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Hunger Games: Impact of Fasting Guidelines for Orthopedic Procedural Sedation in the Pediatric Emergency Department
Robert J Stewart1, Carson D Strickland2, Jeffrey R Sawyer3
1Le Bonheur Children's Hospital, Memphis, Tennessee.
Insights
Fasting before pediatric procedural sedation for orthopedic procedures does not increase adverse events but significantly lengthens emergency department stays. Adhering to fasting guidelines delays care without improving safety outcomes in pediatric procedural sedation.
Area of Science:
- Pediatric Emergency Medicine
- Anesthesiology
- Health Services Research
Background:
- Fasting guidelines for pediatric procedural sedation have historically been debated.
- Recent evidence suggests fasting status does not impact adverse events during sedation.
Purpose of the Study:
- To evaluate adverse outcomes and departmental efficiency in pediatric emergency departments (PEDs) when fasting guidelines are not strictly followed for orthopedic interventions.
- To determine the impact of adhering to American Society of Anesthesiologists (ASA) fasting guidelines on patient flow and safety during procedural sedation.
Main Methods:
- A retrospective chart review of 2674 pediatric patients undergoing procedural sedation for orthopedic injuries between 2011 and 2018.
- Patients were grouped based on adherence to ASA fasting guidelines: pre-presentation fasting, fasting within the PED, or no fasting.
- Primary outcomes included length of stay, time to sedation, sedation duration, and adverse events.
Main Results:
- Patients who fasted in the PED to meet ASA guidelines experienced significantly longer lengths of stay and admission-to-sedation times (approx. 80 minutes longer).
- No significant differences were observed in sedation length or discharge time across groups.
- Adverse events were rare (0.02%), with vomiting being the most common, and no significant difference in adverse events was found among the fasting groups.
Conclusions:
- Following ASA fasting guidelines for pediatric procedural sedation in the PED leads to significantly longer patient stays without improving safety.
- The value of streamlining care and reducing wait times in busy PEDs is highlighted, as fasting adherence does not enhance sedation safety.
- Adverse events associated with pediatric procedural sedation are infrequent and not correlated with fasting status.
Background:
Fasting guidelines for pediatric procedural sedation have historically been controversial. Recent literature suggests that there is no difference in adverse events regardless of fasting status.
Objectives:
The goal of this study was to examine adverse outcomes and departmental efficiency when fasting guidelines are not considered during pediatric emergency department (PED) sedation for orthopedic interventions.
Methods:
Retrospective chart review identified 2674 patients who presented to a level I PED and required procedural sedation for orthopedic injuries between February 2011 and July 2018. This was a level III, retrospective cohort study. Patients were categorized into the following groups: already within American Society of Anesthesiologists (ASA) fasting guidelines on presentation to the PED (n = 671 [25%]), had procedural sedation not within the ASA guidelines (n = 555 [21%]), and had procedural sedation after fasting in the PED to meet ASA guidelines (n = 1448 [54%]). Primary outcomes were length of stay, time from admission to start of sedation, length of sedation, time from end of sedation to discharge, and adverse events.
Discussion:
There was a significant difference in the length of stay and time from admission to sedation-both approximately 80 min longer in those with procedural sedation after fasting in the PED to meet ASA guidelines (p < 0.001). There was no significant difference among groups in length of sedation or time to discharge after sedation. Adverse events were uncommon, with only 55 total adverse events (0.02%). Vomiting during the recovery phase was the most common (n = 17 [0.006%]). Other notable adverse events included nine hypoxic events (0.003%) and five seizures (0.002%). There was no significant difference in adverse events among the groups.
Conclusions:
Length of stay in the PED was significantly longer if ASA fasting guidelines were followed for children requiring sedation for orthopedic procedures. This is a substantial delay in a busy PED where beds and resources are at a premium. Although providing similar care with equivalent outcomes, the value of spending less time in the PED is evident. Overall, adverse events related to sedation are rare and not related to fasting guidelines.
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