Acad
Emerg Med 2002 Jan;9(1):35-42
Pulmonary
aspiration risk during emergency department
procedural sedation--an examination of the role of
fasting and sedation depth.
Green SM, Krauss B
Department of Emergency
Medicine, Loma Linda University Medical Center
& Children's Hospital, Loma Linda, CA 92354,
USA. stevegreen@tarascon.com
The
assessment of pre-procedure fasting and control of
sedation depth are prominent elements of widely
disseminated procedural sedation guidelines and of
the Joint Commission on Accreditation of
Healthcare Organizations' standards. Both exist
primarily to minimize the risk of pulmonary
aspiration of gastric contents. This paper
critically examines the literature on
pre-procedure fasting and controlling sedation
depth in association with pulmonary aspiration,
and interprets this evidence in the context of
modern emergency
medicine practice. The article reviews the
pathophysiology of aspiration and changing
concepts regarding aspiration risk over the last
decade. After reviewing studies on aspiration risk
during general anesthesia, the paper reviews the
risk of aspiration during labor and delivery as a
more appropriate comparison group for aspiration
risk during emergency
department procedural sedation and analgesia
(ED PSA). It is noted that aspiration during ED
PSA has not been reported in the medical
literature and that aspiration during general
anesthesia and labor and delivery is uncommon. The
literature provides no compelling evidence to
support specific fasting periods for either
liquids or solids prior to PSA, and existing
guidelines for elective patients are of necessity
arbitrary and based upon consensus opinion. The
article discusses the implications in the areas of
training and preparedness, monitoring, and
research for the emergency
physician practicing PSA.
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