NPO Status and Adverse Events in Children Undergoing Procedural Sedation and Analgesia in the Emergency Department

BACKGROUND: Assessment of pre-procedural fasting state (NPO status) is considered essential in minimizing the risk of aspiration during procedural sedation and analgesia (PSA) in the emergency department (ED). NPO guidelines for elective procedures have been disseminated by the American Academy of Pediatrics (for solids 4 hrs if age 36 months; for clear liquids 2 hrs for all ages). However, these guidelines are consensus-based, rather than evidence-based, and are difficult to follow for non-elective procedures in the ED. OBJECTIVES: To characterize NPO status of children receiving PSA in the ED and to assess the relationship between NPO status and observed adverse events. METHODS: This prospective cohort study was conducted in a children's hospital ED over an eleven month period. All consecutive patients requiring PSA for non-elective procedures or diagnostic imaging were included. NPO status and adverse events (defined a priori) were recorded. The percentage of patients undergoing PSA who did not meet established NPO guidelines was determined. Adverse events were then analyzed in relation to NPO status. RESULTS: 1,014 patients underwent PSA during the study period, and data on NPO status was available on 905 (89%). Of these 905 patients, 509 (56%; 95%CI 53-60%) did not meet published NPO guidelines. Adverse events occurred in 70 (6.9%) of the 1,014 patients: in 32 of 396 (8.1%) patients who met and 37 of 509 (7.3%) patients who did not meet NPO guidelines (p = 0.65). There were no episodes of aspiration (one-sided 97.5%CI 0-0.4%). Emesis occurred in 15 (1.5%) patients. Average NPO length in patients with emesis was 6.8 hrs +/- 2.7 hrs for solids and 5.9 +/- 2.7 for liquids vs. 7.7 +/- 4.2 (p = 0.42) for solids and 6.5 +/- 3.7 (p = 0.52) for liquids in patients without emesis. CONCLUSIONS: 56% of children undergoing PSA in the ED were not fasted in accordance with published guidelines. There was no association observed between NPO status and adverse events.