Dr Zempsky is correct, my tenor was too cavalier and I don't mean to say
that you should teach residents to sedate children with full stomachs.
I will be cavalier in shooting down dogma that flies in the face of
clinical experience and research which suggests (though admittedly
that there is poor correlation between duration of fasting and volume of
My basic point is this- nearly all patients who I am sedating have had
mouth for two hours simply due to the injury-illness-ER wait- process.
sedated approximately 400 kids (a majority with Ketamine) in the last
without being too rigid about the duration of fasting over and above
this 'two hour'
generalization to which I referred. I have never had an aspiration event
or even a
significant reflux event. My colleagues have had a similar experience.
Perhaps it is
just luck, but I think some of it is because we use reasonable caution,
start with small doses, monitor carefully, use prophylactic
oxygen and good airway positioning.
I'll give you an example of my practice- yesterday I had two completely
displaced radius/ ulna
fractures come in within 20 minutes of each other. The one who presented
second had not
eaten for four hours when he arrived. The other had eaten pizza 30
minutes before he fell.
They were both given IV MS on arrival and ortho was called. We sedated
the second patient first,
and it was about two hours after he presented, using Ketamine 1 mg/kg,
Versed 0.05 mg/kg and glyco-
pyrrolate. By the time we got to the second patient, he had been NPO for
3.5 hours and
we sedated and reduced him similarly. In the same time span, I intubated
an apneic neonate with
RSV and assisted a surgeon removing a upper esophageal coin in an 17
month old using a foley.
(We only have single physician coverage).
Jay Fisher MD
William T. Zempsky wrote:
> I think Dr. Fisher is being a little too cavalier in regards to NPO
> requirements prior to sedation in the ED. In fact the article by
> Ingebo et
> al. discusses 2 hour fasting only in relation to ingestion of clear
> not solids. Also the population studied in this article were patients
> were undergoing elective endoscopy, not our typical ED patient who may
> have a full stomach for other reasons i.e. pain.
> While some patients need sedation immediately it is in our patients
> interest as well as our own to delay sedation when possible.
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