PAIN MANAGEMENT/EDITORIAL

A Procedural Sedation and Analgesia Fasting Consensus

Advisory: One Small Step for Emergency Medicine,
One Giant Challenge Remaining
Paul M. Paris, MD
Donald M. Yealy, MD

From the Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA.

0196-0644/$-see front matter

Copyright 2007 by the American College of Emergency Physicians.
doi:10.1016/j.annemergmed.2006.11.013

SEE RELATED ARTICLES, P. 454 AND 462.

[Ann Emerg Med. 2007;49:465-467.]
A common proverb applies well to emergency care: He who
relieves pain is blessed but he who causes none is double so.
Emergency physicians have invested much effort to improve
acute pain management with education and research. Old
paradigms once taught and practicedno one ever died of
pain or analgesics obscure diagnosesare melting, albeit
more slowly than we may like.1,2
Emergency physicians often perform procedures that can
create moderate to excruciating pain. Although procedure
technique can limit pain, many common emergency
interventions require drug therapy to achieve patient comfort,
drugs that can produce unwanted effects. Our desire to limit
suffering during procedures may conflict with another principle:
primum non nocere (first, do no harm). Balancing the good of
procedural analgesia and sedation compassionate and
successful interventions to promote ideal recoverywith a
desire to avoid creating harm from the methods we choose to
complete those interventions is a daily challenge.
In this issue of Annals, Green et al3 present a consensus
advisory on fasting and emergency department (ED) procedural
sedation and analgesia, drawing on the expertise of an esteemed
group. The goal is laudable: help the thousands of daily ED
patients undergoing procedures to get safe care without having
to bite a bullet as the sole comfort regimen.
Before drafting this editorial, we informally surveyed 15 of our
local emergency medicine faculty members. What was striking was
the huge variability in frequency of use of procedural sedation and
analgesia, fasting approaches, agents chosen, and complications
encountered. One of the interesting findings was that in the
thousands of presumed cases among the group, no one could recall
a patient requiring endotracheal intubation.
Although it is easy to create much heat in a debate about ED
approaches for fasting and procedural sedation, there simply is
little light to guide us. Our patients are unscheduled; they never
arrive with intentional preprocedural fasting, creating the
perception of enhanced aspiration risk during any ED
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procedure. In 2005, the American College of Emergency

Physicians Clinical Policies Subcommittee on Procedure
Sedation and Analgesia published guidelines based on a critical
review and analysis of the peer-reviewed literature.4 The lack of
evidence led to a level C recommendation, stating . . .recent
food intake is not a contraindication for administering
procedural sedation and analgesia, but should be considered in
choosing the timing and target level of sedation.
In the current consensus advisory by Green et al,3 the
authors have taken a bold step of combining the current limited
data with a wealth of collective personal knowledge and
expertise to provide greater definition of the above statement.
Does this expert consensus provide us with more illumination
on aspiration risk and fasting? Will it enhance overall care, from
both a comfort and safety perspective?
It is important to reinforce that although seemingly
pragmatic, there is no evidence that fasting has any relationship
to outcomes of procedural sedation or elective surgery.
Nonetheless, the American Society of Anesthesiologists
recommends a 6-hour fast of solid food before elective
procedures.5 Clearly, many procedures in the ED or the
operative suite happen promptly in nonfasted patients because
of the risk of imminent harm or poorer outcome from delays;
these emergency exceptions to fasting (eg, cardioversion or
major joint reduction) remain in all guidelines. Many other ED
procedures are less emergent (though rarely elective in the
context of the American Society of Anesthesiologists guidelines)
and may require less sedation and analgesia. In the ED,
universal application of the American Society of
Anesthesiologists fasting restrictions means many patients
would have care delayed, with an unknown effect on comfort
and outcome, without clear evidence of benefit or risk
reduction. The proposed fasting advisory by Green et al3 alters
the American Society of Anesthesiologists arbitrary
recommendation to a maximum of 3 hours, again with little but
consensus to support the recommendation.
The consensus advisory may be complex to use in daily practice,
limiting its impact. The advisory requires a 4-step process before a
sedative/analgesic path is chosen. Step 1 assesses patient risk with
Annals of Emergency Medicine 465

