PEDIATRICS Vol. 108 No. 4 October 2001, pp. 1053-1054

Sedation for Electroencephalograms

To the Editor.

Olson et al,¹ in a retrospective review, report their experience regarding electroencephalograms (EEGs) in 2855 children, of which 513 received sedation. The authors are to be complimented for describing methods that allowed successful completion of most EEG examinations while avoiding the need for sedating medications. This is particularly stunning considering that the percentage of sedated children dropped from 32% in 1995 to 2% in 1998. The patients were monitored in accordance with the American Academy of Pediatrics (AAP) guidelines.² But, as with any retrospective study, there are some problems: the data are only as good as the information recorded on the charts, and there is likely to be some degree of underreporting. Nevertheless, there were 3 complications (desaturations in children at increased risk).

The accompanying commentary by Dr Freeman³ raises grave concerns. I agree with the hypothesis that any time a child is sedated there is a risk:benefit ratio, and the benefit needs to outweigh the potential risk. I would not, however, rely on the Olson study as providing adequate information to measure this risk. The number of patients is quite small for looking at rare events such as the need to perform positive pressure ventilation, the need for resuscitation, or resultant injury.^4,5 Such severe adverse outcomes are, fortunately, very rare. Five hundred patients is a completely inadequate number to truly estimate risk. I agree with Dr Freeman that overdoses of chloral hydrate or any drug should never occur especially for a purely elective procedure. However, medication errors do occur at the hands of technologists, nurses, and physicians, as well as dentists.⁶ That is but one of the important reasons that monitoring guidelines were developed for children undergoing sedation for diagnostic procedures. Dr Freeman has focused only on the patients in the Olson report¹ who received chloral hydrate while ignoring those who received 2 to 4 sedating medications. Several studies have demonstrated increased risk for children receiving 3 or more sedating medications.^7,8 As Olson so nicely described, because an appropriate "safety net" was in use (pulse oximetry and skilled nursing personnel observing the patients), these complications were readily recognized, and the patients were rescued successfully, ie, the events did not progress to severe hypoxemia or worse. Dr Freeman suggests that an EEG technician could be adequately trained to obtain the study, observe the patient at the same time, and then intervene successfully should an adverse outcome occur! The AAP guidelines are not limited to just patient observation during the procedure, but describe a systematic approach to sedation. This includes a careful screening process and physical examination to anticipate those patients who are at greater risk and continued observation after the procedure until the patient has recovered. EEG technicians do not have the skills and training for these important components of care. The reason that a skilled practitioner with resuscitation skills needs to be available was confirmed by the Olson study, even with the small number of patients reported.

Dr Freeman suggests that the guidelines published by the Joint Commission on Accreditation of Healthcare Organizations⁹ as well as those of the AAP² were developed by anesthesiologists with a "conflict of interest." Although anesthesiologists were consulted in the development of these guidelines, the guidelines were only published after review and approval by all 39 sections of the Academy as well as endorsement by the Executive Board of the AAP. The Academy is made up of over 50 000 members, of which only about 350 are anesthesiologists. The primary responsibilities of anesthesiologists are related to the perioperative care of children. Anesthesiologists are usually only involved in sedation services at the request of hospitals, pediatricians, or other practitioners. Their involvement and consultation in the development of the AAP guidelines is a powerful pediatric safety advocacy supported by the entire Academy membership and not a conflict of interest!

The sarcasm at the end of Dr Freeman's commentary about pulse oximetry and sudden infant death syndrome seems inappropriate and out of place in the context of this discussion. I am greatly disappointed that instead of looking at the positives, Dr Freeman chooses to look at the negatives. The enhanced level of safety for patients that has come from the widespread adoption of the AAP guidelines is a significant advance for children.

Charles J. Coté
Children's Memorial Hospital
Department of Pediatric Anesthesiology
Chicago, IL 60614

REFERENCES

1. Olson DM, Sheehan MG, Thompson W, Hall PT, Hahn J Sedation of children for electroencephalograms. Pediatrics. 2001; 108:163-165 [Abstract/Free Full Text]
2. American Academy of Pediatrics, 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 [Abstract/Free Full Text]
3. Freeman JM The risks of sedation for electroencephalograms: data at last. Pediatrics. 2001; 108:178 [Free Full Text]
4. McQuay HJ, Moore RA Using numerical results from systematic reviews in clinical practice. Ann Intern Med. 1997; 126:712-720 [Abstract/Free Full Text]
5. Moray N. Error Reduction as a Systems Problem, Human Error in Medicine. Bogner MS, ed. Hillsdale, NJ: Lawrence Erlbaum Associates; 1994:67-91
6. Committee on Quality of Health Care in America, Richardson WC, Berwick DM, Bisgard JC, et al. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000
7. Mitchell AA, Louik C, Lacouture P, Slone D, Goldman P, Shapiro S Risks to children from computed tomographic scan premedication. JAMA. 1982; 247:2385-2388 [Abstract/Free Full Text]
8. Coté CJ, Karl HW, Notterman DA, Weinberg JA, McCloskey C Adverse sedation events in pediatrics: analysis of medications used for sedation. Pediatrics. 2000; 106:633-644 [Abstract/Free Full Text]
9. Joint Commission on Accreditation of Healthcare Organizations. Comprehensive Accreditation Manual for Hospitals. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 2000