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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]> wrote:


From: Lennarz, William :LPH Dir. ES <[log in to unmask]>
Subject: Re: NPO Guidelines
To: [log in to unmask]
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] <mailto:[log in to unmask]>
] On Behalf Of Michael Verive
Sent: Thursday, July 30, 2009 9:59 AM
To: [log in to unmask]
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]> wrote:

> From: Fergus Thornton <[log in to unmask]>
> Subject: Re: NPO Guidelines
> To: [log in to unmask]
> 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]>
> >Sent: Jul 29, 2009 10:43 PM
> >To: [log in to unmask]
> >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]>
> wrote:
> >
> >> From: David Herd <[log in to unmask]>
> >> Subject: Re: NPO Guidelines
> >> To: [log in to unmask]
> >> 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]
> >> 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
> >> reliance on the
> >> > information it contains. Thank you.
> >> >
> >> > For more information, send mail to [log in to unmask]
> >> with the message: info PED-EM-L
> >> > The URL for the PED-EM-L Web Page is:
> >> >             
> >>    http://listserv.brown.edu/ped-em-l.html
<http://listserv.brown.edu/ped-em-l.html> 
> >>
> >>
> >> For more information, send mail to [log in to unmask] with
> >> the message: info PED-EM-L The URL for the PED-EM-L Web Page is:
> >>                 http://listserv.brown.edu/ped-em-l.html
<http://listserv.brown.edu/ped-em-l.html> 
> >>
> >>
> >> Confidentiality Note: This e-mail and/or any
> attachment to
> >> it contains, or may contain, privileged and
> confidential
> >> information intended only for the use of the
> individual(s)
> >> named in the e-mail. If you are not the intended
> recipient,
> >> or the person responsible for delivering it to the
> intended
> >> recipient, please permanently delete it from your
> computer
> >> system and promptly notify me.
> >> For more information, send mail to [log in to unmask] with
> >> the message: info PED-EM-L The URL for the PED-EM-L Web Page is:
> >>                 http://listserv.brown.edu/ped-em-l.html
<http://listserv.brown.edu/ped-em-l.html> 
> >>
> >
> >For more information, send mail to [log in to unmask]
> with the message: info PED-EM-L
> >The URL for the PED-EM-L Web Page is:
> >             
>    http://listserv.brown.edu/ped-em-l.html
<http://listserv.brown.edu/ped-em-l.html> 
>
>
> Fergus Thornton
> read my blog @ http://docdownunder.wordpress.com
<http://docdownunder.wordpress.com> 
>
> For more information, send mail to [log in to unmask]
> with the message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>              
>    http://listserv.brown.edu/ped-em-l.html
<http://listserv.brown.edu/ped-em-l.html> 
>

For more information, send mail to [log in to unmask] with the
message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
                 http://listserv.brown.edu/ped-em-l.html
<http://listserv.brown.edu/ped-em-l.html> 



For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
                 http://listserv.brown.edu/ped-em-l.html


--- On Thu, 7/30/09, Lennarz, William :LPH Dir. ES <[log in to unmask]> wrote:


From: Lennarz, William :LPH Dir. ES <[log in to unmask]>
Subject: Re: NPO Guidelines
To: [log in to unmask]
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] <mailto:[log in to unmask]>
] On Behalf Of Michael Verive
Sent: Thursday, July 30, 2009 9:59 AM
To: [log in to unmask]
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]> wrote:

> From: Fergus Thornton <[log in to unmask]>
> Subject: Re: NPO Guidelines
> To: [log in to unmask]
> 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]>
> >Sent: Jul 29, 2009 10:43 PM
> >To: [log in to unmask]
> >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]>
> wrote:
> >
> >> From: David Herd <[log in to unmask]>
> >> Subject: Re: NPO Guidelines
> >> To: [log in to unmask]
> >> 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]
> >> 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
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> >> use of the Medical Review Committee of the
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> >> protected pursuant to Article 5 of the Hospital
> Licensure
> >> Act of North Carolina, Section 131E-95, and is not
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> >> record within the meaning of North Carolina G.S.
> 132-1."
> >> >
> >> >
> >> >
> >> >
> >> >
> >> > *********
> >> >
> >> >
> >> >
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