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

Efficacy and safety of intravenous thiamylal in sedation for colonoscopy in children

Objectives

Since a standard sedation protocol for pediatric colonoscopy (CS) has not been established, evidence on optimal sedative agents is needed. This study aimed to evaluate the efficacy and safety of thiamylal in sedation for pediatric CS compared to midazolam.

Methods

Children from 7 to 16 years of age who underwent CS under sedation with intravenous thiamylal or midazolam at our hospital between June 2010 and March 2024 were included in this retrospective observational study. The primary outcome was the efficacy (success rate of CS without mid-awakening) of the drugs. Meanwhile, the secondary outcomes were the sedation level during CS, procedure time, recovery time, and adverse events related to sedation.

Results

Sixty children were included in the study. The success rate of CS without mid-awakening was significantly higher in the thiamylal group (90.6%) than in the midazolam group (64.3%; p = 0.03). The two groups had no significant differences in median sedation depth, procedure time, or recovery time. Adverse events related to sedation in thiamylal group (22%) and midazolam group (25%) were similar. No severe adverse events were reported.

Conclusions

Intravenous thiamylal provides effective and safe sedation in children requiring CS, with little or no mid-awakening during the procedure.

Current sedation practices for non-invasive procedures in tertiary maternity and children's hospitals in China: a 5-year update

BACKGROUND

Sedation techniques can ease anxiety during medical procedures for children. Our previous report on Chinese sedation practices for non-invasive procedures in 2018 is outdated due to the rapid development of sedation services. This study provides an updated report on sedation practices for non-invasive procedures in China.

METHODS

This is a cross-sectional study. Questionnaires were sent to tertiary maternity and children's hospitals nationwide through the WeChat Mini Program. The survey questioned the location and caseloads of hospitals providing sedation services, support facilities, contraindications, fasting practices, sedation regimens, monitoring practices, staff structure, certification requirements for sedation providers and quality control data.

RESULTS

Procedural sedation for non-invasive procedures were provided in 88 of 114 hospitals. These hospitals are located across the country except Heilongjiang province and the Tibet Autonomous Region. Compared with previous reports, significant increases were found in the number of hospitals providing sedation services, dedicated sedation rooms and recovery rooms and full-time sedation providers. Most hospitals advocated the 2-4-6 rule for pre-sedation fasting. Dexmedetomidine was the most used first-choice sedative. Anaesthesiologists remain the primary sedation providers, but nurses are also important. The most mentioned qualification requirements for sedation providers were a professional title of attending doctor, ≥5 years of working experience in paediatric anaesthesia and paediatric advanced life support certification. Sedation service records were used in 83 hospitals, but only 42 and 39 recorded success rates and adverse events, respectively.

CONCLUSIONS

Sedation services for non-invasive procedures are available in most areas of China. More hospitals now provide sedation services and full-time sedation providers. Supporting facilities and sedation regimens have improved. Non-anaesthesiologist sedation providers are important at current stage, developing training programmes for them may be necessary. Attention should be focused on quality control and improvement of sedation services.

Safety and efficacy of pediatric sedation protocol for diagnostic examination in a pediatric emergency room: A retrospective study

Pediatric patients undergoing diagnostic tests in the pediatric emergency room are frequently sedated. Although efforts are made to prevent adverse events, no sedation protocol has specified the optimal regimen, dosage, and interval of medication to prevent adverse events. This study analyzed the safety and efficacy of sequential pediatric sedation protocols for pediatric patients undergoing diagnostic tests in the pediatric emergency room of a single tertiary medical center. The medical records of patients aged < 18 years who visited the pediatric emergency room of Seoul Asan Medical Center between January and December 2019 for diagnostic testing were retrospectively reviewed. Sedation protocols consisted of 50 mg/kg and 25 mg/kg chloral hydrate, 0.1 mg/kg and 0.1 mg/kg midazolam, and 1 mg/kg and 0.5 to 1 mg/kg ketamine, administered sequentially at intervals of 30, 20, 10, 10, and 10 minutes, respectively. Patients were assessed prior to sedation, and adverse events were investigated. Of the 289 included patients, 20 (6.9%) experienced adverse events, none serious, and nine (3.1%) failed to reach the depth of sedation required to complete the test. The regimen (P = .622) and dosage (P = .777) of the sedatives were unrelated to the occurrence of adverse events when sedation was performed according to protocol. The sedation protocol used in these patients, consisting of sequential administration of minimum dosages, achieved a sufficient depth of sedation with relatively few adverse events, indicating that this protocol can be used safely and effectively for painless sedation in pediatric patients undergoing diagnostic testing.

