Top Articles from 2018

Reviewed by Pradip Kamat, MD, MBA, FCCM

SPS Plenary Session | May 21, 2019, 1:15 pm
Panel: Dan Tsze, Maala Bhatt, John Unkel

At the 2019 Society for Pediatric Sedation annual conference, panelists reviewed sedation literature from 2018. The panelists classified the 2018 articles chosen for the review into three different categories:

1. Pediatric Procedural Sedation,
2. Emergency Medicine, and
3. Dental Sedation

Procedural Sedation (Dr. Dan Tsze)

Special populations:
Reviewed studies reporting on the sedation of children with autism spectrum disorders.

1. Procedural sedation in children with autism spectrum disorders: A survey of current practice patterns of the Society for Pediatric Sedation members. Kamat PP, Bryan LN, McCracken CE, Simon HK, Berkenbosch JW, Grunwell JR.  Paediatr Anaesth. 2018 Jun; 28(6): 552-557. The above paper reported on the variability amongst sedationists who provide sedation for children with autism spectrum disorders. The overall response rate from the sedation medical directors belonging to the Society of Pediatric Sedation was 75%.  Only 57% of sedation directors and staff were extremely comfortable providing procedural sedation to children with ASD. About 79% of sedation directors wanted more education about behavioral management strategies for procedural sedation of children with ASD.
2. Outpatient Procedural Sedation of Patients with Autism Spectrum Disorders for Magnetic Resonance Imaging of the Brain Using Propofol. Kamat PP, Karaga MK, Wisniewski BL, McCracken CE, Simon HK, Sidhu R, Grunwell JR.  J Child Neurol. 2018 Apr; 33(5): 313-319. The above case-controlled study compared children with autism spectrum disorders (ASD) undergoing magnetic resonance imaging study under procedural sedation to those without ASD. The study reported that, in 10% of the children with ASD, there was a need for additional personnel (besides the sedationist and nurse) before propofol induction.
3. Procedural sedation in children with autism spectrum disorders in the emergency department. Brown JJ, Gray JM, Roback MG, Sethuraman U, Farooqi A, Kannikeswaran N. Am J Emerg Med. 2018 Oct 16. doi: S0735-6757(18) 30839-8. The above paper reported that only 25% of children with ASD received sedation for diagnostic imaging or routine physical examination in the emergency department. In fact, 10% of children with ASD received neuroleptics (haloperidol or olanzapine).  The overall adverse event rate was no different from children without ASD.

Pediatric Sedation Outcome measures

1. Efficacy Outcome Measures for Pediatric Procedural Sedation Clinical Trials: An ACTTION Systematic Review. Williams MR, Nayshtut M, Hoefnagel A, McKeown A, Carlson DW, Cravero J, Lightdale J, Mason KP, Wilson S, Turk DC, Dworkin RH, Ward DS. Anesth Analg. 2018 Mar;126(3):956-967. Objective evaluations comparing different techniques and approaches to pediatric procedural sedation studies have been limited by a lack of consistency among the outcome measures used in assessment (table below). This study reviewed currently existing measures, which have undergone psychometric analysis in a pediatric procedural sedation setting, to determine to what extent and in what circumstances their use is justified across the spectrum of procedures, age groups, and techniques. The results of the above study suggest that a wide range of measures have been used to assess the efficacy and effectiveness of pediatric procedural sedation. Most lack the evidence of validity and reliability that is necessary to facilitate rigorous clinical trial design as well as the evaluation of new drugs and devices. A set of core pediatric sedation outcome domains and outcome measures could be developed on the basis of their findings. The authors concluded that consensus among all stakeholders regarding appropriate domains and measures to evaluate pediatric procedural sedation is possible and that widespread implementation of such recommendations should be pursued.
2. Evaluating the Need for Pediatric Procedural Sedation Training in Pediatric Critical Care Medicine Fellowship. Hooper, MC, Kamat PP, Couloures, KG. Pediatr Crit Care Med. 2019 Mar; 20(3): 259-261. In this study, the authors reported that most pediatric critical care fellows consider procedural sedation training outside the PICU as a valuable skill; however, most ACGME fellowship programs lack a clearly defined pediatric procedural sedation-training pathway. Sixty-two percent of programs lacked a specific procedural sedation rotation. Use of critical incident simulation is essential given that serious adverse events occur in < 1/1000 sedations and are not routinely encountered despite a busy clinical setting.

