Pediatric Sedation Research Consortium Research Articles

Glycopyrrolate Premedication and Procedure-Related Events in Pediatric Upper Endoscopy.

Glycopyrrolate premedication is used for pediatric upper endoscopy procedures, with limited clinical evidence for efficacy. We investigated whether glycopyrrolate use is associated with lower incidence of procedure-related events and serious adverse events (SAEs) using the Pediatric Sedation Research Consortium registry. Pediatric upper endoscopy procedures performed between April 27, 2020 and February 3, 2022 were included (N = 1046). The primary outcome was the incidence of any procedure-related events during induction, maintenance, or recovery, and the secondary outcome was incidence of SAEs. The event rate was 15%, including 30 SAEs (3%). On multivariable analysis, glycopyrrolate was not associated with the overall event rate (odds ratio [OR]: 1.08; 95% confidence interval [CI]: 0.72, 1.61), but was associated with lower odds of SAEs (OR: 0.34; 95% CI: 0.13, 0.91). Although glycopyrrolate was associated with lower odds of SAEs after accounting for patient and procedure characteristics, validation through prospective trials is needed to support its routine use in clinical practice.

Preprocedural Oxygenation and Procedural Oxygenation During Pediatric Procedural Sedation: Patterns of Use and Association With Interventions

ObjectivePre-procedural oxygenation (pre-emptive oxygenation started during pre-sedation and/or induction) and procedural oxygenation (pre-emptive oxygenation started during any phase of sedation) is an easy-to-use strategy with potential to decrease adverse events. We describe practice patterns of pre-procedural oxygenation and procedural oxygenation. We hypothesized that patients who received pre-procedural oxygenation or procedural oxygenation would have a lower risk of airway/breathing/circulation interventions during sedation compared to patients without procedural oxygenation. MethodsWe performed a retrospective, multicenter, cross-sectional study of pediatric sedations from April 2020 – July 2023 using the Pediatric Sedation Research Consortium multicenter database. The patient-level and sedation-level characteristics were described using frequencies and proportions, stratified by pre-procedural oxygenation and procedural oxygenation status. We determined the site-level frequency of pre-procedural oxygenation and procedural oxygenation use. We used inverse-probability of treatment weighting to calculate the risk difference for interventions associated with pre-procedural oxygenation and procedural oxygenation. Results85,599 pediatric sedations; 43,242 (50.5%) received pre-procedural oxygenation (used oxygen pre-sedation and/or at induction) and a total of 52,219 (61.0%) used procedural oxygenation pre-emptively at any time during the sedation. There was no statistical difference in overall interventions with either pre-procedural oxygenation (risk difference -0.06%; 95% CI -4.26%, 4.14%) or procedural oxygenation (risk difference -1.07%; 95% CI -6.44%, 4.30%). ConclusionPre-emptive pre-procedural oxygenation and procedural oxygenation were not associated with a difference in the use of airway/breathing/circulation interventions in pediatric sedations.

Pediatric Sedation/Anesthesia for MRI: Results From the Pediatric Sedation Research Consortium.

Magnetic resonance imaging (MRI) is the most common imaging procedure requiring sedation/anesthesia in children. Understanding adverse events associated with sedation/anesthesia is important in making decisions regarding MRI vs. other imaging modalities. No large studies have evaluated the practice of pediatric sedation/anesthesia for MRI by a variety of pediatric specialists. Utilize a large pediatric sedation database to characterize the patients and adverse events associated with sedation/anesthesia for pediatric MRI. Retrospective analysis of prospectively collected data. The Pediatric Sedation Research Consortium (PSRC) has 109,947 entries for sedations for MRI from November 10, 2011 through December 18, 2017. Patient demographics, sedative medications, interventions, and adverse events are described. Associations with adverse events were assessed. Trends in sedative medications used over time are examined. Descriptive statistics, Chi-Squared and Fisher's Exact tests for categorical variables, logistic regression and assessment of trend using logistic regression and other method. A total of 109,947 MRI-related sedations were examined. Most subjects (66.2%) were 5 years old or younger. Seizure or other neurologic issue prompted MRI in 63.7% of cases. Providers responsible for sedation/anesthesia included intensivists (49.3%), emergency medicine physicians (28.2%), hospitalists (10.2%), and anesthesiologists (9.8%). The most commonly used sedative agent was propofol (89.1%). The most common airway intervention was supplemental oxygen (71.7%), followed by head/airway repositioning (20.6%). Airway-related adverse events occurred in 8.4% of patients. Serious adverse events occurred in only 0.06% of patients, including three cases of cardiac arrest. No mortality was recorded. There was a statistically significant increase in the use of dexmedetomidine over time. Overall, adverse event rates were low. Sedation/anesthesia with propofol infusion and natural airway was the most common method used by this varied group of sedation providers. The use of dexmedetomidine increased over time. 4 TECHNICAL EFFICACY: Stage 5.

