Pediatric Sedation Monitoring Varies by Provider Type

Diedtra Henderson

September 10, 2012

September 10, 2012 — Although more than a dozen different professional organizations have issued guidelines indicating the optimal approach to monitoring sedation used in children undergoing painful procedures or diagnostic imaging, an observational study shows a "large degree of variability" in the monitoring that occurs in the real world, with differences between the types of sedation providers, medications, procedures, and patients.

Melissa L. Langhan, MD, from the Department of Pediatrics, Section of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, and coauthors report the results of their prospective, observational study in an article published online September 10 in the Archives of Pediatrics & Adolescent Medicine.

Sedation is used to safely and comfortably perform diagnostic or therapeutic studies in children by a host of healthcare providers, ranging from anesthesiologists to emergency medicine physicians to nurse practitioners, the authors note.

Monitors such as pulse oximetry are used to check for and reduce the frequency of severe hypoxic events, cuffs capture blood pressure data, capnography has improved detection of hypoventilation and apnea, and electrocardiography (ECG) detects altered heart rate.

However, the current study is believed to be the first large-scale, multispecialty examination of monitors actually used during pediatric sedation across a wide spectrum of practices.

The researchers collected and analyzed data from 114,855 pediatric sedations performed from September 1, 2007, through March 31, 2011, using the Pediatric Sedation Research Consortium (PSRC) database. Of the patients, 51,339 (roughly 45%) were girls younger than 21 years, and 62,983 (approximately 55%) were boys. The PSRC is a collaborative group of 37 institutions, including large children's hospitals, children's hospitals within hospitals, and general community hospitals, that prospectively collects data about pediatric procedural sedation/anesthesia outside of the operating room.

The most common procedures for which sedation was applied included magnetic resonance imaging for radiology, lumbar puncture with intrathecal medication administration and bone marrow biopsy for hematology/oncology, upper endoscopy and colonoscopy for gastroenterology, and brainstem auditory response test and lumbar puncture for nerve/brain/ear, the authors report.

Guidelines published by the American Academy of Pediatrics (AAP), the American College of Emergency Physicians, and the American Society of Anesthesiologists for nonanesthesiologists were adhered to for 52% of the patients, the authors report.

Drilling deeper into the data, the authors write that the "largest difference in monitoring use was seen in the frequency of ECG monitoring between anesthesiologists, those in general practice or in a subspecialty other than pediatrics (95%), and those who self-identified as pediatric anesthesiologists (13%)." Of note, "[g]enerally, radiologists were the least frequent users of all the monitoring devices with the exception of ECG. Notably, radiologists did not use any monitor in more than 40% of children," and only a third used pulse oximetry, the research team writes.

A Disaster Bound to Happen, Warns Independent Expert

Despite the high degree of variability in monitoring, serious adverse outcomes among the children undergoing procedural sedation were uncommon in the database. Still, an outside expert was alarmed by the study's "surprising" result that AAP guidelines were followed by so few practitioners within the self-selected PSRC consortium.

"If this dedicated group of individuals did not follow the AAP guidelines in almost 50% of cases, what is really happening in institutions and with individuals who do not have the positive motivations of the PSRC membership?" Charles J. Coté, MD, from the Department of Anesthesia and Critical Care, Division of Pediatric Anesthesia, Massachusetts General Hospital, Boston, writes in an accompanying editorial.

"It is of particular concern that radiologists did not use any monitors on approximately 40% of children and only 33% used pulse oximetry, yet this subgroup of practitioners are likely to have the least facility with emergency airway management due to their area of specialization and training," Dr. Coté continued. "This lack of adherence to sedation guidelines is akin to driving a car at night with no headlights and no speedometer; at some point a disaster will happen."

Study limitations included the inability of a large database to ensure complete consistency in reporting over a large number of institutions and healthcare providers, the use of data from consortium members who "may represent best practice," and the researchers' inability to know the exact nature of the intended sedation levels or the sedation level that was achieved in every case in the database.

"Further research is needed to develop evidence-based guidelines regarding the appropriateness of various monitoring modalities and their effect on adverse outcomes that are associated with sedation," the authors conclude.

The National Center for Advancing Translational Sciences, part of the National Institutes of Health, provided funding for the study. The National Institutes of Health roadmap for Medical Research provided funding for Dr. Langhan, who also received an honorarium to participate in an expert panel at an advisory board meeting of Oridion Capnography, Inc. The other authors have disclosed no relevant financial relationships.

Arch Pediatrics. Published online September 10, 2012.