Skip to main content

Incidence and Stratification of Adverse Events Associated with Sedation: Is There a Benchmark?

  • Chapter
  • First Online:
Pediatric Sedation Outside of the Operating Room
  • 2181 Accesses

Abstract

A significant and growing number of children receive sedation for procedures performed outside of the operating room each year. While a large number of studies have reported on adverse events occurring in association with procedural sedation in many of these settings, benchmarks for sedation adverse event rates have not been formally established. The intent of this chapter is to add some clarity to the concept that, unlike adverse outcomes (e.g., death, permanent neurologic injury) that are largely preventable and should not occur, the occurrence of adverse events is unavoidable, and acceptable rates of adverse events should exist. Once acceptable rates of sedation adverse events are established, sedation providers and programs should be able to compare their individual outcomes to these national and international standards. This chapter will examine current sedation practice outside the operating room and associated adverse events. It will focus on important barriers that must be overcome before meaningful adverse event rates may be determined and best practice guidelines established.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 129.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 169.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Notes

  1. 1.

    www.AESedationReporting.com or www.InternationalSedationTaskForce.com

References

  1. Cravero JP, Blike GT, Beach ML, et al. Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the Pediatric Sedation Research Consortium. Pediatrics. 2006;118(3):1087–96.

    Article  PubMed  Google Scholar 

  2. Cravero JP, Beach ML, Blike GT, et al. The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: a report from the Pediatric Sedation Research Consortium. Anesth Analg. 2009;108(3):795–805.

    Article  PubMed  CAS  Google Scholar 

  3. Vespasiano M, Finkelstein M, Kurachek S. Propofol sedation: intensivists’ experience with 7304 cases in a children’s hospital. Pediatrics. 2007;120:e1411–7.

    Article  PubMed  Google Scholar 

  4. Roback MG, Wathen JE, Bajaj L, Bothner JP. Adverse events associated with procedural sedation and analgesia in a pediatric emergency department: a comparison of common parenteral drugs. Acad Emerg Med. 2005;12:508–13.

    Article  PubMed  Google Scholar 

  5. Couloures KG, Beach M, Cravero JP, et al. Impact of provider specialty on pediatric procedural sedation complication rates. Pediatrics. 2011;127:e1154–60.

    Article  PubMed  Google Scholar 

  6. Havidich JE, Cravero JP. The current status of procedural sedation for pediatric patients in out-of-operating room locations. Curr Opin Anaesthesiol. 2012;25:453–60.

    Article  PubMed  CAS  Google Scholar 

  7. Mallory MD, Baxter AL, Yanosky DJ, Cravero JP. Emergency physician administered propofol sedation: a report on 25 433 sedations from the pediatric sedation research consortium. Ann Emerg Med. 2011;57:462–468.e1.

    Article  PubMed  Google Scholar 

  8. Srinivasan M, Turmelle M, Depalma LM, et al. Procedural sedation for diagnostic imaging in children by pediatric hospitalists using propofol: analysis of the nature, frequency, and predictors of adverse events and interventions. J Pediatr. 2012;160:801–806.e1.

    Article  PubMed  Google Scholar 

  9. Roback MG, Bajaj L, Wathen J, Bothner J. Preprocedural fasting and adverse Events in procedural sedation and analgesia in a pediatric emergency department – are they related? Ann Emerg Med. 2004;44:454–9.

    Article  PubMed  Google Scholar 

  10. Agrawal D, Manzi SF, Gupta R, et al. Preprocedural fasting state and adverse events in children undergoing procedural sedation and analgesia in a pediatric emergency department. Ann Emerg Med. 2003;42:636–46.

    Article  PubMed  Google Scholar 

  11. Babl FE, Puspitadewi A, Barnett P, et al. Preprocedural fasting state and adverse events in children receiving nitrous oxide for procedural sedation and analgesia. Pediatr Emerg Care. 2005;21:736–43.

    Article  PubMed  Google Scholar 

  12. Pitetti RD, Singh S, Pierce MC. Safe and efficacious use of procedural sedation and analgesia by nonanesthesiologists in a pediatric emergency department. Arch Pediatr Adolesc Med. 2003;157:1090.1096.

