Authors: Mallory M, Travers C, McCracken C, Hertzog J, Cravero J Pediatrics. 2017 July; 140(1): e20170009
Upper respiratory infections (URIs) are associated with airway adverse events (AAEs) during general anesthesia. There have been no large studies examining the relationship between URIs and AAEs during pediatric procedural sedation. We hypothesized that there would be a relationship between URI status and AAEs in pediatric procedural sedation.
We examined prospectively collected data from the Pediatric Sedation Research Consortium database. Specific questions regarding URI status were added to the database to facilitate our analysis. Characteristics of patients, procedure types, adjunctive medications, adverse events, and airway interventions (AIs) were reported. We performed bivariate analysis of adverse events and URI status, then used a multivariable logistic regression model to assess the relationship between URI status and adverse events. We examined the secondary outcome of AI similarly.
Of the 105 728 sedations entered into the Pediatric Sedation Research Consortium database during the study period, we were able to use 83 491 for analysis. Controlling for multiple patient, drug, and procedure characteristics, recent and current URI were associated with increased frequency of AAEs. In general, the frequency of AAEs and AIs increased from recent URI, to current URI-clear secretions to current URI-thick secretions. We did not find a relationship between URI status and non-AAEs.
URI status is associated with a statistically significant increase in frequency of AAEs and AI during pediatric procedural sedation for the population sedated by our consortium. Although URI status merits consideration in determining potential risk for sedation, rates of some AAEs and AIs remained low regardless of URI status.
A number of prior studies have shown that kids with upper respiratory infections who receive general anesthesia are at increased risk for adverse events, particularly airway adverse events. However, there have been no previous reports specifically looking at the association of adverse events with URIs in pediatric procedural sedation. In this study, which reviewed outcomes of >13,000 children with active or recent URI symptoms from the Pediatric Sedation Research Consortium, occurrence of any airway adverse event increased progressively from 6.3% for those with no URI to 22.2% for those with current URI with thick and/or green secretions. Airway interventions, including repositioning, suctioning, supplemental oxygen, airway adjuncts, CPAP, and BVM, were all more commonly utilized in children with active URI symptoms. Also of note – the significantly increased odds of inability to complete the procedure due to sedation related problems, with an AOR ~2-3 for current URI with clear secretions and an AOR ~5-10 for a current URI with thick secretions.
Respiratory infections occur very frequently in the pediatric population, and sedation providers frequently must try and assess the potential risks of proceeding with sedation versus the benefits of successfully accomplishing the procedure or test. Because this analysis includes a large number of patients from 45 different pediatric sedation programs, as well as a variety of medication regimens and procedure types, it should allow for more informed decision making and appropriate counseling regarding risks and benefits of procedural sedation for children with current or recent URI. More specifically, the data collected makes a noted distinction in incidence of adverse events and associated airway interventions between a current URI associated with clear secretions versus one with thick and/or green secretions. Further prospective studies using this information could lead to the development of a specific screening tool incorporating URI characteristics to determine which candidates could be appropriate for sedation.
Although postponement of a procedure for a child with a URI was once common practice, it’s very gratifying to see that nowadays most complications associated with a URI can be anticipated and resolved by an experienced sedation provider. Identifying the appropriate candidate for procedural sedation plays a big role in the successful completion of procedures done with sedation. Results of this study are reassuring that the child with a recent or current URI can often be safely and successfully sedated, but the ultimate decision whether to sedate or not should come from the sedation provider after careful consideration of risks and benefits with patient/families and the rest of the child’s care team. Fortunately, as demonstrated by this study, sedation providers also appear well prepared to deal with the complications if they were to arise.
Moving forward, we need to engage in organized efforts to share this data with proceduralists, referring physicians, and families so they can be better prepared and better able to participate in informed decision making regarding procedural sedation for children with current/recent URIs. We have all had children arrive appropriately NPO, whose families have taken off work and driven from several hours away, only to cancel the elective brain MRI because of their significant nasal congestion. We have all had children show up for procedures with thick green snot after being cleared by their primary care provider for sedation because they are now on antibiotics or cleared by their proceduralist because they aren’t currently febrile. The financial burden to the health care system of cancelling a procedure has certainly been discussed in various articles, but we rarely discuss the potential financial and emotional burden to the child’s family. The results of this study will hopefully give us better ability to provide guidance to our screening staff, families, and referring providers in order to maximize patient and family satisfaction, safely and successfully sedate those children with minimal associated symptoms and risk factors, and (depending on the urgency of the procedure) either defer to anesthesia or reschedule patients with significant symptoms in a timely and efficient manner.