Article Reviews & Commentary
Article Reviews by Thomas J. Mancuso, MD, FAAP
Risk Reduction in Pediatric
Procedural Sedation by Application of an American Academy of Pediatrics/American
Society of Anesthesiologists Process Model.
Hoffman GM, Nowakowski R, Troshynski TJ et
al. Pediatrics 2002:109;236-243
The authors set out to test the hypothesis that adoption and use of a structured approach to sedation of children based on the AAP/ASA guidelines would lead to a decrease in risk associated with procedural sedation. The components of this sedation process, according to the paper, included specific personnel requirements, NPO guidelines, a presedation evaluation, development of a sedation plan, monitoring standards, time-based recording of vital signs on a standardized record and specific criteria for recovery and discharge. The primary outcome measures were the occurrence of any adverse event or complication noted either on the sedation record itself or picked up through quality improvement screening. Adverse events included; inadequate or failed sedation, sustained hypoxemia, airway obstruction, apnea, aspiration, hypotension, bradycardia, prolonged or excessive sedation. A 0 to 6 severity score was assigned to complications.
A policy for a uniform sedation process was adopted at the Children's Hospital of Wisconsin in July 1998. A comprehensive review of all sedation records during the period from 7/99-10/99 was used in this analysis. Sedation was used by a wide variety of services within the hospital including in order of decreasing number of cases, radiology, cardiology, emergency medicine, general surgery, pulmonary, hematology/oncology and others. The ages of the children in this review was as follows: : 0-1 month(41), 1-6 months(149), 6-12 months(138), 1-2 yr(180), 2-5 yr(239) and > 5 yr(212).
Complications were noted in 4.2% of the records, 40 of 960 cases. The complication rate was related to both the target and actual level of sedation. In cases of conscious sedation the complication rate was 3.8% (34 of 895) while in cases of deep sedation the rate was 9.2% (6 of 65). Univariate Mantel-Haenszel odds ratios (OR) were calculated for each factor in the sedation process mentioned above. Complications were reduced significantly by the use if a structured risk assessment ( OR; 0.10), adherence to all guidelines set forth in the sedation process (OR:0), avoidance of deep sedation (OR:0.4). Among the medications used; chloral hydrate, pentobarbital, morphine, meperidine, fentanyl, midazolam and ketamine, only chloral hydrate had a significantly higher complication risk (OR:2.1). The risk of adverse event occurrence increased with the number of medications administered. When 1 drug was used the rate of adverse event occurrence was 2.7% (17 of 642) while in cases when 3 drugs were used the rate was 14.5% (8 of 55). The occurrence of inadvertent deep sedation was lowered by repeated assessment of the depth of sedation, guided by the time-based record of vital signs and sedation level.
Comment
This is a very important paper. The authors demonstrate decreased morbidity with use of a structured approach to sedation based on published AAP/ASA guidelines. They carefully reviewed their experience sedating children using such a system and came to conclusions we all expected, but they actually had the data, not simply opinion. It is no surprise to me that the pre-sedation risk assessment and the use of a time-based record were important parts of their success. How safe would the practice of anesthesia be without a pre-anesthetic assessment or the use of a time-based record?
Although the terms conscious and deep sedation used in this paper are no longer preferred, the results of this review are certainly applicable to current clinical practice. There is no uncertainty about the meaning of the terms used to describe the children's state while sedated during the procedures. The authors include a detailed 0-6 point sedation scale with explanations of the various levels of sedation as well as terms used to describe those states of depressed level of consciousness. #include ./footer_include.iphtml