    Article  PubMed  Google Scholar 

  13. Pena BMG, Krauss B. Adverse events of procedural sedation and analgesia in a pediatric emergency department. Ann Emerg Med. 1999;34:483–91.

    Article  PubMed  CAS  Google Scholar 

  14. Green SM, Rothrock SG, Lynch EL. Intramuscular ketamine for pediatric sedation in the emergency department: safety profile in 1,022 cases. Ann Emerg Med. 1998;31:688–97.

    Article  PubMed  CAS  Google Scholar 

  15. Newman DH, Azer MM, Pitetti RD, et al. When is a patient safe for discharge after procedural sedation? The timing of adverse effect events in 1,367 pediatric procedural sedations. Ann Emerg Med. 2003;42:627–35.

    Article  PubMed  Google Scholar 

  16. Malviya S, Voepel-Lewis T, Eldevik OP, et al. Sedation and general anaesthesia in children undergoing MRI and CT: adverse events and outcomes. Br J Anaesth. 2000;84:743–8.

    Article  PubMed  CAS  Google Scholar 

  17. Malviya S, Voepel-Lewis T, Prochaska G, Tait AR. Prolonged recovery and delayed side effects of sedation for diagnostic imaging studies in children. Pediatrics. 2000;105:e42.

    Article  PubMed  CAS  Google Scholar 

  18. Malviya S, Voepel-Lewis T, Tait AR. Adverse events and risk factors associated with the sedation of children by nonanesthesiologtists. Anesth Analg. 1997;85:1207–13.

    PubMed  CAS  Google Scholar 

  19. Coté CJ, Notterman DA, Karl HW, et al. Adverse sedation events in pediatrics: a critical incident analysis of contributing factors. Pediatrics. 2000;106:633–44.

    Article  PubMed  Google Scholar 

  20. Bhatt M, Kennedy R, Osmond MH, et al. Consensus-based recommendations for standardizing terminology and reporting adverse events for emergency department procedural sedation and analgesia in children. Ann Emerg Med. 2009;53:426–435.e4. Epub 2008 Nov 19.

    Article  PubMed  Google Scholar 

  21. American College of Emergency Physicians. Clinical policy for procedural sedation and analgesia in the emergency department. Ann Emerg Med. 1998;31:663–77.

    Article  Google Scholar 

  22. Krauss B, Green SM. Sedation and analgesia for procedures in children. N Engl J Med. 2000;342:938–45.

    Article  PubMed  CAS  Google Scholar 

  23. Krauss B, Green SM. Procedural sedation and analgesia in children. Lancet. 2006;367:766–80.

    Article  PubMed  CAS  Google Scholar 

  24. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), Accreditation Manual for Hospitals, 2006:253.

    Google Scholar 

  25. Ramaiah R, Bhananker S. Pediatric procedural sedation and analgesia outside the operating room: anticipating, avoiding and managing complications. Expert Rev Neurother. 2011;11:755–63.

    Article  PubMed  Google Scholar 

  26. Green SM, Mason KP. Stratification of sedation risk: a challenge to the sedation continuum. Paediatr Anaesth. 2011;21:924–31.

    Article  PubMed  Google Scholar 

  27. Coté CJ, Karl HW, Notterman DA, et al. Adverse sedation events in pediatrics: analysis of medications used for sedation. Pediatrics. 2000;105:805–14.

    Article  PubMed  Google Scholar 

  28. Parker RI, Mahan RA, Biugliano D, Parker MM. Efficacy and safety of intravenous midazolam and ketamine as sedation for therapeutic and diagnostic procedures in children. Pediatrics. 1997;99:427–31.

    Article  PubMed  CAS  Google Scholar 

  29. Brown ET, Corbett SW, Green SM. Iatrogenic cardiopulmonary arrest during pediatric sedation with meperidine, promethazine, and chlorpromazine. Pediatr Emerg Care. 2001;17:351–3.

    Article  PubMed  CAS  Google Scholar 

  30. Hoffman GM, et al. Risk reduction in pediatric procedural sedation by application of an AAP/ASA process model. Pediatrics. 2002;109:236–43.

    Article  PubMed  Google Scholar 

  31. Sanborn PA, Michna E, Zurakowski D, et al. Adverse cardiovascular and respiratory events during sedation of pediatric patients for imaging examinations. Radiology. 2005;237:288–94.

