Pre-procedural fasting in emergency sedation

Emergency physicians frequently undertake emergency procedural sedation in non-fasted patients. At present, no UK guidelines exist for pre-procedural fasting in emergency sedation, and guidelines from the North American Association of Anesthesiologists (ASA) designed for general anaesthesia (GA) are extrapolated to emergency care. A systematic review of the literature was conducted with the aim of evaluating the evidence for risk of pulmonary aspiration during emergency procedural sedation in adults. All abstracts were read and relevant articles identified. Further literature was identified by hand-searching reference sections. Papers were objectively evaluated for relevance against pre-determined criteria. The risk of aspiration in emergency procedural sedation is low, and no evidence exists to support pre-procedural fasting. In several large case series of adult and paediatric emergency procedural sedation, non-fasted patients have not been shown to be at increased risk of pulmonary aspiration. There is only one reported case of pulmonary aspiration during emergency procedural sedation, among 4657 adult cases and 17 672 paediatric cases reviewed. Furthermore, ASA guidelines for fasting prior to GA are based on questionable evidence, and there is high-level evidence that demonstrates no link between pulmonary aspiration and non-fasted patients. There is no reason to recommend routine fasting prior to procedural sedation in the majority of patients at the Emergency Department. However, selected patients believed to be significantly more prone to aspiration may benefit from risk:benefit assessment prior to sedation.