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PubMed2000

Pharmacologic behavior management for pediatric dental treatment.

Sedatives are an important and necessary management technique for some children during dental procedures. Sedation can be administered safely and efficiently by competent practitioners who have special training in the use of the technique in children and who adhere to sedation guidelines. Nonetheless, some children present with special needs, such as medically compromising conditions, or multiple carious teeth in a child who is fearful or whose family must travel a long distance for care. Sedation cannot always safely and adequately meet the needs of these children. In these cases, general anesthesia in a hospital, ambulatory care facility, or office is indicated and must be provided by an appropriately licensed and trained physician or dentist.

Analgesics↗
PubMedDate not supplied

Development of an outcome/variance tracking tool for sedation and non-surgical procedures.

A large academic cancer center devised a performance improvement plan for special procedures and sedation. A group of interdisciplinary professionals convened to address data collection, complications, and outcomes for non-surgical procedures and sedation. Administrative, medical, and nursing representatives from all areas in which these procedures are performed gathered to assess existing data and data collection methods and to develop an improvement plan. Gastroenterology, pulmonary, diagnostic imaging, intensive care, gynecology, genitourinary, hematology, and anesthesiology specialties were represented. The group was facilitated by staff from the institution's Office of Performance Improvement and co-chaired by an anesthesiologist and a pulmonary specialist. A representative from the Practice Outcomes Department was also an active participant. This article describes group process, design efforts, pilot testing, and analyses for this project. Pilot data are presented as well as a discussion of staff involvement.

Procedural Sedation↗
PubMed2006

Propofol sedation during endoscopic procedures: safe and effective administration by registered nurses supervised by endoscopists.

BACKGROUND AND STUDY AIMS: Propofol has several attractive properties, including a rapid onset of action and rapid recovery. However, the administration of propofol sedation in the absence of anesthesiologists remains controversial. This report describes the safety profile of propofol sedation for endoscopy when administered by registered nurses under the supervision of endoscopists. PATIENTS AND METHODS: The study was conducted in the endoscopic center of a Japanese private hospital. With assistance from an anesthesiologist, a protocol for administration of propofol by registered nurses was developed. Over the past 6 years, 27,500 patients received nurse-administered propofol sedation. The safety and patient satisfaction with this sedation procedure were evaluated. RESULTS: Among the participating patients, 6.7% developed hypoxemia (Sp(O2) < 90%); 6.2% required oxygen administration via a nasal cannula. Severe hypoxemia (Sp(O2) < 85%) occurred in 121 patients (0.62%) during upper gastrointestinal endoscopy and 20 patients (0.25%) during colonoscopy, but neither mask ventilation nor endotracheal intubation was necessary. A decline in blood pressure (systolic blood pressure < 90 mm Hg) was seen in 3.5% of the colonoscopy patients and 1.2% of the upper endoscopy patients. However, hypotension was corrected immediately using an intravenous saline solution. Patients who received propofol sedation expressed overall satisfaction on a 10-point visual analogue scale (with an average of 9.4 points). Among patients who had previously received a combination of midazolam and pethidine for colonoscopy, 85% preferred propofol sedation. The mean time from the end of the procedure to full recovery was 14.6 min. CONCLUSIONS: Administration of propofol by registered nurses under the supervision of endoscopists was safe, and resulted in high rates of patient satisfaction.

Adolescent↗
PubMedDate not supplied

The use of di-hydroxypropylphenol (propophol) in endoscopic procedures.

The authors illustrate different endoscopic procedures that may require anaesthesiological assistance through analgo-sedation procedures. Analgo-sedation is useful to the patient and to the endoscopist that can carry out the exam more rapidly and in optimal conditions. The technique employed consists in the administration of propophol, starting with an initial bolus of the drug followed by a continuous perfusion to maintain the hypnotic state. Monitoring of cardiovascular and respiratory parameters shows a great reliability of the drug and effectiveness of the method.

Adolescent↗
PubMed2006

Cost-effectiveness analysis of sedation and analgesia regimens during fracture manipulation in the pediatric emergency department.

