Anaesthesia
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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. ⋯ 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 patient characteristics, comorbidities, the nature of the procedure and the nature of the anticipated sedation technique. Graded fasting precautions for liquids and solids are then recommended for elective procedures based upon this categorisation of negligible, mild or moderate aspiration risk. This consensus statement can serve as a resource to practitioners and policymakers who perform and oversee procedural sedation in patients of all ages, worldwide.
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Pulmonary aspiration of gastric content is a significant cause of anaesthesia-related morbidity and mortality. High-quality prospective randomised evidence to support prevention strategies, such as rapid sequence intubation, is difficult to generate due to well-described practical, ethical and methodological barriers. We aimed to generate an understanding of worldwide practice through surveying clinically practicing anaesthetists and airway experts. ⋯ Respondents from lower income countries were more likely to prefer [OR (95%CI]: the supine position 2.33 (2.00-2.63), p < 0.001; nasogastric tube insertion 1.29 (1.09-1.51), p = 0.002; and cricoid force application 2.54 (2.09-3.09), p < 0.001 as compared with respondents from higher income countries for a hypothetical patient with intestinal obstruction. This survey, which we believe is the largest of its kind, demonstrates that preferences for positioning, nasogastric tube use and cricoid force application during rapid sequence intubation vary substantially. Achieving agreed consensus may yield better training in the principles of rapid sequence intubation.