For this research edition of the SPS News, we’re privileged to interview Kevin Couloures DO, MPH, as our sedation research expert. Many of you have been fortunate to work with Dr. Couloures through the Pediatric Sedation Research Consortium (PSRC), where he has been very involved with overseeing the database and resulting projects and support for new institutional members. He is also associate chair of the SPS research committee, providing expertise for new project proposal review and development. Kevin and Mark Buckmaster continue to fine tune a scoring system based on years of analysis of PSRC outcomes data that will assess and predict patients’ underlying risk for procedural sedation and ultimately allow tailoring the lowest risk sedation plan for each patient.
Our questions and Dr. Couloures’ replies:
As the director of the sedation program at Yale New Haven Children’s Hospital, can you give us a brief description of your sedation service?
“We were able to transform a small sedation program providing sedation for about 300 children per year into a program that provides sedation for 1200 children per year. We were able to do this by incorporating the use of propofol and now nitrous oxide. The most important aspect though has been defining what works for different situations and getting the right people on the team. Our nurses are fantastic and help us look good.”
You’ve been very involved in sedation research over the years, both with the PSRC and at your own institution. What projects are you currently working on there at Yale?
“We are looking at how to better incorporate nitrous oxide into our sedation practice and ways to improve communication/expectations around the sedation experience. We are also looking at the impact of bi-monthly simulation sessions and how that affects preparedness for events and better defines the roles of each member of the team.”
Graduate medical education, especially the pediatric critical care medicine fellowship, is a very important part of your work at Yale. Can you talk a bit about how you have developed a sedation curriculum for PCCM fellows, what that entails, and how you have gotten fellows more involved in sedation-based activities and research?
“Embarrassingly, our effort to create the curriculum was the result of one of our fellows being ready to graduate and realizing that they had almost no sedation experience. They were being hired into a position where procedural sedation was part of the job and we felt we had let them down. We subsequently established that all fellows would have a mandatory 4-week rotation in accompanied by required readings in sedation. We also have them participate in semi-annual critical incident simulations and provide feedback on their performance. Whenever I hear of an opportunity to write a chapter on sedation or have an idea for research, I coordinate with our fellowship director to see who might need a project. I then propose the project and provide mentoring (nudging) until the final product is ready. They have realized that we have a high success rate of getting things accepted as posters/publications and that many of the potential positions will have sedation as part of the job.”
The sedation risk assessment score would be the holy grail for robust patient screening and adverse event management planning. Would you describe the background for development of the scoring tool, current status, and what is planned for the future?
“The scoring tool is a way to take the distilled knowledge of all the prior sedation practitioners and put it into a score that establishes the likelihood of events. Our analysis to date has established that certain patient characteristics and procedures are more likely to have adverse events than others. The difficult part has been differentiating those type of events that can be managed readily by someone with appropriate skills and those events that could lead to rapid deterioration. The diversity of practice settings contributing data and the low incidence of serious adverse events has also made the analysis very challenging. Our initial approach of go/no-go for sedation may have been too binary and we probably need a more nuanced approach to say patients with these characteristics will have a higher tendency for events. Management of these events will require certain skills and staff. If those needs cannot be met then defer the case to a provider who can. This is probably the “holy grail” that will help best utilize the available resources for sedation.”
You have been very involved with the PSRC since its beginnings. How have the PSRC and your and others’ studies based on PSRC data helped to advance the discipline of pediatric sedation?
“The most important accomplishments that the PSRC has achieved are to demonstrate that procedural sedation can be safely performed outside of the operating room and that the rate of adverse events does not depend on the specialty of the provider. Data from the PSRC has also helped establish which medications have better safety profiles. The next step will be to look at the overall sedation experience. It does no good to have a smooth induction and sedation event followed by a family that needs to stay in the recovery area for 4 hours because their child has not sufficiently recovered from the sedation. Likewise, a sedation that requires multiple IV attempts or 4 staff members holding the child is going to make the next sedation harder and leave an unfavorable impression on the family. Hence, qualitative measures of sedation will likely be the next step to improve care but that may be harder to capture in our current database.”
What additional value do prospective studies bring? How can the energy and collaboration from the PSRC be utilized for prospective pediatric sedation projects?
“Prospective studies allow us to propose an idea and truly see if it works. Retrospective data can look at drug safety, adverse events, recovery time, etc but only a prospective study can truly establish if one protocol is more effective than another. The PSRC is a great incubator for ideas that can be transformed into research projects and the people involved are passionate about providing the best sedation experience possible.”
What current projects are underway in the SPS research committee? What projects are planned for the near future?
- Anticholinergic Drugs and Adverse Events
– Poster to be presented - Trends in Drug Use
– Poster presented; manuscript in preparation - MRI sedation
– Poster presented; manuscript in preparation - Procedures proximal to airway
– Manuscript submitted - Desaturation Data (QA)
– Details of request being submitted - Intranasal DEX Study Study
– Data collection tool in development - Chloral Hydrate Project
– Awaiting proposal - Burn Injuries Sedation
– Awaiting final version of the proposal - IN Midazolam Project
– Should be approved to move forward - Developmental Delay Data
– Awaiting final version of the proposal
How can SPS members who have an interest in sedation research get more involved in current and future projects?
“One way would be to ensure that their institution is part of the PSRC. The next step would be to join in on the SPS listserve and see what topics are being discussed and if any of them are interesting. The last step would be to create a research proposal and submit it to the PSRC. The member may have an idea that others would like to participate in, and many of the members on the research committee have experience reviewing project proposals and manuscripts. The idea can then get turned into a research project that has a reasonable chance of success.”
To learn more about current and future research activities within the SPS, be sure to attend the plenary session titled, “SPS research: database mining and prospective trials,” that Dr. Couloures and Dr. Daniel Tsze, chair of the SPS research committee, will be co-presenting on Tuesday, May 21, at 8:15 am, at the 2019 SPS conference in Denver. Hope to see you there!