OBJECTIVE: To conduct a cost-effectiveness analysis, from a hospital's perspective, of 4 procedural sedation and analgesia (PSA) regimens to facilitate forearm fracture manipulation in the pediatric emergency department (ED): deep sedation with ketamine/midazolam (K/M) administration, propofol/fentanyl administration, fentanyl/midazolam (F/M) administration, and axillary block. DESIGN/METHODS: We constructed a decision analytic model using relevant probabilities from published studies of pediatric patients who underwent fracture manipulation in the EDs. Total costs were calculated by assessing ED resource utilization associated with uncomplicated PSA and with PSA complicated by adverse events. Costs of consumable equipment were considered to be fixed. Total sedation time, personnel time, and drug costs were considered variable. We assumed that all PSA regimens provided effective relief from procedural distress. Failure rates for axillary block were estimated based on reports in the literature. When patients experienced emesis, recovery agitation, respiratory depression, lidocaine toxicity, or regional block failure, we assumed that the patients would require 1 additional hour of ED stay. Sensitivity analyses of all key variables in the model were performed to identify those that may result in a change in the preferred option. Monte Carlo simulations were performed to assess model robustness. RESULTS: Under baseline assumptions, the propofol/fentanyl regimen was the most cost-effective choice (expected cost, 84.06 US dollars), followed by axillary block (88.18 US dollars), K/M (105.32 US dollars), and F/M (159.79 US dollars), respectively. Varying the fixed and variable costs by 50% to 200% of their baseline values did not alter the ranking. When ketamine and propofol were administered without adjunctive midazolam and fentanyl, respectively, propofol remained the optimum choice. With total PSA time as the outcome measure, the incremental cost-effectiveness ratios were 8.1 US dollars and 24.9 US dollars per hour of ED time saved, for propofol/fentanyl versus axillary block and for axillary block versus K/M, respectively. CONCLUSIONS: Among PSA regimens during forearm fracture manipulation in the pediatric ED, propofol/fentanyl is the most cost-effective regimen followed by axillary block, K/M, and F/M.

Analgesics↗
PubMed1999

Sedation for pediatric radiological procedures: analysis of potential causes of sedation failure and paradoxical reactions.

BACKGROUND: Sedation for diagnostic imaging and interventional radiologic procedures in pediatrics has greatly increased over the past decade. With appropriate patient selection and monitoring, serious adverse effects are infrequent, but failure to sedate and paradoxical reactions do occur. OBJECTIVE: The purpose of this study was to determine, among patients undergoing sedation for radiologic procedures, the incidence of sedation failure and paradoxical reaction to pentobarbital and to identify potentially correctable causes. MATERIALS AND METHODS: Records of 1665 patients who were sedated in the radiology department from 1 November 1997 to 1 July 1998 were reviewed. Patients failing sedation or experiencing paradoxical reaction were compared with respect to sex, age group, diagnosis, scan type, time of day, NPO status, use of IV contrast and type of sedation agent using the Fisher exact test, Pearson chi-square, analysis of variance (ANOVA), the Student t-test, and logistic regression. RESULTS: Data analysis revealed a sedation failure rate of 1 % and paradoxical reaction rate of 1.2 %. Stepwise multiple logistic regression revealed that the only significant independent multivariate predictor of failure was the need for the administration of a combination of pentobarbital, fentanyl, and midazolam IV. CONCLUSION: The low rate of sedation failure and paradoxical reactions to pentobarbital was near optimal and probably cannot be improved with the currently available sedatives.

Child↗
PubMed1997

Development of a sedation scoring protocol.

The creation of a research and development post within the Intensive Therapy Unit (ITU) environment at St Helier has provided the opportunity to review all aspects of practice to ensure that the care delivered is evidence-based and not merely rooted in routines and rituals. The first aspect of care to be examined was our sedation practice. It was felt that sedation procedures varied at times and that a research-based protocol was necessary to ensure that patients receive optimal levels of sedation consistently. A 'sedation scoring group' was set up in order to achieve this. Questionnaires were sent to all members of staff and the resulting data used to formulate a sedation scoring system and algorithm as well as a protocol which included information on sedative drugs and the effects of over- and under-sedating patients.

