Pediatric sedation risk lowered when guided risk assessment performed

By Karla Gale

NEW YORK (Reuters Health) – Adherence to a program for pediatric procedural sedation by nonanesthesiologists based on American Academy of Pediatrics/American Society of Anesthesiologists (ASA) guidelines significantly reduces the occurrence of adverse events, Wisconsin investigators have found. The most effective element for risk reduction is the use of guided risk assessment.

As described in the February issue of Pediatrics, components of the program include presedation risk assessment, ASA risk classification, informed consent, generation of a sedation plan, recording of complete sedation score and vital signs, and postsedation assessment.

Dr. George M. Hoffman and associates reviewed all sedation records during a 3-month period in 1999 for procedures conducted at Children's Hospital of Wisconsin in Milwaukee, where this program had been put in place the previous year. Of 960 records, the complication rate was 34 of 895 children with planned conscious sedation and 6 of 65 with planned deep sedation.

After stratification by target sedation plan, the odds ratio for complications when guided risk assessment was performed was 0.10 compared with those cases when it was not performed. No complications were observed among patients who were deeply sedated for whom all components of the program were implemented.

Chloral hydrate significantly increased risk. Complications associated with its use included hypoxemia, hypotension and overt airway obstruction, even when typical dosing was used and chloral hydrate was the only sedative agent. Midazolam was associated with a lower risk of complications.

Risk of complications was not affected by age, ASA physical status or adherence to NPO guidelines.

"This study was important because people are reluctant to do things that add complexity without any demonstrable outcome advantage," Dr. Hoffman said in an interview with Reuters Health. "We wanted to see if actually jumping through the hoops made a difference, and it certainly did."

He speculated that dealing with airway obstruction is the biggest challenge for nonanesthesiologists, especially as adenoidal tissue becomes enlarged in preschool-age children. So his advice is to "have equipment available for providing airway support and for monitoring blood oxygenation and airway patency. Know where your back-up personnel are, and use an objective measure of depth of sedation to help guide treatment."

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