In this month’s issue of Anesthesiology, the updated ASA Guidelines on Preoperative Fasting are published
. The guidelines are largely based on scientific evidence as noted in the document. The guidelines will also be unsurprising for anesthesiologists: for elective cases, intake of clear fluids is allowed up to 2 hours before induction, breast milk is permissible up to 4 hours prior, and intake of solids and infant formula should cease 6 hours before anesthesia.
For another group of physicians, however, the new guidelines present a significant change. This population includes Emergency Department physicians and the surgeons who rely on ED physicians to sedate patients for their ED procedures. ED doctors use different guidelines for “sedation”. (I use the quotes because some of the sedation, especially in children, is what I believe to be general anesthesia via TIVA.)
In two articles published in 2007 (ref 1
), consensus guidelines and an accompanying editorial describing the differences between ACEP (American College of Emergency Physicians) and ASA guidelines were discussed.
The ACEP guidelines use 2 hours for clear liquids and 3 hours for all other oral intake. In addition, ketamine is considered “dissociative sedation” rather than anesthesia. This dissociative sedation is considered less risky than moderate sedation in the ACEP guidelines because “airway reflexes are maintained with ketamine.”
So, what’s new?
The new CMS interpretative guidelines for hospitals state that the anesthesia department is now in charge of overseeing all sedation and anesthesia delivered in a facility/hospital. In the past, you and your group may not have had to deal with this conflict in clinical practice; moving forward, you will no longer have this luxury.
In addition, the solution may not be to simply make ED patients and physicians follow ASA guidelines. I strongly recommend that you read the comments of Paris and Yealy (ref 2
). They point out that the ED is a completely different setting for patients and physicians than elective surgery; sometimes a delay of 6 hours may cause unnecessary pain to, and stress on, the patient and their family. In developing the consensus guidelines, Green et al.(ref 1
) note that some patients need urgent or semi-urgent sedation.
Remember: The next time you are on call, you may be asked to come and sedate a 5 year old for a closed reduction and casting of a forearm fracture. You may say that it needs to be done with an endotracheal tube in the operating room, but the orthopedic surgeon and the ED physician are going to say that they have a long experience of using ketamine in the ED for these cases and have had no problems.
Let’s not even get into a cost of care discussion since we first need to provide good care.
Good luck and have a great call!
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Posted by Amr Abouleish MD, MBA