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February
1998
Adverse
events and risk factors associated with the sedation of children by nonanesthesiologists.
Malviya
S, Voepel-Lewis T, Tait AR; Anesth Analg 1997; 85: 1207-13.
[ see
abstract below
]
The adverse events were collected with a quality assurance tool which
successfully gathered information regarding the numerator and the denominator,
data that has previously eluded us. Approximately 20% of children experienced
an adverse event (239/1140). This included 63 desaturations (saturation
< 90%), 5 airway obstructions, and two apneas. Most interesting is
the fact that the vast majority of these events occurred in children who
received a drug usually felt to be very safe, i.e., chloral hydrate in
the recommended dose range, i.e. < 100 mg/kg.
In addition, the authors found in their study a virtual mirror image of
similar observations in the operating room with desaturation events in
550 children under general anesthesia, (Coté et al, Anesthesiology
1988;68:184-188 and Anesthesiology 1991;74:980-987); there
was a higher incidence of such events in infants < 6 months of age
and in children of ASA status 3 & 4 vs ASA status 1 & 2.
I hope that my fellow pediatricians understand the importance of this
study and that it is not lost to them by being published in an anesthesiology
journal. Infants < 6 months old and children with high ASA status are
at particular risk whether it is for sedation or for general anesthesia.
This QA study clearly demonstrates the need for vigorous enforcement of
appropriate monitoring for sedated children as well as the need for skilled
practitioners to observe for and deal with these relatively common emergencies.
What this study tells me is that following the AAP sedation guidelines
has reduced (and likely will continue to reduce) the incidence of life
threatening events, i.e. the monitoring will provide the early warning
that will allow the practitioner to intervene before a relatively common
and predictable adverse event becomes a tragedy.
Return to the Current
Literature Review Front Page , or read the abstract:
ABSTRACT
After implementation of hospital-wide monitoring standards, a quality assurnace
(QA) tool was prospectively completed for 1140 children (aged 2.96+/- 3.7
yr) sedated for procedures by nonanesthesiologists. The tool captured data
regarding demographics, medications used, adequacy of sedation, monitoring,
adverse events, and requirement of escalated care.
The medical records of children who experienced adverse events were reviewed.
Most (99%) children were monitored with pulse oximetry. Choral hydrate was
the most frequently used sedative (74.9% of cases). Of the children, 239
(20.1%) experienced adverse events related to sedation, including inadequate
sedation in 150 (13.2%) and decrease in oxygen saturation in 63 (5.5%).
Five of these children experienced airway obstruction and two became apneic.
No adverse event resulted in long-term sequelae.
Of the 854 children who received choral hydrate, 46 (5.4%) experienced decreased
oxygen saturation (>/= 90% of baseline). Children experienced desaturation
after the use of choral hydrate had received the recommended doses of choral
hydrate (38 - 83 mg/kg). ASA physical status III or IV and age <1 yr
were predictors of increased risk of sedation-related adverse events. These
data underscore the importance of appropriate monitoring that includes pulse
oximetry to permit early detection of adverse events.
Implications: This quality assurance study highlights the risks associated
with the sedation of children and emphasizes the importance of appropriate
monitoring by trained personnel.
Children with underlying medical conditions and those who are very young
are at increased risk of adverse events, which indicates that a greater
degree of vigilance may be required in these patients.
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