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* Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
Department of Pediatrics, Walter Reed Army Medical Center, Washington, DC
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Methods. The entire pediatric sedation unit database (n = 5640) was reviewed retrospectively. Patients without complete data sets were excluded. The remaining patients were separated into 2 groups: 3272 patients who underwent noninvasive procedures and 1210 who underwent invasive procedures. A subgroup of noninvasive procedure patients <2 years old (n = 1398) was also analyzed. The sedation failure rate (%) and nursing care hours for both sleep-deprived and non-sleep-deprived patients were analyzed.
Results. In the noninvasive procedure group, the sedation failure rate was 5.7% for the sleep-deprived patients and 5.6% for the non-sleep-deprived patients, whereas the sedation failure rate for children <2 years old was 4.2% for sleep-deprived patients and 4.7% for non-sleep-deprived patients. The sedation failure rate in the invasive procedure group was 7.5% for sleep-deprived patients and 7.2% for non-sleep-deprived patients. Nursing care hours in the noninvasive procedure group were significantly longer for the sleep-deprived patients (4.5 ± 1.6 hours) versus the non-sleep-deprived patients (3.8 ± 1.6 hours). This finding was true also for the subgroup of children <2 years old (sleep-deprived patients: 4.2 ± 1.4 hours; non-sleep-deprived patients: 3.5 ± 1.4 hours). No difference was noted in nursing care hours for the invasive procedure group.
Conclusions. Sleep deprivation had no effect in reducing the pediatric sedation failure rate. The patients having noninvasive procedures who were sleep deprived required significantly more nursing care hours than their non-sleep-deprived counterparts. Routine use of sleep deprivation for pediatric sedation should be critically reevaluated.
Key Words: sleep deprivation • pediatric sedation • sedation failure
Abbreviations: EEG, electroencephalography • MRI, magnetic resonance imaging • CT, computed tomography
Sedation is frequently required to facilitate diagnostic and therapeutic procedures in children. When sedation is performed, the focus is twofold: safety and efficacy. The American Academy of Pediatrics, the American Society of Anesthesiologists, and the Joint Commission on Accreditation of Healthcare Organizations have issued guidelines for the monitoring and management of pediatric patients undergoing sedation and analgesia outside the operating-room environment.1–3 These guidelines describe in detail the procedural, equipment, and personnel requirements for safe pediatric sedation.
Because safety is paramount, the many published articles highlight the relative safety of commonly used drugs or outline efforts to reduce risk.4–6 The frequency of adverse events depends on the medications selected and the indication for sedation. Emergent procedures and invasive procedures requiring a deeper level of sedation have a higher incidence of adverse events5,7 than sedated procedures for routine diagnostic imaging.4,8 When a variety of invasive and noninvasive pediatric sedated procedures were reviewed, the complication rates were between 2.3% and 4.2%.6,9 Fortunately, the majority of these events were minor and transient.
There is a great deal of literature delineating the efficacy of various pediatric sedation and analgesia regimens. Published pediatric sedation failure rates range from 1% to 9%.4,6,8,10,11 Sleep deprivation is commonly used to enhance the effectiveness of pediatric sedation.12,13 Although many people adamantly believe that sleep deprivation is a useful adjunct to pediatric sedation success, the literature concerning this practice is unclear.
Sleep deprivation without the use of sedative/hypnotics significantly increased the likelihood of sleep during diagnostic electroencephalography (EEG) in 396 children.14 When combined with oral melatonin, sleep deprivation increased the magnetic resonance imaging (MRI) completion rate from 55% to 76% in 40 children.15 In addition, anesthesiologists anecdotally report prolonged anesthesia recovery times for children who undergo operative procedures in the middle of the night. However, sleep deprivation did not enhance success in a study of 119 children sedated for computed tomography (CT) or MRI,10 and was associated with increased hyperactivity. Children deprived of sleep before dental procedures tended to have less success with sedation than their non-sleep-deprived counterparts.16,17
Given the range of evidence regarding sleep deprivation, we decided to review our sedation unit’s database to evaluate the efficacy of sleep deprivation in reducing the sedation failure rate. The sleep-deprivation program was started in 1993 to combat a 10% sedation failure rate. Preprocedure sleep deprivation was added to the unit’s routine patient counseling in 1994 and has been strictly enforced since 1995. The current sedation failure rate in our unit is 2.5%. Our nursing staff has attributed this decrease to the practice of sleep deprivation. A question arose: "Is there ‘evidence’ that sleep deprivation of children before sedated procedures enhances success?"
