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.

Pulmonary aspiration during procedural sedation: a comprehensive systematic review.

Background: Although pulmonary aspiration complicating operative general anaesthesia has been extensively studied, little is known regarding aspiration during procedural sedation. Methods: We performed a comprehensive, systematic review to identify and catalogue published instances of aspiration involving procedural sedation in patients of all ages. We sought to report descriptively the circumstances, nature, and outcomes of these events. Results: Of 1249 records identified by our search, we found 35 articles describing one or more occurrences of pulmonary aspiration during procedural sedation. Of the 292 occurrences during gastrointestinal endoscopy, there were eight deaths. Of the 34 unique occurrences for procedures other than endoscopy, there was a single death in a moribund patient, full recovery in 31, and unknown recovery status in two. We found no occurrences of aspiration in non-fasted patients receiving procedures other than endoscopy. Conclusions: This first systematic review of pulmonary aspiration during procedural sedation identified few occurrences outside of gastrointestinal endoscopy, with full recovery typical. Although diligent caution remains warranted, our data indicate that aspiration during procedural sedation appears rare, idiosyncratic, and typically benign.

General trauma in a pediatric emergency department: spectrum and consultation patterns.

To assess the consultation patterns of pediatric emergency physicians in the management of injured children and to describe the spectrum of pediatric trauma, we retrospectively reviewed 601 patients treated in the emergency department for injuries during four one-week periods at a designated level I regional pediatric trauma center (50,000 patients/year) with a pediatric emergency medicine fellowship. The majority (94%) of pediatric trauma was minor; only 2% of children had injuries severe enough to require direct transfer to the operating room. The highest volume of patients, the greatest number of consultations, and the majority of admissions to the operating room occurred between 4 PM and midnight. No patients went to the operating room on the night shift. Musculoskeletal injuries constituted the predominant category of pediatric trauma, and lacerations were the most common specific injury. One half of all procedures involved laceration repair, and one third involved splinting or casting. Four hundred ten patients (68%) were managed by physicians in the emergency department without consultation. The orthopedic service performed one half of all consultations and admitted the largest number of patients; the majority of patients taken directly to the operating room had musculoskeletal injuries.(ABSTRACT TRUNCATED AT 250 WORDS)

The spectrum and frequency of illness presenting to a pediatric emergency department.

Knowledge of the spectrum and relative frequencies of pediatric emergencies is an important factor in developing appropriate training curricula for physicians treating children in emergency departments. To provide these data, we reviewed the records for four one-week periods (January, April, July, and October) of a large pediatric emergency department to describe the population in terms of age, chief complaints, diagnoses, time of arrival, seasonal variation, and disposition. There were 3796 log entries. Complete information on all variables was obtained on 3784 patients. Age ranged from one day to 39 years, and the mean age was 6.0 +/- 6.15 years. One half of all emergency department visits were by children three years old or younger. On the other hand, 12% of visits were by adolescents (ages 13 to 18), and one in 25 visits was made by an adult (greater than 18 years old). The majority of chief complaints and final diagnoses were related to infection and trauma. More than half of the patients arrived on the evening shift, between 4 pm and 12 am. Eleven percent of the children seen on day and evening shifts and 13% from the night shift were admitted. From the analysis of our data we recommend expanded skills in the management of minor trauma for pediatric residents, an emphasis on management of infections for nonpediatric emergency specialists, and extensive training in both pediatric and adult trauma for physicians in pediatric emergency medicine fellowships.