Report from the 4th International Multidisciplinary Conference on Pediatric Sedation

The Fourth International Multidisciplinary Conference on Pediatric Sedation took place in Philadelphia, June 8-9, 2009.  For the first time, the conference was officially sponsored by and supported primarily by the Society for Pediatric Sedation.  The Society was assisted by the “host” children’s hospital – The Children’s Hospital of Philadelphia (CHOP).  Approximately 180 people attended.

Prior to the start of the official meeting, the SPS (and CHOP) sponsored a Pediatric Sedation Provider Course on Sunday, June 7. It included a Primer on Pediatric Sedation that served as the overall course syllabus, now available on www.pedsedation.org under “Sedation Courses."  The course was comprised of several lectures and small group sessions including presentations on Presedation Assessment, Adverse Events in Sedation, Monitoring Sedation, Invasive vs. Non-Invasive Procedures and Post-Sedation Recovery.  Unique to this course were multiple Human Patient Simulation Sessions that taught and reinforced critical competencies for sedation, including Apnea/Hypoventilation, Airway Obstruction, Secretions and Aspiration, Hemodynamic Changes, Invasive Procedures, Non-Invasive Procedures, Tailoring Sedation, and Inadequate Sedation.  The course concluded with a written test.

By all reports this course was a smashing success with all attendees commenting on the usefulness of the combination of didactic content and the human simulation sessions.  Course director, Greg Hollman MD, and all who participated should be congratulated.    Plans are already underway to repeat the course this fall in Atlanta, GA and subsequently to assist other institutions that wish to conduct a Provider Course.  Much more information on this will be available in the near future.

The Sedation Conference began on Monday morning with a lecture from Michael Mallory, MD, on Quality Improvement in Pediatric Sedation: How to Measure Complications and Efficacy/Effectiveness.  In this lecture, Dr. Mallory asked the audience to consider the kinds of information that should be collected for each sedation encounter and how this information could be cataloged.  He pointed out that we lack generally agreed upon definitions for various adverse events and suggested that these definitions be based on both observed events and provider interventions. He then demonstrated in real time the data collection tool based on a Filemaker Pro® platform that is used at Children’s Healthcare of Atlanta – Scottish Rite Campus sedation service.  This service (one of the largest in the country) is a leader in quality improvement data collection.  Dr. Mallory clearly showed how critical data on the patient, procedure, and adverse events could be recorded in a matter of minutes using a very user-friendly interface.  In summarizing his work, Dr. Mallory emphasized the fact that it is only through collection of quality improvement data such as this that a program can come to understand the nature of its practice and hope to improve its outcomes.

This lecture was followed by a four lecture series on Optimizing Sedation Systems for Children in which Drs. Jeana Havidich, Trish Scherrer, Mick Connors, and Jan Boswinkel each shared specific aspects of the process of sedation in their home institutions that is critical to optimizing their systems.

Dr. Havidich described an anesthesiology-based system and focused on issues related to communication of patient risk factors and patient assessment.  She talked about special populations such as former premature infants and children with SS disease who deserve special consideration and care.

Dr. Scherrer highlighted the needs and possible advantages to a traveling sedation system. She also detailed the issues that ensure safety in these systems.

Dr. Connors reviewed optimal screening processes for sedation and described high risk states that should raise red flags for sedation providers – anatomical or functional airway abnormalities, cardiac issues, chromosomal abnormalities, obesity, and patients with previous problems with sedation. 

Finally, Dr. Boswinkel finished the session by describing the issues that led to the creation of the hospitalist-based sedation system in his institution and the various aspects that characterize that system as it exists right now. He highlighted the training of sedation providers and the ongoing quality improvement data collection in this sedation system.

After lunch, Dr. Lia Lowery gave a lecture on Optimizing Sedation Unit Design in which she detailed the issues she worked through in heading the creation of a new sedation unit at Rainbow Babies Children’s Hospital in Cleveland.  Dr. Lowry talked about multiple aspects of design, including issues such as appropriate waiting areas for families and location of the unit in proximity to the radiology department or other sedation sites in the medical center.  The specific design of the rooms and the monitors used, as well as the issue of plumbing for medical gases also came up in the question and answer session.