Procedural Sedation and Analgesia Fasting Consensus Advisory

20 factors, including common maladies such as hiatal hernia, age
older than 70 years, and frail appearance, with unclear relative
importance of these many variables. Step 2 considers oral intake,
step 3 the urgency of the procedure, and finally step 4 determines
the targeted depth of sedation and length of the procedure.
According to all these data, the clinician is then referred to a table
to determine suggested depth of sedation and length of procedure.
This process is orderly and could be followed with a wall chart or
computer prompt but would be a challenge to commit to memory.
We know that complex care algorithms are frequently unused or
misapplied, affecting the effectiveness in daily care. Further
compounding the issue is the need for the current advisory
approach by Green et al3 to be reconciled with all the external
regulatory body standards for procedural sedation, a daunting but
achievable task.
Will use of the advisory improve care and avoid
complications? Although zero morbidity and mortality
associated with procedural sedation is desired, the realistic target
is to make serious complications an extraordinarily rare event.
In this issue, the first known case report of aspiration
pneumonitis occurring after ED procedural sedation is
detailed.6 It is likely that hundreds of thousands of patients
received procedural sedation or analgesia in EDs during the past
decade, yet this is the first report of this complication. No doubt
this complication has occurred previously, albeit unreported.
Nonetheless, the presumable rarity of aspiration raises the
question of whether this ED-based procedure is already close to
or at the six sigma level of safety. The current case report is
unusual in that the patient had ingested alcohol and had 2
separate episodes of procedural sedation and analgesia.
Aspiration occurred 5 hours after her last meal; hence, following
the Green et al3 consensus recommendations may not have
prevented the complication. Given the case nuances, it cannot
be used to support or refute any fasting guideline, including the
6-hour American Society of Anesthesiologists recommendation.
Careful drug administration, patient monitoring, and
resuscitative care seem to be the real learning messages in this
report, things not in debate currently.
Many of the drugs and procedures routinely used by
emergency physicians were once in the sole purview of
anesthesiologists. Those physicians have had remarkable success
in improving patient safety. In the early 1980s, deaths occurred
in approximately 1 in every 10,000 general anesthetics. The
Anesthesia Patient Safety Foundation, founded in 1985, helped
establish policies and guidelines that are associated with decreased
mortality and morbidity from general anesthesia. The latest
retrospective analysis of perioperative pulmonary aspiration
identified an incidence of 1 case in 7,103, morbidity in 1 patient of
every 16,573, and death of only 1 patient in 99,441.7
Emergency medicine should learn from the experience and
successes of others, though simply accepting guidelines derived
from other settings may not be the optimal method of
improving care. As it did for our anesthesiology colleagues, a
data-driven and ED-based effort should guide our approaches to
466 Annals of Emergency Medicine

Paris & Yealy

procedural sedation and analgesia. Mirroring those riskreduction efforts, we should create and encourage nonpunitive
reporting of complications regionally and nationally. According
to these data, we can expect improvements from better
treatment plans, patient monitoring, and reporting.
Many emergency physicians are still challenged by
limitations on the drugs they are authorized to use because of
well-intended opposition from others, including our anesthesia
colleagues. Well-trained emergency physicians should possess all
of the knowledge and skills necessary to be credentialed to use
all of the commonly used agents for procedural sedation and
analgesia, such as etomidate, propofol, ketamine, opioids,
benzodiazepines, and barbituates.
Finally, although not minimizing the importance of the
Green et al3 advisory for fasting and procedural sedation and
analgesia, there are more glaring issues that must be addressed.
The suggestion that In the past [our emphasis added], pediatric
laceration repair and fracture reduction were routinely
accomplished through forcible immobilizationtypically with
the child crying. . .Similarly, emergency physicians would
reduce hip dislocations using small doses of diazepam and
morphine as a historical notation is inaccurate. We suspect this
cruel practice occurs frequently in spite of advances in
knowledge. The oligoanalgesia in the ED, coined by Wilson
and Pendleton8 in 1989, still exists.1,2
The Green et al3 fasting and procedural sedation and
analgesia consensus is a helpful addition and good starting point
for collaboration to improve ED procedural sedation and
analgesia. Our challenge is provide the tools and the ongoing
evidence to allow our patients the widespread benefit of safe,
effective pain relief and anxiolysis during procedures.
Supervising editor: Michael L. Callaham, MD
Funding and support: The authors report this study did not
receive any outside funding or support.
Publication dates: Available online December 18, 2006.
Reprints not available from the authors.
Address for correspondence: Donald M. Yealy, MD,
Department of Emergency Medicine, University of Pittsburgh,
230 McKee Place, Suite 500, Pittsburgh, PA 15241; 412-6478295, fax 412-647-4670; E-mail yealydm@upmc.edu.

REFERENCES
1. Rupp T, Delaney KA. Inadequate analgesia in emergency medicine.
Ann Emerg Med. 2004;43:494-502.
2. Todd KH, Crandall C, Choiniere M, et al. Pain in the emergency
department: a multicenter study. Acad Emerg Med. 2006;13:88-89.
3. Green SM, Roback MG, Miner JR, et al. Fasting and emergency
department procedural sedation and analgesia: a consensus-based
clinical practice advisory. Ann Emerg Med. 2007;49:454-461.
4. Godwin SA, Caro DA, Wolf SJ, et al. Clinical policy: procedural
sedation and analgesia in the emergency department. Ann Emerg
Med. 2005;45:177-196.
5. Practice guidelines for sedation and analgesia by
non-anesthesiologists: an updated report by the American Society

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of Anesthesiologists Task Force on sedation and analgesia by
non-anesthesiologists. Anesthesiology. 2002;96:1004-1017.
6. Cheung KW, Watson ML, Field S, et al. Aspiration pneumonitis
requiring intubation after procedural sedation and analgesia: a
case report. Ann Emerg Med. 2007;49:462-464.

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Procedural Sedation and Analgesia Fasting Consensus Advisory

7. Sakai T, Planinsic RM, Quinlan JJ, et al. The incidence and outcome
of perioperative pulmonary aspiration in a university hospital: a 4 year
retrospective analysis. Anesth Anal. 2006;103:941-947.
8. Wilson JE, Pendleton JM. Oligoanalgesia in the emergency
department. Am J Emerg Med. 1989;7:620-623.

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