Our local Guru of EBM, Brian Doyle, hosts a monthly Journal Club for the locals. In the spirit of consolidating knowledge and sharing this with the world, with permission, here is a re-post of one of the articles discussed.
For more juicy journals served on a platter, head over to Brian's JC blog: EmergencyMedJc
Bhatt M, Johnson DW, Taljaard M, et al. Association of Preprocedural Fasting with Outcomes of Emergency Department Sedation in Children. JAMA Peiatr. 2018. 172(7):678-685.
Many guidelines still call for patients to be properly fasted prior to ED procedural sedation. Although this is steeped in consensus and tradition, is this really beneficial?
This was a planned secondary analysis of a multicentre prospective cohort study of 6183 children who received parenteral procedural sedation in one of 6 Canadian ED’s.
They compared fasted and non-fasted children with the occurrence of pulmonary aspiration, adverse events, serious adverse events and vomiting.
Most children were very healthy at baseline. 80% of the procedures were for orthopaedic reductions and laceration repairs. Two thirds of children got ketamine alone. (This is obviously a different cohort from those patients that get treated in the operating theatre.)
How many children were not properly fasted?
About 50% for solids and 5% for liquids.
In the end, there was no association between fasting and any bad outcomes. This is concordant with all of the previous studies on this subject.
Naysayers can complain about the limitations of this study; not huge enough to make definitive claims about safety, ketamine is airway protective, conducted in tertiary centres, and it was not randomised.
The excellent accompanying editorial by Steve Green (Dr Ketamine) shreds these arguments with further evidence. In addition, he emphasises many of the potential harms of fasting.
Even before this study was published, the American Collegeof Emergency Physicians (ACEP) 2014 clinical policy recommended not to delay procedures solely on fasting time.
Outside the USA, I would imagine most of us have quietly changed our practice anyway and don’t consider fasting to be a mandatory requirement. Perhaps is time to formally change our policies.
About the Author
Dr Brian Doyle is an emergency physician originally from the United States but now very much calls Tasmania his home. Unfortunately, it will now be a bit more difficult to deport him from the country as he passed his Australian citizenship test a few years ago. (He was able to answer that Phar Lap won the Melbourne rather than the Davis Cup). His main interests are mostly the clinical aspects of emergency medicine but also in education, ultrasound and critical appraisal of the literature. He spends much of his time annoying people to help out with conferences.