Physician Self-Reported Practice Patterns: Midazolam for Minor Procedures in Pediatric Patients

Midazolam is frequently used as a single agent to provide minimal sedation (also called anxiolysis) when performing procedures in minor children. Published guidelines on the optimal use of intranasal (INM) and oral midazolam (POM) are lacking. The purpose of this study is to explore the self-reported physician practice related to midazolam use in facilitating minor procedures in children. We developed a survey that was approved by the Academy of Pediatrics Section on Emergency Medicine (APP-SOEM) and was then electronically distributed via its listserve. Questions were posed about the therapeutic and maximum dosing of INM and POM, consideration of Nothing-By-Mouth (NPO) status, use of cardiopulmonary monitors, as well as discharge criteria. There was a 47% (218/465) response rate. For therapeutic INM doses, 65% of responders used a dose range of 0.3 to 0.6 mg/kg, and 75% selected a maximum dose of 10 mg irrespective of the child's weight. About 20% of the responders selected a dosage range of 0.7 to 1 mg/kg for therapeutic POM dose, with 43% opting for a maximum dose of 20 mg irrespective of the child's weight. We observed a dichotomous variation in reported physician use of cardiopulmonary monitors; 42% never employ monitors, and the remainder used monitors some of the time. There was consensus on the NPO status and discharge criteria; 80% of physicians did not consider NPO status prior to midazolam use. The level of alertness was the most commonly selected discharge criterion. This nationwide survey of physicians indicates practice variation with midazolam dosing and cardiopulmonary monitor usage when performing minor procedures in children. Implementing practice guidelines, specifically for minimal sedation with mainstay agents such as midazolam, may standardize physician practice and improve overall patient care.

Residential greenness exposure and decreased prevalence of diabetic retinopathy: A nationwide analysis in China

OBJECTIVE

Diabetic retinopathy (DR) is a leading cause of vision impairment and blindness among diabetics. We aimed to explore whether long-term exposure to residential greenness was beneficial to DR.

RESEARCH DESIGN AND METHODS

We used data from a large-scale, cross-sectional screening survey conducted in 129 cities of 27 provincial regions of China from 2018 to 2021 among patients with diabetes. We measured residential greenness exposure as the 3-year average of annual maximum Normalized Difference Vegetation Index (NDVI) at a spatial resolution of 250 m. DR was assessed by ophthalmologists based on fundus photographs. The primary outcome was DR, and secondary outcome included DR severity status (i.e., nonproliferative and proliferative), hallmarks of retinal lesions and macular oedema.

RESULTS

A total of 484,380 adult participants with diabetes were included in the current analysis, and 15.7% of them were diagnosed with DR. NDVI was inversely and linearly associated with DR prevalence, and an increment of 0.1 NDVI was associated with a 10% (9%-10%) decrease in DR prevalence. Significant and inverse associations were further found for nonproliferative and proliferative DR, hallmarks of lesions and macular oedema. The association between greenness and DR was stronger among participants who were older, obese, lived in the south, had longer duration of diabetes or did not take antidiabetic medications.

CONCLUSIONS

This large-scale nationwide study provides the first-hand epidemiological evidence on the associations of residential greenness with DR. Our findings highlight the importance of residential greenness in alleviating DR risk especially in an era of aging and urbanization.

Inappropriate use of clinical practices in Canada: a systematic review

Background:

Inappropriate health care leads to negative patient experiences, poor health outcomes and inefficient use of resources. We aimed to conduct a systematic review of inappropriately used clinical practices in Canada.

