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IMPORTANCE: It is not clear whether adherence to preprocedural fasting guidelines prevent pulmonary aspiration and associated adverse outcomes during emergency department (ED) sedation of children. OBJECTIVE: To examine the association between preprocedural fasting duration and the incidence of sedation-related adverse outcomes in a large sample of children. DESIGN, SETTING, AND PARTICIPANTS: We conducted a planned secondary analysis of a multicenter prospective cohort study of children aged 0 to 18 years who received procedural sedation for a painful procedure in 6 Canadian pediatric EDs from July 2010 to February 2015. The primary risk factor was preprocedural fasting duration. Secondary risk factors were age, sex, American Society of Anesthesiologists classification, preprocedural and sedation medications, and procedure type. MAIN OUTCOMES AND MEASURES: Four outcomes were examined: (1) pulmonary aspiration, (2) the occurrence of any adverse event, (3) serious adverse events, and (4) vomiting. RESULTS: A total of 6183 children with a median age of 8.0 years (interquartile range, 4.0-12.0 years), of whom 6166 (99.7%) had healthy or mild systemic disease (American Society of Anesthesiologists levels I or II), were included in the analysis. Of these, 2974 (48.1%) and 310 (5.0%) children did not meet American Society of Anesthesiologists fasting guidelines for solids and liquids, respectively. There were no cases of pulmonary aspiration. There were 717 adverse events (11.6%; 95% CI, 10.8%-12.4%), of which 68 (1.1%; 95% CI, 0.9%-1.3%) were serious adverse events and 315 (5.1%; 95% CI, 4.6%-5.7%) were vomiting. The odds ratio (OR) of occurrence of any adverse event, serious adverse events, and vomiting did not change significantly with each additional hour of fasting duration for both solids (any adverse event: OR, 1.00; 95% CI, 0.98 to 1.02; serious adverse events, OR, 1.01; 95% CI, 0.95-1.07; vomiting: OR, 1.00; 95% CI, 0.97-1.03) and liquids (any adverse event: OR, 1.00; 95% CI, 0.98-1.02; serious adverse events: 1.01, 95% CI, 0.95-1.07; vomiting: OR, 1.00; 95% CI, 0.96-1.03). CONCLUSIONS AND RELEVANCE: In this study, there was no association between fasting duration and any type of adverse event. These findings do not support delaying sedation to meet established fasting guidelines.

A QUARTER CENTURY AGO, THE CONCEPT OF SEDAtion as a continuum represented by progressive stages was first introduced. These levels of sedation depth were defined by the patient’s response to verbal or tactile (light or painful) stimulation. In 1985 this new sedation continuum nomenclature was revolutionary. Pulse oximetry had not yet been introduced, and physiological monitoring was limited to electrocardiogram and blood pressure. Without an objective way to assess ventilatory quality, the authors of the sedation continuum were forced to select subjective “responsiveness” as a surrogate marker to predict the risk of respiratory depression. With minor modification, their original definitions have been codified by the Joint Commission into the 4 progressive depths of minimal, moderate, and deep sedation followed by general anesthesia, levels between which patients can fluctuate. This nomenclature has been universally accepted and applied by clinicians through all specialties and is used by the Joint Commission and some specialty societies to define the appropriate expertise of the clinician providing sedation. The inherent subjectivity of this taxonomy, however, has fostered contentious, irreconcilable semantic and political disputes regarding sedation boundaries. What is the dividing line between deep sedation and general anesthesia? If some practitioners are judged to have the skills necessary to safely administer moderate but not deep sedation, how is this distinction to be identified or enforced? What are the skills necessary to rescue a patient from general anesthesia? The inevitable acrimony resulting from these ambiguities challenges the ability to advance the multidisciplinary field of procedural sedation and analgesia. The vulnerability of this continuum lies in the inherent subjectivity in identifying and quantifying a patient’s response to verbal or tactile stimulation. For example, moderate sedation is defined as a state during which the patient should “respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation.” Even the most careful and thoughtful physicians are unlikely to consistently agree, and to date, no evidence supports satisfactory interobserver reliability to assigned sedation stages. Furthermore, this definition cannot realistically be applied to patients who may be unable to respond appropriately, eg, those who are hearing impaired, neurologically or developmentally compromised, or at extremes of age. As a result of this subjectivity and a failure to definitively demonstrate increased respiratory risk between moderate and deep sedation, there is a lack of consensus between specialty societies about which specialists, what resuscitation skills, and which sedatives are appropriate at specific sedation depths. Consequently, significant variability can exist between and even within institutions with respect to sedation practice. The expectation of the Joint Commission is that a deeply sedated patient should be able to be rescued from a depth of general anesthesia— implying clinician skills in advanced airway management. Consequently, there can be a reluctance to acknowledge deep sedation. The inherent subjectivity of moderate vs deep sedation makes it relatively easy for physicians to consciously or subconsciously interpret and assign sedation depth to comply with Joint Commission policy. Another important limitation to defining sedation levels based on responsiveness is the implicit need to repeatedly stimulate the patient to assess and monitor sedation depth. Tactile and verbal stimulation throughout sedation is often impractical or impossible and is fundamentally counterproductive. Medications are administered to produce anxiolysis, hypnosis, amnesia, and analgesia, but to assess sedation depth repeatedly, the patient’s tranquil state is repeatedly disturbed via voice or touch. As a result, sedation depth is not always assessed frequently or consistently, and documentation often represents subjective and imperfect estimates based on clinical judgment alone. It is possible to reformulate the sedation continuum, reorienting the assessment of sedation depth away from subjective assessments of responsiveness and redirecting it toward objective vital sign monitoring, eg, pulse oximetry, impedance respiratory rate monitoring, automated noninvasive blood pressure measurement, and ventilation monitoring with capnography. A restructured sedation continuum could retain the general framework of a series of

LEAD poisoning is a well-known occupational hazard in a number of industries and trades. 1-3 While working conditions and health status of employees in industries with well-recognized potential lead hazards are improving, unexpected sources of lead exposure continue to generate disease. 4 We report a clinical case of lead poisoning that occurred as a consequence of an industrial accident— paint spray gun injury to the hand. Such accidents have attracted attention 5-8 for reasons related to the sequelae of the traumatic injury; to our knowledge, this is the first reported case of lead poisoning resulting from such an injury. Report of a Case A 41-year-old man, a painter, used a high-pressure paint-spraying gun to apply paint on the hull of a ship. On Jan 10, 1980, the hose of the paint-spraying installation broke, and paint was injected under high pressure into the palm of his left hand. He was first examined