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PED-EM-L  August 2009

PED-EM-L August 2009

Subject:

Re: NPO Guidelines

From:

"Lennarz, William :LPH Dir. ES" <[log in to unmask]>

Reply-To:

Lennarz, William :LPH Dir. ES

Date:

Mon, 3 Aug 2009 14:35:33 -0700

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (1468 lines)

Or maybe northwestern US... We do around 300 sedations per year in the
peds ED, maybe more at this point.  We have no standard in place
dictating pre-sedation fasting, though we note their "last meal" status
in our pre-sedation eval.  We have not had any aspirations in my 4.5
year tenure here.  I know of one vomiting episode during sedation (vs.
recovery).  That pt. was discharged home after prolonged observation.

(We use more ketamine than propafol, but use both.  Many of us give
ondanstron prior to every sedation)

Billy Lennarz


William M Lennarz, MD, FAAP, FAAEM

Director, Pediatric Emergency Services, Legacy Health System and Legacy
Emanuel Children's Hospital
Emanuel Hospital Room 3067
2801 N Gantenbein
Portland, OR 97227
phone 503.413.2844
fax 503.413.4216
cell 804.307.9328



The information contained in this email message is legally privileged,
confidential and may contain medical information intended for an
established health care provider of the named patient or those involved
in official peer review.  The entire contents of this email
communication (including any subsequent email communication attaching,
responding to or discussing the subject email communication) is
privileged pursuant to ORS 41.675 and 41.685, RCW 4.24.250 and
70.41.200, the federal Health Care Quality Improvement Act of 1986, and
other applicable law.   It is intended ONLY for this use.  If the reader
of this message is not the intended recipient you are hereby notified
that any dissemination, distribution or copying of this email is
strictly prohibited.  If you receive this email in error, please notify
us immediately by telephone 503-413-2844 and destroy this communication.


-----Original Message-----
From: Pediatric Emergency Medicine Discussion List
[mailto:[log in to unmask]] On Behalf Of Rob Ojala
Sent: Sunday, August 02, 2009 5:20 PM
To: [log in to unmask]
Subject: Re: NPO Guidelines

Fair point Mick - I wasn't trying to be awkward -but your 12000 cases
don't confirm or refute the benefit of NPO to me. DO I really need to
wait six[etc] hours?

what I'd love to hear is from some place that largely disregarded NPO in
children [possibly northern European locales] -what actually happened to
such a 'control' group so to speak.



Regards,



Rob



________________________________

From: mick connors [mailto:[log in to unmask]]
Sent: Monday, 3 August 2009 12:00 p.m.
To: [log in to unmask]; Rob Ojala
Subject: Re: NPO Guidelines



Rob,



My point was intended to be simple.  Having experienced 3 deeply sedated
vomiting patients has made me respect the desire to minimize this risk.
Vomiting and sedation aren't a great combination.   Current npo
guidelines aren't perfect but they have a long track record and is the
standard we have right now..  Bottom line, is that I think npo status
should be a consideration in decision making regarding sedation (as well
as the many other points outlined... )   the ideal npo times are still
up for debate...



I dont' quite follow your second comment -- but clearly the goal is to
determine how to avoid aspiration.. hence empty stomach is ideal, if not
empty - avoiding vomiting, if vomiting occurs -- how to avoid aspiration
(airway protective reflexes intact) etc..



Still curious how many folks are using propofol in the ED?  And if not,
what are the barriers to using it?  clinical? political? 



Mick















--- On Sun, 8/2/09, Rob Ojala <[log in to unmask]> wrote:

       
        From: Rob Ojala <[log in to unmask]>
        Subject: Re: NPO Guidelines
        To: [log in to unmask]
        Date: Sunday, August 2, 2009, 5:24 PM

        Dear Mick,
        At the risk of sounding a little bit facetious....
        While I'm not questioning your obvious experience; how can
having 3
        appropriately starved children vomit under sedation turn you
into a
        believer of NPO guidelines? Is this not a variant of inclusion
bias?-
        you don't know whether the other 11997 odd patients would['nt]
have
        aspirated if they weren't NPO?
       
        Regards,
       
        Rob Ojala
       
        -----Original Message-----
        From: Pediatric Emergency Medicine Discussion List
        [mailto:[log in to unmask]
<[log in to unmask]" target="_blank">http:[log in to unmask]
u> ] On Behalf Of mick connors
        Sent: Saturday, 1 August 2009 10:58 p.m.
        To: [log in to unmask]
<[log in to unmask]" target="_blank">http:[log in to unmask]
u>
        Subject: Re: NPO Guidelines
       
        Fergus, et al...
       
