Resident and Fellow Corner - Literature Review

Reviewed by Michael Hooper, MD

Outcomes following implementation of a pediatric procedural sedation guide for referral to general anesthesia for magnetic resonance imaging studies

Grunwell JR et al. Pediatr Anesth 2016; 26:628-36. http://www.ncbi.nlm.nih.gov/pubmed/27061749

The proper matching of providers to patients is necessary in all medical fields but even more so in the pediatric procedural sedation realm.  The work of the PSRC and others have identified possible risk factors and the following review looks at how Grunwell et al, created a sedation guide to reduce failed sedations, and serious adverse events (SAE).  And, although it was not a goal of the study, reduction of failed sedations would likely improve resource utilization and family satisfaction.

The authors started by looking at the risk factors identified in prior publications and the characteristics of the patients in their own institution who had failed sedation.  They hypothesized that implementation of a consensus-based sedation guide would increase the referrals to general anesthesia, decrease severe adverse events and decrease the rate of failed sedations.  There are no current guidelines for referral of children to general anesthesia (GA) and scant information about referral patterns to GA.  They did not look at whether the change in referral practice had an impact on last minute cancellations or inappropriate referrals, which they stated were the driving factors in creating the guide.

The main factors resulting in referral to general anesthesia were ASA PS of 3 or greater, congenital heart disease, obstructive sleep apnea, history of prematurity, developmental delay and obesity.  They then analyzed the change in referrals using an interrupted time series analysis since they knew when they implemented the change. 

Prior to the change in referral practice, they had serious adverse event prevalence and failed sedation rate of 1 and 0.5% respectively.   SAE excluding airway events was low at 0.6% post-pediatric procedural sedation guide vs. 1.1% pre-pediatric procedural sedation guide. They were unable to show a significant change in SAE rate after implementation of the referral guide but did see a significant increase in the number of cases referred to general anesthesia. One thing that could be looked at would be patient satisfaction scores. 

The presumed benefit of referral to GA would be a reduction in the rate of cancelled cases due to sedation risk. However, perhaps the additional workload placed on the GA could cause a backlog of cases just to the sheer added volume on an already stretched system. The authors postulated that since the prevalence was already quite low they may not have been able to detect a statistical or clinical impact upon the change in referrals.

Overall the study affirms that pediatric procedural sedation is effective and safe when provided by trained non-anesthesiologists.  Now the goal is to make pediatric procedural sedation more streamlined with the best possible outcomes.  The paper seems to be on track for that goal but would need to address the concerns brought to light by both the authors and the reviewer of this paper.  A great contribution of this paper would be for institutions to use the methods developed here to assist them in improving their SAE rates and outcomes. 

Finally, it would be beneficial to assess patient satisfaction scores to ensure that perceived improvements are beneficial to the sedation service and the patients/parents.

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