Predictors of Laryngospasm During 276,832 Episodes of Pediatric Procedural Sedation

Laryngospasm is a rare but potentially life-threatening complication of sedation. The objective of this study was to perform a predictor analysis of biologically plausible predictors and the interventions and outcomes associated with laryngospasm. Secondary analysis of prospectively collected data from consecutively sedated patients, less than or equal to 22 years of age, at multiple locations at 64 member institutions of the Pediatric Sedation Research Consortium. The primary outcome was laryngospasm. The independent variables in the multivariable model included American Society of Anesthesiologists category, age, sex, concurrent upper respiratory infection, medication regimen, hospital sedation location, whether the procedure was painful, and whether the procedure involved the airway. The analysis included adjusted odds ratios (aORs) and predicted probabilities. We analyzed 276,832 sedations with 913 reported events of laryngospasm (overall unadjusted prevalence 3.3:1,000). A younger age, a higher American Society of Anesthesiologists category, a concurrent upper respiratory infection (aOR 3.94, 2.57 to 6.03; predicted probability 12.2/1,000, 6.3/1,000 to 18.0/1,000), and airway procedures (aOR 3.73, 2.33 to 5.98; predicted probability 9.6/1,000, 5.2/1,000 to 13.9/1,000) were associated with increased risk. Compared with propofol alone, propofol combination regimens had increased risk (propofol+ketamine: aOR 2.52, 1.41 to 4.50; predicted probability 7.6/1,000, 3.1/1,000 to 12/1,000; and propofol+dexmedetomidine: aOR 2.10, 1.25 to 3.52; predicted probability 6.3/1,000, 3.7,/1,000 to 8.9/1,000). Among patients with laryngospasm, the resulting outcomes included desaturation less than 70% for more than 30 seconds (19.7%), procedure not completed (10.6%), emergency airway intervention (10.0%), endotracheal intubation (5.3%), unplanned admission/increase in level of care (2.3%), aspiration (1.1%), and cardiac arrest (0.2%). We found increased associations of laryngospasm in pediatric procedural sedation with multiple biologic factors, procedure types, and medication regimens. However, effect estimates showed that the laryngospasm prevalence remained low, and this should be taken into consideration in sedation decisionmaking.

Creation of a Pediatric Sedation Risk Assessment Scoring System: A Novel Method to Stratify Risk.

This study aimed to create a pediatric sedation scoring system independent of the American Society of Anesthesiology Physical Status (ASA-PS) classification that is predictive of adverse events, facilitates objective stratification, and resource allocation. Multivariable regression and machine learning algorithm analysis of 134,973 sedation encounters logged in to the Pediatric Sedation Research Consortium (PSRC) database between July 2007 and June 2011. Patient and procedure variables were correlated with adverse events with resultant β -regression coefficients used to assign point values to each variable. Point values were then summed to create a risk assessment score. Validation of the model was performed with the 2011 to 2013 PSRC database followed by calculation of ROC curves and positive predictive values. Factors identified and resultant point values are as follows: 1 point: age ≤ 6 months, cardiac diagnosis, asthma, weight less than 5th percentile or greater than 95 th , and computed tomography (CT) scan; 2 points: magnetic resonance cholangiopancreatography (MRCP) and weight greater than 99th percentile; 4 points: magnetic resonance imaging (MRI); 5 points: trisomy 21 and esophagogastroduodenoscopy (EGD); 7 points: cough at the time of examination; and 18 points: bronchoscopy. Sum of patient and procedural values produced total risk assessment scores. Total risk assessment score of 5 had a sensitivity of 82.69% and a specificity of 26.22%, while risk assessment score of 11 had a sensitivity of 12.70% but a specificity of 95.29%. Inclusion of ASA-PS value did not improve model sensitivity or specificity and was thus excluded. Higher risk assessment scores predicted increased likelihood of adverse events during sedation. The score can be used to triage patients independent of ASA-PS with site-specific cut-off values used to determine appropriate sedation resource allocation.