Algorithms↗
PubMed2002

Conscious sedation for dentistry: risk management and patient selection.

There are many safe and effective medications available to the dental practitioner for producing conscious sedation. Given the many sedatives available, all possessing slightly different clinical characteristics and various degrees of risk, careful consideration needs to be given to the objectives of the sedation when deciding which pharmacologic agents to use. Before making plans to sedate dental patients, however, one needs to make sure that several "layers" of risk management are in place to ensure the sedation procedure is as safe as possible. Included in this risk management plan is a complete understanding of the regulations that define conscious sedation and the training that is required to deliver this state of depressed consciousness. Careful attention also needs to be given to selecting appropriate dental patients for sedation. A thorough understanding of the patient's physical and psychologic status is necessary when making decisions about sedation. Because most dental disease is not life threatening, dental treatment needs tend to be primarily elective in nature. Considering the training requirements for delivering inhalational or enteral conscious sedation with a single agent, it is prudent to limit this type of sedation to the patient population that is healthy (e.g., ASA I and II) and psychologically stable as a way of minimizing risk. The amount of additional risk one encounters when sedating more medically compromised patients (ASA III and greater) should suggest that deferring elective dental treatments until the health status improves is prudent. In situations in which an improvement in the patient's health status is not likely, referral to someone with more experience sedating medically compromised patients is strongly recommended. Equally important to the conscious sedation risk management plan is an assurance that the patient understands what is meant by conscious sedation and that their treatment expectations are realistic. Finally, even though conscious sedation is safe when all precautions are followed, being prepared to manage unexpected sedation-related emergencies is necessary. The principles of risk management covered in this article are applicable to other articles in this issue, in which N2O/O2 inhalational sedation and enteral sedation in adults and children are discussed. The remaining article in this section that reviews the prevention of medical emergencies and the pharmacologic agents necessary to treat emergency events that are likely to occur in dental settings further enhances the level of preparedness necessary when administering conscious sedation to adults and children.

Administration, Inhalation↗
PubMed2004

The educational experience of pediatric emergency medicine fellows in the use and application of procedural sedation/analgesia.

OBJECTIVES: The purpose of this study is to describe the clinical and educational experience provided to the pediatric emergency medicine (PEM) fellows in procedural sedation/analgesia during their course of training. METHODS: A nonanonymous survey was completed by the program director of each Accreditation Council for Graduate Medical Education (ACGME)-accredited PEM fellowship program listed in the 2001 to 2002 Graduate Medical Education Directory. Information relating to program demographics, agents available for use in the emergency department (ED), and the educational opportunities offered to trainees was sought. RESULTS: Each of the 32 ACGME-accredited programs completed the survey. Thirty programs report using procedural sedation and analgesia (PSA) to facilitate the completion of nonpainful and 32 programs to facilitate the completion of painful procedures in the ED. Twenty-nine programs (92%) permit their fellows to provide PSA independently after meeting credentialing criteria at their institution. Formal didactic sessions, direct supervision of procedures, and dedicated journal clubs were the 3 most frequently cited educational methods reported. The educational method chosen was not predicted by the ED type, the size of the training program, or by the volume of patients evaluated in the ED. Twelve program directors report their belief that a minimum number of procedures should be completed prior to completion of the training program. CONCLUSION: There is wide variation in the educational methods used by PEM fellowship training programs in procedural sedation/analgesia.

Analgesia↗
PubMed2004

Infant sedation for MR imaging and CT: oral versus intravenous pentobarbital.

