medications may be taken with a sip of water ASA noted insufficient evidence to assess the impact of timing of fasting on emesis, reflux, or pulmonary aspiration, however, they continue to recommend maintenance of current preprocedure fasting times ACEP publications have also noted that there is insufficient evidence to fully support these time intervals, and offer a “level B recommendation” (moderate clinical certainty) that “procedural sedation may be safely administered to pediatric patients who have had recent oral intake.” Clinicians should be aware of other factors besides stomach contents that can increase the risk of pulmonary aspiration The depth of sedation is an important consideration, as deep sedation may impair airway reflexes, making aspiration more likely Medication choice also plays a role The dissociative sedation caused by ketamine preserves airway reflexes, and aspiration is much less likely with this agent compared to others Conversely volatile agents frequently used by anesthesiologists not only impair airway reflexes, but can also cause vomiting, thereby increasing risk of aspiration Any positive pressure ventilation may increase risk of aspiration in a sedated patient Patient characteristics that increase the risk for pulmonary aspiration include known difficult airway, extremes of age, higher ASA PS, and any medical condition that increases risk of gastroesophageal reflux Patients with known gastroesophageal reflux or dysmotility disorders may benefit from appropriate pharmacologic treatment to reduce gastric volume and increase gastric pH, although routine use for all patients is not recommended Similarly, although presedation antiemetics may decrease the incidence of emesis, they have not been shown to reduce pulmonary aspiration because emesis most commonly occurs during the recovery stage of sedation For the emergency patient, sedation should still be preceded by an evaluation of food and fluid intake It is prudent to assume that patients in the ED have full stomachs when planning the use of sedatives or analgesics When determining preprocedure fasting time, it is important to individualize the decision Clinicians should consider depth of desired sedation, specific agents used, timing and urgency of procedure, and any conditions that may increase the chance of aspiration The risks of sedation must be weighed against the benefits; the lightest effective sedation should be used Some patients may benefit from delaying the procedure or administration of