Anticholinergics and serious adverse events in pediatric procedural sedation: A report of the pediatric sedation research consortiums.

Pediatric sedation is a clinical activity with potential for serious but rare airway adverse events, particularly laryngospasm. Anticholinergic drugs, atropine and glycopyrrolate, are frequently used with the intention to improve sedation safety by virtue of their antisialagogue effects. The objective of this study is to describe the current practice of anticholinergic use in pediatric sedation and to compare the frequency of serious sedation-related adverse events in patients who received anticholinergics to those who did not. We examined prospectively collected data from the Pediatric Sedation Research Consortium database. Patient characteristics, procedure type, sedation provider, sedatives, location of sedation, anticholinergic administered, adverse events, and airway interventions were reported. Propensity score matching and multivariable logistic regression were used to test whether any association exists between anticholinergic use and serious sedation-related adverse events. Anticholinergics were administered in 7.1% (n=18 707) of all cases (n=263 883) reported between November 2011 and October 2017. When anticholinergics were used, atropine was used in 22% (n=4111) and glycopyrrolate in 78.1% (n=14 601) of sedations. Use of anticholinergics was more common in patients with well-described risk factors for airway adverse events: active/history of upper respiratory infection, history of reactive airway disease/asthma, and exposure to smoke. However, infants and ASA 3 patients were not associated with higher rate of anticholinergic use. Anticholinergic use was independently associated with an increase in the odds of serious adverse events, OR 1.8 (95% CI 1.6-2.1), especially airway adverse events. In this large Pediatric Sedation Research Consortium study, we found the use of anticholinergic adjuvants independently associated with greater odds of serious adverse events, especially airway adverse events, after adjusting for well-known sedation risk factors using propensity score matching and multivariate analysis.

An update on pediatric sedation techniques in nonoperating room locations.

To review advancements in care for pediatric patients in nonoperating room settings. Advances in patient monitoring technology, utilization of Child Life specialists, and alternative staffing models are helping anesthesia providers meet the rising demand for coverage of pediatric nonoperating room anesthesia (NORA) cases. The Wake Up Safe and Pediatric Sedation Research Consortium registries are exploring outcome measures regarding the safety of pediatric anesthesia in off-site locations and have reported an increased risk for severe respiratory and cardiac adverse events when compared to OR anesthesia sites. Additionally, malpractice claims for NORA have a higher proportion of claims for death than claims in operating rooms. Pediatric NORA requires thorough preparation, flexibility, and vigilance to provide safe anesthesia care to children in remote locations. Emerging techniques to reduce anesthetic exposure, improve monitoring, and alternative staffing models are expanding the boundaries of pediatric NORA to provide a safer, more satisfying experience for diagnostic and interventional procedures.

The Time Is Now: Standardized Sedation Training for Pediatric Hospitalists.

* Abbreviations: OR — : operating room PH — : pediatric hospitalist PHM — : pediatric hospital medicine PSRC — : Pediatric Sedation Research Consortium SAE — : serious adverse event Changes in technology, training, medication, and resource availability will continually alter the dynamic of procedural sedation. Impacts may be greatest for children, who are more likely to require sedation for any given procedure and have unique anatomic and developmental issues that require specialized expertise. Health care systems and pediatric patients and their families benefit when imaging studies and procedures are performed in a patient-centered manner, without unnecessary delays and with the appropriate amount of sedation for optimizing clinical outcomes as well as ensuring patient safety, comfort, and satisfaction. Although anesthesiologists and nurse anesthetists provide anesthesia inside the operating room (OR), considerable variability exists in providers who offer sedation outside of the OR. In this issue of Pediatrics , Kamat et al1 examine trends from 2007 to 2018 in procedural sedation outside of the OR using the Pediatric Sedation Research Consortium (PSRC) database. The PSRC is a self-selected, voluntary collaborative of clinicians in the United States who provide sedation and collect prospective observational data on sedation encounters outside of the OR. The authors reviewed 432 842 sedation … Address correspondence to Matthew Garber, MD, Department of Pediatrics, College of Medicine–Jacksonville, University of Florida, Third Floor, 800 Prudential Dr, Jacksonville, FL 32207. E-mail: matthew.garber{at}jax.ufl.edu

Trends in Outpatient Procedural Sedation: 2007-2018.

