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Do patients need to fast before procedural sedation?
Background: “Hi there, Johnny. I see your arm is bent at an impossible angle and you’re in extreme pain. Unfortunately you had some crisps 30 minutes ago so we’ll have to let you sit here for another 5 hours till we can fix it.” Admittedly, this is a rare scenario these days, but what about the older lady who presents hypotensive with fast AF? Do you wait, bolusing IV fluids and nervously watching the monitor until she has been NBM (NPO for our American friends) for enough time to cardiovert? What is the evidence for fasting before procedural sedation? This is the largest prospective ED study of this topic to date.
The paper: A planned secondary analysis of a multi-centre cohort study, involving 6,183 children who were undergoing parenteral conscious sedation for painful procedures (mostly fracture reduction, but also foreign body removal, abscess I&D, laceration repair and lumbar puncture). The commonest agent used was ketamine, but propofol and midazolam were used in many. The ASA fasting guidelines for solid food (6 hours) were not met in 48% of cases (5% did not meet the 2-hour requirement for liquids). There was no difference in any of the outcome measures across these groups (aspiration, vomiting or other adverse event). There were in fact no cases of aspiration at all. The commonest adverse events were oxygen desaturation (5.5%) and vomiting (5.1%), but most vomits occurred during recovery. Of the 6 children who vomited during the sedation itself, 3 had been fasting for at least 10 hours before the procedure. (JAMA Pediatrics, July 2018)
The bottom line: This study does not support delaying sedation to meet established fasting guidelines in children
Note: This study is by no means a lone outlier. Each of the following papers had a similar conclusion, some extending the evidence to an adult population: Agrawal 2003, Roback 2004, Treston 2004, Bell 2007, McKee 2008, Thorpe 2010, Taylor 2011, Beach 2016. In all, there are around 20,000 ED cases of procedural sedation reported in the literature, and only 2 reported clinically important aspiration events (one patient was NBM for 6hr, the other for 24hr). Aspiration is a risk that is trivially small and is not reduced by fasting. I think we can let our patients eat.
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By Barrie StevensonBackground: “Hi there, Johnny. I see your arm is bent at an impossible angle and you’re in extreme pain. Unfortunately you had some crisps 30 minutes ago so we’ll have to let you sit here for another 5 hours till we can fix it.” Admittedly, this is a rare scenario these days, but what about the older lady who presents hypotensive with fast AF? Do you wait, bolusing IV fluids and nervously watching the monitor until she has been NBM (NPO for our American friends) for enough time to cardiovert? What is the evidence for fasting before procedural sedation? This is the largest prospective ED study of this topic to date.
The paper: A planned secondary analysis of a multi-centre cohort study, involving 6,183 children who were undergoing parenteral conscious sedation for painful procedures (mostly fracture reduction, but also foreign body removal, abscess I&D, laceration repair and lumbar puncture). The commonest agent used was ketamine, but propofol and midazolam were used in many. The ASA fasting guidelines for solid food (6 hours) were not met in 48% of cases (5% did not meet the 2-hour requirement for liquids). There was no difference in any of the outcome measures across these groups (aspiration, vomiting or other adverse event). There were in fact no cases of aspiration at all. The commonest adverse events were oxygen desaturation (5.5%) and vomiting (5.1%), but most vomits occurred during recovery. Of the 6 children who vomited during the sedation itself, 3 had been fasting for at least 10 hours before the procedure. (JAMA Pediatrics, July 2018)
The bottom line: This study does not support delaying sedation to meet established fasting guidelines in children
Note: This study is by no means a lone outlier. Each of the following papers had a similar conclusion, some extending the evidence to an adult population: Agrawal 2003, Roback 2004, Treston 2004, Bell 2007, McKee 2008, Thorpe 2010, Taylor 2011, Beach 2016. In all, there are around 20,000 ED cases of procedural sedation reported in the literature, and only 2 reported clinically important aspiration events (one patient was NBM for 6hr, the other for 24hr). Aspiration is a risk that is trivially small and is not reduced by fasting. I think we can let our patients eat.