    Article  PubMed  Google Scholar 

  32. Sweeney H, Marai S, Kim C, et al. Creating a sedation service for pediatric urodynamics: our experience. Urol Nurs. 2008;28(4):273–8.

    PubMed  Google Scholar 

  33. Farrell MK, Drake GJ, Rucker D, et al. Creation of a registered nurse-administered nitrous oxide sedation program for radiology and beyond. Pediatr Nurs. 2008;34(1):29–35.

    PubMed  Google Scholar 

  34. Woodthorpe C, Trigg A, Alison G, et al. Nurse led sedation for paediatric MRI: progress and issues. Paediatr Nurs. 2007;19(2):14–8.

    PubMed  Google Scholar 

  35. Wood C, Hurley C, Wettlaufer J, et al. Retrospective comparison of emergency department length of stay for procedural sedation and analgesia by nurse practitioners and physicians. Pediatr Emerg Care. 2007;23(10):709–12.

    Article  PubMed  Google Scholar 

  36. Pershad J, Gilmore B. Successful implementation of a radiology sedation service staffed exclusively by pediatric emergency physicians. Pediatrics. 2006;117(3):e413–22.

    Article  PubMed  Google Scholar 

  37. King WK, Stockwell JA, DeGuzman MA, et al. Evaluation of a pediatric-sedation service for common diagnostic procedures. Acad Emerg Med. 2006;13(6):673–6. Epub 2006 May 2.

    Article  PubMed  Google Scholar 

  38. Yamamoto LG. Initiating a hospital-wide pediatric sedation service provided by emergency physicians. Clin Pediatr. 2008;47(1):37–48.

    Article  Google Scholar 

  39. Shankar VR. Sedating children for radiological procedures: an intensivist’s perspective. Pediatr Radiol. 2008;38 Suppl 2:S213–7.

    Article  PubMed  Google Scholar 

  40. Webb ST, Hunter DN. Is sedation by non-anaesthetists really safe? Br J Anaesth. 2013;111(2):136–8.

    Article  PubMed  CAS  Google Scholar 

  41. Miner JR, Krauss B. Procedural sedation and analgesia research: state of the art. Acad Emerg Med. 2007;14:170–8.

    Article  PubMed  Google Scholar 

  42. 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(pt 1):1110–5.

    Google Scholar 

  43. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 2002;96:1004-17.

    Google Scholar 

  44. American Academy of Pediatrics. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: Addendum. Committee on Drugs. Pediatrics. 2002;110:836–8.

    Article  Google Scholar 

  45. American College of Emergency Physicians. Clinical policy: evidence-based approach to pharmacologic agents used in pediatric sedation and analgesia in the emergency department. Ann Emerg Med. 2004;44:342–77.

    Article  Google Scholar 

  46. American College of Emergency Physicians. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2005;45:177–96.

    Article  Google Scholar 

  47. Miner JR, Burton JH. Clinical practice advisory: emergency department procedural sedation with propofol. Ann Emerg Med. 2007;50:182–7.

    Article  PubMed  Google Scholar 

  48. Green SM, Roback MG, Kennedy R, et al. Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update. Ann Emerg Med. 2011;57:449–61.

    Article  PubMed  Google Scholar 

  49. Cote CJ, Wilson S. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update. Pediatrics. 2006;118:2587–602.

    Article  PubMed  Google Scholar 

  50. Green SM, Roback MG, Miner JR, et al. Fasting and emergency department procedural sedation and analgesia: a consensus-based clinical practice advisory. Ann Emerg Med. 2007;49:454–61.

    Article  PubMed  Google Scholar 

  51. American Academy of Pediatric Dentistry. Guidelines for the elective use of pharmacologic conscious sedation and deep sedation in pediatric dental patients. Pediatr Dent. 1993;15:297–9.

    Google Scholar 

  52. O’Connor RE, Sama A, Burton JH, et al. Procedural sedation and analgesia in the emergency department: recommendations for physician credentialing, privileging, and practice. Ann Emerg Med. 2011;58(4):365–70.

    Article  PubMed  Google Scholar 

  53. Cote CH. Strategies for preventing sedation accidents. Pediatr Ann. 2005;34:625–33.

    Article  PubMed  Google Scholar 

  54. Lee LA, Bomino KB. The closed claims project has it influenced anesthetic practice and outcome? Anesthesiol Clin North America. 2002;20:485–501.