        I think this is a great discussion although a recurring one...
        hopefully this will be an answerable question through more data
        collection and collaboration among ed colleagues.  and would
invite all
        of you to enter data into Society of Pediatric Sedation Research
        Consortium.   The consortium is a great group of institutions
but most
        of the data is from sedation services...(elective outpatient
sedation)
        and more ed data is needed.
       
        Anecdotally, I have directed a sedation service for the last
5+years and
        we have sedated 12000 patients, mostly with propofol..  I have
had 3
        children vomit while deeply sedated even though they met fasting
        guidelines... we also have had a handful that have had food
particles in
        their stomach discovered as the child was sedated for an
egd...(one
        vomited)   We admitted all three for observation and none
developed any
        evidence of aspiration.  Two turned out to have delayed gastric
emptying
        and one had achalasia.
       
        These limited but significantly memorable events have made me a
believer
        in npo guidelines.  Far different from my days of sedating in
the ED,
        where efficiency typically outweighed any interest of mine in
npo
        status... 
       
        I say a believer not in that they always work, as my 3
experiences were
        all in "appropriately" fasted children... but in the fact that
vomiting
        does represent a real risk in the deeply sedated patient and as
Dr.
        Verive mentioned this risk must be weighed with the benefits for
every
        sedation performed.   Also, as ED's move to utilizing more
propofol, we
        ED docs need to recognize that this is a deeper sedation than
the
        benzo/narcotic combo's that most of us have been trained and
have
        utilized to provide sedation in the ED.  Hence, the vomiting
deeply
        sedated has a greater risk (in my opinion) of aspirating than
the child
        who is still being held to accomplish the procedure.  I think we
have to
        be careful about extrapolating all past data from sedation in
the ED...
        ie npo guidelines don't matter ... to drugs such as propofol...
       
        Aspiration risk is rare  but I don't think it is non-existent
even in
        the fasted patient...  hence my belief is that it does need to
be
        considered in patients receiving sedation... along with
co-existent
        medical conditions, airway eval, body habitus,
emergent/urgent/elective,
        depth etc...  all these things should be weighed and ideally
documented
        and if deviated from.. the reasoning should be documented as
well. 
       
        Don't get me wrong --- emergent sedation is needed and I am not
        convinced that sedating a non-fasted child for a 2 minute head
CT is
        more risky than rapid sequence induction/intubation etc...  If
it were
        my child I would sedate them....  but again that would be with
weighing
        and documenting all the above... 
       
       
        Curious how many institutions have propofol available in the
ED??
       
        Mick Connors
        ETCH
        Knoxville
        VP, Society for Pediatric Sedation
       
       
       
        --- On Thu, 7/30/09, Lennarz, William :LPH Dir. ES
<[log in to unmask]
<[log in to unmask]" target="_blank">http:[log in to unmask]> >
        wrote:
       
       
        From: Lennarz, William :LPH Dir. ES <[log in to unmask]
<[log in to unmask]" target="_blank">http:[log in to unmask]> >
        Subject: Re: NPO Guidelines
        To: [log in to unmask]
<[log in to unmask]" target="_blank">http:[log in to unmask]
u>
        Date: Thursday, July 30, 2009, 1:40 PM
       
       
        Having just reviewed the literature and written the chapter on
sedation
        for the next edition of Tintinalli's Emergency Medicine text, I
would
        say that the literature suggests that the risk of aspiration in
        non-fasted children is less than "fairly low"- rather it is
        non-existent.  What is true is that the literature is limited,
and there
        needs to be more done to look at this especially given the high
stakes
        and ever-increasing use of sedation as a valuable adjunct to ED
        procedures.  The Pediatric Sedation Research Consortium, with
30,000+
        cases in its initial analysis, reports a single aspiration event
in a
        child who was fasted.  Numerous other studies fail to show any
        correlation.
       
        Another interesting variable to look at is the routine use of
        ondansetron for sedations.  Our peds anesthesia colleagues, upon
        informal polling by me, seem to use this in almost every case,
        routinely.  I suspect there is a great deal of variation amongst
PEM
        docs regarding its used, routinely, for every ED sedation, even
though
        we know, for example, that ketamine is emetogenic (if that's a
word!).
       
