Association of Preprocedural Fasting With Outcomes of Emergency Department Sedation in Children

Abstract

; for the Sedation Safety Study Group of Pediatric Emergency Research Canada IMPORTANCE It is not clear whether adherence to preprocedural fasting guidelines prevent pulmonary aspiration and associated adverse outcomes during emergency department (ED) sedation of children. OBJECTIVE To examine the association between preprocedural fasting duration and the incidence of sedation-related adverse outcomes in a large sample of children. DESIGN, SETTING, AND PARTICIPANTS We conducted a planned secondary analysis of a multicenter prospective cohort study of children aged 0 to 18 years who received procedural sedation for a painful procedure in 6 Canadian pediatric EDs from July 2010 to February 2015. The primary risk factor was preprocedural fasting duration. Secondary risk factors were age, sex, American Society of Anesthesiologists classification, preprocedural and sedation medications, and procedure type. MAIN OUTCOMES AND MEASURES Four outcomes were examined: (1) pulmonary aspiration, (2) the occurrence of any adverse event, (3) serious adverse events, and (4) vomiting. RESULTS A total of 6183 children with a median age of 8.0 years (interquartile range, 4.0-12.0 years), of whom 6166 (99.7%) had healthy or mild systemic disease (American Society of Anesthesiologists levels I or II), were included in the analysis. Of these, 2974 (48.1%) and 310 (5.0%) children did not meet American Society of Anesthesiologists fasting guidelines for solids and liquids, respectively. There were no cases of pulmonary aspiration. There were 717 adverse events (11.6%; 95% CI, 10.8%-12.4%), of which 68 (1.1%; 95% CI, 0.9%-1.3%) were serious adverse events and 315 (5.1%; 95% CI, 4.6%-5.7%) were vomiting. The odds ratio

An international multidisciplinary consensus statement on fasting before procedural sedation in adults and children

“…Indeed, there have been only two cases of aspiration reported in the emergency department setting; both patients had been fasted (2 hours liquids, 6 hours solids) before sedation, and both made a full recovery [20]. Multiple Emergency Department observational series have not identified any association between non-compliance with elective fasting guidelines and complications or adverse outcomes [11,[64][65][66][67][68][69][70][71].…”

“Full Stomach” Despite the Wait: Point‐of‐care Gastric Ultrasound at the Time of Procedural Sedation in the Pediatric Emergency Department

“…Two recent studies in the PED setting have evaluated the relationship between duration of preprocedural fasting and the risk of sedation‐related adverse events . In a multicenter prospective cohort study of sedation safety, 48.1% of the 6,166 children receiving procedural sedation did not meet fasting guidelines.…”

“…In a multicenter prospective cohort study of sedation safety, 48.1% of the 6,166 children receiving procedural sedation did not meet fasting guidelines. There were no cases of clinically apparent pulmonary aspiration, and the authors found no association between fasting duration and any adverse event and concluded that “delaying sedation to meet established fasting guidelines does not improve sedation outcomes for children in the ED and is not warranted.” A nonrandomized before‐and‐after comparison of 2,188 children concluded that shortening preprocedural fasting from 6 to 3 hours did not result in increased vomiting and decreased ED length of stay . These studies suggest that fasting prior to procedural sedation may be unnecessary, particularly in otherwise low‐risk patients, when ketamine is the sedative agent …”

Unscheduled Procedural Sedation: A Multidisciplinary Consensus Practice Guideline

“…Time is of the essence for urgent and emergent procedures-not just to minimize physical harm from the active condition, but to minimize distress for the patient and their family. Delaying procedural sedation for reasons not supported by evidence [23][24][25][26][27][28][29][30][31] may result in extended periods of unremitting pain and anxiety with a negligible decrease in risk and must be avoided.…”