Is more sedation training needed?

There is an increasing trend of pediatric hospitalists providing sedation to pediatric patients, researchers found.

At the same time, providers have significantly decreased the use of chloral hydrate and pentobarbital in sedating these patients.

This study, which looked at trends in outpatient procedural sedation from 2007-2018, was published in Pediatrics.

According to the study’s authors, Pradip P. Kamat, MD, MBA, FCCM, School of Medicine, Emory University, and colleagues, over the last two decades there has been a tremendous growth in procedural sedation for a variety of invasive and noninvasive procedures outside of the operating room by pediatric subspecialists.

Kamat and colleagues observed, however, that it has been difficult to evaluate and describe these sedation practices because of the disparate practitioners involved, as well as the wide variation in practice across institutions.

Here, the authors wanted to identify trends in pediatric sedation in order to understand how sedation practice has evolved over the last two decades.

Studying these trends, “can be used to provide insight into institutions that are contemplating starting a sedation program,” Kamat and colleagues suggested. “This kind of reporting can allow institutions to understand how their practice aligns with that of a group of high-performing organizations across the country.”

In this study, the authors used data from the Pediatric Sedation Research Consortium (PSRC), which has collected prospective observational data on sedation and anesthesia encounters — including patient characteristics, medications, type of providers, serious adverse events, and interventions — from sedation programs in the United States since 2004.

Kamat and colleagues identified a 432,842 sedation encounters, which were divided into 4-year periods (2007–2010, 2011–2014, and 2015–2018).

They found that there was a clear trend of pediatric hospitalists providing sedation (from <1% of sedations in 2007-2010 to 9.5% in 2015-2018). At the same time there was a decreasing trend seen in other sedation providers (radiologists, nurse anesthetists, other advanced practice nurses or physician’s assistants, physician trainees, nurses, surgeons, and general pediatricians), with those rates decreasing from 13.9% in 2007-2010 to 3.1% in 2015-2018.

“The increasing trend in sedation provided by the hospitalists in this study should concern pediatric hospital medicine program directors,” Kamat and colleagues wrote, noting that a previous study reported that a majority of hospitalists surveyed perceived they had not achieved competency in sedation. “Given that the American Board of Medical Specialties has recognized pediatric hospital medicine as a subspecialty of pediatrics, it is imperative that pediatric hospital medicine program directors inculcate robust sedation training in their curricula.”

In a commentary accompanying the study, Mark Toney, MD, Wolfson Children’s Hospital, Jacksonville, Florida, and colleagues, observed that the increased trend of pediatric hospitalist sedations “is a striking finding that deserves investigation.”

For example, they noted that while serious adverse events (SAE) remained stable as the proportion of pediatric hospitalists increased, “further breakdown of SAEs by provider specialty would further support the safety of this trend.”

They observed out that there are advantages to having trained pediatric hospitalists perform sedations. “An appropriately trained [pediatric hospitalist] is a cost-effective option for most procedural sedations, allowing anesthesiologists and intensivists to care for patients who demand their expertise,” they wrote, adding that another advantage of provided by pediatric hospitalists is in general hospitals that have limited pediatric resources.

Kamat and colleagues also found that while propofol was, by far, the most commonly used sedative, there was a significant decrease in the use of pentobarbital and chloral hydrate during time of the study. Dexmedetomidine, on the other hand, increased in use from 2007-2009, decreased and plateaued from 2010-2014, and has continued to increase since 2014.

“Previous studies from the PSRC have reported high success rates with intravenous and intranasal administration of dexmedetomidine as well as a low association with adverse events,” they wrote. “Sedation providers should consider the use of dexmedetomidine, especially in infants and young children, for short, nonpainful procedures given its distinct advantages over chloral hydrate.”

As for who was undergoing sedation, the authors determined that sedations involving patients younger than 1 year decreased overall (primarily in children younger than 3 months of age) from 10.6% in 2007–2010 to 8.0% in 2015–2018.

There was a small, nonsignificant increase in the rate of serious adverse events, from 1.35% to 1.75% (2007–2011 vs 2014–2018), with airway obstruction the most common serious adverse event, occurring in 1.55% of all sedations.

  1. An increasing number of pediatric sedations are being performed by pediatric hospitalists.

  2. While propofol is the most widely used sedative for pediatric patients, there has been a significant decrease in the use of chloral hydrate and pentobarbital by providers.

Michael Bassett, Contributing Writer, BreakingMED™

The authors had no relevant relationships to disclose.

Cat ID: 138

Topic ID: 85,138,521,730,138,192,421