PURPOSE: To compare the effectiveness and safety of oral (PO) versus intravenous (IV) pentobarbital sedation for magnetic resonance (MR) imaging and computed tomography (CT) in infants younger than 12 months. MATERIALS AND METHODS: The institutional review board approved the review of medical records and determined informed consent to be unnecessary. All parents gave informed consent for patient sedation. Prior to MR imaging or CT, infants younger than 12 months were sedated with PO pentobarbital (4-8 mg per kilogram body weight) or IV pentobarbital (2-6 mg/kg), depending on the presence of an IV catheter or need for IV contrast medium. A computer database used to record sedation data was reviewed for data from January 1997 to September 2003. PO and IV sedation groups were compared for mean age, weight, dose, time to sedation, time to discharge, and duration of sedation with a two-sample Student t test. Multivariate analysis of covariance was used to determine whether differences in sedation time, time to discharge, and duration of sedation between groups were independent of age, weight, sex, American Society of Anesthesiologists physical status classification, dose, and type of procedure. Sedation effectiveness (outcome) was determined as the percentage of sedation failures in each group. Safety was determined separately for other adverse events as a total and for respiratory adverse events. RESULTS: A total of 2164 infants received 2419 (1264 PO, 1155 IV) doses of pentobarbital for sedation. Weight and sex were comparable between groups. Time to sedation was significantly longer with PO than with IV pentobarbital (18 minutes +/- 11 vs 7 minutes +/- 7; P < .01), but time to discharge was similar, at approximately 108 minutes +/- 35. Total adverse events rate during sedation was not significantly different (0.8% [PO] vs 1.3% [IV]), but incidence of abnormal oxygen saturation (5% decrease from baseline, >1 minute duration) differed significantly (0.2% [PO] vs 0.9% [IV]; P = .02). Sedation effectiveness was comparable (failure rate, 0.5% [PO] vs 0.3% [IV]; P = .76). CONCLUSION: PO pentobarbital has comparable effectiveness and a lower rate of respiratory complications compared with IV pentobarbital in infants younger than 12 months; its use should be considered, regardless of presence of an IV catheter.

Administration, Oral↗
PubMed2026

Digital healthcare solutions in preoperative care: A systematic review.

OBJECTIVE: Active participation in preoperative anesthesia preparation is crucial to ensure safe and efficient care. Compliance with preoperative instructions improves clinical outcomes, enhances patient satisfaction and optimizes use of healthcare resources. As digital communication becomes increasingly integrated into healthcare, interactive digital tools such as smartphone applications and Short Message Service (SMS) reminders may offer a valuable means of engaging patients in their own care. In this review, we evaluated the role of digital tools in guiding patients during their preoperative care pathway for anesthesia. METHODS: Following registration (CRD420250655119), we conducted a systematic review of studies evaluating the use of smartphone applications or SMS reminders designed to support preoperative preparation for anesthesia or procedural sedation in adult patients undergoing elective procedures. The primary outcome was compliance with preoperative instructions. Secondary outcomes included rate of late cancellations, patient satisfaction and cost-effectiveness. Studies were eligible if they reported at least one of these outcomes. RESULTS: Ten studies (1 RCT and 9 observational studies), including 11501 participants, were identified. Compliance with preoperative instructions was assessed in 8 studies, most of which reported higher compliance in patients receiving digital interventions across multiple instruction domains, although statistical significance was not consistently observed. Evidence suggested a beneficial effect on reducing late cancellations and improving patient satisfaction. However, results varied across study designs, and data on cost-effectiveness were limited. CONCLUSIONS: Digital tools for preoperative anesthesia guidance were associated with higher compliance and showed potential reduction of late cancellations and increase of patient satisfaction. However, the current evidence is predominantly observational and heterogeneous, limiting the strength of conclusions. PRACTICAL IMPLICATIONS: With healthcare systems under pressure, digital technologies may offer a scalable and patient-centered care solution to support preoperative anesthesia preparation. Nonetheless, further high-quality research is needed to evaluate their long-term clinical, economic and equity implications.

Humans↗
PubMed2006

Pediatric anesthesia in the nonoperating room setting.

