Sedation and Fasting for Interventional Pain Procedures: A Summary of the ASIPP Guidelines
Many interventional pain procedures, such as epidural injections, facet procedures, and nerve ablations, can be done with local anesthetic alone. Some patients, however, are anxious or in significant pain and benefit from sedation. Sedation brings its own risks, mainly to breathing, and those risks are higher in patients who already take medications that depress breathing. Guidelines from the American Society of Interventional Pain Physicians (ASIPP), by Kaye and colleagues in Pain Physician, remain one of the few documents written for this setting.
This summary is based on the published abstract of the paper. Read the abstract on PubMed: https://pubmed.ncbi.nlm.nih.gov/31151329/
What the guidelines address
Many patients who come for these procedures take daily analgesics, muscle relaxants, and other drugs that can add to the effects of sedatives. Many also have obesity, heart disease, or lung disease. The authors note that permanent neurologic injury, hypoxic brain injury, and even death have occurred from oversedation, hypoventilation (breathing too little), and spinal cord injury. Concern about aspiration also leads many physicians to ask patients to fast for long periods.
How the guidance was developed
The fasting recommendations are based on extensive literature and consensus. For monitoring, the authors adapt the American Society of Anesthesiologists (ASA) standards for patients under sedation.
What the guidelines say
- Shorter fasting: at least 2 hours for clear liquids and 4 hours for light meals, rather than 8 hours or from midnight. Acid-reducing drugs and antacids may be used but are not routinely recommended.
- Mild to moderate sedation: many patients may need it because of chronic pain and anxiety.
- Deep sedation and general anesthesia are considered unsafe for most procedures: a deeply sedated patient cannot report pain or tingling when a needle nears a nerve or the spinal cord.
- Same monitoring in every setting: office, surgery center, or hospital, including blood pressure, heart rhythm, temperature, pulse oximetry, and continuous capnography (exhaled carbon dioxide).
- Qualified providers: sedation must be given by providers who understand the drugs, their interactions, and resuscitation.
Limitations
- The guidance is consensus-based, not a formal systematic review with graded evidence.
- It reflects one society's view; other guidance may differ in detail.
- Who may give sedation depends on state rules and facility policy.
- It is not the newest document, and practice continues to evolve.
- Some longer procedures may reasonably involve deeper sedation with an anesthesia professional.
Safety takeaways
- Screen before sedating. Ask about opioids, benzodiazepines, muscle relaxants, sleep apnea, obesity, and heart or lung disease.
- Keep the patient able to respond. A patient who can report new pain or tingling is an important safety feature.
- Monitor breathing, not only oxygen. Capnography detects slowed breathing earlier than pulse oximetry, especially when oxygen is given.
- Apply one standard everywhere. Office procedures deserve the same monitoring as hospital procedures.
- Be ready to rescue. The sedation provider should know what to do if breathing slows or stops.
Reference
- Kaye AD, Jones MR, Viswanath O, et al. ASIPP Guidelines for Sedation and Fasting Status of Patients Undergoing Interventional Pain Management Procedures. Pain Physician. 2019;22(3):201-207. PMID: 31151329. (No DOI is listed for this article in PubMed.) Abstract: https://pubmed.ncbi.nlm.nih.gov/31151329/
Related: Sedation and MAC Cases
This article is educational information, not legal or medical advice.
Back to Blog