        Billy Lennarz
       
        William M Lennarz, MD, FAAP, FAAEM
       
        Director, Pediatric Emergency Services, Legacy Health System and
Legacy
        Emanuel Children's Hospital
        Emanuel Hospital Room 3067
        2801 N Gantenbein
        Portland, OR 97227
        phone 503.413.2844
        fax 503.413.4216
        cell 804.307.9328
       
       
       
        The information contained in this email message is legally
privileged,
        confidential and may contain medical information intended for an
        established health care provider of the named patient or those
involved
        in official peer review.  The entire contents of this email
        communication (including any subsequent email communication
attaching,
        responding to or discussing the subject email communication) is
        privileged pursuant to ORS 41.675 and 41.685, RCW 4.24.250 and
        70.41.200, the federal Health Care Quality Improvement Act of
1986, and
        other applicable law.   It is intended ONLY for this use.  If
the reader
        of this message is not the intended recipient you are hereby
notified
        that any dissemination, distribution or copying of this email is
        strictly prohibited.  If you receive this email in error, please
notify
        us immediately by telephone 503-413-2844 and destroy this
communication.
       
       
        -----Original Message-----
        From: Pediatric Emergency Medicine Discussion List
        [mailto:[log in to unmask]
<[log in to unmask]" target="_blank">http:[log in to unmask]
u>  <mailto:[log in to unmask]
<[log in to unmask]" target="_blank">http:[log in to unmask]
u> >
        ] On Behalf Of Michael Verive
        Sent: Thursday, July 30, 2009 9:59 AM
        To: [log in to unmask]
<[log in to unmask]" target="_blank">http:[log in to unmask]
u>
        Subject: Re: NPO Guidelines
       
        Fergus,
       
        You're correct.  Recent literature suggests that the risk of
aspiration
        events - especially in children - is fairly low.  The Society of
        Pediatric Sedation is accumulating a vast database of pediatric
        sedations, including adverse effects, and hopefully will publish
results
        shortly.
       
        Since sedation at most institutions is overseen by
anesthesiology, the
        guidelines that are put in place for sedation and analgesia by
        non-anesthesia personnel typically mirror guidelines practiced
by
        anesthesiologists.  In 2006 the ASA, AAP, and AAPD issued joint
        guidelines for sedation and analgesia in children.  This update
was
        fueled in part by the death of a young pediatric patient
receiving
        sedation and analgesia for a dental procedure.  Fasting
recommendations
        published in these guidelines were NPO for 2 hours for clear
liquids, 4
        hours for breast milk, and 6 hours for other liquids and foods.
It was
        stated that further research was needed to "better elucidate the
        relationships between various fasting intervals and sedation
        complications".  Also, "When proper fasting has not been
ensured, the
        increased risks of sedation must be carefully weighed against
its
        benefits, and the lightest effective sedation should be used."
       
        So, in the ED, where very few patients come in having read the
        guidelines, you are often left with the need to sedate without
having
        the luxury of time to assure "proper fasting".  While recent
articles
        indicate that fasting may be unnecessary in pediatric patients,
you have
        to make the clinical decision to weigh risks and benefits.
Published
        guidelines are there to provide guidance, but must be applied in
light
        of specific situations.
       
        Michael J. Verive, MD, FAAP
        Medical Director - Pediatric Intensive Care St. Mary's Hospital
for
        Women and Chldren Evansville, IN 47750
       
       
        --- On Thu, 7/30/09, Fergus Thornton <[log in to unmask]
<[log in to unmask]" target="_blank">http:[log in to unmask]> >
wrote:
       
