Pulmonary aspiration under <scp>GA</scp>: a 13‐year audit in a tertiary pediatric unit

Tan, Zihui; Lee, S.Y.

doi:10.1111/pan.12877

Cited by 48 publications

(66 citation statements)

References 9 publications

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“…Since perioperative aspiration is an extremely rare event and may depend on the patient populations studied as well as the clinical practice at each institution, it is possible that risk factors may vary between centers, complicating the prediction of aspiration risk. For example, aspiration was noted in our study to occur with equal likelihood during induction as during maintenance, which is in contrast to prior findings regarding timing . In comparing our outcome with previously published findings from years ago, it should also be noted that practices and medications have changed substantially over the past several decades.…”

Section: Discussioncontrasting

confidence: 78%

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Identification of perioperative pulmonary aspiration in children using quality assurance and hospital administrative billing data

Eisler

Huang

Lee

et al. 2018

Pediatric Anesthesia

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Quality assurance data offer an efficient way to measure the incidence of rare events, but may underestimate perioperative complications. International Classification of Diseases, Ninth Revision codes for aspiration used as a secondary data source were nonspecific for perioperative aspiration, but when combined with record review yielded a 30% increase in identified cases of aspiration over quality assurance data alone. The use of administrative data therefore holds potential for supplementing quality assurance studies of rare complications.

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Section: Discussioncontrasting

confidence: 78%

“…In prior studies, several risk factors have been identified as being associated with perioperative pulmonary aspiration including higher ASA status, younger age, and emergent surgery . Such associations were not found in the present study.…”

Section: Discussioncontrasting

confidence: 71%

Identification of perioperative pulmonary aspiration in children using quality assurance and hospital administrative billing data

Eisler

Huang

Lee

et al. 2018

Pediatric Anesthesia

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“…In many or most settings, ASA physical status 3 and 4 patients often receive anaesthesia when possible. Third, aspiration during general anaesthesia most frequently occurs during airway manoeuvres such as tracheal intubation and extubation, use of muscle relaxants and following positive pressure bag/mask ventilation which can cause gas insufflation of the stomach . Such high‐risk events are less relevant to procedural sedation, where they only occur as part of rescue for significant airway or respiratory adverse events.…”

Section: Resultsmentioning

confidence: 99%

“…Most studies observed that aspiration was more common during emergency surgery in adults , with mixed results in children .…”

Section: Resultsmentioning

confidence: 99%

“…The incidence of aspiration associated with general anaesthesia has been declining over recent decades (see also Supporting Information, Table S2); however, it is not clear whether this is due to pre‐operative fasting or simply improved airway management and other anaesthetic techniques . Given this rarity of aspiration, in 1990, Cote argued that the amount of resources directed at preventing it seemed unjustified, asking: “Is aspiration pneumonia in routine healthy patients a nonissue?” .…”

Section: Resultsmentioning

confidence: 99%

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

Green¹,

et al. 2019

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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 374 This statement presents the first fasting and aspiration prevention recommendations specific to procedural sedation.

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Reevaluating Fasting for Procedural Sedation

2018

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Procedural sedation is widely administered by a variety of practitioners to facilitate painful or frightening procedures in children. [1][2][3][4][5][6][7][8][9] Guidelines 9 recommend a minimum period of fasting (nothing by mouth) prior to elective sedation because of concerns about pulmonary aspiration. [7][8][9] These guidelines most commonly mirror thresholds fixed for elective general anesthesia: 2 hours or longer for clear liquids, 4 hours or longer for breast milk, and 6 hours or longer prior for cow milk, infant formula, or a light meal. 9 Compliance with these requirements-whether for procedural sedation or for general anesthesia-comes at a cost to the child, the family, and to health care delivery. Fasting can be uncomfortable and distressing, 10 can cause dehydration 10 and hypoglycemia, 11 and is associated with decreased sedation efficacy 12 and more frequent sedation failure. 13 In clinical practice, it is common for minimum fasting durations to be substantially exceeded. 14 To minimize the potential for misunderstanding, patients may be intentionally instructed to fast longer, because an instruction of "nothing by mouth after midnight" is less complicated and error prone than separate thresholds for light meals vs breast milk vs clear fluids. Delays in starting scheduled procedures further extend fasting times. 14,15 Children with fasting violations risk lengthy procedure postponement or cancellation.The emergency department (ED) provides an ideal setting to scientifically evaluate the impact of fasting, because restricting oral intake after midnight cannot apply to patients requiring sedation for emergent and urgent procedures. On a daily basis, children in the ED require procedures (eg, laceration repair, abscess drainage, fracture and dislocation reduction, and diagnostic imaging) that must be promptly performed despite noncompliance with elective fasting guidelines. [2][3][4][5][6][7][8] Despite such regular ongoing performance of nonfasted sedation over decades, the ED has not been identified as a setting at greater risk for aspiration. [1][2][3]7,8 In this issue of JAMA Pediatrics, Bhatt et al 3 studied fasting guideline noncompliance for ED procedural sedation. In their multicenter, prospective, observational study, most children (3284 of 6183) receiving procedural sedation were noncompliant with standard elective fasting guidelines (vs 2899 who complied with fasting guidelines for solids and liquids) 9 and, despite this, were no more likely to vomit or experience other adverse events. No aspiration was observed in any child, whether compliant or noncompliant with fasting. These findings confirm multiple similar but smaller prior ED studies in the last 15 years 4-6 and a study including an ED subset. 1 The ED experience thus has consis-

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Pulmonary aspiration under GA: a 13‐year audit in a tertiary pediatric unit

Cited by 48 publications

References 9 publications

Identification of perioperative pulmonary aspiration in children using quality assurance and hospital administrative billing data

Identification of perioperative pulmonary aspiration in children using quality assurance and hospital administrative billing data

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

Reevaluating Fasting for Procedural Sedation

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