Sedation of children in radiology: time to wake up.

Abstract

The objective of conscious sedation of infants and children in radiology is simple: minimizing the deleterious effect of movement on diagnostic information. Achieving this objective is not always simple. This complexity is evident in the different approaches to conscious sedation in radiology [1]. Traditionally, investigations of conscious sedation for diagnostic imaging have dealt with the safety and effectiveness of agents rather than with the monitoring and management of patients [2]. On the basis of such studies, recommendations are typically made for additions to (on occasionally deletions from) the available sedative anmamentanium. Because of the problems inherent in the diversity of sedation practices, the American Academy of Pediatrics, Committee on Drugs (AAPCOD), published guidelines for the practice of conscious sedation in pediatrics [3]. These guidelines established for conscious sedation minimum standards that served as a foundation for more recent standards set by the Joint Commission for Accreditation of Hospitals [4, 5]. These newer standards deal less with the choice and administration of agents (the traditional emphasis of conscious sedation) than with the safety of sedated patients. The contemporary practice of sedation of children in radiology often meets or exceeds these minimum standards for monitoring and management. However, the effect that these published guidelines have on this practice is unclear. In this issue, Vade et al. [6] take an important step in evaluating a sedation program that is specifically designed to focus on the recent guidelines for patient safety. In particular, the authors conclude that a successful sedation program can be safe when specific screening criteria and patient monitoring are used during CT and MR imaging. The patients in that study were all 4 years old or younger, outpatients, and selected on the basis of the American Society of Anesthesiologist (ASA) Physical Status Classification as class I on II. Incremental chlonal hydrate was used for all patients. For those olden than 1 year, oral hydnoxyzmne was added. Children 2-4 years old received supplemental intramuscular mepenidine if choral hydrate and hydnoxyzine were insufficient. Of the 41 0 patients, two patients with moderate on severe hypoxemia had a physical status classification that was, in retrospect, underestimated by initial screening. For these patients, as well as for the 7% of patients with mild hypoxemia, the use of monitoning equipment and documentation of patient status at reguIan intervals were credited with preventing more severe difficulties. This safety record was achieved with a sedation success rate of 97%-i 00%, depending on the sedative and typeof examination. Although this investigation underscores the importance of developing a conscious sedation program with minimum standards for patient welfare, several issues need to be addressed. Patient selection is one factor that is important in evaluating the success of a sedation program. One might wonder whether the touted success of this program was attributable to a patient selection bias because of a relatively narrow interpretation of AAPCOD guidelines. In practical terms, the status of patients requiring sedation is often more varied than that of the patients selected by Vade et al. Patients were selected on the basis of ASA classification guidelines established by the AAPCOD. The authors conclude that strict adherence to these selection criteria minimized sedation-related side effects. In fact, the AAPCOD [3] states that patients in ASA class Ill or IV “present special problems that require additional and individual consideration.” The general context of the guidelines emphasizes this point [3]: “The recommendations in this statement do not indicate an exclusive course of treatment on procedune to be followed. Variations, taking into account individual circumstances, may be appropriate.” Sedation of children who are not in class I on II does not necessarily have