        > From: Fergus Thornton <[log in to unmask]
<[log in to unmask]" target="_blank">http:[log in to unmask]> >
        > Subject: Re: NPO Guidelines
        > To: [log in to unmask]
<[log in to unmask]" target="_blank">http:[log in to unmask]
u>
        > Date: Thursday, July 30, 2009, 9:23 AM The lit on Ketamine
and, to a
        > lesser extent, propafol, indicate that fasting really isn't
necessary
        > given how low the risk of aspiration is.  So why have this
protocol?
        > (not a criticism, want to
        > learn)
        >
        > -----Original Message-----
        > >From: Michael Verive <[log in to unmask]
<[log in to unmask]" target="_blank">http:[log in to unmask]> >
        > >Sent: Jul 29, 2009 10:43 PM
        > >To: [log in to unmask]
<[log in to unmask]" target="_blank">http:[log in to unmask]
u>
        > >Subject: Re: NPO Guidelines
        > >
        > >David, Randy, et al,
        > >
        > >I believe the most recent guidelines from the ASA and
        > AAP recommend 2 hours for clears, 4 hours for breast milk, and
6 hours
        > for everything else, without regard to age.
        > >
        > >Michael J. Verive, MD, FAAP
        > >
        > >--- On Fri, 7/17/09, David Herd <[log in to unmask]
<[log in to unmask]" target="_blank">http:[log in to unmask]> >
        > wrote:
        > >
        > >> From: David Herd <[log in to unmask]
<[log in to unmask]" target="_blank">http:[log in to unmask]> >
        > >> Subject: Re: NPO Guidelines
        > >> To: [log in to unmask]
<[log in to unmask]" target="_blank">http:[log in to unmask]
u>
        > >> Date: Friday, July 17, 2009, 2:19 PM Randy,
        > >>
        > >> Excellent summary, we were having this discussion
        > today in
        > >> our team meeting. I have forwarded your email to
        > my
        > >> colleagues.
        > >>
        > >> Could you reference the ACEP review paper you
        > mentioned?
        > >> Were you referring to Green SM, Roback MG, Miner
        > JR, Burton
        > >> JH, Krauss B. Fasting and emergency department
        > procedural
        > >> sedation and analgesia: a consensus-based clinical
        > practice
        > >> advisory. Ann Emerg Med 2007;49(4):454-61.
        > >>
        > >> Regards,
        > >>
        > >> David
        > >>
        > >> PS The currency you are using is quite valuable if
        > that is
        > >> only two cents worth.
        > >>
        > >>
        > >> Dr David Herd BSc MBChB FRACP
        > >> Paediatric Emergency Medicine Specialist Mater Children's
Hospital
        > >> South Brisbane, Queensland Australia
        > >>
        > >> Preferred email: [log in to unmask]
<[log in to unmask]" target="_blank">http:[log in to unmask]>
        > >> Voicemail:  +617 3041 0276
        > >> Facsimilie: +617 3041 0288
        > >>
        > >> On 18/07/2009, at 2:00 AM, Cordle, Randy wrote:
        > >>
        > >> > NPO  Guidelines
        > >> >
        > >> > We use standard anesthesia based NPO
        > guidelines,
        > >> however, they are just guidelines.
        > >> >
        > >> > Age
        > >> >
        > >> >
        > >> > Solids/Breast
        > >> >
        > >> > Milk/Formula
        > >> >
        > >> >
        > >> > Clear Liquids
        > >> >
        > >> >
        > >> > 0-6 months
        > >> >
        > >> >
        > >> > 4 Hours
        > >> >
        > >> >
        > >> > 2 Hours
        > >> >
        > >> >
        > >> > Six months plus
        > >> >
        > >> >
        > >> > 6 Hours
        > >> >
        > >> >
        > >> > 2 Hours
        > >> >
        > >> >
        > >> > These guidelines are not evidence based at
        > all:
        > >> specifically not for procedural sedation in an
        > ED/CED.
        > >> I believe ACEP's recent review on this topic is
        > most
        > >> appropriate:
        > >> >
        > >> > *          Level C
        > >> recommendations -
        > >> >
        > >> > -         Recent food
        > >> intake is not a contraindication for
        > administration and
        > >> analgesia, but should be considered in choosing
        > the target
        > >> level of sedation.
        > >> >
        > >> >
        > >> >
        > >> > Level C because the number of patients that
        > would need
        > >> to be studied in RCT to show a meaningful
        > difference would
        > >> be astronomical and, therefore, hasn't and likely
        > will not
        > >> be completed any time soon.
        > >> >
        > >> >
        > >> >
        > >> > What is important:
        > >> >
        > >> > *         Other risk
        > >> factors
        > >> >
        > >> > *         Are we talking
        > >> about a sip of water (not too different than
        > swallowing your
        > >> saliva) vs. just at a whopper with cheese
        > >> >
        > >> > *         Emergence of
        > >> procedure (do they need it done now or can it wait
        > 6 hours)
        > >> >
        > >> > *         Preparation to
        > >> deal with any emesis
        > >> >
        > >> > *         What procedure
        > >> is contemplated (i.e. intraoral work risk higher
        > risk then
        > >> suturing ankle)
        > >> >
        > >> > *         What drug is
        > >> being used (may change likely level, time course,
        > and
        > >> inherent risk of emesis).
        > >> >
