Original ContributionThe use of a pediatric emergency medicine–staffed sedation service during imaging: a retrospective analysis
Introduction
The advancement of diagnostic technology has led to an increased need for patient cooperation and immobilization during imaging, especially in children [1], [2]. This has increased the demand for sedation and placed significant pressure on anesthesiology resources to the point where, in some health care facilities, the volume of children needing sedation outside of the operating room is approaching the number of children needing general anesthesia [3], thus resulting in the need for trained nonanesthesia personnel to fill this void [4]. The American Society of Anesthesiologists (ASA), the Joint Commission on the Accreditation of the Hospital Organizations, the American Academy of Pediatrics (AAP), and the American College of Emergency Physicians have developed and updated pediatric sedation levels, physical status classification levels, and practice guidelines in an effort to standardize sedation procedures and reduce the risk of adverse events [2], [5], [6], [7], [8], [9]. The American College of Emergency Physicians describes procedural sedation as the level of analgesia and sedation necessary to produce a depressed level of consciousness while still allowing the patient to continuously maintain independent control of the airway [9]. Procedures requiring immobilization may require this level of sedation.
Sedation occurs along a continuum where a patient may move from a level of mild or moderate sedation to one of deep sedation or even general anesthesia [4]. In addition, adverse effects, such as cardiorespiratory events, airway malalignment, and/or atypical, paradoxical, or emergence reactions to medication may occur [10], [11], [12], [13], [14], [15], [16], [17]. These realities have been recognized by the AAP and ASA who recommend that a practitioner other than the clinician performing the diagnostic procedure be responsible for sedation and patient monitoring [2], [8]. Pediatric sedation services or units have been created to meet this need [17], [18], [19], [20].
The pediatric emergency medicine (PEM) physician–staffed radiology sedation service was developed at our facility after a request from the hospital administration due to the increasing demand for safe and effective pediatric sedation during imaging [20], [21]. Because of the PEM training requirements in sedation and resuscitation techniques, PEM physicians are among the small group of specialists with the qualifications to effectively provide procedural sedation [22]. Multiple published studies have reported that PEM physicians can safely administer procedural sedation within the pediatric emergency department (ED) during unpleasant tests and procedures [4], [10], [22], [23], and this has become common practice [10], [14], [24].
The primary aim of our study was to determine if a sedation service staffed exclusively by PEM specialists could provide effective, uncomplicated procedural sedation to children in a radiology department, with a low rate of adverse events. Secondarily, we attempted to analyze the factors that may have increased or decreased the risk of sedation failure and adverse sedation events.
Section snippets
Design
The study was designed as a retrospective chart review of all sedations administered by a PEM-based pediatric sedation service to children (ages 0 to 18 years) undergoing imaging procedures in the radiology department of LeBonheur Children's Medical Center from September 2003 through August 2004. This study was approved by the institutional review boards of the University of Tennessee Health Sciences Center and Methodist/LeBonheur Medical Services, with waivers of consent.
Setting
Our PEM-based
Results
A total of 1042 sedation episodes were identified for review. Of these, 34 patient records were incomplete and 66 were missing, leaving 942 sedation episodes available for data collection and analysis. A total of 19 cases met exclusion criteria: 14 sedations identified on the PEM sedation log were performed by a pediatric intensivist; one was excluded because of age (22 years, 11 months); in one case, no scan was started after sedation had been initiated, as it was unexpectedly canceled by the
Discussion
The results of this study showed that a sedation service staffed exclusively by PEM physicians could effectively administer sedation in most patients with a minimal risk of minor adverse sedation events and a very low risk for major adverse sedation events. Furthermore, in our patient sample, no sedation-related complications occurred that resulted in hospital admission, increased care, or permanent injury.
A retrospective feasibility study performed by Pershad and Gilmore at our institution
Conclusions
A radiology sedation service staffed solely by PEM physicians can provide procedural sedation to children undergoing imaging, with a low risk for adverse events and a low failure rate. However, this study emphasizes the need for good airway manipulation skills in all clinicians providing sedation. Pediatric sedationists should also keep in mind the implications of sedation agents administered and the current health status of the patient, especially those with active respiratory illness. As the
References (29)
- et al.
Procedural sedation in the pediatric patient
Anesthesiol Clin North America
(2005) - et al.
Clinical policy: procedural sedation and analgesia in the emergency department
Ann Emerg Med
(2005) - et al.
When is a patient safe for discharge after procedural sedation? The timing of adverse effect events in 1367 pediatric procedural sedations
Ann Emerg Med
(2003) - et al.
Adverse events of procedural sedation and analgesia in a pediatric emergency department
Ann Emerg Med
(1999) - et al.
Preprocedural fasting state and adverse events in children undergoing procedural sedation and analgesia in a pediatric emergency department
Ann Emerg Med
(2003) - et al.
A pediatric sedation/anesthesia program with dedicated care by anesthesiologists and nurses for procedures outside the operating room
J Pediatr
(2004) - et al.
Clinical policy: evidence-based approach to pharmacologic agents used in pediatric sedation and analgesia in the emergency department
Ann Emerg Med
(2004) - et al.
Propofol for procedural sedation in children in the emergency department
Ann Emerg Med
(2003) - et al.
Propofol sedation by emergency physicians for elective pediatric outpatient procedures
Ann Emerg Med
(2003) - et al.
Sedation for pediatric patients undergoing CT and MRI
J Comput Assist Tomogr
(1992)
Practice guidelines for sedation and analgesia by non-anesthesiologists
Anesthesiology
Safety and comfort during sedation for diagnostic or therapeutic procedures
Hong Kong Med J
Guidelines for the elective use of conscious sedation, deep sedation, and general anesthesia in pediatric patients. Committee on Drugs. Section on anesthesiology
Pediatrics
Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures
Pediatrics
Cited by (15)
Sedation for Diagnostic and Therapeutic Procedures Outside the Operating Room
2019, A Practice of Anesthesia for Infants and ChildrenSedation for Diagnostic and Therapeutic Procedures Outside the Operating Room
2018, A Practice of Anesthesia for Infants and ChildrenAdverse events in pediatrics patients subject to magnetic resonance imaging under sedation or anaesthesia
2017, Revista Colombiana de AnestesiologiaUltra-low-dose chest computed tomography without anesthesia in the assessment of pediatric pulmonary diseases
2020, Jornal de PediatriaCitation Excerpt :Studies on pediatric imaging demonstrating a low incidence of adverse events (6.6%) for high risk populations, such as ASA 325 (patient with a severe systemic disease that is not life-threatening), after receiving propofol or fentanyl, the most commonly used drugs for sedation.26 On the other hand, a previous review with 923 pediatric patients undergoing radiological imaging in emergency demonstrated a 10% overall incidence of adverse events, with 0.76% major adverse events requiring intervention, such as significant hypoxemia, apnea, and laryngospasm.27 A topic that is currently under discussion is the potential risk of neurotoxicity related to GA.
Comparative Sedation with Sevoflurane and Thiopental in Children Undergoing MR Imaging
2022, Journal of the College of Physicians and Surgeons PakistanChloral hydrate as a sedating agent for neurodiagnostic procedures in children
2021, Cochrane Database of Systematic Reviews