SPS Plenary Session | May 20, 2019, 4:15 pm
Benjamin F. Jackson, MD, FAAP, FACEP; and Maala Bhatt, MD, MSc, FRCPC
Dr. Jackson introduced the American College of Emergency Physicians’ new guideline: “Multidisciplinary Consensus Practice Guideline for Unscheduled Procedural Sedation”
“We look to guidelines to point us in a direction of safety, to help identify risk, and risky practices to avoid. But we must admit that all sedation encounters involve some measure of risk. There is no risk free sedation patient nor sedation encounter.”
Certain conditions warrant time-sensitive, unscheduled procedural management, and patients deserve compassionate, effective, safe facilitation thereof. Existent guidelines insufficiently address and unnecessarily limit the scope, considerations, and elements of procedural sedation care for these patients with urgent/emergent needs. An evidence-based guideline for unscheduled procedural sedation establishes a framework for such patient care.
The leadership of ACEP brought together a multidisciplinary task force to address guidelines for unscheduled procedural sedation care. The group included representation from AAP sections of CCM and EM, and the SPS, among many others. This new ACEP guideline differed from ACEP procedural sedation guidelines in the past in that, through collaboration, it addresses unscheduled sedation.
Each of the six aims of quality of the Institute of Medicine are addressed by the guideline. The guideline takes the approach of describing the continuum of sedation in terms of the degree of airway patency and ventilation adequacy that can be anticipated at the various levels of sedation. Assessing the effectiveness of the sedation is recommended using the Pediatric Sedation State Scale.
There is a description of the skill sets for the roles of Procedural Sedation Provider (Licensed Independent Sedationist) and the Procedural Sedation Monitor (Registered Nurse, Respiratory Therapist.) There is discussion of the optimal staffing model which includes a sedationist providing sedation who is separate from the proceduralist. However, the guideline acknowledges that there are times when the risk-benefit assessment dictates that the sedation for the procedure is necessary to provide appropriate care to a patient and when staff is limited such that the proceduralist is also providing sedation.
The ACEP Guideline emphasis is on assurance of provider competency, necessary resources in procedure location, and patient safety and comfort. Members of the AAP sections on EM and CCM have supported this guideline, as has the SPS. Unfortunately, the AAP as a whole has not.
Maala Bhatt, MD, MSc, FRCPC
The evidence behind the fasting guidelines.
Why do fasting guidelines exist? So that we have time to empty our stomachs to prevent pulmonary aspiration and aspiration pneumonitis.
ICAPS, the International Committee for the Advancement of Procedural Sedation, reviewed existing large studies to determine the incidence of pulmonary aspiration in general anesthesia or procedural sedation. The incidence of aspiration in children under GA was 1:4800 and for sedation was 0.8:10,000. The incidence of mortality with GA was very low, at <1:334,856 and for procedural sedation in these studies, zero.
Michael Beach, et al, published a report from the PSRC which is currently the largest pediatric sedation study looking at major adverse events in relation to NPO status. Approximately 108,000 sedation cases had documented NPO times. 24% did not meet ASA fasting guidelines. There were 10 aspirations – 8 of these 10 cases fasted 8 hours prior to sedation, and all ten had fasted 6 or more hours. The authors’ conclusions: Aspiration is uncommon, and fasting status for liquids and solids is not an independent risk factor for aspiration. This paper examines the largest series of aspiration events associated with sedation, and does identify certain patients that are at greater risk for aspiration. They are: age < 1 month; having a bronchoscopy or endoscopy; history of obstructive sleep apnea; and, ASA III or IV.
The second clinical study discussed was a multi-center prospective cohort from 6 Canadian Emergency Departments, authored by Dr. Bhatt et al. Just over 6000 cases were enrolled, and the sedations were performed by ED providers. This represents the largest ED sedation cohort collected in North America. The procedures were short and painful, with the most common being fracture reduction. Fasting status was documented in 98%. There were 15 adverse events, but no cases of pulmonary aspiration. The data analysis demonstrated that there was no relationship between the time a patient fasted and the occurrence of any adverse event. Delaying sedation to meet fasting guidelines was not associated with change in outcomes.
Dr. Bhaat also discussed a paper by Leviter regarding Point of Care Ultrasound estimations of gastric contents in patients undergoing Emergency Department procedural sedation. The results demonstrated that 70% of patients had full stomachs by POCUS at the time of sedation, regardless of fasting duration.
NPO and Aspiration Risk Summary:
- Aspiration is uncommon, rate is 0.8 in 10,000
- Adherence to NPO guidelines does not guarantee protection against aspiration
– Elective: little downside to adherence
– Emergent: choose your patient/procedure
- Providers must assess risks and benefits
– Should sedation be performed at this time?
- Waiting a few hours is likely not going to change the situation.
– Must be prepared to perform RESCUE
- Special considerations (consider referral to anesthesiology)
ASA >III, very young age, endoscopy or bronchoscopy
No discrete Fasting Time Point, beyond which the risk of aspiration or sedation-related adverse events decreases, has been identified. Delaying sedation to meet specific NPO guidelines does not decrease adverse events and is not safer.