Pediatric subspecialists routinely provide procedural sedation outside the operating room. No large study has reported trends in outpatient pediatric procedural sedation. Our purpose in this study was to identify significant trends in outpatient procedural sedation using the Pediatric Sedation Research Consortium. Prospectively collected data from 2007 to 2018 were used for trending procedural sedation. Patient characteristics, medications, type of providers, serious adverse events, and interventions were reported. The Cochran-Armitage test for trend was used to explore the association between the year and a given characteristic. A total of 432 842 sedation encounters were identified and divided into 3 4-year epochs (2007-2011, 2011-2014, and 2014-2018). There was a significant decrease in infants <3 months of age receiving procedural sedation (odds ratio = 0.97; 95% confidence interval, 0.96-0.98). A large increase was noticed in pediatric hospitalists providing procedural sedation (0.6%-9.5%; P < .001); there was a decreasing trend in sedation by other providers who were not in emergency medicine, critical care, or anesthesiology (13.9%-3.9%; P < .001). There was an increasing trend in the use of dexmedetomidine (6.3%-9.3%; P < .001) and a decreasing trend in the use of chloral hydrate (6.3%-0.01%; P < .001) and pentobarbital (7.3%-0.5%; P < .001). Serious adverse events showed a nonsignificant increase overall (1.35%-1.75%). We report an increase in pediatric hospitalists providing sedation and a significant decrease in the use of chloral hydrate and pentobarbital by providers. Further studies are required to see if sedation services decrease costs and optimize resource use.

Major Adverse Events and Relationship to Nil per Os Status in Pediatric Sedation/Anesthesia outside the Operating Room: A Report of the Pediatric Sedation Research Consortium: Erratum: Erratum.

Major Adverse Events and Relationship to Nil per Os Status in Pediatric Sedation/Anesthesia outside the Operating Room: A Report of the Pediatric Sedation Research Consortium: Erratum: Erratum.

The Incidence and Nature of Allergic and Anaphylactic Reactions During Pediatric Procedural Sedation: A Report From the Pediatric Sedation Research Consortium.

Anaphylaxis is rare but life-threatening. Its incidence during pediatric procedural sedation outside of the operating room is unknown. We used data from the Pediatric Sedation Research Consortium (PSRC) to determine the incidence and nature of allergic and anaphylactic reactions in this practice. A retrospective observational study of prospectively collected information in the PSRC's multicenter database was performed. Cases of allergic reaction were identified. Because anaphylaxis is not a listed complication in the PSRC database, all cases for which allergic reaction was noted were reviewed for the occurrence of other complications or interventions that would suggest at least 2 organ system derangements consistent with anaphylaxis as well as for practitioner commentary stating the occurrence of anaphylaxis. Descriptive analyses of demographic information and summary statistics were performed, and multiple logistic regression analysis was used to evaluate associations between the occurrence of allergic reactions and medications. During the study period, 227 833 cases were entered into the PSRC database. There were 54 cases of allergic reaction (incidence 1:4219); 6 were consistent with anaphylaxis (incidence 1:37 972). A significant association between the development of allergic reaction and 4 sedative and/or analgesic medications was noted: midazolam (odds ratio [OR] 2.2; confidence interval [CI] 1.2-3.9), ketamine (OR 3.8; CI 2.1-7.1), methohexital (OR 48.8; CI 14.9-159.9), and morphine (OR 4.4; CI 1.04-18.2). There were no mortalities. Allergic reactions and anaphylaxis during pediatric procedural sedation are rare. In this study, the development of allergic reactions was significantly associated with the use of midazolam, ketamine, methohexital, and morphine.