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Sleep deprivation was defined as <5 hours of sleep. When the sedation nurse called a family for preprocedure counseling, ideally the afternoon before the sedated study, the child’s normal sleep routine was obtained. The parents then would be directed to reduce the normal amount of sleep from both ends of the night. An ideal sleep deprivation would be a child sleeping from 12:00 AM to 5 AM. Additionally, parents of infants were encouraged to keep the infant up for at least 4 hours immediately before the study. On arrival to the sedation unit, the patient’s parents were asked specifically, in a nonjudgmental fashion, how many hours of sleep their child received. Any child who slept >5 hours or who napped in the car in route to the hospital was not considered sleep deprived.
Sedation was considered a success if the patient successfully completed the planned procedure without undo anxiety or distress. For the noninvasive procedures, EEG, MRI, and CT scans, that usually meant sleeping and motionless for the duration of the procedure. For invasive procedures, success meant that the child was not actively crying and did not require any additional restraint for excess motion. Nursing care hours were defined as the time from the initial patient intake examination in the sedation unit through the time of final clearance and discharge. The duration of the actual procedures was not captured. Major reportable events included oxygen saturation <90% for 5 minutes, any desaturation <80%, hypotension (<25% below baseline), use of reversal agents for respiratory depression, cardiopulmonary instability requiring resuscitation, and any required increase in level of care (eg, admission or pediatric intensive care unit transfer). We also tracked minor events such as emesis, paradoxical reactions, prolonged sedation, and respiratory changes requiring intervention.
The data from October 1993 through May 2002 were included in this review. Because of clerical errors, there were several time periods during which no patient data were recorded. These periods were based on personnel changes and encompassed a total of 22 months spanning July 1995 through August 1996, November 1996, parts of September to November 1997, and January to May 1999.
The entire Pediatric Sedation Unit database was reviewed retrospectively. There were 6781 patients, but only 5640 received sedation. The nonsedated patients included children who were talked through their procedure and those who required multiple nursing procedures or intravenous infusions under observation. Patients whose data sets were not complete for age, date, procedure, sleep-deprivation status, medication used, sedation success, and nursing care hours then were excluded. Patients undergoing several (>2) back-to-back procedures were also excluded, because it was thought that these patients were more likely to have sedation failures.
The remaining 4482 patients were subsequently separated into 2 groups. There were 3272 patients who underwent noninvasive procedures, whereas 1210 underwent invasive procedures. Table 1 highlights the common procedures from both groups. Some patients had >1 procedure; frequent combinations included head MRI and EEG or esophagogastroduodenoscopy and colonoscopy. Procedures accounting for <2% of the group’s totals are not included in the table.
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To look for a possible drug-sparing effect of sleep deprivation, the patient data were separated into 3 main categories based on the most common medication combinations used for sedation for the noninvasive procedures. The medication categories were oral chloral hydrate supplemented with oral hydroxyzine, intravenous pentobarbital, and oral midazolam supplemented with intravenous pentobarbital. These regimens were the drug packages used by protocol in the sedation unit depending on the child’s age and procedure. The amounts of sedation medication in mg/kg were compared. We did not look specifically at medication usage for the invasive procedure group because of the wide variation in levels of stimulation for each procedure (time to complete the procedure and operator expertise and experience with the invasive procedures).
The procedure failure rate was determined for the group of patients who did not receive any sedation to determine whether sleep deprivation enhanced success in nonsedated patients. Finally, both major and minor adverse events also were reviewed.
Statistical comparisons between groups for sedation failures and procedure failures were performed by using 
2 tests with significance accepted at P < .05. Comparisons between groups for nursing care hours and medication dosing were performed by using unpaired t tests (2-sided significance was accepted at P < .05). Data are expressed as mean ± SD and medians where appropriate.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Sleep deprivation occurred in 82.3% of the patients in the noninvasive procedure group compared with only 54.6% of the invasive procedure group (P < .001). The sedation failure rate over the 9 years of data collection steadily fell from 10% in the first 12 months to 2.5% for the most recent 12-month period in the noninvasive group (P < .001). The invasive procedure group saw a more modest decrease in sedation failures from an initial rate of 11.4% to 6.5% for the last 12 months of data collection.
The sedation failure rate in the noninvasive procedure group was 5.7% for the sleep-deprived patients and 5.6% for the non-sleep-deprived patients (P = 1). Similar results are seen in the invasive procedure group. The sedation failure rate in the invasive procedure group was 7.5% for the sleep-deprived patients versus 7.2% for non-sleep-deprived patients (P = .83) (see Table 2).