        > >> > *         What level and
        > >> duration is anticipated.
        > >> >
        > >> > *         Would it be
        > >> safer to "protect" airway?
        > >> >
        > >> > *         Good consent
        > >> with discussion with parents and in chart
        > regarding
        > >> decision-making.
        > >> >
        > >> > o        If these elements were
        > >> considered, I would have no problem defending a
        > colleague's
        > >> decision to provide appropriate sedation and
        > analgesia in
        > >> the ED.
        > >> >
        > >> >
        > >> >
        > >> > Based on these factors I have a discussion
        > with the
        > >> parents and we make a decision together.  I feel
        > very
        > >> comfortable that the risk is exceedingly small
        > when these
        > >> characteristics are taken into account and that
        > hard fast
        > >> rules likely lead to many children not receiving
        > appropriate
        > >> sedation in a non-evidence based attempt to
        > prevent an
        > >> extraordinarily rare potential event.  BTW
        > meeting NPO
        > >> guidelines does not remove risk aspiration
        > either.
        > >> >
        > >> >
        > >> >
        > >> > Remember:  What kills children during
        > sedation
        > >> and analgesia?
        > >> >
        > >> > 1.      Provider error (occasionally)
        > >> >
        > >> > 2.      Failure to assure patient has
        > >> appropriate reserves (selection of appropriate
        > patients) and
        > >> failure to prepare to rescue the patient should
        > they have
        > >> airway, oxygenation, blood pressure, or other problems.
Failure to
        > >> have appropriate training
        > and
        > >> experience to rescue is the most important point
        > in my
        > >> opinion.  Every case I can recall where a
        > preventable
        > >> negative outcome occurred, it was due to failure
        > to prepare
        > >> or possess the proper skills and training to
        > rescue.
        > >> >
        > >> > a.    Along these lines, I would
        > >> emphatically state that having a PALS card means
        > nearly
        > >> nothing when it comes to the ability to
        > appropriately manage
        > >> a child's airway.  I am not anti-PALS by any
        > means, but
        > >> even the AHA notes clearly that a PALS Card is not
        > a
        > >> certification of skills or abilities but rather
        > just a
        > >> notification that a course was taken.  Prior
        > studies
        > >> have shown it makes one more confident but not
        > better at
        > >> resuscitation.  I believe that privileging based
        > on
        > >> PALS certification is not only silly but also dangerous.
Board
        > >> certification in EM or PEM or
        > similar
        > >> evidence of training and skills should trump this
        > card in
        > >> all cases.  PALS is useful and helps give
        > providers a
        > >> common language and usual approach from which to expand.
It is
        > >> introductory at best.
        > >> >
        > >> >
        > >> >
        > >> > My two cents,
        > >> >
        > >> > Randy
        > >> >
        > >> >
        > >> >
        > >> >
        > >> >
        > >> > Randy Cordle FACEP, FAAP, FAAEM.
        > >> >
        > >> > Medical Director: Division of Pediatric
        > Emergency
        > >> Medicine
        > >> >
        > >> > Fellowship Director: PEM Fellowship
        > >> >
        > >> > Levine Children's Hospital
        > >> >
        > >> > Department of Emergency Medicine
        > >> >
        > >> >
        > >> >
        > >> > "This material is produced by and is for the
        > exclusive
        > >> use of the Medical Review Committee of the
        > Department of
        > >> Emergency Medicine. This material is confidential
        > and
        > >> protected pursuant to Article 5 of the Hospital
        > Licensure
        > >> Act of North Carolina, Section 131E-95, and is not
        > a public
        > >> record within the meaning of North Carolina G.S.
        > 132-1."
        > >> >
        > >> >
        > >> >
        > >> >
        > >> >
        > >> > *********
        > >> >
        > >> >
        > >> >
        > >> > -----------------------------------------
        > >> > This electronic message may contain
        > information that
        > >> is
        > >> > confidential and/or legally privileged. It is
        > intended
        > >> only for the
        > >> > use of the individual(s) and entity named as
        > >> recipients in the
        > >> > message. If you are not an intended recipient
        > of this
        > >> message,
        > >> > please notify the sender immediately and
        > delete the
        > >> material from
        > >> > any computer. Do not deliver, distribute or
        > copy this
        > >> message, and
        > >> > do not disclose its contents or take any
        > action in
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        > read my blog @ http://docdownunder.wordpress.com
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        --- On Thu, 7/30/09, Lennarz, William :LPH Dir. ES
<[log in to unmask]
<[log in to unmask]" target="_blank">http:[log in to unmask]> >
        wrote:
       