Pediatric Procedural Sedation Using the Combination of Ketamine and Propofol Outside of the Emergency Department: A Report From the Pediatric Sedation Research Consortium.

Outcomes associated with a sedative regimen comprised ketamine + propofol for pediatric procedural sedation outside of both the pediatric emergency department and operating room are underreported. We used the Pediatric Sedation Research Consortium database to describe a multicenter experience with ketamine + propofol by pediatric sedation providers. Prospective observational study of children receiving IV ketamine + propofol for procedural sedation outside of the operating room and emergency department using data abstracted from the Pediatric Sedation Research Consortium during 2007-2015. Procedural sedation services from academic, community, free-standing children's hospitals, and pediatric wards within general hospitals. Children from birth to less than or equal to 21 years old. None. A total of 7,313 pediatric procedural sedations were performed using IV ketamine + propofol as the primary sedative regimen. Median age was 84 months (range, < 1 mo to ≤ 21 yr; interquartile range, 36-144); 80.6% were American Society of Anesthesiologists-Physical Status less than III. The majority of sedation was performed in dedicated sedation or radiology units (76.1%). Procedures were successfully completed in 99.8% of patients. Anticholinergics (glycopyrrolate and atropine) or benzodiazepines (midazolam and lorazepam) were used in 14.2% and 41.3%, respectively. The overall adverse event and serious adverse event rates were 9.79% (95% CI, 9.12-10.49%) and 3.47% (95% CI, 3.07-3.92%), respectively. No deaths occurred. Risk factors associated with an increase in odds of adverse event included ASA status greater than or equal to III, dental suite, cardiac catheterization laboratory or radiology/sedation suite location, a primary diagnosis of having a gastrointestinal illness, and the coadministration of an anticholinergic. Using Pediatric Sedation Research Consortium data, we describe the diverse use of IV ketamine + propofol for procedural sedation in the largest reported cohort of children to date. Data from this study may be used to design sufficiently powered prospective randomized, double-blind studies comparing outcomes of sedation between commonly administered sedative and analgesic medication regimens.

Upper Respiratory Infections and Airway Adverse Events in Pediatric Procedural Sedation.

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.

The Use of Intranasal Dexmedetomidine and Midazolam for Sedated Magnetic Resonance Imaging in Children: A Report From the Pediatric Sedation Research Consortium.

The objective of this study was to describe the use of intranasal dexmedetomidine (IN DEX) for sedated magnetic resonance imaging (MRI) examinations in children. The use of IN DEX for MRI in children has not been well described in the literature. The Pediatric Sedation Research Consortium (PSRC) is a collaborative and multidisciplinary group of sedation practitioners dedicated to understanding and improving the process of pediatric sedation. We searched the 2007 version of the PSRC database solely for instances in which IN DEX was used for MRI diagnostic studies. Patients receiving intravenous medications were excluded. Patient demographics, IN DEX dose, adjunct medications and dose, as well as procedure completion, complications, interventions, and monitoring providers were analyzed. A total of 224 sedation encounters were included in our primary analysis. There were no major adverse events. Most sedations (88%) required no intervention. Registered nurses were the monitoring provider in over 99% of cases. The median (interquartile range) dose of dexmedetomidine was 3 (2.5-3) mcg/kg. Adjunctive midazolam was used in 219/224 (98%) of the cases. All procedures were completed. This report from the PSRC shows that IN DEX in combination with midazolam is an effective medication regimen for children who require an MRI with sedation.

Procedural Sedation Outside of the Operating Room Using Ketamine in 22,645 Children: A Report From the Pediatric Sedation Research Consortium.

Most studies of ketamine administered to children for procedural sedation are limited to emergency department use. The objective of this study was to describe the practice of ketamine procedural sedation outside of the operating room and identify risk factors for adverse events. Observational cohort review of data prospectively collected from 2007 to 2015 from the multicenter Pediatric Sedation Research Consortium. Sedation services from academic, community, free-standing children's hospitals and pediatric wards within general hospitals. Children from birth to 21 years old or younger. None. Describe patient characteristics, procedure type, and location of administration of ketamine procedural sedation. Analyze sedation-related adverse events and severe adverse events. Identify risk factors for adverse events using multivariable logistic regression. A total of 22,645 sedations performed using ketamine were analyzed. Median age was 60 months (range, < 1 mo to < 22 yr); 72.0% were American Society of Anesthesiologists-Physical Status less than III. The majority of sedations were performed in dedicated sedation or radiology units (64.6%). Anticholinergics, benzodiazepines, or propofol were coadministered in 19.8%, 57.9%, and 35.4%, respectively. The overall adverse event occurrence rate was 7.26% (95% CI, 6.92-7.60%), and the frequency of severe adverse events was 1.77% (95% CI, 1.60-1.94%). Procedures were not completed in 39 of 19,747 patients (0.2%). Three patients experienced cardiac arrest without death, all associated with laryngospasm. This is a description of a large prospectively collected dataset of pediatric ketamine administration predominantly outside of the operating room. The overall incidence of severe adverse events was low. Risk factors associated with increased odds of adverse events were as follows: cardiac and gastrointestinal disease, lower respiratory tract infection, and the coadministration of propofol and anticholinergics.

Differences in Pediatric Non-Interventional Radiology Procedural Sedation Practices and Adverse Events by Registered Nurses and Physicians

PurposeThe purpose of this study was to determine differences in sedation-related adverse events according to the type of provider monitoring and delivering sedation. Design and MethodsA retrospective, cross-sectional, correlational design using secondary data from the Pediatric Sedation Research Consortium database was used for this study. ResultsA sample of 36,352 cases (0–14 years of age) sedated and monitored for diagnostic radiology procedures by three types of providers (registered nurses [RNs] alone, physicians (MDs) alone, or registered nurse + physician [RN+MD sedation teams]) were compared. Patients sedated by RNs alone or MDs alone had lower odds of unanticipated adverse events (odds ratios 0.46 and 0.53, respectively; p<0.0001) compared with RN+MD sedation provider teams. ConclusionsTeam skills may be an important competency for RN+MD sedation teams in the non-interventional radiology setting. Practice ImplicationsThis study can inform clinicians, administrators, and quality-improvement managers of the differences in adverse event outcomes of pediatric radiology procedures when RN+MD teams provide sedation compared with RNs or MDs alone.

Procedural SedationOutside the Operating Room Using Ketamine in 22645 Children: A Report from the Pediatric Sedation Research Consortium

目的 大多数关于儿童应用氯胺酮行操作中镇静(procedural sedation，PS)的研究局限于急诊科。本研究旨在了解氯胺酮于手术室外PS的应用现状并确定导致不良事件的危险因素。 设计 观察性队列回顾分析2007至2015年间儿科镇静研究协会多中心前瞻性收集的数据。 场所 可开展镇静治疗的学院型，社区或独立儿童医院以及综合医院儿科病房。 对象 生后至≤21岁的青少年儿童。 干预措施 无。 方法及主要结果 了解患儿特点、操作种类及氯胺酮注射部位。分析镇静相关不良事件(adverse events，AE)以及严重不良事件(severe adverse events，SAE)。采用logistic多因素回归分析确定AE危险因素。共分析22645次氯胺酮镇静，中位年龄60月(<1月至<22岁)；72.0%患者美国麻醉师协会生理状况评估(American Society of Anesthiologists－Physical Status，ASA－PS)<Ⅲ。大部分镇静(64.6%)在专用的镇静病房或影像科进行。联合应用抗胆碱药、苯二氮类和丙泊酚的患儿比例分别为19.8%、57.9%和35.4%；不良事件总体发生率为7.26%(95%CI 6.92%～7.60%)，SAE发生率为1.77%(95%CI 1.60%～1.94%)；39/19747(0.2%)的患儿操作中断；3例患者因喉痉挛发生心脏骤停，但均存活。 结论 本研究对应用氯胺酮行手术室外儿童操作镇静的大规模前瞻性收集数据进行描述分析，SAE总体发生率低。与AE增加优势比相关的风险因素包括：心脏和胃肠道疾病、下呼吸道感染以及联合应用丙泊酚和抗胆碱药。

Pediatric Procedural Sedation Using Dexmedetomidine: A Report From the Pediatric Sedation Research Consortium.

Dexmedetomidine (DEX) is widely used in pediatric procedural sedation (PPS) by a variety of pediatric subspecialists. The objective of our study was to describe the overall rates of adverse events and serious adverse events (SAEs) when DEX is used by various pediatric subspecialists. Patients from the Pediatric Sedation Research Consortium (PSRC) database were retrospectively reviewed and children that received DEX as their primary sedation agent for elective PPS were identified. Demographic and clinical data, provider subspecialty, and sedation-related complications were abstracted. SAEs were defined as death, cardiac arrest, upper airway obstruction, laryngospasm, emergent airway intervention, unplanned hospital admission/increased level of care, aspiration, or emergency anesthesia consult. Event rates and 95% confidence intervals (CIs) were calculated. During the study period, 13 072 children were sedated using DEX, accounting for 5.3% of all sedation cases entered into the PSRC. Of the sedated patients, 73% were American Society of Anesthesiologists Physical Status class 1 or 2. The pediatric providers responsible for patients sedated with DEX were anesthesiologists (35%), intensivists (34%), emergency medicine physicians (12.7%), hospitalists (1.1%), and others (17%). The overall AE rate was 466/13 072 (3.6%, 95% CI 3.3% to 3.9%). The overall SAE rate was 45/13 072 (0.34%, 95% CI 0.19% to 0.037%). Airway obstruction was the most common SAE: 35/13 072 (0.27%, 95% CI 0.19% to 0.37%). Sedations were successful in 99.7% of cases. We report the largest series of PPS using DEX outside the operating room. Within the PSRC, PPS performed using DEX has a very high success rate and is unlikely to yield a high rate of SAEs.

Outcomes following implementation of a pediatric procedural sedation guide for referral to general anesthesia for magnetic resonance imaging studies.

Guidelines for referral of children to general anesthesia (GA) to complete MRI studies are lacking. We devised a pediatric procedural sedation guide to determine whether a pediatric procedural sedation guide would decrease serious adverse events and decrease failed sedations requiring rescheduling with GA. We constructed a consensus-based sedation guide by combining a retrospective review of reasons for referral of children to GA (n = 221) with published risk factors associated with the inability to complete the MRI study with sedation. An interrupted time series analysis of 11 530 local sedation records from the Pediatric Sedation Research Consortium between July 2008 and March 2013, adjusted for case-mix differences in the pre- and postsedation guide cohorts, evaluated whether a sedation guide resulted in decreased severe adverse events (SAE) and failed sedation rates. A significant increase in referrals to GA following implementation of a sedation guide occurred (P < 0.001), and fewer children with an ASA-PS class ≥III were sedated using procedural sedation (P < 0.001). There was no decrease in SAE (P = 0.874) or in SAE plus airway obstruction with concurrent hypoxia (P = 0.435). There was no change in the percentage of failed sedations (P = 0.169). More studies are needed to determine the impact of a sedation guide on pediatric procedural sedation services.

The Use of Patient Registries to Detect Risk Factors of Anesthesia and Sedation Complications.

* Abbreviation: PSRC — : Pediatric Sedation Research Consortium Beginning in the 1980s, prospective studies confirmed what was previously suspected from case reports: that prematurely born infants were at a higher risk of developing central and obstructive apneas after general anesthesia compared with their term counterparts.1,2 This finding resulted in the extended use of cardiorespiratory monitoring (ie, usually overnight) in these infants after exposure to anesthetic agents before discharge from the hospital. Although a number of centers reported varying results, this increased risk seemed to last until ∼5 or 6 months into the first year of life. Similarly, an increased risk of postprocedure oxyhemoglobin desaturation was found in preterm infants after chloral hydrate sedation for MRIs.3 Although most pediatric anesthesiologists would agree that prematurity is a strong risk factor for additional respiratory complications (eg, bronchospasm, laryngospasm), surprisingly little information has been published on the subject. With this in mind, the Pediatric Sedation Research Consortium (PSRC) was created and, in this issue of Pediatrics , Havidich et al4 report their analysis of sedation- and anesthesia-related adverse events across a wider range … Address correspondence to Ronald S. Litman, DO, Department of Anesthesiology, The Children's Hospital of Philadelphia, 34th St and Civic Center Blvd, Philadelphia, PA 19104. E-mail: litmanr{at}email.chop.edu