Original Contribution
The use of a pediatric emergency medicine–staffed sedation service during imaging: a retrospective analysis

https://doi.org/10.1016/j.ajem.2006.11.043Get rights and content

Abstract

Hypothesis

A sedation service staffed by pediatric emergency medicine (PEM) physicians can sedate children during imaging, with a low adverse event risk and minimal sedation failures.

Design/Methods

We reviewed 1042 PEM-administered sedations during a 12-month period, collecting data regarding demographics, presedation evaluation, medications used, sedation length, adverse events, corrective measures, and postsedation disposition. Successful image completion without patient awakening defined effective sedation. Minor adverse events included hypoxia (<93%), malaligned airway, self-resolving transient bradycardia, and atypical reactions to sedation agents. Cardiorespiratory incidents requiring resuscitation were considered major events.

Results

Of 923 sedation episodes, 92 (10.0%) experienced adverse events; 7 (0.76%) were major. Sedation failed in 17 (1.8%). No sedation resulted in an increased level of care or permanent injury.

Conclusions

A PEM-staffed sedation service provided sedation to children undergoing imaging with a low adverse event risk, minimal failures, and no residual morbidity. However, all sedating clinicians should possess critical airway skills.

Introduction

The advancement of diagnostic technology has led to an increased need for patient cooperation and immobilization during imaging, especially in children [1], [2]. This has increased the demand for sedation and placed significant pressure on anesthesiology resources to the point where, in some health care facilities, the volume of children needing sedation outside of the operating room is approaching the number of children needing general anesthesia [3], thus resulting in the need for trained nonanesthesia personnel to fill this void [4]. The American Society of Anesthesiologists (ASA), the Joint Commission on the Accreditation of the Hospital Organizations, the American Academy of Pediatrics (AAP), and the American College of Emergency Physicians have developed and updated pediatric sedation levels, physical status classification levels, and practice guidelines in an effort to standardize sedation procedures and reduce the risk of adverse events [2], [5], [6], [7], [8], [9]. The American College of Emergency Physicians describes procedural sedation as the level of analgesia and sedation necessary to produce a depressed level of consciousness while still allowing the patient to continuously maintain independent control of the airway [9]. Procedures requiring immobilization may require this level of sedation.

Sedation occurs along a continuum where a patient may move from a level of mild or moderate sedation to one of deep sedation or even general anesthesia [4]. In addition, adverse effects, such as cardiorespiratory events, airway malalignment, and/or atypical, paradoxical, or emergence reactions to medication may occur [10], [11], [12], [13], [14], [15], [16], [17]. These realities have been recognized by the AAP and ASA who recommend that a practitioner other than the clinician performing the diagnostic procedure be responsible for sedation and patient monitoring [2], [8]. Pediatric sedation services or units have been created to meet this need [17], [18], [19], [20].

The pediatric emergency medicine (PEM) physician–staffed radiology sedation service was developed at our facility after a request from the hospital administration due to the increasing demand for safe and effective pediatric sedation during imaging [20], [21]. Because of the PEM training requirements in sedation and resuscitation techniques, PEM physicians are among the small group of specialists with the qualifications to effectively provide procedural sedation [22]. Multiple published studies have reported that PEM physicians can safely administer procedural sedation within the pediatric emergency department (ED) during unpleasant tests and procedures [4], [10], [22], [23], and this has become common practice [10], [14], [24].

The primary aim of our study was to determine if a sedation service staffed exclusively by PEM specialists could provide effective, uncomplicated procedural sedation to children in a radiology department, with a low rate of adverse events. Secondarily, we attempted to analyze the factors that may have increased or decreased the risk of sedation failure and adverse sedation events.

Section snippets

Design

The study was designed as a retrospective chart review of all sedations administered by a PEM-based pediatric sedation service to children (ages 0 to 18 years) undergoing imaging procedures in the radiology department of LeBonheur Children's Medical Center from September 2003 through August 2004. This study was approved by the institutional review boards of the University of Tennessee Health Sciences Center and Methodist/LeBonheur Medical Services, with waivers of consent.

Setting

Our PEM-based

Results

A total of 1042 sedation episodes were identified for review. Of these, 34 patient records were incomplete and 66 were missing, leaving 942 sedation episodes available for data collection and analysis. A total of 19 cases met exclusion criteria: 14 sedations identified on the PEM sedation log were performed by a pediatric intensivist; one was excluded because of age (22 years, 11 months); in one case, no scan was started after sedation had been initiated, as it was unexpectedly canceled by the

Discussion

The results of this study showed that a sedation service staffed exclusively by PEM physicians could effectively administer sedation in most patients with a minimal risk of minor adverse sedation events and a very low risk for major adverse sedation events. Furthermore, in our patient sample, no sedation-related complications occurred that resulted in hospital admission, increased care, or permanent injury.

A retrospective feasibility study performed by Pershad and Gilmore at our institution

Conclusions

A radiology sedation service staffed solely by PEM physicians can provide procedural sedation to children undergoing imaging, with a low risk for adverse events and a low failure rate. However, this study emphasizes the need for good airway manipulation skills in all clinicians providing sedation. Pediatric sedationists should also keep in mind the implications of sedation agents administered and the current health status of the patient, especially those with active respiratory illness. As the

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