PURPOSE OF REVIEW: The paper will review the few studies that have been published recently on nonoperating room pediatric anesthesia/sedation. These studies target gaps in our understanding of critical factors associated with the provision of nonoperating room anesthesia safety and reliability in children. RECENT FINDINGS: More objective data regarding the safety and reliability of this practice have become available. Video can accurately capture a child's state and allow comparison of different sedation techniques more objectively than is possible with available literature. The use of standard simulated events allows rescue performance in actual care systems to be tested for their ability to manage a rare, but critical respiratory depression episode. Preliminary findings from a large multicenter study from the Pediatric Procedural Sedation Research Consortium suggests critical adverse events are rare (one cardiac arrest in over 30,000 sedation encounters), but that potentially critical events occur commonly (one in 400 procedures was associated with stridor, laryngospasm, wheezing or apnea). SUMMARY: Research into the critical factors that impact safety and reliability in the performance of nonoperating room anesthesia for children is providing objective observational techniques along with large outcomes databases that should enable targeted improvements in the safety and reliability of this growing practice.

Anesthesia↗
PubMed2005

Rescue sedation with dexmedetomidine for diagnostic imaging: a preliminary report.

BACKGROUND: Sedation is frequently required during noninvasive radiological imaging in children. Although commonly used agents such as chloral hydrate and midazolam are generally effective, failures may occur. The authors report their experience with dexmedetomidine for rescue sedation during magnetic resonance imaging. METHODS: A retrospective chart review was undertaken. RESULTS: The cohort included five patients ranging in age from 11 months to 16 years. Following the failure of other agents (chloral hydrate and/or midazolam), dexmedetomidine was administered as a loading dose of 0.3-1.0 microg x kg(-1) x min(-1) over 5-10 min followed by an infusion of 0.5-1.0 microg x kg(-1) x h(-1). The dexmedetomidine loading dose required to induce sedation was 0.78 +/- 0.42 microg x kg(-1) (range 0.3-1.2). The maintenance infusion rate was 0.57 +/- 0.06 microg x kg(-1) x h(-1) (range 0.48-0.69). The imaging procedures were completed without difficulty. No patient required additional bolus administrations or changes in the infusion rate. The duration of the dexmedetomidine infusion ranged from 30 to 50 min. The mean decrease in heart rate was 13.6 +/- 5.1 b x min(-1) (14.3 +/- 5.0% from baseline; P = 0.02), the mean decrease in systolic blood pressure was 26.4 +/- 15.2 mmHg (24.6 +/- 12.4% decrease from baseline; P = 0.004), and the mean decrease in respiratory rate was 1.4 +/- 1.5 min(-1) (7.5 +/- 7.9% decrease from baseline; P = NS). P(E)CO2 exceeded 6.5 kPa (50 mmHg) in one patient [maximum 6.6 kPa (51 mmHg)] with a maximum value of 6.0 +/- 0.4 kPa (46 +/- 3 mmHg). Oxygen saturation decreased from 98 +/- 1 to 95 +/- 1%; P = 0.001. No patient developed hypoxemia (oxygen saturation less than 90%). Mean time to recovery to baseline status was 112.5 +/- 50.6 min and time to discharge was 173.8 +/- 83.8 min. CONCLUSIONS: Our preliminary experience suggests that dexmedetomidine may be an effective agent for procedural sedation during radiological imaging. Its potential application in this setting is discussed and other reports regarding its use in pediatric patients are reviewed.

Adolescent↗
PubMed2000

Propofol sedation for endoscopic procedures in children.

BACKGROUND AND STUDY AIMS: Propofol sedation has been used successfully in various outpatient minor procedures in children. Limited data are available on the usefulness of propofol sedation during gastrointestinal endoscopic procedures in children. The aim of this study was to evaluate our experience of propofol sedation in pediatric gastrointestinal endoscopic procedures. MATERIALS AND METHODS: The charts of all children who had undergone diagnostic endoscopic procedures, and were sedated by propofol, were retrospectively reviewed. Demographic data, cardiovascular monitoring, and drug dosages were recorded. Patients evaluated their sedation efficacy by answering a questionnaire before discharge. RESULTS: A total of 104 children underwent 107 procedures. Propofol alone was given in 19 procedures and in combination with midazolam and/or fentanyl in 88 procedures. All procedures were completed and significant complication occurred in only one patient. No significant difference was observed in the amount of sedative drugs or recovery time between upper and lower endoscopic procedures. A lower propofol dosage was needed when a combination of drugs was given compared to propofol drug alone. Patients' assessment of their sedation showed that the vast majority had experienced postendoscopic amnesia. CONCLUSION: Propofol sedation for endoscopic procedures is safe and acceptable for children. Propofol sedation should be offered to young children, especially those who express significant anxiety.

