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Original Investigation
July 2018

Association of Preprocedural Fasting With Outcomes of Emergency Department Sedation in Children

Author Affiliations
  • 1Department of Pediatrics, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
  • 2Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  • 3Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  • 4Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  • 5Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
  • 6Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
  • 7School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
  • 8Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
  • 9Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
  • 10Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
  • 11Department of Pediatrics, the Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
  • 12Department of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
  • 13Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada
  • 14Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, Montreal, Quebec, Canada
  • 15Department of Pediatrics, University of Minnesota Medical School, Minneapolis
  • 16Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis
JAMA Pediatr. 2018;172(7):678-685. doi:10.1001/jamapediatrics.2018.0830
Key Points

Question  Does the duration of preprocedural fasting alter the risk pulmonary aspiration and associated adverse outcomes in children undergoing emergency department procedural sedation?

Findings  In this study of 6183 healthy patients undergoing sedation in 1 of 6 geographically separate and nationally representative Canadian emergency departments, 2974 (48.1%) did not meet fasting guidelines prior to sedation. Data analysis failed to identify an association between preprocedural fasting of any duration and any type of adverse event, and there were no cases of clinically apparent pulmonary aspiration.

Meaning  Delaying sedation to meet established fasting guidelines appears not to improve sedation outcomes for children in the emergency department.

Abstract

Importance  It is not clear whether adherence to preprocedural fasting guidelines prevent pulmonary aspiration and associated adverse outcomes during emergency department (ED) sedation of children.

Objective  To examine the association between preprocedural fasting duration and the incidence of sedation-related adverse outcomes in a large sample of children.

Design, Setting, and Participants  We conducted a planned secondary analysis of a multicenter prospective cohort study of children aged 0 to 18 years who received procedural sedation for a painful procedure in 6 Canadian pediatric EDs from July 2010 to February 2015. The primary risk factor was preprocedural fasting duration. Secondary risk factors were age, sex, American Society of Anesthesiologists classification, preprocedural and sedation medications, and procedure type.

Main Outcomes and Measures  Four outcomes were examined: (1) pulmonary aspiration, (2) the occurrence of any adverse event, (3) serious adverse events, and (4) vomiting.

Results  A total of 6183 children with a median age of 8.0 years (interquartile range, 4.0-12.0 years), of whom 6166 (99.7%) had healthy or mild systemic disease (American Society of Anesthesiologists levels I or II), were included in the analysis. Of these, 2974 (48.1%) and 310 (5.0%) children did not meet American Society of Anesthesiologists fasting guidelines for solids and liquids, respectively. There were no cases of pulmonary aspiration. There were 717 adverse events (11.6%; 95% CI, 10.8%-12.4%), of which 68 (1.1%; 95% CI, 0.9%-1.3%) were serious adverse events and 315 (5.1%; 95% CI, 4.6%-5.7%) were vomiting. The odds ratio (OR) of occurrence of any adverse event, serious adverse events, and vomiting did not change significantly with each additional hour of fasting duration for both solids (any adverse event: OR, 1.00; 95% CI, 0.98 to 1.02; serious adverse events, OR, 1.01; 95% CI, 0.95-1.07; vomiting: OR, 1.00; 95% CI, 0.97-1.03) and liquids (any adverse event: OR, 1.00; 95% CI, 0.98-1.02; serious adverse events: 1.01, 95% CI, 0.95-1.07; vomiting: OR, 1.00; 95% CI, 0.96-1.03).

Conclusions and Relevance  In this study, there was no association between fasting duration and any type of adverse event. These findings do not support delaying sedation to meet established fasting guidelines.

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