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The 1398 patients in the <2-year-old subgroup of the noninvasive procedure group then were analyzed. The sedation failure rate was 4.2% for sleep-deprived patients and 4.7% for non-sleep-deprived patients (P = .75). Again, those patients who had been sleep deprived required more nursing care hours (4.2 ± 1.4 vs 3.5 ± 1.4 hours) than those who were not (P < .001).
The amount of sedative medication administered (mg/kg) was calculated for 3032 patients (Table 3). The analysis revealed that sleep deprivation was associated with only 1 difference in the amount of medications given. Non-sleep-deprived patients who received oral midazolam as their initial sedative required an extra 0.8 mg/kg of intravenous pentobarbital, compared with sleep-deprived patients (P < .04).
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There was a total of 165 (3.5%) adverse events recorded. Only 31 (0.67%) were considered reportable events. This number included pediatric intensive care unit (2) and inpatient ward (22) admissions, severe hypoxemia (2), reversal agent used (5), and apnea and bradycardia (2). Some patients had >1 event. The most common causes for ward admission were persistent emesis (13) and prolonged recovery (7). Prolonged recovery was defined as a patient who was still sedated when the sedation unit closed at 3 PM. The other minor adverse events included obstructive airway symptoms, cut lip, cough, fever, transient hypoxemia, rash, and wheezing. Sleep-deprived patients did not have any increased incidence of complications.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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A corollary to the concept that sleep deprivation enhances sedation success is the notion that it may reduce the amount of drug necessary for a successful sedation. Our review of >3000 patients sedated for noninvasive procedures did not support this assumption. The only difference in sedation dosing was found in the group of patients given oral-versed followed by intravenous pentobarbital. The non-sleep-deprived patients received 0.8 mg/kg more pentobarbital than their sleep-deprived counterparts. This difference does not seem clinically relevant, and it is arguably not worth the effort involved to sleep-deprive these patients.
To quantify the nursing effort involved, we looked at the nursing care hours of both sleep-deprived and non-sleep-deprived patients. There was no reduction of nursing work for sleep-deprived patients. In the noninvasive procedure group, patients who had been sleep deprived successfully required an extra 41 minutes of care on average. The extra time required to care for these patients may well increase costs and decrease the efficiency of the sedation unit.
This study was unable to quantify the effort that parents expend to sleep-deprive their children. To keep a young child awake, a parent must be awake. If the parents of these sleep-deprived children lose only 2 hours of sleep per attempt at sleep deprivation, then the parents of our patients lose at least 2 whole nights of sleep weekly. The practice of sleep deprivation even failed to benefit the nonsedated patients who were talked through or napped during their procedures.
A retrospective review of a database comes with inherent difficulties. Although many hours were spent maintaining the data, it is still missing 22 months of data, and >1000 patients were excluded, mostly because of incomplete information for comparison. A thorough search did not yield any evidence of the data from the missing months, and we felt it was important only to analyze patient entries that had all the pertinent information. The prerequisites were decided on before any patient data were excluded.
Although there is no standard definition of sleep deprivation, <5 hours of sleep and no morning nap represent a good-faith effort to reduce normal sleep hours in children who normally sleep 8 to 10 hours nightly. The nursing care hours recorded may not completely represent the nursing care time spent with each individual patient. Some patients may have reported to the sedation unit early or had more wait time if procedures were delayed because of technical or scheduling reasons. Conversely, a patient may require the attention of 2 or 3 nurses at a time for brief periods, for intravenous placement, other catheter insertion, or transport to and from procedure site. This workload was not captured by our retrospective review. Nevertheless, we believe a comparison of nursing care hours is a valid way of evaluating for the potential prolongation of the sedation process by sleep deprivation.
Despite the reduction in patient numbers and the difficulties of a retrospective database review, the 4482 sedated and 686 nonsedated patients remaining were sufficient to answer the question: "Does sleep deprivation result in fewer sedation failures?"
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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Reprint requests to (C.H.S.) Department of Anesthesiology, Uniformed Services University of the Health Services, 4301 Jones Bridge Rd, Bethesda, MD 20814. E-mail: cshields{at}usuhs.mil
The opinions expressed within this article are those of the authors and are not to be construed as reflecting the views of the Uniformed Services University of the Health Sciences, the Department of the Army, or the Department of Defense.
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REFERENCES |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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This article has been cited by other articles:
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  M. R. J. Sury and K. Fairweather The effect of melatonin on sedation of children undergoing magnetic resonance imaging Br. J. Anaesth., August 1, 2006; 97(2): 220 - 225. [Abstract] [Full Text] [PDF]
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 C. Kemp Sleep deprivation not helpful for pediatric sedated procedures AAP News, June 1, 2004; 24(6): 258 - 258. [Full Text] [PDF]
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