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Pediatric Conscious Sedation
Risk Reduction in Pediatric Procedural Sedation by Application of the AAP/ASA Process Model. Hoffman GM, Nowakowski R, Troshynski TJ, et al. Pediatrics (Feb 2002); 109:236-43.
This study examined whether adherence to American Academy of Pediatrics (AAP) / American Society of Anesthesiologists (ASA) guidelines for procedural anesthesia would reduce the risk of sedation-related adverse events. Records of 960 patients who underwent procedural sedation were reviewed. Process variables included NPO status, assignment of ASA physical status score, obtaining informed consent, generation of a sedation plan, and assessment of level of sedation using a quantitative scoring system. Content variables included adherence to AAP NPO guidelines, ASA class, target sedation level, actual sedation level, age, procedure and drugs used.
Results. The complication rate was 34 / 809 (3.8%) with planned conscious sedation, and 6/65 (9.2%) with planned deep sedation. Complications were reduced by performance of a structured risk assessment (OR = 0.10), adherence to all process guidelines (OR = 0), and avoiding actual deep sedation (OR = 0.4). The only drug associated with a higher risk was chloral hydrate (OR = 2.1). Failure to adhere to NPO guidelines did not increase risk in this assessment; however, the adverse event rate was 0 if all process guidelines were followed.
Comment. Neonatologists are frequently being called upon to administer conscious sedation to neonates undergoing MRI or CT studies. We need to be aware that there are established guidelines for risk reduction during procedural sedation published by the AAP and the ASA. These guidelines represent a standard of care to which we can be held in the event of an adverse event associated with our sedative therapy. You may review the AAP sedation guidelines on-line at: http://www.aap.org/policy/04789.html. In this review, chloral hydrate was associated with the highest level of adverse events (hypoxemia, hypotension, airway obstruction) and was the most common cause of inadvertent deep sedation. These adverse events occurred despite typical dosing at 50-75 mg/kg. There have been widespread misperceptions about the safety of this medication, and its routine use for conscious sedation should be re-evaluated. The medication that was associated with the lowest incidence of adverse events was midazolam (versed).
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