Methods:

We searched multiple bibliometric databases and grey literature to identify inappropriately used clinical practices in Canada between 2007 and 2021. Two team members independently screened citations, extracted data and assessed methodological quality. Findings were synthesized in 2 categories: diagnostics and therapeutics. We reported ranges of proportions of inappropriate use for all practices. Medians and interquartile ranges (IQRs), based on the percentage of patients not receiving recommended practices (underuse) or receiving practices not recommended (overuse), were calculated. All statistics are at the study summary level.

Results:

We included 174 studies, representing 228 clinical practices and 28 900 762 patients. The median proportion of inappropriate care, as assessed in the studies, was 30.0% (IQR 12.0%–56.6%). Underuse (median 43.9%, IQR 23.8%–66.3%) was more frequent than overuse (median 13.6%, IQR 3.2%–30.7%). The most frequently investigated diagnostics were glycated hemoglobin (underused, range 18.0%–85.7%, n = 9) and thyroid-stimulating hormone (overused, range 3.0%–35.1%, n = 5). The most frequently investigated therapeutics were statin medications (underused, range 18.5%–71.0%, n = 6) and potentially inappropriate medications (overused, range 13.5%–97.3%, n = 9).

Interpretation:

We have provided a summary of inappropriately used clinical practices in Canadian health care systems. Our findings can be used to support health care professionals and quality agencies to improve patient care and safety in Canada.

Effects of the new fasting standard on sedation in the pediatric emergency room

BACKGROUND

This study compared adherence to the fasting-time guidelines of the International Committee for the Advancement of Procedural Sedation (ICAPS) and the North American Society of Anesthesiologists (ASA) and complication rates in pediatric patients requiring procedure sedation and analgesia during treatment in the emergency room (ER).

METHODS

This retrospective, single-center study was performed between 2016 and 2020, and enrolled patients who received procedural sedation and analgesia in the ER with the fasting times recommended in the ICAPS and ASA guidelines.

RESULTS

In total, 857 patients were included. The most frequent indication for procedural sedation and analgesia was fracture reduction in 420 patients (49.0%). Ketamine, the most commonly administered drug, was given to 710 patients (82.8%). Adherence to the ICAPS guidelines was higher (P < 0.01), with 772 (95.7%) and 351 (41.0%) patients, respectively, adhering to the ICAPS and ASA recommendations for food and drink fasting times. Complications occurred in 130 patients (15.2%), including SpO₂ <90% in 75 patients (8.7%) and vomiting in 20 patients (2.3%). No serious complications, such as aspiration, cardiac arrest, or death, occurred. The complication rate between the two groups did not differ significantly, with 50 (14.2%) and 127 (15.5%) patients experiencing complications according to the ICAPS and ASA guidelines, respectively (P = 0.586).

CONCLUSIONS

The fasting recommendations of the ICAPS guidelines, which propose risk stratification to determine the appropriate fasting time for procedural sedation and analgesia, are more tolerable to patients and the rate of adverse events did not appear to be different from that experienced when following the ASA guidelines.

Point-of-Care Ultrasound to Assess Gastric Content in Pediatric Emergency Department Procedural Sedation Patients

OBJECTIVES

There is debate regarding the timing of procedural sedation and analgesia (PSA) in relation to fasting status. Point-of-care ultrasound (POCUS) provides the ability to measure gastric content and is being used as a surrogate for aspiration risk in anesthesia. We sought to evaluate the gastric content of pediatric emergency department (PED) patients undergoing PSA using POCUS.

METHODS

We performed a prospective observational study using a convenience sample of pediatric patients undergoing PSA between July 1, 2018, and June 30, 2019. Following a brief history, gastric content was measured using POCUS in both supine and right lateral decubitus positions at 2-hour intervals until the time of PSA. Qualitative content and calculated volume were classified based on the Perlas Model of anesthesia "Risk" assessment.

RESULTS

Ninety-three patients were enrolled with 61.3% male and mean age of 6.5 years. Gastric content was determined in 92 patients. There were 79.3% that had "high risk" content at the time of PSA, with a median fasting time of 6.25 hours and no serious adverse events. Fasting duration had a weak to moderate ability to predict "risk" category (area under the curve = 0.73), with no patient (n = 17) who underwent multiple evaluations awaiting PSA progressing from "high" to "low risk."

