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[Malviya S, Voepl- Lewis T, Tait AR. Adverse
events and risk factors associated with the sedation of children by non-anesthesiologists. Anesth Analg
1997; 85: 1207-1213].
Many diagnostic and therapeutic procedures are performed with the help of conscious or deep sedation, on children out- side the operating room environment. These procedures are most often conducted by clinicians who are not adequately trained for ensuring safe sedation practices. The present study examines the adverse events and outcomes related to the sedation of children by non-anesthesiologists and attempts at identifying patient factors and sedation techniques that predict an increased risk of sedation mishaps.
After implementation of hospital wide monitoring standards, a quality assurance (QA) tool was developed and completed prospectively for 1140 children (aged 2.96
±
3.7 yr) sedated for procedures by non-anesthesiologists at the University of Michigan Hospital. The tool captured data regarding demographics, type of procedure, medication used, duration of sedation, adequacy of sedation, monitoring used and adverse events. Sedative medications were ordered by the primary care giving physician; the nurse providing care for the
child during sedation was responsible for concurrent completion of the QA tool.
The incidence of failed procedures be- cause of an adverse event was documented. Adverse events included inadequate sedation, over sedation, decrease in
oxygen saturation to
≤80% of baseline, cardiac arrest and arrhythmia, adverse drug reaction and requirements for escalation of care such as increased level of monitoring or hospital admission. The medical records of children who experienced adverse events were reviewed. To evaluate the reliability of data, medical records of 81 other children for whom no adverse events were recorded were randomly selected and reviewed.
Chloral hydrate was the most frequently used sedative in 854 (74.9%) cases; others being benzodiazepines in 72 (6.3%), anxiolytic combinations in 123 (10.8%), analgesic and anxiolytic combinations in 24 (2.1%), opioids alone in 2 and diphenhydramine alone in 2 children. Of the 1140 children, 239 (20.1%) experienced adverse events related to sedation including inadequate sedation in 150 (13.2%) cases resulting in 43 (28.6%) failed procedures. In children who received combination of sedatives, 47 (32%) were
inadequately sedated, compared with 77 (10%) children who received chloral hydrate alone (mean dose 62
±
20 mg/kg, p <0.0001).
Sixty three children (5.5%) experienced a respiratory event resulting in a decrease in oxygen saturation to
≤90% of baseline. Five of these children experienced airway obstruction and became apneic requiring bag and mask ventilation. Forty six of the children, who experienced a respiratory event had received chloral hydrate as sole sedative in the recommended range.
Three children did not desaturate during the procedure-but did so afterwards. One of these three had received an opioid and the other two, chloral hydrate. Nine procedures were aborted because of respiratory events and five patients required escalated monitoring and care following the procedure.
Other adverse events reported included hypotension (n
= 4), bradycardia (n = 2)
and supraventricular tachycardia in one patient. Eighteen children (2%) experienced an adverse reaction to medications including
paradoxical excitement, agitation or vomiting. All children with
paradoxical excitement had received chloral hydrate.
ASA physical status III or IV and age less than one year were predictors of in- creased risk of sedation related adverse events. Medical records of 81 Children for whom no adverse events
were reported revealed that for 14(17.3%) children, the sedation flow sheet indicated that
an adverse event had occurred which was inconsistent with QA documentation. Of these, 6
children experienced considerable desaturation, one became apneic and other 7 were inadequately sedated resulting in 5 aborted procedures.
This quality assurance study highlights the risks associated with the sedation of children and emphasizes
the importance of appropriate monitoring by trained personnel.
Children with underlying medical conditions and those who are very young are at increased risk of adverse events, which indicates that a greater degree of vigilance may be required in certain situations.
Comments
All pediatricians at sometime or other have to face, though
unwillingly, the iatrogenic potential hazards associated with
sedation of their patients. As expected, respiratory depression remains the most concerning adverse effect of sedation. Most of such events remain unnoticed in our set up to lack of adequate monitoring; clinically symptomatic cases presenting
with apnea or airway obstruction just rep- resent the tip of the iceberg. Chloral hydrate, the most popular sedating agent for children is also associated with a consider- able risk of oxygen desaturation even with usual recommended
dosages(1).
