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

The multidisciplinary International Committee for the Advancement of Procedural Sedation presents the first fasting and aspiration prevention recommendations specific to procedural sedation, based on an extensive review of the literature. These were developed using Delphi methodology and assessment of the robustness of the available evidence. The literature evidence is clear that fasting, as currently practiced, often substantially exceeds recommended time thresholds and has known adverse consequences, for example, irritability, dehydration and hypoglycaemia. Fasting does not guarantee an empty stomach, and there is no observed association between aspiration and compliance with common fasting guidelines. The probability of clinically important aspiration during procedural sedation is negligible. In the post-1984 literature there are no published reports of aspiration-associated mortality in children, no reports of death in healthy adults (ASA physical status 1 or 2) and just nine reported deaths in adults of ASA physical status 3 or above. Current concerns about aspiration are out of proportion to the actual risk. Given the lower observed frequency of aspiration and mortality than during general anaesthesia, and the theoretical basis for assuming a lesser risk, fasting strategies in procedural sedation can reasonably be less restrictive. We present a consensus-derived algorithm in which each patient is first risk-stratified during their pre-sedation assessment, using evidence-based factors relating to patient characteristics, comorbidities, the nature of the procedure and the nature of the anticipated sedation technique. Graded fasting precautions for liquids and solids are then recommended for elective procedures based upon this categorisation of negligible, mild or moderate aspiration risk. This consensus statement can serve as a resource to practitioners and policymakers who perform and oversee procedural sedation in patients of all ages, worldwide.

Intranasal fentanyl and inhaled nitrous oxide for fracture reduction: The FAN observational study.

INTRODUCTION: Procedural sedation and analgesia (PSA) are frequently used for fracture reduction in pediatric emergency departments (ED). Combining intranasal (IN) fentanyl with inhalation of nitrous oxide (N2O) allow for short recovery time and obviates painful and time-consuming IV access insertions. METHODS: We performed a bicentric, prospective, observational cohort study. Patients aged 4-18years were included if they received combined PSA with IN fentanyl and N2O for the reduction of mildly/moderately displaced fracture or of dislocation. Facial Pain Scale Revised (FPS-R) and Face, Leg, Activity, Cry, Consolability (FLACC) scores were used to evaluate pain and anxiety before, during and after procedure. University of Michigan Sedation Score (UMSS), adverse events, detailed side effects and satisfaction of patients, parents and medical staff were recorded at discharge. A follow up telephone call was made after 24-72h. RESULTS: 90 patients were included. There was no difference in FPS-R during the procedure (median score 2 versus 2), but the FLACC score was significantly higher as compared to before (median score 4 versus 0, Δ 2, 95% CI 0, 2). Median UMSS was 1 (95% CI 1, 2). We recorded no serious adverse events. Rate of vomiting was 12% (11/84). Satisfaction was high among participants responding to this question 85/88 (97%) of parents, 74/83 (89%) of patients and 82/85 (96%) of physicians would want the same sedation again. CONCLUSION: PSA with IN fentanyl and N2O is effective and safe for the reduction of mildly/moderately displaced fracture or dislocation, and has a high satisfaction rate.

Adolescents in mental health crisis: the role of routine follow-up calls after emergency department visits.

To improve care of adolescents in mental health crisis, the role of routine follow-up calls in discharged patients with referral plans after emergency department (ED) presentation to a children's hospital was explored. Main outcome measure was patient attendance at referral sites. In 113 mental health patients with follow-up appointments, either patient/carers or corresponding referral services could be contacted. Median age was 14 years, 77% were girls, and most presentations were after self-harm/depression (61%). Eighty-three per cent (95% CI 75% to 90%) were compliant with the discharge plan without prompting from the ED staff. Fourteen per cent (95% CI 8% to 22%) did not comply after being called by ED staff, and only 3% (95% CI 1% to 7%) were persuaded to attend their outpatient care after being prompted by ED staff. Routine follow-up calls for adolescent mental health patients after ED care are not warranted in all settings.

Limited analgesic efficacy of nitrous oxide for painful procedures in children.

