Sedation, Anesthesia Risk Doubled for Children Born Preterm

Troy Brown, RN

February 26, 2016

Children born preterm who receive sedation or anesthesia for procedures outside of the operating room are almost twice as likely to experience adverse events compared with those born at term, and these risks persist into adulthood, according to a new study.

"Our analysis suggests that preterm and formerly preterm patients undergoing sedation/anesthesia for nonoperating room procedures should be considered a population at risk for the development of adverse events," write Jeana E. Havidich, MD, from the Dartmouth Institute, Lebanon, New Hampshire, and colleagues in an article published online February 25 in Pediatrics.

Ronald S. Litman, DO, from the Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, reiterated that point in an accompanying commentary. "This novel (but not surprising) finding that prematurely born children have an increased risk of sedation-related respiratory complications throughout all ages of childhood should now influence the way in which sedation practitioners and anesthesiologists approach risk management in this population."

The researchers analyzed data from 57,628 children from birth through age 22 years who were part of the Pediatric Sedation Research Consortium, which has been collecting data on sedation and anesthesia safety and effectiveness since 2003.

"We hypothesized that children born preterm would have a higher rate of adverse events, and that this difference in adverse event rate would decrease with increasing age," the researchers explain.

The researchers categorized children born at less than 37 weeks' gestational age as preterm children and children born at 37 weeks' gestational age or older as term children.

In the preterm children, the most frequent procedures requiring sedation or anesthesia were magnetic resonance imaging scans (57.5%), auditory brainstem response testing (7.7%), and upper endoscopy (7.5%). In term children, the most frequent procedures requiring sedation or anesthesia included magnetic resonance imaging scans (41.7%), lumbar puncture for chemotherapy administration (14.7%), and upper endoscopy (6.6%).

In all, 8.6% of the children had an adverse sedation/anesthesia event, which occurred most frequently in children younger than 6 months. The most frequently reported adverse events included airway obstruction (2.0%), coughing (2.0%), snoring (1.7%), and oxygen desaturation (1.8%), defined as oxygen saturation lower than 90% for longer than 30 seconds. No children died in the study.

The frequency of emergency intubation did not differ between the term and preterm children (P = .7).

After adjustment for age and sex, the preterm children had a 93% increased risk for an adverse event (odds ratio [OR], 1.93; 95% confidence interval [CI], 1.56 - 2.39; P < .001) compared with the term children.

Adverse events were more frequent in preterm and former preterm children compared with term children (14.7% vs 8.5%, respectively), regardless of age. In the preterm children, the most commonly reported adverse events were oxygen desaturation (4.5%), coughing (3.4%), and airway obstruction (2.9%).

In the term children, the most commonly reported adverse events were airway obstruction (2.0%), coughing (1.9%), and oxygen desaturation (1.8%).

After adjustment for age, sex, and responsible provider, adverse events were more frequent in the preterm children in both the noninvasive (OR, 1.69; P < .001) and invasive (OR, 2.02; P < .001) procedures compared with in the term children.

The authors found that the risk was highest among patients younger than 6 months; however, an increase in the rate of adverse events was noted in the 10- to 13-year-old age group. "These data suggest that age and history of prematurity should be considered during the development and implementation of a sedation/anesthetic plan," the researchers conclude.

A variety of providers, including pediatric intensive care physicians (59.2%), pediatric emergency department physicians (18.3%), and pediatric anesthesiologists (8.7%), administered the sedations or anesthetics. The type of provider did not differ significantly between the term and preterm children aged 0 to 36 months (P = .12). Moreover, the rate of adverse events in the preterm children did not differ significantly among different providers (P = .4).

In his commentary, Dr Litman address the need to further understand and mitigate the excess risks. "Now that we know about this increased risk, what is the best way to determine how to change our management of these vulnerable children? There are 2 main approaches," Dr Litman writes.

Analyzing data from prospectively created patient registries such as the Pediatric Sedation Research Consortium "allows the use of a relatively large number of data points to determine patterns and correlations that would otherwise be too difficult to detect in a prospective trial with a smaller and less random sample," Dr Litman notes.

A weakness of using this approach is that the large variety of patient encounter types makes comparisons difficult. "One cannot reasonably compare outcomes between an anesthesiologist, who in the course of caring for a child undergoing an upper endoscopy, will use endotracheal intubation and inhaled anesthetic agents, versus a pediatric hospitalist who administers less potent intravenous sedation agents to a child undergoing [a magnetic resonance imaging scan]," Dr Litman explains.

"The second approach is to use the results gleaned from patient registry studies to design smaller and more focused, hypothesis-driven controlled studies to determine the root causes of complications and effective interventions in specific populations at risk," Dr Litman writes.

However, such studies may be too narrow for a subject as broad as pediatric sedation and its outcomes, he notes.

The best approach may be to use both methods, he suggests. "For example, if an analysis of a large registry of children undergoing [a magnetic resonance imaging scan] with a specific sedative agent found that prematurely born infants had a greater incidence of respiratory complications, a subsequent prospective study would compare the efficacy of certain interventions (eg, positioning, oxygen supplementation, capnography) to decrease those risks under similar conditions," Dr Litman explains.

"The accumulation of greater numbers of patients into these registries will allow increasingly granular analyses to improve the treatment of specific populations and to identify more focused interventions for improving the safety of pediatric anesthesia and sedation," Dr Litman concludes.

The authors and Dr Litman have disclosed no relevant financial relationships.

Pediatrics. Published online February 25, 2016. Article abstract, Commentary extract

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