Pediatric Procedural Sedation is Safe for Emergency Department Procedures without Fasting

The American College of Physicians (ACEP) has previously published guidelines in October 2013 about Procedural Sedation and Analgesia. In these guidelines, they provided Level B recommendations that state, “Do not delay procedural sedation in adults or pediatrics in the ED based on fasting time.  Preprocedural fasting for any duration has not demonstrated a reduction in the risk of emesis or aspiration when administering procedural sedation and analgesia.”¹ Based on these guidelines, emergency physicians and hospitalists have felt safe performing bedside procedures in adults using moderate-deep procedural sedation without waiting any prespecified period of pre-procedural fasting. Clinicians have always been more hesitant sedating children who are undergoing similar procedures.

A new retrospective cohort study from the University of Tennessee confirms that preprocedural fasting prior to moderate-deep procedural sedation in children does not reduce adverse outcomes and dramatically increases the ED length of stay.  The investigators analyzed 2674 patients admitted to the University of Tennessee ED with orthopedic injuries and categorized the patients into three groups: Group 1 had already met the American Society of Anesthesiologists (ASA) fasting guidelines on ED presentation (25%); Group II underwent procedural sedation not within the ASA guidelines (21%); Group III fasted in the ED until they me the ASA fasting guidelines prior to procedural sedation (54%). The orthopedic procedures that were performed included extremity fracture reductions, joint dislocation reductions, digit repairs, arthrocentesis and casting procedures.

The sedation used included ketamine alone, ketamine + propofol (ketofol), propofol alone, or etomidate. Each group had a similar number of adverse events with emesis and transient hypoxia as the most common adverse events. All episodes of hypoxia were effectively managed with stimulation and jaw thrust maneuvers. There were no episodes of aspiration or need for positive pressure ventilation.

The most important difference between the groups is that Group III (the group that fasted in the ED) had an average length of stay about 1.5 hours longer than the other two groups. This is obviously significant in a busy ED. In summary, this study confirmed the recommendations by ACEP that procedural sedation can be safely performed in both adults and children without any specified preprocedural fasting.

Reference:

1. Godwin SA et al. Clinical Policy: procedural sedation and analgesia in the emergency department. Ann Emer Med. 2014; 63: 247-258
2. Stewart RJ et al. Hunger Games: Impact of Fasting Guidelines for Orthopedic Procedural Sedation in the Pediatric Emergency Department. J Emer Med. 2021; 60 (4): 436-443.