2015 Conference Review
Sedation Literature Year in Review
Reviewed by Jocelyn Grunwell, MD and Pradip Kamat, MD
The Sedation Year in Review Panel from the SPS 2015 Annual Conference held in St. Louis, Missouri reviewed articles from June 2014 to May 2015. The articles were selected based on the hierarchy of evidence. For example, randomized control trials over observational studies, and studies from large patient multi-center databases, such as the Pediatric Sedation Research Consortium (PSRC), were given preference. Main search terms included: drugs, monitoring, adverse events, quality, safety, sedation regulation, and sedation education.
A brief summary of the articles reviewed follows:
1) Hospital Pediatrics. 2015; 5(3): 148-53: Variation in Procedural Sedation Practices Among Children’s Hospitals. This survey showed variation in procedural sedation with respect to sedation provider, site of sedation and sedation agent. In hospitals where sedation was not provided by pediatric hospitalists, more procedures requiring sedation and analgesia were performed in the operating room, otherwise no sedation was provided to the patient.
2) Pediatr Crit Care Med. 2015; 16:11-20. Pediatric Critical Care Physician-Administered Procedural Sedation Using Propofol: A Report From the Pediatric Sedation Research Consortium Database. This is the largest report of adverse events using propofol by pediatric critical care physicians outside the ICU. The overall adverse event rate for procedural sedation was 5%, and the serious adverse event rate was 2.21%. In a logistic regression, the highest risk was seen when patients were sedated in the dental suite for dental procedures and when > 3 medications were used.
3) Paediatr Anaesth. 2015 Jul; 25 (7): 689-97. The impact of obesity on pediatric procedural sedation-related outcomes: results from the Pediatric Sedation Research Consortium. This study looked at the impact of obesity on sedation adverse events and required interventions in 29,000 pediatric patients. The study found that obesity is an independent risk factor for adverse respiratory events including, airway obstruction, laryngospasm, inability to complete procedure, and prolonged recovery, during procedural sedation. These severe adverse respiratory events led to an increased frequency of airway interventions in obese patients compared with non-obese patients.
4) Dexmedetomdine (DEX) studies:
a) Int J Pediatr. 2015; 2015:397372: High Dose Dexmedetomidine: Effective as a Sole Agent Sedation for Children Undergoing MRI. In this retrospective study the investigators looked at the efficacy of high dose DEX as a sole agent for pediatric magnetic resonance imaging (MRI) compared with patients who received additional Dex bolus, or an opioid in addition to a second Dex bolus in 544 patients. Procedural sedation success with DEX was 100%. Procedural time was significantly shorter for the group receiving a single bolus of DEX. Time to discharge was not significantly different between the groups. This study confirms the previous evidence on safety and efficacy of high dose DEX as a sole agent for procedural sedation in children .
b) J Pediatr. 2015 May; 166(5): 1313-1315. Intranasal Dexmedetomidine for Sedation for Pediatric Computed Tomography Imaging. This is the first study to evaluate the use of intranasal DEX for pediatric CT imaging. It showed that IN DEX (2.5mcg/kg initial dose, repeated if necessary) led to high quality CT imaging with minor hemodynamic issues needing no intervention.
5) European J Emer Med. 2015 Apr; 22(2) 111-6. A Retrospective Comparison of Ketamine Dosing Regimens for Pediatric Procedural Sedation. This study looked at 370 patients receiving ketamine at a dose of 1mg/kg vs. 1.5mg/kg. The higher dose ketamine group to determine whether high-dose ketamine required fewer additional doses of ketamine. Neither groups had any major adverse events.
6) Pediatr Surg Int. 2015 Feb; 31(2): 173-80. Nitrous oxide procedural sedation in non-fasting pediatric patients undergoing minor surgery: A 12-year experience with 1058 patients. This retrospective study showed that the use of nitrous oxide provided safe sedation and amnesia without need for pre-procedure fasting or post procedure monitoring.
7) American Journal of Emergency Medicine. 2015; 3:25-30. A Randomized Controlled Trial of Capnography During Sedation in a Pediatric Emergency Setting. This study looked at the impact of adding capnography to sedation in the pediatric emergency medicine room. The investigators found that the use of capnography led to more timely and appropriate airway interventions, such as suctioning and airway repositioning, in emergency room patients undergoing sedation. There were fewer oxygen desaturations compared with the control group that did not use capnography.
The panel concluded the sedation literature year in review with two editorials:
a) British Journal of Anesthesia 113(S2): ii48-ii62 (2014). Challenges in paediatric procedural sedation: political, economic, and clinical aspects by Dr. Kiera Mason, highlights the lack of conformity and agreement amongst sedation providers on sedation guidelines, recommendation and practice, application of simulation and role of sedation education.
b) Pediatric Anesthesia 25 (2014) 2-4. Raising the bar for pediatric sedation studies and trials. In this editorial, Dr. Joseph Cravero discussed the need for more randomized control trials in pediatric sedation. In addition, he expressed that future studies in pediatric sedation should focus on the long term neurological outcomes of sedation. The standardization of adverse event reporting is also mentioned.
In summary, the review of the sedation literature focused mainly on articles that examined adverse event rates associated with propofol, the impact of obesity on sedation complications, different dosing regimens of ketamine, delivery of dexemedetomidine, nitrous oxide for completing pediatric procedural sedation, and the use of capnography for monitoring during sedation procedures. These articles demonstrate the overall safety of pediatric procedural sedation; however, heterogeneity exists in the practice and delivery of pediatric procedural sedation. Future research should focus on large multi-center randomized trials that look at patient selection and the long-term effects of sedation (or lack of adequate sedation) in children.
Anesthetic Related Neurotoxicity in Young Children
Reviewed by Kevin Couloures, DO
Randall Flick, MD presented an excellent summary of the current research involving various agents that are used in anesthesia/sedation. There are known differences in neuronal development across species, such as neuronal pruning that occurs later in humans than in monkeys. Commonly used agents may impair learning and behavior. This may be the case when there are repeated exposures in early childhood. However, there are no clear studies to help guide how much exposure is significant. Early exposure, especially of a longer duration, does seem to impair cognition as demonstrated in the research by Greg Stratmann.
Although, there does seem to be an association between early and prolonged exposure to anesthetic/sedation agents, the hazards ratio is small. The hazards ratio for most of the studies linking anesthesia/sedation with learning and language impairment is 2-3. In contrast, the hazards ratio for sudden infant death and prone sleeping is in the 20’s. Dr. Flick’s research demonstrated a hazards ratio of 2, which would mean that if 1 in 5 children have a learning disability then exposure to multiple anesthetics would add an additional child with learning disability. Hence, even though the effect is small the potential public health burden could be quite large.
Nowadays, all providers of anesthetic/sedation agents are faced with the question as to whether or not the information on neurotoxicity has changed their discussion with parents. Not yet, according to the research performed by Lena Sun. The PANDA (Pediatric Anesthetic and Neurodevelopmental Assessment Study), GAS and MASK (Mayo Anesthesia Safety in Kids) studies are all trying to look at the neuro-cognitive effect of anesthesia given before three years of age but this will take several years before the results are known.