Logo

Log In Sign Up |  An official publication of: American College of Emergency Physicians
Navigation
  • Home
  • Multimedia
    • Podcasts
    • Videos
  • Clinical
    • Airway Managment
    • Case Reports
    • Critical Care
    • Guidelines
    • Imaging & Ultrasound
    • Pain & Palliative Care
    • Pediatrics
    • Resuscitation
    • Trauma & Injury
  • Resource Centers
    • mTBI Resource Center
  • Career
    • Practice Management
      • Benchmarking
      • Reimbursement & Coding
      • Care Team
      • Legal
      • Operations
      • Quality & Safety
    • Awards
    • Certification
    • Compensation
    • Early Career
    • Education
    • Leadership
    • Profiles
    • Retirement
    • Work-Life Balance
  • Columns
    • ACEP4U
    • Airway
    • Benchmarking
    • Brief19
    • By the Numbers
    • Coding Wizard
    • EM Cases
    • End of the Rainbow
    • Equity Equation
    • FACEPs in the Crowd
    • Forensic Facts
    • From the College
    • Images in EM
    • Kids Korner
    • Medicolegal Mind
    • Opinion
      • Break Room
      • New Spin
      • Pro-Con
    • Pearls From EM Literature
    • Policy Rx
    • Practice Changers
    • Problem Solvers
    • Residency Spotlight
    • Resident Voice
    • Skeptics’ Guide to Emergency Medicine
    • Sound Advice
    • Special OPs
    • Toxicology Q&A
    • WorldTravelERs
  • Resources
    • ACEP.org
    • ACEP Knowledge Quiz
    • Issue Archives
    • CME Now
    • Annual Scientific Assembly
      • ACEP14
      • ACEP15
      • ACEP16
      • ACEP17
      • ACEP18
      • ACEP19
    • Annals of Emergency Medicine
    • JACEP Open
    • Emergency Medicine Foundation
  • About
    • Our Mission
    • Medical Editor in Chief
    • Editorial Advisory Board
    • Awards
    • Authors
    • Article Submission
    • Contact Us
    • Advertise
    • Subscribe
    • Privacy Policy
    • Copyright Information

Procedural Sedation Delays and NPO Status for Pediatric Patients in the Emergency Department

By Ken Milne, MD | on January 22, 2017 | 0 Comment
CME CME Now Skeptics' Guide to EM
  • Tweet
  • Click to email a link to a friend (Opens in new window) Email
Print-Friendly Version
ILLUSTRATION: PAUL JUESTRICH; PHOTOs: shutterstock.com

The Case

An 8-year-old boy falls while playing ice hockey. He has an isolated distal radius fracture that needs a closed reduction. The patient had been eating a bag of chips one hour ago, and you wonder if you need to wait before performing procedural sedation.
CME Now

You Might Also Like
  • ACEP Revises Clinical Policy on Procedural Sedation and Analgesia in the Emergency Department
  • Upper Respiratory Infection Tied to Adverse Events During Pediatric Sedation
  • ACEP Coordinates Multidisciplinary Sedation Guideline
Explore This Issue
ACEP Now: Vol 36 – No 01 – January 2017

Background

Procedural sedation is a common practice in the emergency department. The American Society of Anesthesiologists 2011 Practice Guidelines recommend fasting from the intake of clear liquids for at least two hours, fasting from the intake of a light meal for at least six hours, and fasting from the intake of fried or fatty foods or meat for eight or more hours.1 They do acknowledge that these guidelines may not apply to emergency care.

The ACEP 2013 Clinical Policy on procedural sedation and analgesia in the emergency department recommends not delaying procedural sedation in adults or pediatric emergency department patients based on fasting time (Level B).2 This is because “pre-procedural fasting for any duration has not demonstrated a reduction in the risk of emesis or aspiration when administering procedural sedation and analgesia.”

Clinical Question

Does procedural sedation of a pediatric emergency department patient need to be delayed based on nil per os (NPO) status?

