Procedural sedation in the ed – part 1 preprocedural fasting – emottawa

However, procedural sedation is also an extraordinarily resource-intensive endeavor. Most often, it requires cardiac monitoring and many interprofessional personnel. Also, despite its frequent use, it is an area where there is significant practice variation and many controversies.

In this post, the first in a two-part series, we will delve into these controversies regarding procedural sedation and explore how to reduce resource utilization and ED length of stay. To illustrate these points, let’s begin with a case. Case

In PART 2, we will review the safety profile and adverse event rates of Ketamine and Propofol – two commonly used agents in procedural sedation. We will subsequently explore whether agent choice affects sedation time and ED LOS.

Aspiration during Sedation – How common is it? OR Data

Knowing that general anesthesia in the OR and out-of-OR procedural sedation are fundamentally different, what do the guidelines recommend regarding procedural sedations in the ED environment? Fasting Prior to Procedural Sedation – The Guidelines

Traditionally, it has been suggested that patients should meet fasting guidelines prior to procedural sedation. This teaching predominately comes from the ASA’s Practice Guideline for Sedation and Analgesia by Non-Anesthesiologists published in 2002 (and earlier iterations).

This overview of guidelines shows a wide variation in recommendations regarding preprocedural fasting by various guiding agencies. This suggests that preprocedural fasting is still an area of controversy. Let’s see what the contemporary literature shows. Fasting Prior to Procedural Sedation – Review of Recent Literature

In approximately 46 500 ED based procedural sedations described in the recent literature, >4800 of which were performed in patients who had not met fasting criteria, there were only 2 reported cases of aspiration 11–20; both of these were in adults who had met fasting guidelines.

ACEP’s Clinical Policy on Procedural Sedation in the ED recommends that we do not delay procedural sedation based on fasting time alone and a review of the existing literature supports this recommendation. There is no evidence that preprocedural fasting reduces rates of adverse events including aspiration.

We are taught to consider the adverse events related to sedating non-fasted patients, but rarely do we think about the downsides of delaying an important procedure. Fasting increases our patients’ length of stay in the Emergency Department. Furthermore, delaying procedures leaves patients in pain/discomfort longer, requiring more opioid analgesia as they wait, and potentially makes the procedure more difficult (e.g. dislocations become more difficult to reduce with time, atrial fibrillation can become more difficult to cardiovert the longer patients are in it, etc.). Caveats & Directions for Future Research

The vast majority of recommendations presented above come from data derived from studies of healthy (ASA I & II) patients. There is insufficient data in the literature exploring the relationship between rates of adverse events and fasting duration in high ASA class patients. This is an area that requires further research.

• AMERICAN SOCIETY OF ANESTHESIOLOGISTS COMMITTEE. Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures. Anesthesiology. 2011;114(3):495-511. doi:10.1097/ALN.0b013e3181fcbfd9.

• Cote CJ, Wilson S. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatrics. 2016;138(1):e20161212-e20161212. doi:10.1542/peds.2016-1212.

• Smits GJP, Kuypers MI, Mignot LAA, et al. Procedural sedation in the emergency department by Dutch emergency physicians: A prospective multicentre observational study of 1711 adults. Emerg Med J. 2017;34(4):237-242. doi:10.1136/emermed-2016-205767.

• Roback MG, Bajaj L, Wathen JE, Bothner J. Preprocedural fasting and adverse events in procedural sedation and analgesia in a pediatric emergency department: Are they related? Ann Emerg Med. 2004;44(5):454-459. doi:10.1016/j.annemergmed.2004.03.015.

• Bell A, Treston G, McNabb C, Monypenny K, Cardwell R. Profiling adverse respiratory events and vomiting when using propofol for emergency department procedural sedation. EMA – Emerg Med Australas. 2007;19(5):405-410. doi:10.1111/j.1742-6723.2007.00982.x.