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For other articles and previous issues click here. December 16, 2005 Pleasant
Dreams Instead of Nightmares — New Approaches to Anesthesia
for Pediatric Imaging There is tremendous variance in how different facilities handle anesthesia for pediatric imaging—including different providers, sets of drugs, and systems for recovery. Experts differ on whether more uniform care standards are necessary, or if the situation merely reflects individual clinical requirements and restraints. In the past few years, the guidelines for the use of anesthesia on children, whether for diagnostic or therapeutic applications, have been appreciably revamped. The American Society of Anesthesiologists (ASA) and the American Academy of Pediatrics (AAP) have each released new guidelines since 2001. The new versions reflect a decade’s worth of technology development, new drugs, and—most significantly—better understanding of the ways children’s responses to sedation differ from adults’. Today, all major medical organizations conform to guidelines based on the AAP and ASA revisions, including, among others, the American Medical Association, JCAHO, American College of Radiology, Society of Nuclear Medicine, Society for Pediatric Radiology, Society for Pediatric Anesthesia, and National Patient Safety Foundation. Most leading research institutions and children’s hospitals around the country have now developed their own internal protocols based on the ASA and AAP revisions. Redefining
Sedation Levels Revised guidelines for pediatric anesthesia have included the redefinition of previously accepted sedation levels. Specifically, the term conscious sedation has been eliminated and largely replaced by the definition for moderate sedation. The accompanying chart shows (on page 24) current ASA/AAP guidelines delineating sedation as four levels within a continuum. Changing
Expectations Joseph P. Cravero, MD, head of the anesthesiology department of the Children’s Hospital at Dartmouth, says changing societal expectations have also played a role in rethinking sedation protocols. “To a certain extent, the requirement for [better] pediatric sedation services is driven by a paradigm shift and a population that expects better service than they used to. Twenty-five years ago, people brought their children to the hospital, and if the kid cried and had to be held down to get a procedure done, people sort of put up with it. These days, patients expect something professional, slick, and efficient.” Lynne Maxwell, MD, head of the general anesthesia division of The Children’s Hospital of Philadelphia’s anesthesiology department, concurs: “It used to be, if the patient survived and the procedure got done, that was success. Now we have to go beyond that.” That means, she says, ensuring not only that each child is safe but also feels safe. “Is the child going to be terrorized by the experience for the rest of their life? Or will they regard it as a neutral, or even a positive, experience?” Going beyond making sedation as efficient as possible for the facility and providers, clinicians are examining new answers to such questions. Redefining
Risks The most severe sedation reactions in children can include anaphylaxis, vision impairment, paraplegia, and death. These most serious consequences typically occur only when the person administering sedation fails to recognize and rescue a patient who has lapsed into cardio-respiratory collapse, most often signaled by loss of airway patency. While extremely rare and usually preventable with appropriate monitoring, the potential for such problems tends to be exacerbated in pediatric sedation, and not only due to the subtleties of drug dosages. Children differ significantly from adults in terms of heart rates and blood pressure, body temperature regulation, oxygen consumption, and drug metabolism, to name just a few factors that affect anesthesia. Along with realigning these definitions, the newest guidelines recommend that facilities develop various protocols recognizing the anatomic, physiologic, and psychological differences among age groups, starting with neonates (less than 1 month old), children 1 to 6 months old, 6 months to 2 years old, and 2 years and older. The clinical literature on pediatric sedation includes numerous studies—most produced over the last decade—that review complications and assess the effects of various drug regimens. (See the accompanying box for a list of some key titles.) Tracking
Encounters To help fill those kinds of gaps, clinicians can now look to a national interactive database of pediatric sedation encounter records Cravero created. Since July 2004, the database has documented the details of more than 30,000 encounters from 24 institutions. One key goal has been comparing efficiencies and outcomes for the many varied methods in use, by tracking demographic patient information as well as data on safety, effectiveness, and efficiency data. He explains, “[By comparing] the relative pluses and minuses of these different models, we hope to get a gross idea of what the risk is—and a general idea of what the efficiency is—of one system versus another. Combining all the data will help us to see if everybody gets about the same result, or if there is reason to think that some [approaches] do better than others.” Maxwell praises the database for its detail. “The advantage to the database is, you’re looking across the board, not prejudging or comparing one thing to something different,” she says. “You’ve got everything recorded in real-time practice; not just the drugs but also the doses and the patient’s underlying medical problems… You can analyze the effect of different drugs on recovery times, or look at the same procedure using different techniques. You can sort out serious adverse events [as well as] the thing most people are concerned about, which is, ‘How soon can the patient safely walk out the door?’” Equally important, “each [contributing] institution can also use it for quality assurance purposes, by getting their own data back out and looking at percentages of adverse events [by procedure or methodology],” she adds. Sharing
