FOAM Eye-Catchers 5: ACEP says fasting is not required for procedural sedation in ED

HOT OFF THE PRESS: ACEP has just published a new Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department, in the February edition of Annals of Emergency Medicine. After reviewing the relevant literature they have made several important recommendations including:

1. Do not delay procedural sedation in adults or pediatrics in the ED based on fasting time. Pre procedural fasting for any duration has not demonstrated a reduction in the risk of emesis or aspiration when administering procedural sedation and analgesia [Level B]

2. Capnography may be used as an adjunct to pulse oximetry and clinical assessment to detect hypoventilation and apnea earlier than pulse oximetry and/or clinical assessment alone in patients undergoing procedural sedation and analgesia in the ED [Level B]

The suggestion to use capnography will probably be obvious to anyone who manages airways these days but the clear guidance that fasting is not required before procedural sedation is an extremely worthwhile evidence based clarification of our clinical practice. Too often in ED we base our practice on policies generated in different patients in different clinical scenarios and blindly accept them without question. ACEP addresses this by stating that fasting guidelines produced by other bodies are based on “extrapolation of general anesthesia cases in the operating room, in which airway manipulation during intubation and extubation increases the aspiration risk”. They go on to dissect the literature and find no basis for fasting before procedural sedation in ED.

Other recommendations in the document include:

– a level C recommendation that in addition to the proceduralist, “a nurse or other qualified individual should be present for continuous monitoring of the patient”

–  that propofol, ketamine or a combination of propofol and ketamine (ketafol) can be safely administered to both children and adults for procedural sedation and analgesia in ED. All were level A recommendations except for ketamine alone in adults which was level C.

The guideline is currently available for free via Annals or ACEP. It is worth reading in full including the discussion of the relevant literature.

Addendum 13/2/14: Of note for Australians, ACEP’s equivalent here ACEM joined intercollegiate Guidelines on Sedation and/or Analgesia for Diagnostic and Interventional Medical, Dental or Surgical Procedures in 2010. Here it states fasting should be assessed but does not specify any required fasting times pre-procedure.

Addendum 19/2/14: Emcrit just released a podcast discussing these new ACEP guidelines.