Pediatrics 139/5/e20162897
In May 2017, Joseph Cravero et al published a newly developed and validated procedural sedation scale. The intent of this scale is to provide a scoring tool that not only represents the depth of the sedation but also reflects the quality of the sedation, which includes pain control, anxiety, movement, and adverse side effects. This contrasts with other tools currently used to document sedation such as the University of Michigan Sedation Scale (UMSS) and the Observer’s Assessment of Alertness/Sedation Scale (OAA/S), which only document the depth of sedation.
Previously their group had developed the Dartmouth Operative Conditions Scale (DOCS) to assess the appropriateness of conditions prior to procedural sedation, which would allow comparison between different settings, providers, and procedure types. However, it was not designed for daily use but rather as a way to determine which set of conditions provided the best environment. The authors built upon their experience creating DOCS to produce a simplified scale that could be used during routine sedations for procedures.
Utilizing an expert panel of procedural sedation providers, and adverse event information extracted from the Pediatric Sedation Research Consortium, the Delphi method was used to create the following scale:
| State | Behavior |
| 5 | Patient is moving (purposefully or nonpurposefully) in a manner that impedes the proceduralist and requires forceful immobilization. This includes crying or shouting during the procedure, but vocalization is not required. Score is based on movement. |
| 4 | Moving during procedure (awake or sedated) that requires gentle immobilization for positioning. May verbalize some discomfort or stress, but there is no crying or shouting that expresses stress or objection. |
| 3 | Expression of pain or anxiety on face (may verbalize discomfort), but not moving or impeding completion of the procedure. May require help positioning but does not require restraint to stop movement during procedure. |
| 2 | Quiet (asleep or awake), not moving during procedure, and no frown (or brow furrow) indicating pain or anxiety. No verbalization of any complaint |
| 1 | Deeply asleep with normal vital signs, but requiring airway intervention and/or assistance |
| 0 | Sedation associated with abnormal physiologic parameters that require acute intervention |
They then recorded 25 patients undergoing sedation and created 40 15-second video clips. These clips were reviewed and 13 were selected to evaluate inter-rater and intra-rater reliability. Twenty sedation providers, who ranged from recovery room assistants to attending anesthesiologists reviewed each of the 13 video clips and assigned a score. Six months later, 8 of the original 20 providers were then asked to perform a second review of the video clips. The authors reported that the inter-rater reliability had an ICC = 0.994 and the intra-rater reliability had an ICC = 0.986. Both of these values are excellent and indicate that the score is easy to use and has low variability. They then further validated the score by comparing it to the Observational Scale of Behavioral Distress-revised (OSBD-r) for 96 children who received intranasal midazolam to facilitate laceration repair. They found high correlation between the 2 scoring methods (r=0.841, p< 0.001), which indicated that they had strong criterion validity.
The authors propose that the scoring tool could be used to assess not only those procedures where medications are given but could also be used when non-pharmacological strategies such as distraction, imagery, or hypnosis are utilized. They also propose that the scoring tool could be used to assess how long it takes to achieve an acceptable sedation level and then how long it takes to recover. The addition of this qualitative data would help inform decisions about the best delivery route and type of medication provided for procedural sedation.
However, before this scoring tool can be widely adopted, additional validation of this scoring tool will be needed. The initial video clips were of procedural sedation performed by a variety of providers in varied settings. However, the validation data is from a single institution, and although the training period is less than 30 minutes there may be more scoring variability at another institution. The tool will also need to be compared against other validated tools during procedures that are more painful than laceration repair. Given these caveats, if this tool stands up to these further validation tests then it will help ensure that children receive safe and effective procedural sedation.