Emergency Department Sedation (Dr. Maala Bhatt)

Pre-sedation assessment

Higher Mallampati Scores Are Not Associated with More Adverse Events During Pediatric Procedural Sedation and Analgesia. Iyer MS, Pitetti RD, Vitale M. 2018; 19(2): 430-436. West J Emerg Med. 2018; 19(2): 430

The authors of the above study evaluated respiratory adverse events in 575 patients, of which 290 had a Mallampati of I/II and 168 had Mallampati III/IV. They reported that patients with Mallampati III/IV were more likely to need repositioning but had a similar rate of airway adverse events compared to those with a Mallampati of I/II.

In another study: Green SM, Roback, MG. Ann Emerg Med. 2019 Feb 16, similarly reported pitfalls in the use of Mallampati for airway evaluation. They reported poor sensitivity for identification of difficult airway as well as inadequate data to conclude about the risk of difficult mask ventilation and adverse events during sedation.  The authors concluded that the overall reliability of Mallampati was at best moderate with a high failure rate in children < 3 years.

Challenging the convention

Full Stomach Despite the Wait: Point-of-Care Gastric Ultrasound at the Time of Procedural Sedation in the Pediatric Emergency Department. Leviter J Steele DW,Constantine E, Linakis JG, Amanullah S. Acad Emerg Med 2018 Oct

The authors of the above study evaluated 116 patients (median age 8.4 years) of whom 107 had interpretable ultrasound findings. These patients had a median fasting duration of 5.8 hours and were sedated with ketamine +/- midazolam. The authors reported that many children (74 patients, 69% [95% confidence interval 60%-77%] were categorized as having a full stomach) were deemed NPO ready but had full stomachs before procedural sedation. The above gastric ultrasound findings may inform risk-benefit considerations when planning the timing and medication choice for procedural sedation.

Sedation monitoring

Using continuous quantitative capnography for emergency department procedural sedation: a systematic review and cost-effectiveness analysis. Mohr NM, Stoltze A, Ahmed A, Kiscaden E, Shane D. Intern Emerg Med. 2018; 13(1): 75-85

The above study aimed to estimate the cost-effectiveness of routine use of continuous waveform quantitative end-tidal CO₂ monitoring for ED procedural sedation for the prevention of catastrophic events. Markov modeling was used to perform cost-effectiveness analysis to estimate societal costs per prevented catastrophic event (death or hypoxic brain injury) during routine ED procedural sedation. Assuming that capnography decreased the catastrophic adverse event rate by 40.7% (proportional to efficacy in preventing hypoxia), routine use of capnography would decrease the 5-year estimated catastrophic event rate in all US EDs from 15.5 events to 9.2 events (difference 6.3 prevented events per five years). Over 5-years, implementing routine end-tidal CO₂ monitoring would cost an estimated $2,830,326 per prevented catastrophic event, which translates into $114,007 per quality-adjusted-life-year. Sensitivity analyses suggested that reasonable assumptions continue to estimate high costs of prevented catastrophic events. Continuous waveform quantitative end-tidal CO₂ monitoring is a very costly strategy to prevent catastrophic complications of procedural sedation when applied routinely in ED procedural sedations.

Dental Sedation (Dr. John Unkel)

Does Parental Anxiety, Coping, and Pain Catastrophizing Influence Child Behavior During Sedation? de Castro Morais Machado G, Van Wijk A, van der Heijden G, Costa LR. Pediatr Dent. 2018 Sep 15;40(5):365-369.

Little is known about psychological factors associated with children’s behavior during dental sedation. The purpose of this study was to ascertain if children’s behavior during treatment under sedation is associated with parental dental anxiety, pain catastrophizing, and coping style. The authors studied 110 parents of children (60 boys, 50 girls; mean age 47.0 months, range 20 to 81 months) with disruptive behavior during previous dental sedation for which drugs such as ketamine and midazolam were used.   Children’s behavior was assessed using the Ohio State University Behavioral Rating Scale based on video files of the procedure. Parents completed the Dental Anxiety Scale, the Coping Orientation to Problems Experienced Scale, and the Pain Catastrophizing Scale-Parents.

This study found that parents of children with more positive behavior scored higher on planning (P=0.02) and acceptance (P=0.02) strategies than parents of children in the regular and negative behavior groups. Additionally, the authors reported that the majority of the parents’ coping strategies were adaptive based on their religion and on the active condition of the child. In conclusion, this study reported that parental adaptive coping strategies could have a positive impact on children’s behavior during dental treatment under moderate sedation.