CONCLUSIONS

The majority of PED patients undergoing PSA at our institution had "high risk" gastric content with no clinically significant change occurring during serial evaluations. This calls into question the utility of delaying PSA based upon fasting status and lends support to a more comprehensive risk-benefit approach when planning pediatric PSA.

Does Point-of-Care Gastric Ultrasound Correlate With Reported Fasting Time?

OBJECTIVE

Traditionally, patient-reported fasting time has been the primary objective presedation measure of aspiration risk. Recently, gastric ultrasound has been used to assess gastric volume for the determination of aspiration risk in patients undergoing anesthesia in the operative setting. We sought to determine the correlation of gastric volume estimated by point-of-care ultrasound (POCUS) to reported fasting time.

METHODS

We included children 4 to 18 years of age who presented with an acute traumatic injury. Enrolled children underwent POCUS to calculate gastric volume, which was calculated using a validated formula: Volume (mL) = -7.8 + (3.5 × Cross-sectional Area [CSA]) + (0.127 × Age in months). The CSA was measured (CSA = (anterior-posterior diameter × craniocaudal diameter × π)/4). We analyzed the relationship between time since last reported oral intake and measured gastric volume using Spearman rank correlation (ρ).

RESULTS

A total of 103 patients with a median age of 10.5 years (interquartile range, 7.3-13.7 years) were enrolled. The gastric antrum was identified and measured in 88 (85%) patients; air obstructing the posterior surface of the gastric antrum prevented measurement in 14 of the 15 remaining patients. We observed a weak inverse correlation between fasting time (either liquid or solid) and estimated gastric volume (ρ = -0.33), with no significant difference based on type of intake (solids, ρ = 0.28; liquids, ρ = 0.22).

CONCLUSION

Gastric volume can be estimated by POCUS and is not strongly correlated with fasting time in children in the emergency department setting.

Pediatric Sedation in the Emergency Department: Trends from a Nationwide Population-based Study in Korea, 2007-2018

BACKGROUND

Pediatric sedation in the emergency department (ED) is widely performed in Korea; thus exploring the trends of its use is necessary. This study aimed to investigate the characteristics of patients and sedatives use in the ED and verify their changes over recent years.

METHODS

A nationwide population-based retrospective study was conducted including pediatric patients aged ≤ 15 years who received sedative medication in the ED and were discharged during 2007-2018, using the Korean Health Insurance Review and Assessment Service database. Patient characteristics (age, sex, level of ED, and diagnosis) and type of sedative used were analyzed.

RESULTS

Sedation was performed in total 468,221 visits during 2007-2018 (399,320 visits, at least 3.8% of overall ED visits during 2009-2018). Among these, 71.0% were children aged 1-3 years and 93.5% were sedated to support diagnosis of injury. An increase in total sedation was observed in patients aged 4-6 years during the study period (from 13.8% to 21.8%). A gradual decrease in the use of chloral hydrate (CH) compared with an increase in ketamine use was observed (CH, from 70.6% to 28.6%; ketamine, from 23.8% to 60.7%). Therefore, ketamine was the most used sedative since 2014. The most frequently used sedatives over the study period differed according to age groups (CH in <1 year and 1-3 years; ketamine in 4-6 years and 7-10 years; and midazolam in 11-15 years).

CONCLUSIONS

The characteristics of patients related to sedatives use in the ED have changed over time. These changes should be considered in the development of future Korean guidelines regarding pediatric sedation in the ED.

National survey revealed variable practices in paediatric procedural sedation and patient monitoring

