PEDIATRICS Vol. 109 No. 2 February 2002, pp. 236-243
Risk Reduction in Pediatric Procedural Sedation by Application of an American Academy of Pediatrics/American Society of Anesthesiologists Process Model
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* Departments of Anesthesiology, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin
Critical Care Medicine, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin
Pediatrics, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin
|| Quality Improvement, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin
¶ Medical College of Wisconsin, Milwaukee, Wisconsin
--> Objective. Guidelines for risk reduction during procedural sedation from the American Academy of Pediatrics (AAP) and the American Society of Anesthesiologists (ASA) rely on expert opinion and consensus. In this article, we tested the hypothesis that application of an AAP/ASA-structured model would reduce the risk of sedation-related adverse events.
Methods. Prospectively coded sedation records were abstracted by a hospital quality improvement specialist with practical and administrative experience in pediatric sedation. Process variables included notation of nulla per os (NPO) status, performance of a guided risk assessment, assignment of ASA physical status score, obtaining informed consent, generation of a sedation plan, and assessment of sedation level using a quantitative scoring system. Content variables included adherence to AAP NPO guidelines, ASA class, target sedation level, actual sedation level, age, procedure, and drugs used. Complication risk was assessed by logistic regression and Mantel-Haenszel odds ratios (OR).
Results. Complications were identified in 40 of 960 records (4.2%). The complication rate was 34 of 895 (3.8%) with planned conscious sedation and 6 of 65 (9.2%) with planned deep sedation ([DS]; OR: 2.6). Complications were reduced by performance of structured risk assessment (OR: 0.10), adherence to all process guidelines (OR: 0), and avoiding actual DS (OR: 0.4). The only drug associated with higher risk was chloral hydrate (OR: 2.1). Failure to adhere to NPO guidelines did not increase risk in this assessment; however, the adverse event rate was 0 if all process guidelines were followed.
Conclusions. Presedation assessment reduces complications of DS. Repeated assessment of sedation score reduces the risk of inadvertent DS. The data provide direct evidence that AAP/ASA guidelines can reduce the risk of pediatric procedural sedation.
Key Words: sedation • analgesia • conscious sedation • procedural sedation • deep sedation • adverse events • patient safety • practice guidelines • anesthesia
Abbreviations: AAP, American Academy of Pediatrics • ASA, American Society of Anesthesiologists • NPO, nulla per os • DS, deep sedation • CS, conscious sedation • GRA, guided risk assessment • OR, odds ratio • CI, confidence interval
Received for publication Apr 20, 2001; Accepted Sep 19, 2001.
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