Responsibility The current guidelines require a team of personnel reflecting various levels of expertise and specifically call for someone other than the person performing the procedure to monitor the patient. For moderate sedation, once the patient’s vital signs have stabilized, the person monitoring “may assist the practitioner with interruptible ancillary tasks of short duration,” according to the ASA recommendations. However, for deep sedation, that person’s sole responsibility throughout the procedure should be monitoring the patient. In addition, whoever administers moderate or deep sedation must have the knowledge and skills to rescue the patient from the next level (ie, deep sedation and general anesthesia). During moderate sedation, at least one staff member present in the procedure room should be able to provide basic life support skills such as CPR and bag-valve-mask ventilation. Advanced life support skills, such as tracheal intubation, defibrillation, and the use of resuscitation medications, should be immediately accessible (no more than five minutes away). For deep sedation, both basic and advanced life support skills should be available in the procedure room itself. Notes Maxwell, “Once the guidelines were implemented, it became necessary for other departments to have not only people who [were specifically trained in] sedation, but to have extra people involved in the procedure… So there was a lot of resentment initially. [Other physicians] felt that anesthesiologists were somehow responsible for the guidelines, that it was some kind of plot to make it difficult or impossible for other departments to do their own sedation, so that anesthesiologists could have more business.” Conversely, she adds, “many anesthesia departments thought that they were commanded to be the supervisors of sedation practice in their hospital. It made a lot of [anesthesiologists] very uncomfortable to have to be involved in credentialing people in other departments to do sedation when they weren’t going to be managing the protocols or quality control.” To the relief of both factions, says Maxwell, “over the last few years, it’s become clear that the guidelines don’t require anesthesiologists to be the gatekeepers and the supervisors of sedation in hospitals … and the idea that departments must have people who are knowledgeable about sedation has become less of a flashpoint. It’s obvious that there’s no way we have enough anesthesiologists—and, in many hospitals, anesthesiologists are less comfortable administering sedation outside the OR [operating room].” Supervising
Radiology Sedation Even without hiring a dedicated anesthesiologist, assembling a team of professionals to collectively meet the current criteria isn’t always easy, even in very large hospitals. For most institutions, the answer has been broader-based continuing medical education for radiology and other staff. “Technology has helped a lot,” says Maxwell, noting the expanding use of CD- and Web-based training and testing. The problem with such training to date has been its limited ability to reproduce real-life situations and teach people how to react to them. “Most nurses, for example, unless they’ve worked in an emergency room or some other high-acuity setting, don’t really have much of a familiarity with the drugs used for sedation,” says Maxwell. “The courses given now are all about pharmacology—onset and half-lifes and side effects. It’s very difficult to get the most important points across to people who have no [basis of experience] to help them apply that knowledge practically.” Much better, she believes, are computer-based simulator systems, like ones used by airlines and the army. Such programs can test the student’s response to random, unpredictable contingencies, better reflecting the reality of pediatric sedation more fully than simply reading a monitor or practicing with dummies. However, simulator training is still fairly new and not yet widespread. As Maxwell points out, “many hospital administrations still [want anesthesiologists to supervise all sedation], just because they’re viewed as knowing more about the drugs and the guidelines, and overall safety.” Establishing
Expert Systems “From the time of patient admission to patient discharge, [the data show] it’s generally quickest when you have an expert system using ultra-short-acting sedative medications,” Cravero says. “Expert systems also have the fewest number of failures of sedation, meaning the times the child shows up at the scanner but can’t be sedated because of an adverse reaction to the drugs. With an expert team headed by anesthesiology staff, that number is essentially zero. And with other expert-provision teams—meaning emergency medicine doctors, or any system specifically set up to run sedation for the radiology department with robust backup—that failure rate is extremely low.” When comparing methodologies, the widest variations are seen not in safety but in efficiency and effectiveness, says Cravero. “Specifically, we find that when you put together an expert sedation system, with either anesthesia or other specialists, they tend to get more cases through the scanner in a day.” At Dartmouth-Hitchcock, the anesthesiology department has set up its own sedation unit. “So kids come in, they are admitted, we sedate them, we take them to the scanner, then we bring them back to the sedation unit and they recover there and are discharged there,” he explains. Once the center switched from its previous protocol of oral sedation given by radiology nurses to an anesthesiologist administering intravenous sedation during the MRI scan, “we went from about five or six MRIs a day to about 10 per day,” says Cravero. “That’s a fairly significant bump up in the number of studies we are able to handle.” In contrast, The Children’s Hospital