Preprocedural Fasting Not Necessary for Children in ED

Veronica Hackethal, MD

May 07, 2018

Fasting before procedures in the pediatric emergency department (ED) does not decrease adverse events related to sedation, according to a study published online today in JAMA Pediatrics.

"These results indicate that delaying sedation to meet established fasting guidelines does not improve sedation outcomes for children in the ED and is not warranted," write Maala Bhatt, MD, a pediatric emergency medicine physician at Children's Hospital of Eastern Ontario in Ottawa, Ontario, Canada, and colleagues with the Sedation Safety Study Group of Pediatric Emergency Research Canada.

"These findings support the recommendation from the American College of Emergency Physicians not to delay ED procedural sedation based solely on fasting time," they add.

Sedation for common procedures such as setting fractures and stitching complicated wounds occurs in about 1 in 100 pediatric ED visits. Although sedation is generally considered safe, about 1% of children experience adverse events, with some being serious. The latter include life-threatening pulmonary aspiration, which occurs when a patients inhales contents of the mouth or stomach into the respiratory tract and/or lungs.

To decrease the risk for pulmonary aspiration, the American Society of Anesthesiologists and American Academy of Pediatrics have established preprocedural fasting guidelines. However, these guidelines were developed for patients undergoing elective procedures, not emergent ones. That has raised questions about whether fasting guidelines should apply to the ED, where procedures must be performed promptly and where the risk for aspiration is considered lower than in the operative setting.

The reality is that nonadherence to fasting guidelines is widespread in the pediatric ED. Fasting can be distressing to children and can increase the risk for dehydration and hypoglycemia. In addition, it can increase the length of stay in the ED, using up valuable healthcare resources.

Past studies have suggested that preprocedural fasting in the pediatric ED may not be necessary. However, these studies were small, and the American Academy of Pediatrics has stated that the link between presedation fasting and serious adverse events is unknown in the pediatric ED.

To clarify the issue, researchers analyzed data from a multicenter prospective study that took place at six nationally representative Canadian pediatric EDs between July 2010 and February 2015. The current study is the largest prospective analysis so far of children who have undergone emergency procedural sedation.

It included 6183 children aged 0 to 18 years (mean age, 8.0 years; 66.7% were boys; 99.7% were either healthy or with mild systemic disease) who received procedural sedation for painful procedures.

Results showed that 48.1% (n = 2974) of children failed to meet American Society of Anesthesiology fasting guidelines for solids, and 5.0% (n = 310) for liquids.

Just 11.6% (n = 717) of children experienced adverse events, of which only 1.1% (n = 68; 95% confidence interval [CI], 0.9% - 1.3%) were serious. The most common adverse events were oxygen desaturation (n = 340; 5.5%; 95% CI, 5.0%-6.1%) and vomiting (n = 315; 5.1%; 95% CI, 4.6% - 5.7%). No cases of pulmonary aspiration occurred.

Results adjusted for age, sex, sedation medication, and procedure showed that the odds of adverse events remained about the same with each additional hour of fasting for both solids (any adverse event: odds ratio [OR], 1.00 [95% CI, 0.98 - 1.02]; serious adverse events, OR, 1.01 [95% CI, 0.95 - 1.07]; vomiting: OR, 1.00 [95% CI, 0.97 - 1.03]) and liquids (any adverse event: OR, 1.00 [95% CI, 0.98 - 1.02]; serious adverse events: 1.01 [95% CI, 0.95 - 1.07]; vomiting: OR, 1.00 [95% CI, 0.96 - 1.03]).

On the basis of these findings, the authors estimated that the risk for pulmonary aspiration among healthy children undergoing sedation in the ED is no more than 3.1 cases per 10,000.

In an accompanying editorial, Steven M. Green, MD, an emergency physician from Loma Linda University in California, and colleagues write that the results confirm many smaller studies conducted during the last 15 years.

"The ED experience thus has consistently failed to identify any measurable consequence from fasting noncompliance," they write.

However, they do not recommend abandoning preprocedural fasting entirely, instead recommending "progressive yet cautious and prudent steps based on current knowledge."

"Bhatt et al show that traditional reliance upon rigidly applied, arbitrary fasting intervals is a practice without evidence of benefit," they conclude. "The risk of pulmonary aspiration in healthy children during procedural sedation is functionally negligible, and the time for fasting reform is past due."

An International Committee for the Advancement of Procedural Sedation is currently preparing the first fasting and aspiration prevention guidelines tailored to procedural sedation.

The study was supported by the Canadian Institute of Health. The authors and editorialists have disclosed no relevant financial relationships.

JAMA Pediatr. Published online May 7, 2018.

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