Child↗
PubMed1998

Pediatric flexible bronchoscopy under conscious sedation: nursing considerations for preparation and monitoring.

Flexible bronchoscopy provides a powerful tool to evaluate pulmonary abnormalities in the pediatric population. Nursing involvement may range from age-appropriate preparation of the patient and family to administration of conscious sedation agents. Meticulous nursing assessment of the child, family, and environment facilitates identifying and meeting client needs related to flexible bronchoscopy. Preparation of the physical environment as well as physiological and psychological preparation of the child increase the likelihood of a positive experience. By increasing their familiarity with the procedure, sedation strategies, and monitoring standards, nurses increase the probability of safe and successful flexible bronchoscopic evaluations.

Anti-Anxiety Agents↗
PubMed2006

Update on bispectral index monitoring.

Since 1997, bispectral index (BIS; Aspect Medical Systems Inc., Natick, MA) has been in clinical practice and a wealth of experimental research has accumulated on its use. Originally, the device was approved only for monitoring hypnosis and has now received an indication for reducing the incidence of intraoperative awareness during anesthesia. Numerous studies have documented the ability of BIS to reduce intermediate outcomes such as hypnotic drug administration, extubation time, postoperative nausea and shortened recovery room discharge. Two recent large-scale outcome studies using BIS (one randomized controlled trial and one prospective, nonrandomized historical cohort study) identified an approximately 80% reduction in the incidence of recall after anesthesia. BIS provides clinicians with unique information that can be used to tailor hypnotic drug doses to individual patient requirements. BIS does not predict movement or hemodynamic response to stimulation, nor will it predict the exact moment consciousness returns. This review will also discuss other BIS applications including use in pediatrics, intensive care and for procedural sedation. Some limitations exist to the use of BIS and it is not useful for some individual hypnotic agents (ketamine, dexmedetomidine, nitrous oxide, xenon, opioids). BIS technology is moving out of the operating room and into diverse environments where conscious and deep sedation are provided. Anesthesiologists need to be actively involved in promoting patient safety and helping transition this technology into broader use.

Adult↗
PubMed2004

Pediatric sedation.

PURPOSE OF REVIEW: Pediatric sedation continues to evolve. It is an area of practice that involves a variety of pediatric subspecialties, the practitioners of many of which are not fully aware of what is being done by others involved in this care. The purpose of this review is to consider the current status of pediatric sedation in general and to discuss the most recent literature concerning this practice. Specifically we will discuss the use of new medications for pediatric sedation, issues concerning fasting status, issues surrounding the effectiveness of sedation, and discharge criteria after sedation. RECENT FINDINGS: Propofol sedation is growing rapidly outside of the operating room environment. Emergency-medicine and intensive-care providers are regularly employing propofol for procedural sedation and reporting its effective use in their hands. Also in the emergency-medicine field, evidence is emerging that fasting status is not a particularly important factor in the genesis of critical events during sedation. Anesthesiologists are evaluating the use of dexmedetomidine for sedation of children and new reports describe the advantages of deep sedation and anesthesia over moderate sedation for painful procedures. Finally an important study shows that a patient's condition on discharge after sedation can be improved through the implementation of specific criteria using objective scoring techniques. SUMMARY: Anesthesiologists and those outside of anesthesiology are employing new potent sedative hypnotic agents to accomplish effective pediatric sedation. At the same time, the consensus-generated sedation guidelines--particularly with respect to fasting guidelines--are being questioned. All of this is occurring in the face of mounting evidence that sedation depth needs to be adequate to provide optimal operating conditions and patient satisfaction. Regardless of sedation method used, recovery criteria need to be carefully considered in order to optimize patient safety.

Journal Article↗