       
        From: Lennarz, William :LPH Dir. ES <[log in to unmask]
<[log in to unmask]" target="_blank">http:[log in to unmask]> >
        Subject: Re: NPO Guidelines
        To: [log in to unmask]
<[log in to unmask]" target="_blank">http:[log in to unmask]
u>
        Date: Thursday, July 30, 2009, 1:40 PM
       
       
        Having just reviewed the literature and written the chapter on
sedation
        for the next edition of Tintinalli's Emergency Medicine text, I
would
        say that the literature suggests that the risk of aspiration in
        non-fasted children is less than "fairly low"- rather it is
        non-existent.  What is true is that the literature is limited,
and there
        needs to be more done to look at this especially given the high
stakes
        and ever-increasing use of sedation as a valuable adjunct to ED
        procedures.  The Pediatric Sedation Research Consortium, with
30,000+
        cases in its initial analysis, reports a single aspiration event
in a
        child who was fasted.  Numerous other studies fail to show any
        correlation.
       
        Another interesting variable to look at is the routine use of
        ondansetron for sedations.  Our peds anesthesia colleagues, upon
        informal polling by me, seem to use this in almost every case,
        routinely.  I suspect there is a great deal of variation amongst
PEM
        docs regarding its used, routinely, for every ED sedation, even
though
        we know, for example, that ketamine is emetogenic (if that's a
word!).
       
        Billy Lennarz
       
        William M Lennarz, MD, FAAP, FAAEM
       
        Director, Pediatric Emergency Services, Legacy Health System and
Legacy
        Emanuel Children's Hospital
        Emanuel Hospital Room 3067
        2801 N Gantenbein
        Portland, OR 97227
        phone 503.413.2844
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        -----Original Message-----
        From: Pediatric Emergency Medicine Discussion List
        [mailto:[log in to unmask]
<[log in to unmask]" target="_blank">http:[log in to unmask]
u>  <mailto:[log in to unmask]
<[log in to unmask]" target="_blank">http:[log in to unmask]
u> >
        ] On Behalf Of Michael Verive
        Sent: Thursday, July 30, 2009 9:59 AM
        To: [log in to unmask]
<[log in to unmask]" target="_blank">http:[log in to unmask]
u>
        Subject: Re: NPO Guidelines
       
        Fergus,
       
        You're correct.  Recent literature suggests that the risk of
aspiration
        events - especially in children - is fairly low.  The Society of
        Pediatric Sedation is accumulating a vast database of pediatric
        sedations, including adverse effects, and hopefully will publish
results
        shortly.
       
        Since sedation at most institutions is overseen by
anesthesiology, the
        guidelines that are put in place for sedation and analgesia by
        non-anesthesia personnel typically mirror guidelines practiced
by
        anesthesiologists.  In 2006 the ASA, AAP, and AAPD issued joint
        guidelines for sedation and analgesia in children.  This update
was
        fueled in part by the death of a young pediatric patient
receiving
        sedation and analgesia for a dental procedure.  Fasting
recommendations
        published in these guidelines were NPO for 2 hours for clear
liquids, 4
        hours for breast milk, and 6 hours for other liquids and foods.
It was
        stated that further research was needed to "better elucidate the
        relationships between various fasting intervals and sedation
        complications".  Also, "When proper fasting has not been
ensured, the
        increased risks of sedation must be carefully weighed against
its
        benefits, and the lightest effective sedation should be used."
       
        So, in the ED, where very few patients come in having read the
        guidelines, you are often left with the need to sedate without
having
        the luxury of time to assure "proper fasting".  While recent
articles
        indicate that fasting may be unnecessary in pediatric patients,
you have
        to make the clinical decision to weigh risks and benefits.
Published
        guidelines are there to provide guidance, but must be applied in
light
        of specific situations.
       
        Michael J. Verive, MD, FAAP
        Medical Director - Pediatric Intensive Care St. Mary's Hospital
for
        Women and Chldren Evansville, IN 47750
       
       
        --- On Thu, 7/30/09, Fergus Thornton <[log in to unmask]
<[log in to unmask]" target="_blank">http:[log in to unmask]> >
wrote:
       