    Article  PubMed  Google Scholar 

  55. Tinker JH, Dull DL, Caplan RA, et al. Role of monitoring devices in prevention of anesthetic mishaps: a closed claims analysis. Anesthesiology. 1989;71:541–6.

    Article  PubMed  CAS  Google Scholar 

  56. Bhananker SM, Posner KL, Cheney FW, et al. Injury and liability associated with monitored anesthesia care. A closed claims analysis. Anesthesiology. 2006;104:228–34.

    Article  PubMed  Google Scholar 

  57. Petty WE, Kremer M, Biddle C. A synthesis of the Australian patient safety foundation anesthesia incident monitoring study, the American society of anesthesiologists closed claims project, and the American association of nurse anesthetists closed claims study. AANA J. 2002;70:193–202.

    PubMed  Google Scholar 

  58. Roback MG, Wathen JE, Mackenzie T, Bajaj L. A Randomized, Controlled Trial of IV versus IM Ketamine for Sedation of Pediatric Patients Receiving Emergency Department Orthopedic Procedures. Ann Emerg Med. 2006;48:605–12.

    Article  PubMed  Google Scholar 

  59. Dachs RJ, Innes GM. Intravenous ketamine sedation of pediatric patients in the emergency department. Ann Emerg Med. 1997;29:146–50.

    Article  PubMed  CAS  Google Scholar 

  60. McCarty EC, Mencio GA, Anderson Walker L, et al. Ketamine sedation for the reduction of children’s fractures in the emergency department. J Bone Joint Surg Am. 2000;82:912–8.

    PubMed  Google Scholar 

  61. Green SM, Rothrock SG, Harris T, et al. Intravenous ketamine for pediatric sedation in the emergency department: safety profile with 156 cases. Acad Emerg Med. 1998;5(10):971–6.

    Article  PubMed  CAS  Google Scholar 

  62. Heinz P, Geelhoed GC, Wee C, et al. Is atropine needed with ketamine sedation? A prospective, randomized, double blind study. Emerg Med J. 2006;23:206–9.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  63. McGlone RG, Fleet T, Durham S, et al. A comparison of intramuscular ketamine with high dose intramuscular midazolam with and without intranasal flumazenil in children before suturing. Emerg Med J. 2001;18:34–8.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  64. Godambe SA, Elliot V, Matheny D, et al. Comparison of propofol/fentanyl versus ketamine/midazolam for brief orthopedic procedural sedation in a pediatric emergency department. Pediatrics. 2003;112:116–23.

    Article  PubMed  Google Scholar 

  65. Guenther-Skokan E, Pribble C, Bassett KE, et al. Use of propofol sedation in a pediatric emergency department: a prospective study. Clin Pediatr. 2001;40:663–71.

    Article  Google Scholar 

  66. Bassett KE, Anderson JL, Pribble CG, et al. Propofol for procedural sedation in children in the emergency department. Ann Emerg Med. 2003;42:773–82.

    Article  PubMed  Google Scholar 

  67. Shah A, Mosdossy G, McLeod S, et al. A blinded, randomized controlled trial to evaluate ketamine-propofol versus ketamine alone for procedural sedation in children. Ann Emerg Med. 2011;57:425–33.

    Article  PubMed  Google Scholar 

  68. Hertzog JH, Dalton HJ, Anderson BD, et al. Prospective evaluation of propofol anesthesia in the pediatric intensive care unit for elective oncology procedures in ambulatory and hospitalized children. Pediatrics. 2000;106:742–7.

    Article  PubMed  CAS  Google Scholar 

  69. Andolfatto G, Abu-Laban RB, Zed PJ, et al. Ketamine-propofol combination (ketofol) versus propofol alone. for emergency department procedural sedation and analgesia: a randomized double-blind trial. Ann Emerg Med. 2012;59(6):504–12.e1-2.

    Article  PubMed  Google Scholar 

  70. Barbi E, Gerarduzzi T, Marchetti F, et al. Deep sedation with propofol by nonanesthesiologists : a prospective pediatric experience. Arch Pediatr Adolesc Med. 2003;157:1097–103.