STUDY OBJECTIVE: Nitrous oxide (N(2)O) is an attractive agent for procedural analgesia and sedation of children in the emergency department (ED). Despite increasing use, efficacy data for painful procedures are limited. This study aimed to determine pain scores during ED procedural sedation with N(2)O in the ED setting. METHODS: Prospective observational study of N(2)O use as a sole agent for procedural analgesia at a tertiary children's hospital ED. Pain scores were obtained from patients and parents using visual analogue or faces scales, as appropriate. Parent and staff satisfaction with sedation and analgesia were assessed. RESULTS: 124 children aged 1-17 years (mean 8.1) underwent procedural analgesia with N(2)O for 131 procedures. Most procedures were orthopaedic (44%) or laceration repair (30%). In 51% of patients (95% CI 42% to 60 to 23%) pain scores remained unchanged and in 34% (95% CI 26% to 43%) pain scores increased. Overall, 34% (95% CI 26% to 43%) patients had intraprocedural scores of 50 mm or greater and 21% (95% CI 14% to 29%) had pain scores of 70 mm or greater. Some procedures such as fracture reduction had a larger proportion of patients with high pain scores or 50 mm or greater (45%) and 70 mm or greater (29%). Staff rated both sedation and analgesia as "adequate" in 92%. Parents contacted in follow-up were satisfied or very satisfied with procedures in 96% and sedations in 93%. CONCLUSION: Data indicate that parents and staff are generally satisfied with N(2)O for procedural use in the ED. The efficacy of N(2)O as a sole agent in very painful procedures is limited.

Prophylaxis against possible human immunodeficiency virus exposure after nonoccupational needlestick injuries or sexual assaults in children and adolescents.

BACKGROUND: Nonoccupational human immunodeficiency virus (HIV) postexposure prophylaxis (PEP) for adults has been described, although the Centers for Disease Control and Prevention, Atlanta, Ga, offer no specific recommendations. There is limited information about its use in children and adolescents. OBJECTIVE: To describe the current practices of physicians in pediatric infectious disease (PID) and pediatric emergency medicine (PEM) departments regarding nonoccupational HIV PEP for children and adolescents. DESIGN: Survey. PARTICIPANTS: Directors of all PID and PEM departments with fellowship programs in the United States and Canada between July and November 1998. MAIN OUTCOME MEASURES: General questions regarding HIV PEP and questions concerning 2 scenarios (5-year-old with a needlestick injury and a 15-year-old after sexual assault). RESULTS: The return rate was 67 (78%) of 86 for PID and 36 (75%) of 48 for PEM physicians. Fewer than 20% of physicians reported institutional policies for nonoccupational HIV PEP; 33% had ever initiated nonoccupational HIV PEP. In both scenarios, PID physicians were more likely than PEM physicians to recommend or offer HIV PEP in the first 24 hours after the incident (55 [83%] of 66 vs 20 [56%] of 36 for needlestick injuries [odds ratio, 4.0; 95% confidence interval, 1.6-10.1] and 47 [72%] of 65 vs 16 [50%] of 32 for sexual assault [odds ratio, 2.6; 95% confidence interval, 1.1-6.3]). Seven different antiretroviral agents in single, dual, or triple drug regimens administered for 2 to 12 weeks were suggested. CONCLUSIONS: Although few physicians reported institutional policies, and only one third had ever initiated HIV PEP, many would offer or recommend HIV PEP for children and adolescents within 24 hours after possible HIV exposure. A wide variation of regimens have been suggested. There is a need for a national consensus for nonoccupational HIV PEP.

Paediatric acute asthma management in Australia and New Zealand: practice patterns in the context of clinical practice guidelines.

OBJECTIVES: To compare clinical practice guideline (CPG) recommendations and reported physician management of acute paediatric asthma in the 11 largest paediatric emergency departments, all of which have CPGs, in Australia (n = 9) and New Zealand (n = 2). All 11 sites participate in the Paediatric Research in Emergency Departments International Collaborative (PREDICT) research network. METHODS: (a) A review of CPGs for acute childhood asthma from all PREDICT sites. (b) A standardised anonymous survey of senior emergency doctors at PREDICT sites investigating management of acute childhood asthma. RESULTS: CPGs for mild to moderate asthma were similar across sites and based on salbutamol delivery by metered dose inhaler with spacer and oral prednisolone. In severe to critical asthma, differences between sites were common and related to recommendations for: ipratropium use; metered-dose inhaler versus nebulised delivery of salbutamol in severe asthma; use of intravenous aminophylline, intravenous magnesium and dosing of intravenous salbutamol in critical asthma. The questionnaire (78 of 83 doctors responded) also revealed significant differences between doctors in the treatment of moderate to severe asthma. Ipratropium was used for moderate asthma by 42%. For severe to critical asthma, nebulised delivery of salbutamol was preferred by 79% of doctors over metered dose inhalers. For critical asthma, doctors reported using intravenous aminophylline in 45%, intravenous magnesium in 55%, and intravenous salbutamol in 87% of cases. Thirty-nine different dosing regimens for intravenous salbutamol were reported. CONCLUSIONS: CPG recommendations and reported physician practice for mild to moderate paediatric asthma management were broadly similar across PREDICT sites and consistent with national guidelines. Practice was highly variable for severe to critical asthma and probably reflects limitations of available evidence. Areas of controversy, in particular the comparative efficacy of intravenous bronchodilators, would benefit from multi-centre trials. Collaborative development of CPGs should be considered.