Paediatric procedures requiring sedation are increasingly being performed off site, but there are no national guidelines for paediatric procedural sedation in Finland or studies on it. Therefore, the aim of this survey was to assess national practices for paediatric procedural sedation outside operation rooms and intensive care units in terms of indications, sedative medication, treatment facilities, patient safety and training of the personnel. An online survey including single- and multiple-choice questions and open-ended questions was sent to Finnish paediatricians, paediatric surgeons and paediatric anaesthesiologists via the electronic mailing lists of national societies in December 2019. A total of 71 responses were received. Lumbar puncture (41%), intra-articular injections (38%) and MRI (17%) were the most common procedures that required routine sedation. Benzodiazepines were the most frequently used sedatives during both painful procedures (80%) and imaging (61%). Pulse oximetry monitoring was reported by 75% of the respondents, but other physiological parameters were rarely monitored (ECG 28%; blood pressure 39%; respiratory rate 34%). The level of sedation was not objectively assessed. Adrenaline (72%) and equipment for managing adverse respiratory outcomes (supplemental oxygen 98%; ventilation equipment 92%) were available in most facilities in which sedation was performed. Only one-third of the respondents had undergone training for paediatric procedural sedation, and only 39% of the hospital units compiled statistical data on sedation-related adverse events. The paediatric procedural sedation practices vary across hospitals. National guidelines for patient monitoring and training of personnel could improve treatment quality and patient safety.

Hunger Games: Impact of Fasting Guidelines for Orthopedic Procedural Sedation in the Pediatric Emergency Department

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.

Moderate and deep sedation for non-invasive paediatric procedures in tertiary maternity and children’s hospitals in China: a questionnaire survey from China

Background

Moderate and deep sedation are well-established techniques in many developed countries, and several guidelines have been published. However, they have received attention in China only in recent years. The aim of this study is to investigate current paediatric sedation practices in tertiary children’s hospitals and tertiary maternity and children hospitals in China.

Methods

All tertiary children’s hospitals and tertiary maternity and children hospitals registered with the National Health Commission of the People’s Republic of China were invited to participate in an electronic survey, which included information on the sedation caseload, facility availability, staff structure, clinical skill requirements for sedation providers, fasting guidelines, patient-monitoring practices, and choice of sedatives.

Results

Fifty-eight of the 63 hospitals that completed the survey (92.1%) provided moderate and deep sedation. Dedicated sedation rooms and post-sedation recovery rooms were found in 14 (24.1%) and 19 (32.8%) hospitals, respectively. Sedation for non-invasive procedures was primarily performed by anaesthesiologists (69.0%); however, 75.9% of the sedation providers had not received paediatric basic or advanced life-support training. Children were asked to fast from clear liquids for at least 2 h in 44.8% of hospitals and up to 6 h in 5.2% of hospitals; they were asked to fast from solid food/milk for at least 4 h in 27.6% of hospitals and more than 8 h in 1.7% of hospitals. The most commonly used sedative in all groups was chloral hydrate. For rescue, propofol was the most widely used sedative, particularly for children older than 4 years.

Conclusions

Moderate and deep sedation practices vary widely in tertiary children’s hospitals and tertiary maternity and children hospitals in China. Optimised practices should be established to improve the quality of moderate and deep sedation.

Point-of-Care Ultrasound to Assess Gastric Content

Gastric ultrasound (US) is a growing modality within the point-of-care ultrasound (POCUS) field. It provides the ability to directly measure an individual patient's gastric content and has potential use as both a clinical and a research tool. Here, we review the historical development of current gastric US models and their clinical application within the field of general anesthesia, describe the US findings and technique for using POCUS to assess gastric content, and discuss the current and potential applications of gastric POCUS within the emergency department.

Perioperative aspiration events in children: A report from the Wake Up Safe Collaborative

BACKGROUND

Perioperative aspiration, while rare, is a serious complication of anesthetic care. Consequences of aspiration may include physical obstruction, wheezing, and pneumonia, resulting in mild to severe hypoxemia and even death.

AIM

We used a multi-institutional registry of pediatric patients to identify factors that influence the rate and resulting harm of perioperative pulmonary aspiration.

METHODS

The Wake Up Safe registry was queried for all severe adverse events reported from 29 institutions from 2010 to 2017. Aspiration events were identified through the "respiratory adverse event" data entry form or through free text search. Multivariable regression was used to predict aspiration events, and contributory factors were identified by reviewing free text case comments.