Reference

Beach ML, Cohen DM, Gallagher SM, et al. Major adverse events and relationship to nil per os status in pediatric sedation/anesthesia outside the operating room: a report of the pediatric sedation research consortium. Anesthesiology. 2016;124(1):80-88.

  • Population: All pediatric patients undergoing procedural sedation at one of the 42 Pediatric Sedation Research Consortium (PSRC) sites. Procedural sedation/anesthesia was defined as “any pharmacologic intervention made to facilitate an invasive procedure or test in a pediatric-age patient outside of the operating room environment.”
  • Intervention: NPO to solids for at least eight hours, non-clear fluids for at least six hours, and clear fluids for at least two hours.
  • Comparison: Patients who failed to meet the above NPO criteria.
  • Outcome: Two primary outcomes:
    • Rate of aspiration. Defined as an event where emesis was noted or food material was found in the oropharyngeal cavity and associated with any of the following: new cough, wheeze, increase in respiratory effort, change in chest radiograph indicative of aspiration, or new need for oxygen therapy after recovery from sedation.
    • Occurrence of a major adverse event. Defined as aspiration, death, cardiac arrest, or uoonplanned admission to a hospital.

Authors’ Conclusions:

“The analysis suggests that aspiration is uncommon. NPO status for liquids and solids is not an independent predictor of major complications or aspiration in this sedation/anesthesia data set.”

Key Results

There were 139,142 procedural sedation/anesthesia encounters identified in the data set. NPO status was known for 107,947 patients, including 25,401 (24 percent) who were not NPO. They observed 75 major complications that included 62 unplanned admissions, 10 aspirations, three cardiac arrests, and no deaths.

  • Primary outcome: No statistical association between NPO status and major complications or aspiration was shown.

EBM Commentary

  1. Association versus causation: A prospective observational study like this can be used to identify associations between NPO status and aspiration and major adverse events. However, it would take a randomized controlled trial to investigate causation.
  2. Precision of the results: Because there were only a few events, the 95 percent confidence intervals around the point estimate were wide.
  3. External validity: High-performance sedation teams provided the procedural sedation in this study. You may not have these teams in your community hospital. In addition, the majority of these elective procedural sedations were classified as routine, not emergency, and only a minority of the sedations were provided by an emergency physician.

Bottom Line

Not delaying procedural sedation in pediatric emergency department patients based on their NPO status is reasonable.

Case Resolution

You have an informed discussion with the parents regarding their son’s injury and the risks of sedation. You proceed with the sedation and perform a closed fracture reduction with no complications.

Pages: 1 2 | Single Page

Topics: AnesthesiaED Critical CareEmergency DepartmentEmergency MedicineEmergency PhysicianNPO StatusPatient CarePediatricsPractice ManagementProcedures & SkillsSedation

Related

  • Case Report: When Syncope Gets Hairy

    June 17, 2025 - 0 Comment
  • Influenza, Muscle Pain, and an Elevated Serum Creatine Kinase

    May 10, 2025 - 0 Comment
  • Can This Patient Leave Against Medical Advice?

    March 10, 2025 - 0 Comment

Current Issue

ACEP Now: July 2025

Download PDF

Read More

About the Author

Ken Milne, MD

Ken Milne, MD, is chief of emergency medicine and chief of staff at South Huron Hospital, Ontario, Canada. He is on the Best Evidence in Emergency Medicine faculty and is creator of the knowledge translation project the Skeptics Guide to Emergency Medicine.

View this author's posts »

No Responses to “Procedural Sedation Delays and NPO Status for Pediatric Patients in the Emergency Department”

Leave a Reply Cancel Reply

Your email address will not be published. Required fields are marked *


*
*

Wiley
  • Home
  • About Us
  • Contact Us
  • Privacy
  • Terms of Use
  • Advertise
  • Cookie Preferences
Copyright © 2025 by John Wiley & Sons, Inc. All rights reserved, including rights for text and data mining and training of artificial technologies or similar technologies. ISSN 2333-2603