        > From: Fergus Thornton <[log in to unmask]
<[log in to unmask]" target="_blank">http:[log in to unmask]> >
        > Subject: Re: NPO Guidelines
        > To: [log in to unmask]
<[log in to unmask]" target="_blank">http:[log in to unmask]
u>
        > Date: Thursday, July 30, 2009, 9:23 AM The lit on Ketamine
and, to a
        > lesser extent, propafol, indicate that fasting really isn't
necessary
        > given how low the risk of aspiration is.  So why have this
protocol?
        > (not a criticism, want to
        > learn)
        >
        > -----Original Message-----
        > >From: Michael Verive <[log in to unmask]
<[log in to unmask]" target="_blank">http:[log in to unmask]> >
        > >Sent: Jul 29, 2009 10:43 PM
        > >To: [log in to unmask]
<[log in to unmask]" target="_blank">http:[log in to unmask]
u>
        > >Subject: Re: NPO Guidelines
        > >
        > >David, Randy, et al,
        > >
        > >I believe the most recent guidelines from the ASA and
        > AAP recommend 2 hours for clears, 4 hours for breast milk, and
6 hours
        > for everything else, without regard to age.
        > >
        > >Michael J. Verive, MD, FAAP
        > >
        > >--- On Fri, 7/17/09, David Herd <[log in to unmask]
<[log in to unmask]" target="_blank">http:[log in to unmask]> >
        > wrote:
        > >
        > >> From: David Herd <[log in to unmask]
<[log in to unmask]" target="_blank">http:[log in to unmask]> >
        > >> Subject: Re: NPO Guidelines
        > >> To: [log in to unmask]
<[log in to unmask]" target="_blank">http:[log in to unmask]
u>
        > >> Date: Friday, July 17, 2009, 2:19 PM Randy,
        > >>
        > >> Excellent summary, we were having this discussion
        > today in
        > >> our team meeting. I have forwarded your email to
        > my
        > >> colleagues.
        > >>
        > >> Could you reference the ACEP review paper you
        > mentioned?
        > >> Were you referring to Green SM, Roback MG, Miner
        > JR, Burton
        > >> JH, Krauss B. Fasting and emergency department
        > procedural
        > >> sedation and analgesia: a consensus-based clinical
        > practice
        > >> advisory. Ann Emerg Med 2007;49(4):454-61.
        > >>
        > >> Regards,
        > >>
        > >> David
        > >>
        > >> PS The currency you are using is quite valuable if
        > that is
        > >> only two cents worth.
        > >>
        > >>
        > >> Dr David Herd BSc MBChB FRACP
        > >> Paediatric Emergency Medicine Specialist Mater Children's
Hospital
        > >> South Brisbane, Queensland Australia
        > >>
        > >> Preferred email: [log in to unmask]
<[log in to unmask]" target="_blank">http:[log in to unmask]>
        > >> Voicemail:  +617 3041 0276
        > >> Facsimilie: +617 3041 0288
        > >>
        > >> On 18/07/2009, at 2:00 AM, Cordle, Randy wrote:
        > >>
        > >> > NPO  Guidelines
        > >> >
        > >> > We use standard anesthesia based NPO
        > guidelines,
        > >> however, they are just guidelines.
        > >> >
        > >> > Age
        > >> >
        > >> >
        > >> > Solids/Breast
        > >> >
        > >> > Milk/Formula
        > >> >
        > >> >
        > >> > Clear Liquids
        > >> >
        > >> >
        > >> > 0-6 months
        > >> >
        > >> >
        > >> > 4 Hours
        > >> >
        > >> >
        > >> > 2 Hours
        > >> >
        > >> >
        > >> > Six months plus
        > >> >
        > >> >
        > >> > 6 Hours
        > >> >
        > >> >
        > >> > 2 Hours
        > >> >
        > >> >
        > >> > These guidelines are not evidence based at
        > all:
        > >> specifically not for procedural sedation in an
        > ED/CED.
        > >> I believe ACEP's recent review on this topic is
        > most
        > >> appropriate:
        > >> >
        > >> > *          Level C
        > >> recommendations -
        > >> >
        > >> > -         Recent food
        > >> intake is not a contraindication for
        > administration and
        > >> analgesia, but should be considered in choosing
        > the target
        > >> level of sedation.
        > >> >
        > >> >
        > >> >
        > >> > Level C because the number of patients that
        > would need
        > >> to be studied in RCT to show a meaningful
        > difference would
        > >> be astronomical and, therefore, hasn't and likely
        > will not
        > >> be completed any time soon.
        > >> >
        > >> >
        > >> >
        > >> > What is important:
        > >> >
        > >> > *         Other risk
        > >> factors
        > >> >
        > >> > *         Are we talking
        > >> about a sip of water (not too different than
        > swallowing your
        > >> saliva) vs. just at a whopper with cheese
        > >> >
        > >> > *         Emergence of
        > >> procedure (do they need it done now or can it wait
        > 6 hours)
        > >> >
        > >> > *         Preparation to
        > >> deal with any emesis
        > >> >