The afternoon lectures were completed by a thought-provoking lecture from Dr. Alfred Sacchetti who spoke on Lessons Learned from Pediatric Sedation in the Community Setting.  In this lecture, Dr. Sacchetti reviewed the data he has collected in a database from his study group of community emergency departments – the ProSCED registry.  He described the motivation behind the creation of the registry which allows data for research as well as quality improvement.  Procedures involved in the roughly 2,000 cases included in this registry included many joint relocations, laceration repairs, and spinal taps. He presented charts which showed the sedation drugs used in this setting and the ages of the patients in which they are utilized.  The data reflected a very interesting trend toward the use of potent sedatives and opiates in this setting including propofol, etomidate, ketamine and remifentanil.  In general, the data was impressive for the general safety of the work involved with an adverse event rate of 3%. In this setting it was not at all unusual for the emergency medicine physician to be performing the procedure and overseeing the sedation – no difference seen in adverse event rates at this point. He finished with a discussion of some unique approaches to sedation including droperidol-based sedation, remifentanil based sedation, nitrous oxide utilization, as well as the use of BiPAP for obese patients during sedation.

Monday’s proceedings concluded with a tour of the CHOP sedation unit hosted by the CHOP staff.

The Conference continued on Tuesday morning with a series of lectures on Sedation for Special Pediatric Populations.  Joe Cravero began the session with a discussion of the issues involved in Neonatal Sedation.  He detailed the data that indicates appropriate pain and sedation care in neonates is important for normal growth and development later in life.  He also reviewed the current concerns about neurotoxicity related to exposure to sedative agents in the neonates.  He finished with a discussion of high tech “bundling” options and unique issues in this population relating to new agents for sedation including propofol and dexmedetomidine. 

Jennifer O’Flaherty, MD reviewed the issues involved in sedating Children with Metabolic Diseases. She talked about strategies for avoiding metabolic acidosis in these patients. She also discussed the influence of various drugs on children with metabolic inborn errors including the effects of nitrous oxide on B12 dependent enzyme systems and propofol on mitochondrial complex deficiencies. 

Laura Diaz, MD gave a lecture on Sedating the Child with Congenital Heart Disease. She pointed out the increasing numbers of these patients in our population and the key pre-sedation considerations in these cases.  She also outlined appropriate special resuscitation and monitoring equipment for these patients.  The lecture included a review of drugs for sedation including ketamine, barbiturates, benzodiazepines, propofol, etomidate, and dexmedetomidine. 

The lecture on Obstructive Sleep Apnea Syndrome and Obesity was given by B. Randall Brenn.  This lecture reviewed the pathophysiology and etiology of OSAS.  Dr. Brenn talked about the relationship between obesity and OSAS and included a description of narcotic sensitivity related to recurrent hypoxia, which these patients experience.

 Also included in the morning lectures was The Pediatric Airway and Sedation delivered by Ron Litman. He demonstrated the anatomical changes in airway configuration during sedation using three dimensional MRI and CT imaging.  He also described many functional studies that have looked at the degree of obstruction during sedation.  The lecture concluded with a discussion of the effects of various drugs on the anatomical and functional aspects of the airway.

Tuesday’s agenda included two lunchtime lectures.  Charles Coté began this session with his lecture Pediatric Sedation Guidelines Past and Future: How do New Drugs Fit?  He outlined the history of the current guidelines for sedation from the AAP and their genesis from the Committee on Drugs.  He also highlighted the key features of each iteration of the guidelines and outlined some of the statements on sedation that have come from the American College of Emergency Medicine as well as the directives from JCAHO concerning the sedation of children. He touched on several areas of controversy including the use of propofol by non-anesthesiologists, the relative safety of ketamine sedation, and the need for NPO status prior to sedation. 

Sara Aldridge, ARNP and Michelle Rhoads, APRN presented a lecture on The Evolving Role of the Non-Physician.  This lecture focused on the various levels of providers and the roles that each can fill according to different state regulatory agencies.  They described the role that non-physicians are filling in several sedation systems across the country.

The conference offered multiple breakout sessions, including:

Ideal Use of Sedation Agents – Joe Cravero and Jim Hertzog
Billing and Reimbursement: What Works – David Werner and Jeff Linzer
Monitoring to Improve Sedation Delivery – Connie Houck
Nitrous Oxide Sedation – Judy Zier
Dexmedetomidine – Jon Berkenbosch
Non-Pharmacologic Methods of Sedation – Beth Carlough and Laura Mitchell
Training and Credentialing of Sedation Providers – George Blike

The Society would like to thank all who attended the conference and especially those who allowed us to make it happen.

To see a photo gallery from the meeting, click here.

Editors:
Joseph Cravero MD
George Blike MD

Departments of Anesthesiology
and Pediatrics,
Children’s Hospital
at Dartmouth,
Dartmouth Hitchcock
Medical Center,
Lebanon, NH

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