Conference Reviews

Top Sedation and Pain Articles

Summarized by Pradip Kamat, MD, MBA, FCCM

In this session that was well received by the audience, the presenters discussed recently published articles in sedation and pain and what those articles mean to our clinical practice.

Dr. William Zempsky presented three articles

1) Trends in opioid prescriptions among children and adolescents in the United States: a nationally representative study from 1996 to 2012 (Groenewald CB et al. Pain May 2016; 157(5).

This study aimed to assess trends in opioid prescriptions made to children and adolescents, to their families, and to adults in the United States from 1996 to 2012. Data was obtained from Medical Expenditure Panel Surveys for the study period. Study groups were divided into 0-17 years, adults (18 years or older), and family members of children and adolescents.

This study found that:

  1. From 1996-2012, the trends in the opioid prescription to children and adolescents remained stable. Opioids prescribed to adults and family members of children and adolescents more than doubled during the study period.
  2. Codeine, hydrocodone, and oxycodone were the most common opioids prescribed in children and adolescents. Codeine can lead to toxicity or inadequate pain relief due to variability in metabolism.
  3. In children and adolescents, the opioid prescriptions were for trauma (36%), for dental concerns (16%), and for visits related to procedures (13.2%).
  4. Risk factors for higher rates of opioid prescriptions included: older age, White non-Hispanic ethnicity, and public or private insurance from a region other than the Northeastern US.

Big take home points

  • The opioid epidemic is not due to increase in pediatric prescribing.
  • There is a need to advocate for improved storage and disposal in homes where there are children or adolescents.
  • Appropriate pain management is needed in the pediatric population and safer alternatives to codeine must be used.

2) Effect of gabapentin on morphine consumption and pain after surgical debridement of burn wounds: a double-blind, randomized clinical trial study. Rimaz S. et al. Arch trauma Res Spring 2012; 1(1)

Burn pain is maximal during procedures. The above study looked at the effect of gabapentin on morphine consumption and postoperative pain in burn patients undergoing resection of wounds. This was a randomized double-blinded placebo controlled study. Pain was analyzed using a visual analog scale.  This study found that using a single dose of gabapentin resulted in substantial decrease in postoperative morphine consumption and pain scores after surgical debridement in burn patients.

Big take home points
Although gabapentin may help in reducing need for pain medications during procedural sedation, more studies are required to better define population that would benefit, dose, and procedures.

3) Assessment of procedural pain in children using analgesia nociception index: A Pilot study. Avez-Couturier J et al. Clinical Journal of Pain. Feb. 2016

The Analgesic Nociceptive Index (ANI) is based on analysis of heart rate variability, which is known to decrease after a painful stimulus during surgery or anesthesia in adults. This study looked at the ANI response to procedural pain and its feasibility in children. A total of 26 children were prospectively enrolled. ANI and heart rate variations after incision for muscle biopsy were assessed. This study found that ANI decreased from time before to time after incision. There was no difference in ANI, heart rate or FLACC scale in children younger or older than six years.

Big take home points

  • This study tells us that pain can be non-invasively monitored during procedural sedation. The device is awaiting FDA approval.
  • Further studies will be required to better define its use in pediatric procedural sedation.

Dr. Jocelyn Grunwell presented two articles

1) Outcomes following implementation of a pediatric procedural sedation guide for referral to general anesthesia for magnetic resonance imaging studies. Grunwell et al. Paediatr Anaesth. June 2016; 26(6)

Guidelines for referral of children to general anesthesia (GA) to complete MRI studies are lacking. The aim of this study was to see if a pediatric procedural sedation guide would decrease serious adverse events and decrease failed sedations requiring rescheduling with GA. A consensus based institutional guideline was used to select patients who were not sedation candidates and would be better taken care of by an anesthesiologist. Institutional data from the pediatric sedation consortium was analyzed to see if there was a decrease in adverse events and failed sedations.

This study found that using a presedation guideline increased referrals to GA. There was no change in the number of failed sedations or decrease in serious adverse events.

Big take home points

  • The overall serious adverse event rate in pediatric sedation is low. Hence this study was unable to show a difference.
  • More studies are needed to really evaluate the utility of a prescreening guideline in pediatric procedural sedation.

