Pediatrics
Preprocedural fasting state and adverse events in children undergoing procedural sedation and analgesia in a pediatric emergency department

https://doi.org/10.1016/S0196-0644(03)00516-XGet rights and content

Abstract

Study objective

Assessment of preprocedural fasting is considered essential in minimizing the risks of procedural sedation and analgesia. Established fasting guidelines are difficult to follow in the emergency department (ED). We characterize the fasting status of patients receiving procedural sedation and analgesia in a pediatric ED and assess the relationship between fasting status and adverse events.

Methods

A prospective case series was conducted in a children's hospital ED during an 11-month period. All consecutive patients requiring procedural sedation and analgesia were included. Preprocedural fasting state and adverse events were recorded. The percentage of patients undergoing procedural sedation and analgesia who did not meet fasting guidelines was determined. Adverse events were analyzed in relation to fasting status.

Results

One thousand fourteen patients underwent procedural sedation and analgesia, and data on fasting status were available for 905 (89%) patients. Of these 905 patients, 509 (56%; 95% confidence interval [CI] 53% to 60%) did not meet fasting guidelines. Seventy-seven adverse events occurred in 68 (6.7%; 95% CI 5.2% to 8.4%) of the 1,014 patients. All adverse events were minor and successfully treated. Adverse events occurred in 32 (8.1%; 95% CI 5.6% to 11.2%) of 396 patients who met and 35 (6.9%; 95% CI 4.8% to 9.4%) of 509 patients who did not meet fasting guidelines. There was no significant difference in median fasting duration between patients with and without adverse events and between patients with and without emesis. Emesis occurred in 15 (1.5%) patients. There were no episodes of aspiration (1-sided 97.5% CI 0% to 0.4%).

Conclusion

Fifty-six percent of children undergoing ED procedural sedation and analgesia were not fasted in accordance with established guidelines. There was no association between preprocedural fasting state and adverse events.

Introduction

The assessment of preprocedural fasting (defined as complete fasting, ie, neither solids nor liquids by mouth) is widely held to be essential in minimizing the risk of aspiration during procedural sedation and analgesia1 in the emergency department (ED).2 Age-based guidelines for preprocedural fasting for elective procedures (Table 1) have been published by the American Academy of Pediatrics (AAP)3, 4 according to similar guidelines set by the American Society of Anesthesiologists (ASA).5, 6 However, these consensus-based guidelines are difficult to follow for nonelective ED procedures and present a special challenge in the pediatric ED, where children are rarely fasted before their presentation and often require urgent or emergency procedures for acute injuries.

Previous studies have demonstrated the safety of procedural sedation and analgesia for children in the ED.2, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17 However, the fasting state of patients undergoing ED procedural sedation and analgesia has not been adequately characterized, and data on optimal fasting times are lacking.2, 5, 6, 18, 19, 20, 21 Furthermore, the relationship between fasting status and adverse events during procedural sedation and analgesia in the pediatric ED has not been studied.

The primary objective of our study was to characterize the fasting status of patients receiving procedural sedation and analgesia in a pediatric ED. Secondary objectives included assessing the relationship of preprocedural fasting state to observed adverse events.

Section snippets

Materials and methods

We conducted a prospective observational study in the ED of a large, urban, pediatric teaching hospital with a pediatric emergency medicine fellowship program.

All consecutive ED patients who required intravenous, intramuscular, oral, rectal, or inhalational agents for painful procedures or diagnostic imaging studies were included in 2 data collection intervals during an 11-month period (pilot study, August to October 2001; extended study, February to September 2002). Emergency attending

Results

One thousand four hundred seventy patients were dispensed sedative, dissociative, or analgesic medications from the Pyxis during the study period. Of these patients, 456 were excluded because the medications were administered for purposes other than procedural sedation and analgesia, leaving 1,014 patients who received procedural sedation and analgesia. Ages ranged from 5 days to 31 years, with a median age of 5.4 years. Five hundred eighty (57%) were male patients. According to the ASA

Limitations

Our study has several limitations. Some adverse events may not have been captured by the present study design because we did not follow up patients once they were discharged from the ED. Adverse events, including emesis, could have occurred on the way home or at home. Given that all patients were required by ED protocol24 to be at baseline (awake and alert) before discharge, we would not expect any significant adverse events to have occurred after ED discharge.

In addition, our study included

Discussion

The difficulty of following established fasting guidelines during ED procedural sedation and analgesia has been discussed in the emergency medicine literature, but the percentage of ED patients not conforming to fasting guidelines has not been documented. Furthermore, the adverse event rate associated with appropriately fasted versus nonfasted patients during ED procedural sedation and analgesia has not been characterized. Consensus-based AAP/ASA guidelines for preprocedural fasting for

References (29)

  • American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists

    Practice guidelines for sedation and analgesia by non-anesthesiologists

    Anesthesiology

    (1996)
  • American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists

    Practice guidelines for sedation and analgesia by non-anesthesiologists

    Anesthesiology

    (2002)
  • SM Green et al.

    Intravenous ketamine for pediatric sedation in the emergency department: safety profile with 156 cases

    Acad Emerg Med

    (1998)
  • H Sedik

    Use of intravenous methohexital as a sedative in pediatric emergency departments

    Arch Pediatr Adolesc Med.

    (2001)
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    Author contributions: DA and BK conceived of and designed the study. DA oversaw the data collection, and SFM and RG assisted in data collection. DA and BK analyzed the data and drafted the manuscript. All authors contributed substantially to the manuscript's revisions. DA and BK take responsibility for the paper as a whole.

    Presented at the American Academy of Pediatrics annual meeting, Boston, MA, October 2002; the Pediatric Academic Societies' annual meeting, Seattle, WA, May 2003; and the Society for Academic Emergency Medicine annual meeting, Boston, MA, May 2003.

    The authors report this study did not receive any outside funding or support.

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