None of the observed adverse events in the present study resulted in long term sequelae.
Not .that the sedative was not capable of doing so; the good outcome was achieved due to diligent and appropriate monitoring. The American Academy of Pediatrics Committee on Drugs and the Joint Commission on Accreditation of Health Care Organization
(JCAHO) have promoted guidelines to ensure safe practice and to reduce the risk associated with sedation of children(2,3). JCAHO mandates that the standard of care
for sedated patients be uniform and Director of Anesthesia, together with primary care providers be responsible for ensuring safe sedation practices. Pediatric anesthesiology is now being recognized as a sub
specialty within anesthesiology( 4).
Though there is no denying the fact that sedation mishaps are
frequent, yet it would seem too far fetched and unrealistic to
depend upon an anesthesiologist for each sedation, even for minor procedures. In a country with scarce resources, it may result in poor utilization of highly skilled manpower. Therefore. the JCAHO guidelines
may not be applicable at the levels of health
care specially in the developing world, due to shortage of manpower, equipment and other logistic problems. Relegation of selection and administration of sedation to the anesthetist may be optimal for patient safety but result in highly escalated cost.
It is therefore desirable that the primary care physician or
pediatrician should willingly accept the responsibility for
carrying out and monitoring sedation for minor procedures. The physician should be competent enough to handle any adverse consequences of the same. All children planned for sedation should undergo pre-sedation evaluation for their ASA physical status which can very well be carried out by the Pediatrician. High risk patients with ASA status III or IV should not be sedated with- out the vigilant supervision of anesthesiologist.
To care safety for a pediatric patient, there must be a system in the facility that provides adequate comprehensive care. Equipment must be appropriate and there must be personnel available to provide the necessary services throughout the periprocedural period. Both pediatrician as well as the anesthesiologist must be well prepared to manage the patient besides adequate medical and nursing back up(S). Unfortunately, need of training courses for pediatricians and pediatric nurses in use of sedatives and anesthetic care for children is still being ignored by and large in this part of the world. A plan for short term training courses can be drawn up at local levels with the help of an intensivist.
Piyush Gupta,
Associate Professor in Pediatrics,.
B.P. Koirala Institute of Health Sciences,
Dharan, Nepal.
REFERENCES
1.
Vade. A, Sukhani R, Dolenga M, Habisohn-Schuck C. Chloral hydrate sedation of children undergoing CT and MR imaging. Safety as judged by the American Academy of Pediatrics guidelines. AJR Am J Rpentegenol 1995; 165: 905-909.
2.
Committee on Drugs. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures. Pediatrics 1992;89: 1110-1115.
3.
American Society of Anesthesiologist Task Force on Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology 1996; 84: 459-470.
4.
Rockoff MA, Hall Sc. Subspeciality training in Pediatric anesthesiology. What does it mean? Anesth Analg 1997; 85:, 1185-1190.
5.
Cote CJ. Sedation for the pediatric patient: A review. Pediatric Clin North Am 1994; 41: 31-58.
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Ultrasound Guided Suprapubic Bladder Aspiration |
[Neito VG, Navarro JF, Almeida ES, Garcia Me. Standards for ultrasound guidance of suprapubic bladder aspiration. Pediatric Nephrol1997; 11: 607-6091].
Accurate diagnosis of urinary tract infection in infants is important. Collection of urine is done preferably by suprapubic
aspiration as bag collections are often contaminated(1). Moreover, with suprapubic aspiration there are minimal chances of skin or urethral contamination, no risk of urethral injury or introduction of bacteria into the bladder(2). The main problem with this technique is the low success rate of this procedure even in experienced hands(2).
Ultrasonography is an innocuous technique used for diagnosis and direct visualization during a procedure. Ultrasound guidance of SBA (Suprapubic
Bladder Aspiration) improves the success rate
of the
procedure and reduces the complications(3). Although this procedure is widely performed, there have been no reports on the conditions and measurements necessary to obtain optimal results.
