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PED-EM-L  August 2009

PED-EM-L August 2009

Subject:

Re: NPO Guidelines

From:

Rob Ojala <[log in to unmask]>

Reply-To:

Rob Ojala <[log in to unmask]>

Date:

Mon, 3 Aug 2009 12:19:34 +1200

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (1408 lines)

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."
	> >> >
	> >> >
	> >> >
	> >> >
	> >> >
	> >> > *********
	> >> >
	> >> >
	> >> >
	> >> > -----------------------------------------
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	> >>
	> >
	> >For more information, send mail to
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	>    http://listserv.brown.edu/ped-em-l.html
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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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	--- 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
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	confidential and may contain medical information intended for an
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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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	> >
	> >For more information, send mail to
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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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