectal and oral cimetidine for prophylaxis of aspiration pneumonitis in paediatric anaesthesia. You will also find usable tools to guide your practice and help you integrate tobacco treatment into routine clinical care. Attenuation of gastric effects of famotidine by preoperative administration of intravenous fluids. Preoperative fastingnihil per os a difficult myth to break down: A randomized controlled study. The consultants agree and the ASA members strongly agree that for otherwise healthy neonates (< 44 gestational weeks) and infants, fasting from the intake of breast milk for 4 or more hours before elective procedures requiring general anesthesia, regional anesthesia, or procedural sedation and analgesia should be maintained. American Society of Anesthesia Definitions of Types of Sedation: General Concepts The primary options a patient has for intravenous (IV) sedation during gastroenterological procedures include: Mild Sedation and Moderate Sedation Breathing takes place independently The patient remains responsive to stimuli Ingestion of glutamine and maltodextrin two hours preoperatively improves insulin sensitivity after surgery: A randomized, double blind, controlled trial. Ultrasound-guided assessment of gastric residual volume in patients receiving three types of clear fluids: A randomised blinded study. The mean age of participants was 43.2 yr, and 64% were female. Survey responses from Task Forceappointed expert consultants are reported in summary form in the text, with a complete listing of consultant survey responses reported in appendix 2 (table 3). Girish P. Joshi, Basem B. Abdelmalak, Wade A. Weigel, Monica W. Harbell, Catherine I. Kuo, Sulpicio G. Soriano, Paul A. Stricker, Tommie Tipton, Mark D. Grant, Anne M. Marbella, Madhulika Agarkar, Jaime F. Blanck, Karen B. Domino; 2023 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting: Carbohydrate-containing Clear Liquids with or without Protein, Chewing Gum, and Pediatric Fasting DurationA Modular Update of the 2017 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting. Oral carbohydrate supplementation reduces preoperative discomfort in laparoscopic cholecystectomy. Impact of oral carbohydrate consumption prior to cesarean delivery on preoperative well-being: A randomized interventional study. Guidance regarding the cigarette tax rate increase was provided in the Virginia Cigarette Tax Rate Increase . And I'd probably RSI them anyway. Influence of cigarette smoking on the risk of acid pulmonary aspiration. Pre-operative oral carbohydrate loading in colorectal surgery: A randomized controlled trial. A complete bibliography of articles used to develop these updated guidelines, organized by section, is available as Supplemental Digital Content 2, http://links.lww.com/ALN/B348. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints, and are not intended to replace local institutional policies. The overall assessment of aspiration risk may not rely on ASA Physical Status alone, as many of the comorbidities that qualify patients for a higher ASA Physical Status score may be unrelated to delayed gastric emptying or aspiration risk (for example, poorly controlled hypertension). Ninety-six percent of the respondents indicated that the guidelines would have no effect on the amount of time spent on a typical case. Southern African Journal of Anaesthesia and Analgesia 2020; 26(2)(Supplement 1):S1-75 SVI Foreword to the 2020-2025 edition of the SASA Guidelines for the safe use of procedural sedation and analgesia for diagnostic and therapeutic procedures in adults Writing guidelines on procedural sedation and analgesia is a formidable and challenging task. Preoperative oral carbohydrate administration to ASA III-IV patients undergoing elective cardiac surgery. Two combined probability tests were employed as follows: (1) the Fisher combined test, producing chi-square values based on logarithmic transformations of the reported P values from the independent studies, and (2) the Stouffer combined test, providing weighted representation of the studies by weighting each of the standard normal deviates by the size of the sample.
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