We use standard anesthesia based NPO guidelines, however, they are just guidelines.
Six months plus
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 Cordle FACEP, FAAP, FAAEM.
Medical Director: Division of Pediatric Emergency Medicine
Fellowship Director: PEM Fellowship
Levine Children's Hospital
Department of Emergency Medicine
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