RESULTS

Analysis included 2 440 810 anesthetics administered involving patients ≤18 years of age. There were 135 pulmonary aspiration events, for an incidence of 0.006%. Within these 135 cases, 110 cases (82%) resulted in escalation of care and 51 (38%) resulted in patient harm, including 2 deaths (1.5%). In multivariable analysis, patients undergoing emergency surgery (OR 2.0 [1.2-3.5]) or with higher ASA status were more likely to experience aspiration (ASA 3 (OR 5.0 [2.6-9.1]); ASA ≥ 4 (OR 5.5 [3.8-16.8])). Noted causes of aspiration included gastrointestinal comorbid conditions (19%), postcoughing event or laryngospasm (14%), nil per os (NPO) violation (11%), blood or secretions in the airway following or during the procedure (6%), and oral premedication reaction (3%).

CONCLUSION

Although infrequent, death was reported as a consequence of perioperative aspiration in two patients. The frequency with which NPO violations were identified as a potential cause of aspiration highlights the struggles institutions face with adherence to NPO regulations, as these cases may be preventable. Furthermore, preventive measures may be needed to address other common causes of aspiration, such as gastrointestinal comorbid conditions.

Safety and Efficacy of Procedural Sedation and Analgesia in Pediatric Oncology Patients

Objective Procedural sedation and analgesia are the standard of care for painful procedures in children that require immobility. The aim is to assess the safety and efficacy of procedural sedation and analgesia in pediatric oncological patients in a large tertiary care hospital. Method An observational study performed to review medical records of children who received procedural sedation and analgesia (PSA) for pediatric oncological procedures from July 2018 to September 2018. Patients undergoing oncology procedures (lumbar puncture, intrathecal chemotherapy, bone marrow aspiration +/- trephine) were included, and non-anesthesiologist (intensive care physician/emergency physician certified in pediatric advanced life support) provided PSA. Patients were assessed according to PSA protocol guidelines by the American Society of Anesthesiology (ASA). Low-dose ketamine (0.5 mg/kg) and propofol (2 mg/kg) were administered. Results A total of 565 children underwent 1216 procedures in whom the median age was 7.4 years, and the majority (65.1%) were males. The most common procedure was the lumbar puncture (n = 956; 78.6%) followed by bone marrow aspirate only (n = 137, 11.3%) and both (n = 123, 10.1%). Eight (0.7%) patients developed transient oxygen desaturation only as an adverse effect of ketamine-propofol drug combination with 50% procedures utilizing propofol 1 mg/kg for sedation. Conclusion According to the results of our study, the majority of the pediatric patients responded and reported no adverse events during the procedure with ketamine and propofol. Therefore, we conclude that ketamine and propofol are safe and effective as both sedative and an analgesic in procedures on pediatric oncology patients.

Unscheduled Procedural Sedation: A Multidisciplinary Consensus Practice Guideline

The American College of Emergency Physicians (ACEP) organized a multidisciplinary effort to create a clinical practice guideline specific to unscheduled, time-sensitive procedural sedation, which differs in important ways from scheduled, elective procedural sedation. The purpose of this guideline is to serve as a resource for practitioners who perform unscheduled procedural sedation regardless of location or patient age. This document outlines the underlying background and rationale, and issues relating to staffing, practice, and quality improvement.

An international multidisciplinary consensus statement on fasting before procedural sedation in adults and children

The multidisciplinary International Committee for the Advancement of Procedural Sedation presents the first fasting and aspiration prevention recommendations specific to procedural sedation, based on an extensive review of the literature. These were developed using Delphi methodology and assessment of the robustness of the available evidence. The literature evidence is clear that fasting, as currently practiced, often substantially exceeds recommended time thresholds and has known adverse consequences, for example, irritability, dehydration and hypoglycaemia. Fasting does not guarantee an empty stomach, and there is no observed association between aspiration and compliance with common fasting guidelines. The probability of clinically important aspiration during procedural sedation is negligible. In the post-1984 literature there are no published reports of aspiration-associated mortality in children, no reports of death in healthy adults (ASA physical status 1 or 2) and just nine reported deaths in adults of ASA physical status 3 or above. Current concerns about aspiration are out of proportion to the actual risk. Given the lower observed frequency of aspiration and mortality than during general anaesthesia, and the theoretical basis for assuming a lesser risk, fasting strategies in procedural sedation can reasonably be less restrictive. We present a consensus-derived algorithm in which each patient is first risk-stratified during their pre-sedation assessment, using evidence-based factors relating to patient characteristics, comorbidities, the nature of the procedure and the nature of the anticipated sedation technique. Graded fasting precautions for liquids and solids are then recommended for elective procedures based upon this categorisation of negligible, mild or moderate aspiration risk. This consensus statement can serve as a resource to practitioners and policymakers who perform and oversee procedural sedation in patients of all ages, worldwide.

