Pediatric sedation for imaging appears safe for outpatient centers

With skilled nurses and sound criteria for choosing patients, pediatric imaging that requires sedation can be performed safely at outpatient facilities, according to a study conducted at the University of California, Los Angeles (UCLA) Health System.

Just two of nearly 1,300 young patients evaluated had minor complications from nurse-administered sedation. None of the patients experienced moderate or major complications. The results are encouraging because they show that there are less costly and more accessible ways of performing sedation imaging that do not compromise patient safety.

"Moderate sedation tends to be relegated to clinicians in pediatric critical care, emergency radiology, and pediatric anesthesiology," said Dr. Adrienne Bean, a pediatric radiology resident who presented the findings at the Society for Pediatric Radiology (SPR) annual meeting held in April in Carlsbad, CA. "But there are high costs associated with having procedures at pediatric hospitals."

In an outpatient setting within the UCLA hospital, a team of sedation-trained nurses cared for 1,291 pediatric patients who were sedated for advanced imaging procedures including MRI, CT, urodynamic studies, and barium enemas. The research looked at procedures performed between 2001 and 2008.

Bean attributed the success of the procedures to three elements: skilled and well-trained nurses, strict guidelines for excluding patients, and the characteristics of the drug.

"We were predominantly using propofol, which increasingly is recognized as a safe and effective sedation drug because of the low risk of complication and because it allows for optimal acquisition of images," Bean said. Propofol is known for its quick onset, short duration of action, and shorter waking and recovery times.

"The sedation goal is up to deep sedation. Not every child is going to require deep sedation to remain motionless throughout the exam," Bean said.

The clinic's nursing staff is also a key factor -- UCLA's nurses and patients are on a one-to-one ratio.

Working under supervision of a pediatric anesthesiologist, the staff was certified under California Society of Anesthesiologists guidelines for deep sedation by nonanesthesiologists.

"These nurses are very capable," Bean said. "They have a minimum of five years experience and are reassessed annually. They've trained in pediatrics and in anesthesiology in operating rooms. They have training in airway management, intervention, and cardiopulmonary compromise, and often do a rotation in oncology."

Patients at UCLA outpatient facilities are screened to make sure they are at lower risk for complications. Risks include obesity, obstructive apnea, sleep apnea, craniofacial anomalies, and any other factors that may give the child breathing difficulties.

"We look for anything that has a baseline cardiopulmonary respiratory compromise, and any recent upper respiratory infection is triaged for later," Bean said. "However, the vast majority of children aren't going to have these risks."

Children are also not suited to outpatient sedation if they are taking certain medications, have certain allergies, were born prematurely, have reflux or neurological compromise, or have any condition that makes it hard to monitor arousal, according to Bean.

After the procedure, parents are given very specific instructions, and they must show that they understand the information before the child is released. Parents are instructed to stay with the child for 24 hours after the procedure.

With just two patients (0.2%) experiencing mild complications, defined as desaturation and respiratory suppression, the possibility for expanding the use of UCLA's approach to sedation imaging in an outpatient setting seems real.

"We're hoping that we're coming up with a model that will communicate that there are safe and effective sedation procedures that can be performed on pediatric patients of all ages, and, with appropriately trained staff, we may be able to increase the availability of these advanced imaging studies outside the tertiary academic referral centers," Bean said.

However, the study did benefit from its location because if major complications had occurred, surgeons were immediately available to intervene, Bean acknowledged.

By Marty Graham contributing writer
July 29, 2009

Related Reading

Ketamine could replace anesthesia for some pediatric IVR, March 13, 2009

Anesthesiologists refine pediatric sedation for MRI, October 25, 2007

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