Michael D. Mallory

Emergency Physician–Administered Propofol Sedation: A Report on 25,433 Sedations From the Pediatric Sedation Research Consortium

STUDY OBJECTIVE We describe the adverse events observed in a large sample of children sedated with propofol by emergency physicians and identify patient and procedure characteristics predictive of more serious adverse events. METHODS We identified sedations performed by emergency physicians using propofol as the primary sedative, included in the Pediatric Sedation Research Consortium database from July 2004 to September 2008. We describe the characteristics of the patients, procedures, location, adjunctive medications, and adverse events. We use a multivariable logistic regression model to identify predictors of more serious adverse events. RESULTS Of 25,433 propofol sedations performed by emergency physicians, most (76%) were performed in a radiology department. More serious adverse events occurred in 581 sedations (2.28%; 95% confidence interval 2.1% to 2.5%). There were 2 instances of aspiration, 1 unplanned intubation, and 1 cardiac arrest. Significant predictors of serious adverse events were weight less than or equal to 5 kg, American Society of Anesthesiologists classification greater than 2, adjunctive medications (benzodiazepines, ketamine, opioids, or anticholinergics), nonpainful procedures, and primary diagnoses of upper respiratory illness or prematurity. CONCLUSION We observed a low adverse event prevalence in this largest series of propofol sedations by emergency physicians. Factors indicating greater risk of more serious adverse events are detailed.

Propofol vs pentobarbital for sedation of children undergoing magnetic resonance imaging: results from the Pediatric Sedation Research Consortium

Background:  Pentobarbital and propofol are commonly used to sedate children undergoing magnetic resonance imaging (MRI). The Pediatric Sedation Research Consortium (PSRC) was created in 2003 to improve pediatric sedation process and outcomes.

Physiologic Monitoring Practices During Pediatric Procedural Sedation: A Report From the Pediatric Sedation Research Consortium

OBJECTIVES To describe the frequency of different physiologic monitoring modalities and combinations of modalities used during pediatric procedural sedation; to describe how physiologic monitoring varies among different classes of patients, health care providers (ie, ranging from anesthesiologists to emergency medicine physicians to nurse practitioners), procedures, and sedative medications employed; and to determine the proportion of sedations meeting published guidelines for physiologic monitoring. DESIGN This was a prospective, observational study from September 1, 2007, through March 31, 2011. SETTING Data were collected in areas outside of the operating room, such as intensive care units, radiology, emergency departments, and clinics. PARTICIPANTS Thirty-seven institutions comprise the Pediatric Sedation Research Consortium that prospectively collects data on procedural sedation/anesthesia performed outside of the operating room in all children up to age 21 years. MAIN OUTCOME MEASURES Data including demographics, procedure performed, provider level, adverse events, medications, and physiologic monitors used are entered into a web-based system. RESULTS Data from 114 855 subjects were collected and analyzed. The frequency of use of each physiologic monitoring modality by health care provider type, medication used, and procedure performed varied significantly. The largest difference in frequency of monitoring use was seen between providers using electrocardiography (13%-95%); the smallest overall differences were seen in monitoring use based on the American Society of Anesthesiologists classifications (1%-10%). Guidelines published by the American Academy of Pediatrics, the American College of Emergency Physicians, and the American Society of Anesthesiologists for nonanesthesiologists were adhered to for 52% of subjects. CONCLUSIONS A large degree of variability exists in the use of physiologic monitoring modalities for pediatric procedural sedation. Differences in monitoring are evident between sedation providers, medications, procedures, and patient types.

The impact of obesity on pediatric procedural sedation-related outcomes: results from the Pediatric Sedation Research Consortium

To evaluate the impact of obesity on adverse events and required interventions during pediatric procedural sedation.

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

OBJECTIVES 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.

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

Objective 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. Materials and Methods 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. Results 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. Conclusions 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.

Upper Respiratory Infections and Airway Adverse Events in Pediatric Procedural Sedation

We used prospectively collected data from the Pediatric Sedation Research Consortium to evaluate the relationship between URIs and the frequency of AAEs. BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Evaluation of methohexital as an alternative to propofol in a high volume outpatient pediatric sedation service

Background Propofol is a preferred agent for many pediatric sedation providers because of its rapid onset and short duration of action. It allows for quick turn around times and enhanced throughput. Occasionally, intravenous (IV) methohexital (MHX), an ultra‐short acting barbiturate is utilized instead of propofol. Objective Describe the experience with MHX in a primarily propofol driven outpatient sedation program and to see if it serves as an acceptable alternative when propofol is not the preferred pharmacologic option. Methods Retrospective chart review from 2012 to 2015 of patients receiving IV MHX as their primary sedation agent. Data collected included demographics, reason for methohexital use, dosing, type of procedure, success rate, adverse events (AE), duration of the procedure, and time to discharge. Results Methohexital was used in 240 patient encounters. Median age was 4 years (IQR 2–7), 71.8% were male, and 80.4% were ASA‐PS I or II. Indications for MHX use: egg + soy/peanut allergy in 93 (38.8%) and mitochondrial disorder 9 (3.8%). Median induction bolus was 2.1 mg/kg (IQR, 1.9–2.8), median maintenance infusion was 4.5 mg/kg/h (IQR, 3.0–6.0). Hiccups 15 (6.3%), secretions requiring intervention 14 (5.8%), and cough 12 (5.0%) were the most commonly occurring minor AEs. Airway obstruction was seen in 28 (11.6%). Overall success rate was 94%. Median time to discharge after procedure completion was 40.5 min (IQR 28–57). Conclusion Methohexital can be used with a high success rate and AEs that are not inconsistent with propofol administration. Methohexital should be considered when propofol is not a preferred option.