2) Pediatric critical care physician-administered procedural sedation using propofol: A report from the Pediatric Sedation Research Consortium Database. Kamat et al. Pediatr Crit Care Medicine. Jan 2015; 16(1)

This prospective observational study looked at ninety-one thousand pediatric procedural sedations from the Pediatric Sedation Research Consortium (PSRC) database from 2007-2012 performed by pediatric critical care (PCCM) physicians.

The study found that overall adverse event incidence was 5.0% (95% CI, 4.9-5.2%). There were no deaths, one patient had a cardiac arrest but survived neurologically intact. Procedure success was 99.9%.

Risk factors associated with adverse event included: location of sedation, number of adjunctive medications, upper and lower respiratory diagnosis, prematurity diagnosis, weight, American Society of Anesthesiologists status, and painful procedure.

Big take home points

  • PCCM physicians are trained in recognition and management of airway and hemodynamic issues in critically ill patients. Therefore, they can provide effective pediatric procedural sedation not only within the PICU but also in a variety of locations within the hospital.  
  • They can be used to develop sedation programs where there is a shortage of pediatric anesthesiologists. Careful attention needs to be paid to patients who are at a higher risk for airway events.

Dr. Joseph Cravero presented three articles

1) Major adverse events and relationship to Nil per Os (NPO) status in pediatric sedation/anesthesia outside the operating Room: A Report of the Pediatric Sedation Research Consortium (PSRC). Beach M et al. Anesthesiology. Jan. 2016; 124(1)

In this study, the authors looked at the relationship between NPO status and adverse events in pediatric sedation outside the operating room using PSRC data. Prospective observational study of almost 140 thousand procedural sedation/anesthesia encounters.

NPO status was known in 107,000 patients and 23% of these patients were not NPO.
Number of aspiration events in patients who were NPO was 0.97/10,000 vs. 0.79/10,000 in patients not NPO (Odds ratio 0.81; 95%CI 0.08-4.08). The major complication rate was similar in both groups (~5/10,000). No one died, 10 patients had an aspiration, and there were 75 major complications.

Big take home points

  • This study provides evidence that NPO status may not correlate directly with aspiration risk.
  • A larger prospective randomized study is required.
  • Sedation providers should focus on pathology (for example a patient with intestinal obstruction is more likely to aspirate vs. a patient who is healthy but NPO for only five hours instead of six hours before a procedure).

2) Creation of an integrated outcome database for pediatric anesthesia.
Cravero J et al. Paediatr Anaesth. Apr 2016; 26(4)

Outcome data analysis is important for quality improvement in healthcare. The authors found that, in their institution (Boston Children's Hospital), perioperative data existed in five distinct environments. In this study, they describe a method to integrate these datasets into a single web-based relational database that provides researchers and clinicians with regular anesthesia outcome data that can be reviewed on a daily, weekly, or monthly basis. Because of its complexity, the project also entailed the creation of a 'dashboard,' allowing tracking of data trends and rapid feedback of measured metrics to promote and sustain improvements. The authors presented the first use of such a database and dashboard for pediatric anesthesia professionals as well as successfully demonstrated its capabilities to perform as described above.

Big take home points
In the future, practice strategies will be comparable on an ongoing basis – for all important (and some unimportant) outcomes. Provider specific data will also be available.

3) Preterm versus Term children: Analysis of sedation/anesthesia adverse events and longitudinal risk.
Havidich J et al. Pediatrics. March 2016; 137(3)

The objective of this study was to determine the age at which children who are born <37 weeks gestational are no longer at increased risk for sedation/anesthesia adverse events. The secondary objective was to describe the nature and incidence of adverse events.

This observational prospective trial looked at fifty-seven thousand patients from the PSRC database. The most common procedure performed was MRI

The study reported that preterm and former preterm children have a higher incidence of adverse event rates (14.7% vs. 8.5%) compared to children born at term. Airway and respiratory adverse events were most commonly reported. This risk of adverse events in these preterm children persists till 23 years of age.

Big take home points
Preterm and former preterm patients are twice likely to have sedation related airway/respiratory complications and therefore require a heightened awareness and preparedness.