    Article  PubMed  Google Scholar 

  71. Hasan RA, Shayevitz JR, Patel V. Deep sedation with propofol for children undergoing ambulatory magnetic resonance imaging of the brain: experience from a pediatric intensive care unit. Pediatr Crit Care Med. 2003;4:454–8.

    Article  PubMed  Google Scholar 

  72. Pershad J, Godambe SA. Propofol for procedural sedation in the pediatric emergency department. J Emerg Med. 2004;27:11–4.

    Article  PubMed  Google Scholar 

  73. Willman EV, Andolfatto G. A prospective evaluation of “ketofol” (ketamine/propofol combination) for procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2007;49:23–30.

    Article  PubMed  Google Scholar 

  74. Messenger DW, Murray HE, Dungey PE, et al. Subdissociative dose ketamine versus fentanyl for analgesia during propofol procedural sedation: a randomized controlled trial. Acad Emerg Med. 2008;15:877–86.

    Article  PubMed  Google Scholar 

  75. Cheung KW, Watson M-L, Field SG, et al. Aspiration pneumonitis requiring intubation after procedural sedation and analgesia: a case report. Ann Emerg Med. 2007;49(4):462–4. Epub 2006 Nov 3.

    Article  PubMed  Google Scholar 

  76. American Society of Anesthesiologists. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures. Anesthesiology. 1999;90:896–905.

    Article  Google Scholar 

  77. Green SM. Fasting is a consideration—not a necessity—for emergency department procedural sedation and analgesia. Ann Emerg Med. 2003;42:647–50.

    Article  PubMed  Google Scholar 

  78. Green SM, Krauss B. Pulmonary aspiration risk during ED procedural sedation: an examination of the role of fasting and sedation depth. Acad Emerg Med. 2002;9:35–42.

    PubMed  Google Scholar 

  79. Sacchetti A, Stander E, Ferguson N, et al. Pediatric procedural sedation in the community emergency department: results from the ProSCED registry. Pediatr Emerg Care. 2007;23:218–22.

    Article  PubMed  Google Scholar 

  80. Green SM, Yealy DM. Procedural sedation goes Utstein: the Quebec guidelines. Ann Emerg Med. 2009;53(4):436–8. Epub 2008 Dec 21.

    Article  PubMed  Google Scholar 

  81. Green SM, Roback MG, Krauss B, et al. Predictors of airway and respiratory adverse events of ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children. Ann Emerg Med. 2009;54(2):158–68.e1-4.

    Article  PubMed  Google Scholar 

  82. Bhargava R, Young KD. Procedural pain management patterns in academic pediatric emergency departments. Acad Emerg Med. 2007;14:479–82.

    Article  PubMed  Google Scholar 

  83. Haley-Andrews S. Ketamine—the sedative of choice in a busy pediatric emergency department. J Emerg Nurs. 2006;32:186–8.

    Article  PubMed  Google Scholar 

  84. Hanley JA, Loppman-Hand A. If nothing goes wrong is everything all right? Interpreting zero numerators. JAMA. 1983;249(13):1743–5.

    Article  PubMed  CAS  Google Scholar 

  85. Mason KP, Green SM. Piacevoli Q and the International Sedation Task Force. Adverse event reporting tool to standardize the reporting and tracking of adverse events during procedural sedation: a consensus document from the World SIVA International Sedation Task Force. Br J Anaesth. 2012;108(1):13–20.

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Mark G. Roback M.D. .

Editor information

Editors and Affiliations

Appendix: Recommended Documentation for Sedation Research

Appendix: Recommended Documentation for Sedation Research

figure afigure a

Rights and permissions

Reprints and permissions

Copyright information

© 2015 Springer Science+Business Media New York

About this chapter

Cite this chapter

Roback, M.G. (2015). Incidence and Stratification of Adverse Events Associated with Sedation: Is There a Benchmark?. In: Mason, K. (eds) Pediatric Sedation Outside of the Operating Room. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-1390-9_28

Download citation

  • DOI: https://doi.org/10.1007/978-1-4939-1390-9_28

  • Published:

  • Publisher Name: Springer, New York, NY

  • Print ISBN: 978-1-4939-1389-3

  • Online ISBN: 978-1-4939-1390-9

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics