An exploratory study of distractions during the induction phase of pediatric procedural sedation with propofol.

INTRODUCTION: Distractions are a leading cause of disturbance to workflow during medical care. Distractions affecting the anesthetic team in the operating room are frequent and have a negative impact on patient care one-fifth of the time. The objective of this study was to evaluate the frequency, source, target, and impact of distractions during the induction phase of pediatric procedural sedation outside the operating room. METHODS: Distractions were analyzed during propofol induction for oncology procedures from 45 video recordings. Distraction was defined as any event that disturbs or has potential to disturb the sedation team from performing their primary tasks. The type of distraction was cataloged into communication, coordination, extraneous events, equipment, layout, and usability. A five-point Likert scale was used to quantify the impact on the sedation team or its members. RESULTS: All patients had a diagnosis of acute lymphocytic leukemia and had a mean age of 8.4 years. Five hundred and sixty-seven distractions occurred and averaged 12.6 events (±5.6) per induction (mean induction time 3 min 12 s). Extraneous events were most common, accounting for 55% (312/567) of all distractions. Most distractions had an impact on the sedation team's workflow, resulting in multitasking (46%, n = 262), and in either brief or complete disruption from a primary task (17%). Sedation nurses were impacted most often, 62% of the time. Coordination and usability issues resulted in the greatest negative impact, mean ± SD, 3.7 ± 1.0 and 3.5 ± 0.9, respectively. There was no significant association between distractions and adverse events or induction length. DISCUSSION: Distractions are common during procedural sedation, with extraneous events being most frequent. Coordination issues within the team and usability problems had the greatest negative impact on sedation team workflow. Nurses were the most frequent target. CONCLUSION: Distractions impacted sedation team workflow but had no association with patient outcomes.

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

BACKGROUND: 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. AIMS: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Reducing Delays in a Pediatric Procedural Unit With Ultrasound-Guided Intravenous Line Insertion.

OBJECTIVES: Delay in vascular access is a leading cause of procedure delay in our pediatric procedure and infusion center. Use of ultrasound decreases time to peripheral intravenous catheter (PIV) insertion; however, ultrasound availability in our center was limited to an external venous access team (VAT). The objective of this project was to reduce PIV-related delays by 25%. METHODS: Stakeholders convened and theorized that creating a unit-based nurse team specializing in ultrasound-guided peripheral intravenous catheter (USgPIV) insertion would facilitate faster access and a reduction in delayed procedures. An initial plan-do-study-act cycle was performed, training 2 nurses in USgPIV placement. Subsequent cycles were focused on increasing availability of USgPIV-trained nurses. The outcome measure was the rate of procedures delayed by PIV placement, analyzed on a statistical process control U-chart. The process measure was the percentage of USgPIV placements requiring consultations to the VAT, analyzed on a statistical process control P-chart. The balancing measure was the success rate per method of insertion. Comparisons of success rates were conducted by using a χ2 test and Fisher's exact test. RESULTS: The mean rate of procedures delayed because of vascular access fell by special cause variation from 10.8% to 6.4%. The mean VAT consultation rate fell from 86.4% to 32.0%. The VAT had higher rates of overall success (100% vs 87%; P = .01) and first-attempt success (93% vs 77%; P = .03) compared with unit nurse USgPIV placement. CONCLUSIONS: Unit-based USgPIV placement in a pediatric procedural center was successfully implemented, with a significant decline in procedures delayed by PIV access.

Safety and Efficacy of Buccal Dexmedetomidine for MRI Sedation in School-Aged Children.

OBJECTIVES: Intranasal, intramuscular, and intravenous (IV) dexmedetomidine routes have been used successfully for pediatric MRI studies. We designed this retrospective study to determine efficacy and safety of buccal dexmedetomidine for pediatric MRI sedation. METHODS: Medical records were reviewed of outpatient children ages 5 to 18 years who received buccal dexmedetomidine with or without oral midazolam for MRI sedation at a freestanding children's hospital sedation program in 2015 and 2016. RESULTS: A total of 220 outpatient encounters received buccal dexmedetomidine for MRI. Mean age of the cohort was 10.1 ± 2.6 years (range: 5-18.7). Buccal dexmedetomidine dose administered was a mean of 2.20 ± 0.38 µg/kg (range: 0.88-3.19). Of the 220 sedation encounters, 179 (81.4%) patients had satisfactory sedation with buccal dexmedetomidine with or without oral midazolam: 84 had buccal dexmedetomidine as the sole sedative, 95 had satisfactory sedation when buccal dexmedetomidine and oral midazolam (mean: 0.33 ± 0.07 mg/kg; range: 0.21-0.53) were given together, 1 (0.4%) had satisfactory sedation when intranasal fentanyl and midazolam were administered in addition to buccal dexmedetomidine, and 35 (15.9%) required IV sedatives to achieve satisfactory sedation. All patients completed their MRI successfully except 5 (2.2%): 2 encounters were sedation failures, 2 IV sedations developed severe upper airway obstruction, and 1 IV sedation experienced MRI contrast anaphylaxis. CONCLUSIONS: In a selected population of pediatric patients, buccal dexmedetomidine with or without midazolam provides adequate sedation for most MRI studies with few adverse effects, but given a failure rate of almost 20%, modifications to buccal dexmedetomidine dosing should be investigated.

The utility of the pretracheal stethoscope in detecting ventilatory abnormalities during propofol sedation in children.

BACKGROUND: Monitoring of ventilation with capnography or a stethoscope is recommended because the detection of ventilatory abnormalities can be significantly delayed by the use of pulse oximetry alone in patients receiving supplemental oxygen. The aim of this study was to evaluate the diagnostic performance of the pretracheal stethoscope with pulse oximetry and capnography in detecting adverse respiratory events during propofol sedation in nonintubated children. We hypothesized that use of the pretracheal stethoscope would facilitate earlier detection of adverse respiratory events. METHODS: This was a prospective observational study of children undergoing procedural sedation at a pediatric sedation program. A pretracheal stethoscope, pulse oximetry, and nasal capnography were attached at the discretion of the sedation nurse and provider to monitor ventilation. RESULTS: We enrolled 104 patient encounters (mean recorded time, SD 8.3 ± 5.3 minutes) from February, 2015 to March, 2017. The pretracheal stethoscope was the first monitor to detect adverse events in 64% (25/39) of patients compared to 18% (7/39) for capnography and 15% (6/39) for pulse oximetry. Auscultation performed best at detecting upper airway obstruction but capnography and pulse oximetry performed best at detecting hypoventilation. The positive predictive value for detecting a true ventilation abnormality and 95% CI of the pretracheal stethoscope, pulse oximetry, and capnography was 100% (90%-100%), 18% (10%-31%), and 27% (18%-38%), respectively. The negative predictive value and 95% CI of the pretracheal stethoscope, pulse oximetry, and capnography was 88% (82%-92%), 68% (59%-75%), and 70% (61%-78%), respectively. Limitations are short observation time, nonstandardized application of respiratory monitors, and too much focus on auscultation. CONCLUSION: A pretracheal stethoscope in conjunction with capnography and pulse oximetry detects most sedation-related adverse events first. Auscultation performed best at detecting upper airway obstruction but capnography and pulse oximetry performed best at detecting hypoventilation.

A retrospective comparison of propofol alone to propofol in combination with dexmedetomidine for pediatric 3T MRI sedation.

BACKGROUND AND AIM: Both propofol and dexmedetomidine have been found to be safe and effective sedation for magnetic resonance imaging (MRI). Our program experienced an increase in patients arousing and experiencing an adverse airway event during propofol sedation for MRI in the first months of using a new 3T (Tesla) MRI scanner that was found to have a longer reverberation time compared to the previous 1.5 T MRI. In an effort to decrease patient arousal and adverse airway events during MRI, we administered a dexmedetomidine load prior to our standard propofol protocol. The objective was to compare adverse events and other outcome measures of patients sedated with propofol alone (Pro) and propofol preceded by a dexmedetomidine load (D+P). METHODS: We reviewed a sedation database and medical records for all children undergoing 3T MRI studies while sedated with propofol alone or propofol preceded by a dexmedetomidine load in 2014. RESULTS: Two hundred and fifty-six sedations were performed for MRI (87 Pro and 169 D+P). The two groups were comparable with regard to age, weight, gender, and American Society of Anesthesiologists status. Subjects in the D+P cohort had significantly fewer adverse events (10/169 patients (5.9%) vs 23/87 patients (26.4%) [OR 0.18, 95% CI: 0.08-0.39, P < 0.001]), particularly upper airway obstruction. Mean discharge time was longer in the D+P cohort compared to the Pro cohort (87.1, SD 26.3 min vs 69.7, SD 23.6; [mean difference 17.7 min, 95% CI: 10.6-24.8, P < 0.001]). CONCLUSIONS: The addition of a dexmedetomidine infusion prior to our propofol MRI sedation protocol resulted in fewer sedation-related adverse events, particularly upper airway obstruction. Further studies are needed to evaluate the potential for a reduction on adverse events with this drug combination.

Current State of Institutional Privileging Profiles for Pediatric Procedural Sedation Providers.

BACKGROUND AND OBJECTIVE: Providers from a variety of training backgrounds and specialties provide procedural sedation at institutions in the United States. We sought to better understand the privileging patterns and practices for sedation providers. METHODS: Surveys were sent to 56 program directors belonging to the Society for Pediatric Sedation using Research Electronic Data Capture to 56 pediatric sedation programs. The survey was designed to gather information regarding characteristics of their sedation service and the privileging of their sedation providers. RESULTS: The overall response rate was 41 (73%) of 56. Most programs surveyed (81%) said their physicians provided sedation as a part of their primary subspecialty job description, and 17% had physicians whose sole practice was pediatric sedation and no longer practiced in their primary subspecialty. Fifty-one percent of surveyed sedation programs were within freestanding children's hospitals and 61% receive oversight by the anesthesiology department at their institution. Eighty-one percent of the sedation programs require physicians to undergo special credentialing to provide sedation. Of these, 79% grant privileging through their primary specialty, whereas 39% require separate credentialing through sedation as a stand-alone section. For initial credentialing, requirements included completion of a pediatric sedation orientation and training packet (51% of programs), sedation training during fellowship (59%), and documentation of a specific number of pediatric procedural sedation cases (49%). CONCLUSIONS: In this survey of pediatric sedation programs belonging to the Society for Pediatric Sedation, the process for privileging providers in procedural sedation varies significantly from institution to institution. An opportunity exists to propose privileging standards for providers of pediatric procedural sedation.

Development, implementation, and initial participant feedback of a pediatric sedation provider course.

BACKGROUND: No standardized educational curriculum exists for pediatric sedation practitioners. We sought to describe the curriculum and implementation of a pediatric sedation provider course and assess learner satisfaction with the course curriculum. DESCRIPTION: The course content was determined by formulating a needs assessment using published sedation guidelines, reports of sedation related adverse events, and a survey of sedation practitioners. Students provided feedback regarding satisfaction with the course immediately following the course and 6 months later. EVALUATION: The course consisted of 5 didactic lectures, 1 small-group session, 6 simulation scenarios, a course syllabus, and a written examination. The course was conducted over 1 day at 3 different locations. Sixty-nine students completed the course and were uniformly satisfied with the course curriculum. CONCLUSIONS: A standardized pediatric sedation provider course was developed for sedation practitioners and consisted of a series of lectures and simulation scenarios. Overall satisfaction with the course was positive.

Respiratory Depression in Young Prader Willi Syndrome Patients following Clonidine Provocation for Growth Hormone Secretion Testing.

Objectives. To determine the sedative and respiratory effects of clonidine when used to evaluate growth hormone (GH) secretion in children with Prader Willi Syndrome (PWS). Methods. The study prospectively evaluated children with PWS who received clonidine (0.15 mg/m(2)) to assess GH responsiveness. Patients were studied up to four times over three years. Vital signs, oxygen saturation, and sedation level were recorded at baseline and every five minutes following clonidine. Changes between baseline and post-clonidine were evaluated using a repeated measurement analysis. Results. Sixty studies were performed on 17 patients, mean age 30.4 +/- 15.0 months. The mean +/- SD dose of clonidine was 0.074 +/- 0.027 mg (5.3 +/- 1.72 mcg/kg). All patients achieved a sedation score of 4 to 5 (drowsy to asleep). Mean declines in respiratory rate (7.5 +/- 6.1 breaths/min; P < .001), and oxygen saturation (2.2 +/- 2.0%; P < .001) occurred following clonidine. Five patients (29%) experienced oxygen saturations

Propofol-fentanyl versus propofol alone for lumbar puncture sedation in children with acute hematologic malignancies: propofol dosing and adverse events.

OBJECTIVE: We sought to determine whether the combination of propofol and fentanyl results in lower propofol doses and fewer adverse cardiopulmonary events than propofol and placebo for lumbar puncture in children with acute hematologic malignancies. DESIGN: Randomized, controlled, double blind, crossover study. SETTING: Pediatric Sedation Program. PATIENTS: Children with acute leukemia or lymphoma receiving sedation for lumbar puncture. INTERVENTIONS: Each patient received two sedations in random order, one with propofol/placebo and one with propofol/fentanyl. The study investigator and patient/parent were blinded to placebo or fentanyl. Data collected included patient age and diagnosis, propofol dose and adverse events. Adverse events included oxygen saturation <94%, airway obstruction, apnea, hypotension, and bradycardia (<5% mean for age). Logistic regression analysis was used to assess probability of adverse events and the Wilcoxon Signed Rank and McNemar's tests were used for paired comparisons. MEASUREMENTS AND MAIN RESULTS: Twenty-two patients were enrolled. Fourteen patients were male and eight were female. Each patient was studied twice for a total of 44 sedations. The median age was 5.0 yrs (range, 2.2-17.2 yrs). All procedures were successfully completed. The median total dose of propofol was 5.05 mg/kg (range, 2.4-10.2 mg/kg) for propofol/placebo vs. 3.00 mg/kg (range 1.4-10.5 mg/kg) for propofol/fentanyl (p < 0.001). Twelve adverse events occurred in 11 of 22 patients (50.0%) propofol/placebo compared with 6 of 22 (18.2%) propofol/fentanyl (p = 0.02). The most common adverse event was hypotension. CONCLUSIONS: The combination of propofol and fentanyl vs. propofol alone for lumbar puncture sedation in children with acute hematologic malignancies resulted in lower propofol doses and fewer adverse events.

Sedative preference of families for lumbar punctures in children with acute leukemia: propofol alone or propofol and fentanyl.

Propofol is a common sedative/anesthetic used for invasive procedures in children with cancer. The purpose of this study was to determine whether families of children with acute leukemia prefer propofol alone or propofol plus fentanyl for lumbar puncture (LP) sedation. We conducted a randomized, placebo controlled, double blind, crossover study. Each patient was studied twice, once with propofol/placebo and once with propofol/fentanyl. Data collected included the modified Yale Preoperative Anxiety Score (M-YPAS) at baseline and after placebo or fentanyl, Induction Compliance Checklist, recovery excitement, recovery time, and adverse events. After the study, families were asked which sedative regimen they preferred for future LPs. Twenty-two patients received 44 LP sedations: propofol 22, propofol/fentanyl 22. The average age was 6.4+/-4.2 years (mean+/-SD). There were no significant differences between groups in M-YPAS, Induction Compliance Checklist or recovery excitement. Adverse events occurred in 11/22 patients (50%) propofol and 4/22 (18.2%) propofol/fentanyl (P=0.0196). Average recovery time (mean+/-SD) was 36.86+/-17.1 minutes propofol versus 26.36+/-16.4 minutes propofol/fentanyl (P=0.047). Sixteen families (72.7%) chose propofol with fentanyl for future LP sedations (P=0.05). In conclusion, most families prefer propofol and fentanyl for LPs. Propofol with fentanyl was also associated with fewer adverse events and faster recovery.