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Pediatric Procedural Sedation and Analgesia: Practices and Complications

Data from a large registry show that serious adverse events are rare.

The current literature does not provide an adequate estimate of the type and frequency of adverse events associated with pediatric procedural sedation and analgesia (PSA). In a prospective observational study, researchers evaluated data from the first 30,000 cases submitted to the Pediatric Sedation Research Consortium database, a prospective registry of patients receiving PSA at 35 institutions in the U.S., Canada, Europe, and Australia.

Data collection methods were standardized, and definitions were based on guidelines from professional societies. Overall, 80% of patients were in the American Society of Anesthesiologists class I or II; 77% were younger than 8 years; and 47% were NPO for liquids and 75% were NPO for solids for at least 8 hours before the procedure. Eight percent of cases were classified as emergency sedations. Sedation was performed most often by intensivists, emergency physicians, and anesthesiologists. Most procedures (62%) were radiologic, and the most common category of primary diagnosis was neurologic (41%). The most frequently used sedatives and analgesic agents were propofol (50%), midazolam (27%), ketamine (14%), and pentobarbital (13%).

The overall rate of complications was 5.3%. The most frequent complication was desaturation below 90% (incidence, 157 per 10,000 sedations). One case each of aspiration pneumonia and cardiac arrest occurred in patients who received propofol sedation in a pediatric intensive care unit. There were no deaths. Bag-mask-ventilation was the most common unplanned treatment (incidence, 64 per 10,000 sedations).

Comment: The choice of provider, method, and medications for pediatric PSA is often particular to the institution where it is performed. This concept is reflected in the data submitted to the registry. Nevertheless, the registry provides systematic epidemiologic information that can and should serve as the basis for future recommendations and guidelines. Most important, the data demonstrate that although serious adverse events are rare, procedural sedation is not entirely without risk. The very low incidence of serious adverse events in this large, multicenter study reinforces both the overall safety of procedural sedation and the need to ensure that protocols call for appropriate training and monitoring. Overall, procedural sedation in children is remarkably safe when performed by appropriately trained providers, such as emergency physicians, using appropriate safeguards.

— Jill M. Baren, MD, MBE, FACEP, FAAP

Published in Journal Watch Emergency Medicine October 13, 2006

Citation(s):

Cravero JP et al. Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: Report from the Pediatric Sedation Research Consortium. Pediatrics 2006 Sep; 118:1087-96.

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