Many guidelines still call for patients to be properly
fasted prior to ED procedural sedation. Although this is steeped in consensus
and tradition, is this really beneficial?
No.
This was a planned
secondary analysis of a multicentre prospective cohort study of 6183 children who received parenteral
procedural sedation in one of 6 Canadian
ED’s.
They compared fasted
and non-fasted children with the occurrence of pulmonary aspiration,
adverse events, serious adverse events and vomiting.
Results?
Most children were very
healthy at baseline. 80% of the procedures were for orthopaedic reductions
and laceration repairs. Two thirds of
children got ketamine alone. (This is obviously a different cohort from
those patients that get treated in the operating theatre.)
How many children
were not properly fasted?
About 50% for solids
and 5% for liquids.
In the end, there was no
association between fasting and any bad outcomes. This is concordant with
all of the previous studies on this subject.
Naysayers can complain about the limitations of this study; not huge enough to make definitive
claims about safety, ketamine is airway protective, conducted in tertiary centres,
and it was not randomised.
The excellent accompanying editorial by Steve Green (Dr Ketamine) shreds these arguments with further
evidence. In addition, he emphasises many of the potential harms
of fasting.
Even before this study was published, the American Collegeof Emergency Physicians (ACEP) 2014 clinical policy recommended not to delay procedures
solely on fasting time.
Outside the USA, I would imagine most of us have quietly changed
our practice anyway and don’t consider fasting to be a mandatory requirement. Perhaps
is time to formally change our policies.
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