Many parents are terrified of anesthesia and other forms of sedation.  This fear is often not rationale given the excellent safety record.  Given the high publicity though, it is surprising how much variation occurs with regard to monitoring pediatric patients during procedures (Arch Pediatr Adolesc Med 2012; 166: 990-98, editorial 1067-68).  Thanks to Ben Gold for forwarding this article.

In this prospective observational study (2007-2011), 37 U.S. pediatric institutions which comprise the Pediatric Sedation Research Consortium collected data on subjects up to 21 years of age.  In total, data from 114,855 patients were collected.

The most common procedure specialties were radiology (59%), hematology/oncology (14%), and gastroenterology (9%); the most common procedures included MRI, lumbar puncture, bone marrow biopsy, upper endoscopy/colonoscopy, brainstem auditory response test, and catheter placement.

The ASA class were the following: 26% class 1, 56%  class 2, 17% class 3, and <1% class 4 & 5.  The location of procedures were predominantly in either radiology (51%) or sedation unit (43%).

Specific findings:

• 5% of children did not have pulse oximetry monitoring; this included some ASA 3 and 4 patients.
• 87% had noninvasive blood pressure monitoring
• 67% had electrocardiogram (ECG) monitoring; ECG monitoring had the greatest variability in use among various providers
• Radiologists were the least likely to use any of the measured monitoring modalities.  Pulse oximetry was used in only 33% of procedures in which the radiologist was responsible for sedation; this is compared with >90% of all other providers.
• 45% were monitored with capnography
• Guidelines for sedation (AAP, ACEP, ASA) were adhered to for 52% of subjects

While the authors frame the discrepancies as in part due to tailoring the sedation to the individual, they also argue for less variation because patients may have unknown diagnoses and due to iatrogenic error.  Currently, strong evidence-based data on sedation protocols is lacking.  As a consequence, expert opinion guides current practice.

While ECG monitoring had the most variation, it is known to be rarely needed in relatively healthy pediatric populations.  As such, the authors state that ECG monitoring “may be best used in those patients with specific cardiac pathologic features or when a rhythm disturbance is present.”

Use of pulse oximetry should not be overlooked.  Mild hypoxemia has been observed to precede more serious adverse events and may prompt interventions that preclude poor outcomes.

This report has many acknowledged limitations which are common with large database studies.  Nevertheless, the variability in monitoring should help guide ongoing improvement efforts.  While the study also showed very good outcomes (no deaths, one case of cardiac arrest), it is clear that the safety net could be better by making sure each procedure is monitored carefully.  According to AAP guidelines, the minimum consists of continuous pulse oximetry, and intermittent blood pressure monitoring; in addition, capnography (ETCO2) is encouraged.