Pediatric sedation: Adverse events

Sedation is often requested for pediatric patients outside the OR for nonsurgical procedures such as imaging studies, bronchoscopy, endoscopy, cardiac catheterization as well as minor procedures such as casting and bone marrow aspiration. The level of sedation needed can vary from minimal for anxiolysis to moderate (conscious sedation with analgesia) to deep sedation or general anesthesia. The major goals of pediatric sedation vary with the procedure, but generally include anxiety relief, pain control and control of excessive movement. The same standards used for general anesthesia also apply to moderate and deep sedation, which includes fasting guidelines, preoperative assessment, monitoring and postprocedure care.

Adverse events during pediatric sedation can occur for many reasons, including drug overdose, inadequate monitoring, drug errors, inadequate skills of the personnel administering drugs and premature discharge. A majority of adverse events during sedation are related to the airway and/or respiratory events such as laryngospasm. Adverse events can also include cardiovascular depression, especially with deep sedation. The most serious complication of pediatric sedation, death, is most often caused by unmanaged respiratory depression.

The majority of airway complications can be managed easily with simple maneuvers such as supplemental oxygen, jaw thrust to open the airway, suctioning and providing ventilation via a bag mask. Occasionally, endotracheal intubation or a laryngeal mask airway is required to assist with ventilation. In one large study examining roughly 50,000 sedations, there were no deaths, cardiopulmonary resuscitation was required twice and aspiration occurred four times. Less serious events were more common; desaturation below 90% for more than 30 seconds occurred 154 times per 10,000 sedation administrations and central apnea or airway obstruction occurred 575 times per 10,000 sedation administrations. Stridor, laryngospasm and vomiting had frequencies of 50, 96 and 49 per 10,000 encounters respectively. Unexpected admissions occurred 7.1 times per 10,000 encounters. In an unadjusted analysis, the rate of pulmonary adverse events was no different for anesthesiologists versus other providers.

Pediatric Adverse Events (per 10,000 encounters):

Death 0

Cardiopulmonary resuscitation 2

Aspiration 4

Vomiting 49

Stridor 50

Laryngospasm 96

Desaturation below 90% for > 30 seconds 154

Excessive secretions 341

Apnea/Airway obstruction 575