"Full Stomach" Despite the Wait: Point-of-care Gastric Ultrasound at the Time of Procedural Sedation in the Pediatric Emergency Department

OBJECTIVES

The objective was to use gastric point-of-care ultrasound (POCUS) to assess gastric contents and volume, summarize the prevalence of "full stomach," and explore the relationship between fasting time and gastric contents at the time of procedural sedation.

METHODS

This was a prospective study of patients aged 2 to 17 years fasting prior to procedural sedation. A single sonographer scanned each patient's gastric antrum in two positions: supine with the upper body elevated and right lateral decubitus (RLD). Gastric content (empty, liquid, or solid) was noted, and the gastric volume (mL/kg) was estimated from antral cross-sectional area (CSA). "Full stomach" was defined as any solid content or >1.2 mL/kg of liquid gastric content.

RESULTS

We enrolled 116 subjects, with a median fasting time of 5.8 hours. Of the 107 with evaluable images, 74 patients, 69% (95% confidence interval [CI] = 60%-77%), were categorized as having a full stomach. Each hour of fasting was associated with lower odds (odds ratio = 0.79, 95% CI = 0.65-0) of a full stomach. However, the knowledge of fasting time alone provides little ability to discriminate between risk groups (C-index = 0.66).

CONCLUSIONS

Gastric POCUS classified many patients as having a full stomach at the time of expected procedural sedation, despite prolonged fasting times. These findings may inform risk-benefit considerations when planning the timing and medication choice for procedural sedation.

Future of paediatric sedation: towards a unified goal of improving practice

This review offers a perspective on the future of paediatric sedation. This future will require continued evaluation of adverse events, their risk factors, and predictors. As the introduction of new sedatives with paediatric applications will remain limited, the potential role of mainstay sedatives administered by new routes, for new indications, and with new delivery techniques, should be considered. The role of non-pharmacological strategies for anxiolysis, along with the application of non-mainstay physiologic monitoring, may aid in the improvement of targeted sedation delivery. Understanding the mechanism and location of action of the different sedatives will remain an important focus. Important developments in paediatric sedation will require that large scale studies with global data contribution be conducted in order to support changes in sedation practice, improve the patient experience, and make sedation safer.

Factors affecting same-day cancelation of outpatient pediatric oncologic procedural sedation

BACKGROUND

Children with cancer undergo serial invasive, painful procedures as a part of their diagnosis, treatment, and surveillance regimens that require procedural sedation (PS). Some may have a delay in their treatment plan due to same-day cancelation (SDC) of the procedure due to issues related to sedation or other factors. The objective of this report was to evaluate the factors resulting in the SDC of hematology and oncology patients in an outpatient pediatric sedation service.

METHODS

Retrospective review of children with cancer or other hematologic disorders undergoing outpatient procedures using a dedicated pediatric sedation team from January 2012 to December 2017. The children with SDC were compared to controls (ie, patients not canceled) during the above study period.

RESULTS

A total of 100 patients had SDC during the study. The median age was 10 years (25th percentile to 75th percentile: 7-10 years). The overall SDC rate was 3% and 78/100 (78%) had acute lymphoblastic leukemia. Most common procedure was lumbar puncture with intrathecal chemotherapy in 82/100 (82%) patients. Inadequate blood counts, acute illness, and not nil per os (NPO) accounted for 83% of the reasons for SDC. Type of health insurance, estimated household income, or distance traveled to the clinic did not impact SDC.

CONCLUSIONS

The most common factors for SDC included inadequate blood counts, acute illness, and not meeting NPO guidelines. Understanding factors affecting SDC may help improve the efficiency of time-sensitive care delivered to children with cancer and other hematologic concerns by a pediatric sedation service.