@JoePinero – Much literature has been devoted to the attempt of proving the benefit of fasting as it relates to dangerous aspiration events during intubation or procedural sedation. Despite an overwhelming amount of literature pointing out a lack of benefit to fasting, most radiologist and anesthesiologists are very upset if they find out that their patient had a glass of water 2 hours prior to being intubated. This myth dates back to 1946 when Mendelson studied 44000 OB cases undergoing general anesthesia, which resulted in 46 cases of aspiration and 2 deaths.

This study was then repeated in 1951 by Culver et al, who had patients swallow dye pills prior to intubation and surgery, and then post-surgery would explore the lungs via bronchoscope/laryngoscopy to evaluate whether or not dye was in the lungs. He determined that 26% of his 300 cases had vomited gastric contents, and of the 26%, 16% had evidence of aspiration. There are numerous glaring flaws with these reports, which I will not get into here, but essentially, some physicians today are basing their fear of aspiration off of outdated studies from the 40’s and 50’s. Here are some papers that support the idea that fasting is not harmful in procedural sedation.

ACEP Guideline: Level B –  Do not delay procedural sedation in adults or pediatrics in the ED based on fasting time. Preprocedural fasting for any duration has not demonstrated a reduction in the risk of emesis or aspiration when administering procedural sedation and analgesia.

Godwin SA, Burton JH, Fesmire FM et al. Clincal policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2014 Feb;63(2):247-58

Thorpe and benger – Meta-analysis consisting of 5000 patients, 17 events of vomiting during procedure, no clinical signs of aspiration

Pasaron et al. – 1000 peds patients undergoing minor procedures with procedural sedation, none were fasted, 1.8% adverse events, none related to aspiration, none were more than minor

Molina et al. – Cohort study, 400 peds patients, 2 episodes vomiting, 1 fasted, 1 non-fasted, no clinical aspiration

Roback et al. – 2000 patients age 1 mo – 32 yo, 156 episodes vomiting, no difference between fasting vs non-fasting groups

Agrawal et al. – 1000 patients, ~70 adverse events (all minor, 0 aspirations), 35 from non-fasting, 32 from fasting group,

July 2024