PEDIATRICS Vol. 107 No. 4 April 2001, pp. 808

Sedation of Children

To the Editor.

We read with interest the article by Coté et al¹ and the commentary by Selbst.² We would like to compliment Dr Coté for his work in developing standards of monitoring and care of children who need sedation for painful diagnostic and therapeutic procedures.^3,4 The current article by Coté et al¹ is another in his series to define problems that occur when sedation is used and high standards are not met. Despite the inherent problems of a retrospective analysis, the current study demonstrates that problems do not occur when the patient is carefully monitored with ongoing vigilance and due attention to the information given by the monitors.

We are concerned by the tone and comments of Dr Selbst.² Although he is correct in pointing out the difficulties with retrospective studies, he goes further to suggest that we should concentrate on the successes of sedating children rather than the problems. As each of us (E.D., A.H., and J.M.) have helped develop protocols for sedating and monitoring sedated children, we have found similar sentiments by our colleagues that such standards are not necessary because they themselves have successfully sedated children for procedures without incident. However, to improve our care and increase our success in safely sedating children, we must look at areas that need such improvement. Coté et al¹ have made a significant step in helping us in this endeavor. Other pediatric specialities have been involved in reviewing the process of sedating children for procedures.⁵ The Committee on Professional Liability of the American Society of Anesthesiologists has conducted a review of closed anesthesia malpractice claims evaluating mechanisms of injury, outcome, costs, and the role of care judged to be substandard. Some very specific recommendations have come out of these reviews. These include the need for early identification of respiratory insufficiency and the need for early intervention. Pediatric claims (age <15 years) had a 43% incidence of respiratory events compared with adult claims (30%). The complications were more frequently thought to be preventable with better monitoring (45% pediatric vs 30% adult), and a higher prevalence of patient injury was caused by inadequate ventilation in the pediatric claims (20% pediatric vs 9% adult). Cyanosis (49%) and/or bradycardia (64%) often preceded cardiac arrest in pediatric claims related to inadequate ventilation resulting in death (70%) or brain damage (30%) in previously healthy children.⁶ Although these case reviews were performed retrospectively and were specifically done with claims regarding anesthesia care, not all involved general anesthesia. Even in the cases involving general anesthesia, the importance of control of the airway is evident. And although these particular cases involved anesthesia care, the same issues are involved, namely, adequate and patent airway and preparation for potential untoward events.

Elizabeth Drum
Andrew Herlich
Bruce Levine
James Mayhew
Division of Pediatric Anesthesiology and Pediatrics
Temple University
Health Sciences Center
Philadelphia, PA 19140

REFERENCES

1. Coté CJ, Notterman DA, Karl HW, Weinberg JA, McCloskey C Adverse sedation events in pediatrics: a critical incident analysis of contributing factors. Pediatrics. 2000; 105:805-814 [Abstract/Free Full Text]
2. Selbst SM Adverse sedation events in pediatrics: a critical incident analysis of contributing factors. Pediatrics. 2000; 105:864-865 [Free Full Text]
3. American Academy of Pediatrics, Committee on Drugs, Section on Anesthesiology Guidelines for the elective use of conscious sedation, deep sedation, and general anesthesia in pediatric patients. Pediatrics. 1985; 76:317-321 [Abstract/Free Full Text]
4. American Academy Pediatrics, Committee on Drugs Guidelines for monitoring and management of pediatrics patients during and after sedation for diagnostic and therapeutic procedures. Pediatrics. 1992; 89:1110-1115 [Abstract/Free Full Text]
5. Krauss B, Green S Sedation and analgesia for procedures in children. N Engl J Med. 2000; 342:938-945 [Free Full Text]
6. Morray JP, Geiduscheck JM, Caplan RA, Posner KL, Gild WM, Cheney FW A comparison of pediatric and adult anesthesia closed malpractice claims. Anesthesiology. 1993; 78:461-467 [Medline]

In Reply.

I appreciate the letter to the editor by Drum et al with regard to my commentary on the article by Coté et al.¹ The statistics in their letter to the editor involving pediatric claims were very interesting. Like the authors, I am in agreement that critical incident analysis has value. In my commentary, I did not imply that we should concentrate on successes of sedating children rather than the problems. Instead, we should evaluate the successes in addition to the problems. Again, controlled prospective studies are best if we hope to get a true picture of the safety of sedation practices and individual sedatives for children.

Steven M. Selbst
Department of Pediatrics
Alfred I. duPont Hospital for Children
Wilmington, DE 19899

REFERENCE

1. Coté CJ, Notterman DA, Karl HW, Weinberg JA, McCloskey C Adverse sedation events in pediatrics: a critical incident analysis of contributing factors. Pediatrics. 2000; 105:805-814