SPS Plenary Session | May 21, 2019, 12:45 pm | Yoke Hwee Chan, MBBS
Dr. Yoke Hwee Chan, Pediatric Intensivist, Chair of SingHealth Duke-NUS Paediatrics Academic Clinical Programme, and Chair of the Division of Medicine at KKK Women’s and Children’s Hospital in Singapore came from halfway across the world to present on international sedation practices, with a specific focus on pediatric procedural sedation in Singapore.
Noting that pediatric sedation guidelines have been formulated not only in North America but also in Australasia, Latin America and Europe, and that pediatric sedation societies are flourishing in much of the world with the notable exception of Africa (except for South Africa), the Middle East and parts of eastern Europe, she highlighted some key differences in sedation practice in China, South America and Africa.
In these areas, most sedation out of the operating room is provided by anesthesiologists (vs. primarily pediatric intensivist and emergency medicine physician in the United States) and there is generally a very significant shortage of clinicians, nurses and adequate finances. Chloral hydrate is still the most common medication used in China with propofol and dexmedetomidine each used about 20% of the time. In Africa, sedation is largely ketamine based and in South America there is much variation in practice.
The Women and Children’s Hospital in Singapore has 492 beds and provides over 1,600 sedations each year. There is a well-developed sedation program including a multi-disciplinary Hospital Sedation Committee with representatives from anesthesiology, emergency medicine, PICU, NICU, Pediatrics and Nursing. Formalized credentialing in sedation is required using both on-line lectures and simulation training.
Of interest is that pediatric intensivists, like anesthesiologists, may provide sedation for ASA III and IV patients, but that emergency room and pediatric providers may only provide sedation for ASA I and II patients, and they do not use propofol but do use nitrous oxide and, as expected, ketamine. A very unique feature of the program is the electronic sedation order set that requires the incorporation of patient information and gives both dosing recommendations and contraindications. Adverse events are defined and tracked with aggregate data showing continuous decrease in adverse events.
Dr. Chan ended with the discussion of an observational study done at their hospital which examined predictors of emesis with ketamine. In a multivariate analysis, children between the ages of 8-16 years were 4.6x more likely to have emesis than the younger age group.
In summary, this excellent presentation made SPS Conference attendees aware that pediatric procedural sedation practice continues to advance throughout the world, that there are significant challenges especially with the lack of trained providers, and that there is a variation in practice often dependent on regional circumstances. The Children’s Hospital in Singapore seems to have a well-developed system of procedural sedation care and continues to both perfect their system and develop new knowledge about the science of sedation. This may be a role model in Asia that others can look to as they develop their own sedation practice.