A Child Needs Sedation: When Is It OK?

Krista Preisberga, MD


January 25, 2013

Significant Aspiration Events

There is a limited number of studies evaluating clinically significant aspiration events during procedural sedation and analgesia. None of the currently available studies were adequately powered to determine the incidence of aspiration in procedural sedation and analgesia. A brief review of the literature is below:

  • In 2002, Hoffman and colleagues[8] published a retrospective cohort analysis of 960 sedation cases with 2 aspiration events that required only observation and supplemental oxygen overnight. Of note, however, both patients had met the strict NPO criteria.

  • A retrospective cohort of 200 infants that received only chloral hydrate for hearing tests reported by Keidan and colleagues[9] found no increased adverse events in the fasted vs the nonfasted group.

  • A retrospective review of a prospective database of 2000 emergency department sedations found no relationship between vomiting and fasting times. No clinical aspirations were detected in this study; however, the study was underpowered to capture a relatively rare event.[10]

  • In a study of 1014 emergency department patients receiving procedural sedation and analgesia, Agrawal and colleagues[11] found no relationship between fasting times and either vomiting (1.5%) or adverse events (6.7%).

  • A study of 260 patients randomly assigned to ketamine/midazolam vs fentanyl/midazolam reported that patients in the ketamine group had more emesis in the recovery phase but found no significant difference between fasting times of patients who experienced vomiting vs those who did not.[12] It is interesting to note that most patients were not fasted prior to sedation.

The American Academy of Pediatrics (AAP) and the American Academy of Pediatric Dentistry have issued a joint guideline for the use of sedation in children undergoing diagnostic and therapeutic procedures.[13] The guideline authors note that "when proper fasting has not been assured, the increased risks of sedation must be carefully weighed against its benefits, and the lightest effective sedation should be used."[13] There is, however, no definite tailored guideline regarding depth of sedation and fasting promulgated by either ASA or AAP. The American College of Emergency Physicians, in a clinical policy on procedural sedation and analgesia, notes: "Recent food intake is not a contraindication for administering procedural sedation and analgesia, but should be considered in choosing the timing and target level of sedation."[14]