The authors conducted this prospective study on 40 infants with suspected urinary tract infection to substantiate the use of ultrasound and to determine the standards for ultrasound guidance of SBA. The authors performed transabdominal sonography in supine position using Philips Orion Scanner with' a 7 MHz transducer and obtained the AP, and Cephalocaudal (Sagittal) diameters by sagittal scanning and the transverse diameter by transverse scanning. The vesical volume was calculated using the formula for elliptic volume taking the three dimensions as the diameters of an ellipsoid.
SBA was performed using a 22 Gauze needle and a 5ml syringe. The place and the angle of puncture was chosen
according to the maximum diameter of the bladder as determined by ultrasound. The final position for puncture in most cases was located 1
cm above the symphysis pubis in midline with the needle held perpendicular.
Out of the 40 infants weighing 7.2±2.1
kg and aged 1-12 months, urine was obtained by SBA in 36 (90%). The diameters of the bladder. in the, successful punctures were: AP 2.69±0.67 cm (range 1.7-4.3
cm), transverse 4.4±0.8
cm (range 3-6.1 cm) and cephalocaudal 4.64±1.08 cm (range 3-6.3
cm). The volume of urine in the bladder ranged from 13.1 to 47 ml (mean 29.4±10.9 ml). The AP and cephalocaudal diameters did not show significant correlation with bladder volume (r
=
0.53 and 0.28, respectively) but the transverse diameter showed a significant positive correlation with bladder volume (r
= 0.83, P <.001). In the 4
patients where urine was not obtained, the
mean transverse dimeter was 3.2±0.2
cm (range 2.9-3.5 cm) . The authors concluded that although the calculation of bladder volume requires all the three diameters, only the transverse diameter had a significant correlation with the bladder volume. Hence measurement of just the transverse diameter would suffice and if this is greater than 3.5
cm, a successful SBA is likely whereas if it is less than 3.0 cm the aspiration is not likely to be successful.
Comments
SBA is a widely accepted method for obtaining urine in infants but the major hindrance is the low success rate coupled with risk of visceral injury. The success rate has been reported to improve from 36% in unscanned taps to virtually 100% in scanned taps. The reason for this is not a faulty technique but
it has been seen that if random bladder scans are performed in
infants, at a given time only about one third of the bladders
are seen to contain urine explaining this kind of a success rate. The scanning repeated twice after 10-15 min usually reveals urine in almost all the cases(4).
The advantages of ultrasound guided SBA are manifold as it not only verifies the anatomical midline position of the bladder and rules out atypical bladder position but also confirms that the bladder is adequately distended for successful aspiration of urine. The path of the needle can be adequately visualized and can be directed towards even it smaller amount of urine or the yield can be increased by suitable relocation of the needle tip. Ultrasound guidance does not increase the procedure time as the technique can be taught to the resident medical staff in as short a duration as ten minutes. The technique apart from increasing
the success rate reduces the number of unsuccessful passes and thus the discomfort to the infant as well as the wastage
of supplies (disposables). The risk of puncturing abdominal viscera is also diminished resulting in a lower overall rate of complications.
Ultrasound scanners are currently in use to assist the clinician improve his diagnostic and therapeutic acumen. US guided SBA can be another use of this multipurpose modality.
Sushma Nangia,
Pool
Officer,
Department of Pediatrics,
Kalawati Saran Childrens Hospital and
Lady Hardinge Medical College,
New Delhi 110 001.
REFERENCES
1.
Nelson JD, Peters Pc. Suprapubic aspiration of urine in premature and term infants. Pediatrics 1986; 36: 132-133.
2.
O'Callaghan C, McDougall PN. Successful suprapubic aspiration of urine. Arch Dis Child 1987; 62: 1072-1073.
3.
Kiernan SC, Pinckert TL, Keszler M. Ultrasound guidance of suprapubic bladder
aspiration in neonates.
J
Pediatr 1993; 123:
789-791.
4.
Gochman RF, Karasic RB, Heller MB. Use of portable ultrasound to assist urine collection by suprapubic aspiration. Ann Emerg Med 1991; 20: 631-635.
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