of Philadelphia deploys hospitalists, who are pediatricians with intensive training in sedation, including pharmacology and advanced life support. A key element of the job involves patient evaluations prior to any procedure. Previously, radiology nurses administered sedation under the supervision of the radiologist, but with house pediatricians writing the drug orders. If they encountered a problem, the nurses would have to call the house officer back to ask for more or different medications. “It’s much more common that these children would have inadequate sedation than that they would have complications from the sedation,” Maxwell says. “And the kinetics of the medications are such that if you wait till the phone call, and the callback, and the other medicine, what you’ve started with [had dissipated]. So it was very difficult [to monitor and regulate sedation effectively], and there was really no supervising physician.” With the newer system in place, although radiology nurses still administer anesthesia and monitor the patient during procedures, a hospitalist always acts as a “sedation supervising physician.” This arrangement gives the nurses greater flexibility to combine and add medications if children are not satisfactorily sedated. An anesthesiologist still provides services for children who have high-risk medical conditions. Both Cravero and Maxwell also note the pioneering work being done at Children’s Hospital Boston, which has corralled all its diagnostic imaging services into a central area that includes a large sedation staging and recovery area. Rather than a radiologist or pediatrician, a staff anesthesiologist supervises radiology nurses who administer sedation for imaging procedures. Children’s Boston has also developed new nurse protocols for using oral pentobarbital and intravenous ketamine in children. Pursuing
‘Best Practice’ “The interesting thing about sedation right now is that nobody has the single answer,” Cravero says. “There are many different types of solutions, and everybody thinks their answer is the right one… If you look across the board, there’s a huge variance from one place to another in terms of what people do. [We find] completely different types of providers, whole different sets of drugs, different systems for recovery, and so on. That’s as opposed to, for instance, if you brought your kid in for an appendectomy, the care would be almost the same, in terms of the providers, the drugs, aftercare, and so on, whether you came to [the Children’s Hospital at] Dartmouth, or Boston, or Philadelphia.” Ultimately, he says, the database project may put anesthesia one step closer to finding a uniform best practice standard: “That’s one of the reasons we wanted to create it.” Continuing
Evolution Maxwell isn’t quite as convinced that a best practice standard for pediatric sedation can ever be developed. “While most [anesthesiologists] don’t really think that anesthesiology should take care of every patient, we do care that there’s an understanding of what’s safest, in terms of drugs and monitoring, and that those practices are followed,” she says. But she believes technologies, techniques, and particularly pharmaceutical choices will continue to expand, adding more variables to the mix. For example, right now she notes growing interest in dexmedetomidine and a resurgence in the popularity of ketamine—which a decade ago was nearly discarded for use in children—as well as efforts underway to reformulate protocol to counter its trickiest side effects. Expect continuing medical innovations to drive the development of another round of new protocols fairly quickly. As Maxwell notes, “There will always be new compounds coming out. In a way, the newest drugs are competing not with current protocol, for instance, but with protocol of the future.” — J. K. Bucsko is a freelance healthcare writer and editor based in Westville, N.J. FYI
Pediatric Anesthesia
Practice Recommendations Task Force on Pediatric Anesthesia of the
American Society of Anesthesiologists Committee on Pediatric Anesthesia
Practice Guidelines
for Sedation and Analgesia by Non-Anesthesiologists Society for Pediatric
Anesthesia Policy Statement on Provision of Pediatric Anesthesia
Care Society of Nuclear Medicine
Procedure Guideline for Pediatric Sedation in Nuclear Medicine
Clark RM, Flick RP, Litman RS. Hot topics in pediatric anesthesiology. ASA Newsletter. 2005;69:3. 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; and Addendum: Pediatrics. 2002;110(4):836-838. Coté CJ, Notterman DA, Karl HW, et al. Adverse sedation events in pediatrics: A critical incident analysis of contributing factors. Pediatrics. 2004;105(4):805-814. Cravero JP, Blike GT. Pride, prejudice, and pediatric sedation: A multispecialty evaluation of the state of the art. Report from a Dartmouth Summit on Pediatric Sedation. September 2000. Available at: http://www.npsf.org/download/PediatricSedation.pdf Cravero JP, Blike GT. Review of pediatric sedation. Anesth-Analg. 2004;99(5):1355-1364. Hackel A. Providing anesthesia for pediatric patients. ASA Newsletter. 2005;69:3. Hoffman GM, Nowakowski R, Troshynski TJ, et al. Risk reduction in pediatric procedural sedation by application of an American Academy of Pediatrics/American Society of Anesthesiologists process model. Pediatrics. 2002;109(2):236-243. Leak JA. Hospital-based anesthesia outside of the operating room. ASA Newsletter. 2003;67:10. Lowrie L, Weiss AH, Lacombe C. The pediatric sedation unit: A mechanism for pediatric sedation. Pediatrics. 1998;102;3:e30. Available at: http://pediatrics.aappublications.org/cgi/content/full/102/3/e30 Mason KP, et al. Sedatives used in pediatric imaging comparison of IV pentobarbital with IV pentobarbital with midazolam added. AJR. 2001;177:427-430. Sanborn PA, Mason KP,
et al. Adverse cardiovascular and respiratory events during sedation
of pediatric patients for imaging examinations. Radiology. 2005;237(1):288-294. |
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