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Quality Corner

More on Sedation Patient Safety Issues

Cheri LandersBy Cheri Landers, MD, FAAP, FCCM
Section Editor

In the last newsletter I asked for case studies or reports from a sedation service that had tackled a sedation patient safety issue. For this edition of the Quality Corner, Lorie Reilly and Melissa Patel from The Children’s Hospital of Philadelphia tell how they identified a safety concern through their Sedation M&M conference and developed a protocol to improve the routine care of their sedated patients. 





Safety Story - Prevention of Hypoglycemia

By Lorie Reilly MSN, CRNP- CPNP-AC
Nurse Practitioner, Department of Sedation, Radiology and Vascular Access Nursing
The Children’s Hospital of Philadelphia

and Melissa Patel, MD
Medical Director, Sedation Service
Division of Pediatrics
The Children’s Hospital of Philadelphia

The Sedation Service, consisting of Pediatrician Hospitalists and Nurse Practitioners, at The Children’s Hospital of Philadelphia identified an issue with hypoglycemia occurring with sedated patients.  From May 2011 to June 2012, there were five cases of hypoglycemia identified in our bimonthly Sedation Mortality and Morbidity conferences (out of a total of approximately 7,000 sedations performed annually). 

In the Mortality and Morbidity conferences, attended by sedation physicians, nurse practitioners and staff nurses, cases meeting the following criteria are discussed:

  1. Use of reversal medications
  2. Procedure or scan not completed due to airway or other complications
  3. Escalation of care (outpatient requiring inpatient admission or floor patient requiring transfer to ICU post sedation)
  4. Prolonged emesis
  5. Prolonged recovery

Situation and Background
Several patients who were slow to wake up post-sedation were found to be hypoglycemic to 30s, in the setting of being NPO for their studies.  MRI scanner delays contributed to one case of prolonged NPO time.  One patient was an inpatient who had not been started on maintenance fluids once being made NPO.  The other patients followed instructions for NPO times based on ASA fasting guidelines, as is our policy.

All patients had been NPO for greater than 12 hours. Ages ranged from < 6 months to three years of age.

Recommendation and Conclusion
In March 2012, the Sedation Service mandated that dextrose containing maintenance fluids be started on any patient who has been NPO for greater than 12 hours and all infants less than 6 months of age regardless of npo time.  Inpatients who are NPO for sedation (placed NPO after midnight with clear liquids allowed up to 2 hours prior to sedation) are to be placed on IV maintenance fluids once NPO.  We also suggest that all patients who will be deeply sedated receive a fluid bolus of 20ml/kg of Normal Saline followed by maintenance fluids of D5 0.45NS until they recover from sedation.
As of June 2012, since this policy change, there have been no documented cases of hypoglycemia post-sedation out of a total of approximately 7,000 sedation cases performed annually.

Editor's Note
This case illustrates a couple of important reminders.  First, having a regularly scheduled and standardized approach to reviewing sedation cases is important.  Reviewing sedation cases that do not proceed as expected identifies areas for improvement in patient safety. 

Second, the criteria to send a case for review at the Sedation M&M committee should be those that are obviously significant (reversal medications, incomplete procedure, escalation of care) but include more broad criteria so that more subtle situations can be captured.  In this report, the screening criteria of prolonged recovery lead to the discovery of a higher than expected rate of hypoglycemia.   The Children’s Hospital of Philadelphia’s Sedation M&M committee had not specifically reviewed cases with hypoglycemia, however, these situations were brought to light through the mandatory review of prolonged recovery cases. 

Many thanks to Lorie and Melissa for volunteering their work!

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