        > >> > *         What procedure
        > >> is contemplated (i.e. intraoral work risk higher
        > risk then
        > >> suturing ankle)
        > >> >
        > >> > *         What drug is
        > >> being used (may change likely level, time course,
        > and
        > >> inherent risk of emesis).
        > >> >
        > >> > *         What level and
        > >> duration is anticipated.
        > >> >
        > >> > *         Would it be
        > >> safer to "protect" airway?
        > >> >
        > >> > *         Good consent
        > >> with discussion with parents and in chart
        > regarding
        > >> decision-making.
        > >> >
        > >> > o        If these elements were
        > >> considered, I would have no problem defending a
        > colleague's
        > >> decision to provide appropriate sedation and
        > analgesia in
        > >> the ED.
        > >> >
        > >> >
        > >> >
        > >> > Based on these factors I have a discussion
        > with the
        > >> parents and we make a decision together.  I feel
        > very
        > >> comfortable that the risk is exceedingly small
        > when these
        > >> characteristics are taken into account and that
        > hard fast
        > >> rules likely lead to many children not receiving
        > appropriate
        > >> sedation in a non-evidence based attempt to
        > prevent an
        > >> extraordinarily rare potential event.  BTW
        > meeting NPO
        > >> guidelines does not remove risk aspiration
        > either.
        > >> >
        > >> >
        > >> >
        > >> > Remember:  What kills children during
        > sedation
        > >> and analgesia?
        > >> >
        > >> > 1.      Provider error (occasionally)
        > >> >
        > >> > 2.      Failure to assure patient has
        > >> appropriate reserves (selection of appropriate
        > patients) and
        > >> failure to prepare to rescue the patient should
        > they have
        > >> airway, oxygenation, blood pressure, or other problems.
Failure to
        > >> have appropriate training
        > and
        > >> experience to rescue is the most important point
        > in my
        > >> opinion.  Every case I can recall where a
        > preventable
        > >> negative outcome occurred, it was due to failure
        > to prepare
        > >> or possess the proper skills and training to
        > rescue.
        > >> >
        > >> > a.    Along these lines, I would
        > >> emphatically state that having a PALS card means
        > nearly
        > >> nothing when it comes to the ability to
        > appropriately manage
        > >> a child's airway.  I am not anti-PALS by any
        > means, but
        > >> even the AHA notes clearly that a PALS Card is not
        > a
        > >> certification of skills or abilities but rather
        > just a
        > >> notification that a course was taken.  Prior
        > studies
        > >> have shown it makes one more confident but not
        > better at
        > >> resuscitation.  I believe that privileging based
        > on
        > >> PALS certification is not only silly but also dangerous.
Board
        > >> certification in EM or PEM or
        > similar
        > >> evidence of training and skills should trump this
        > card in
        > >> all cases.  PALS is useful and helps give
        > providers a
        > >> common language and usual approach from which to expand.
It is
        > >> introductory at best.
        > >> >
        > >> >
        > >> >
        > >> > My two cents,
        > >> >
        > >> > Randy
        > >> >
        > >> >
        > >> >
        > >> >
        > >> >
        > >> > Randy Cordle FACEP, FAAP, FAAEM.
        > >> >
        > >> > Medical Director: Division of Pediatric
        > Emergency
        > >> Medicine
        > >> >
        > >> > Fellowship Director: PEM Fellowship
        > >> >
        > >> > Levine Children's Hospital
        > >> >
        > >> > Department of Emergency Medicine
        > >> >
        > >> >
        > >> >
        > >> > "This material is produced by and is for the
        > exclusive
        > >> use of the Medical Review Committee of the
        > Department of
        > >> Emergency Medicine. This material is confidential
        > and
        > >> protected pursuant to Article 5 of the Hospital
        > Licensure
        > >> Act of North Carolina, Section 131E-95, and is not
        > a public
        > >> record within the meaning of North Carolina G.S.
        > 132-1."
        > >> >
        > >> >
        > >> >
        > >> >
        > >> >
        > >> > *********
        > >> >
        > >> >
        > >> >
        > >> > -----------------------------------------
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        >
        > Fergus Thornton
        > read my blog @ http://docdownunder.wordpress.com
<http://docdownunder.wordpress.com/>
        <http://docdownunder.wordpress.com
<http://docdownunder.wordpress.com/> >
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