Correspondence
Sedation and Analgesia for Procedures in Children
N Engl J Med 2000; 343:302-303July 27, 2000
- Article
To the Editor:
We disagree with the approach to sedation and analgesia for children proposed by Krauss and Green in their review article (March 30 issue).1 Unfortunately, there is minimal outcomes-based research to guide these directives. The complication rate associated with sedation of children by nonanesthesiologists has been cited as 20 percent.2
First, treatment of opioid-induced respiratory depression consists of stimulation, ventilation, and oxygenation. Naloxone at a dose of 100 μg per kilogram of body weight has been cited as the dose for resuscitation from life-threatening opioid overdose but may precipitate the onset of pulmonary edema, hypertension, and seizures.3 Naloxone given in incremental doses of 1 to 10 μg per kilogram nearly always restores spontaneous ventilation without reversing analgesia from sedative doses of opioids. Flumazenil may reverse midazolam-induced hypnotic and amnesic effects but may not reverse ventilatory depression.4 Resedation after administration of flumazenil is not uncommon.5 In 1992, Karl et al. reported an unacceptably high incidence of hypoxia, stiffness of the chest, and ventilatory depression with use of intranasal sufentanil, reinforcing its inappropriateness for sedation in children.6
Second, sedatives and analgesics do not provide immobility. If immobility is critical (e.g., for cerebral angiography), then general anesthesia with airway control and muscle relaxation is indicated. Attempting to deepen sedation for predictable control of motion will probably result in depressed ventilation and loss of airway reflexes.
Third, vigilance is paramount. Obtaining vital signs at only three periods during the procedure (before and after drug administration and during recovery) is not a strategy supported by the pharmacodynamics of the reviewed agents or by the guidelines of the American Society of Anesthesiologists or the American Academy of Pediatrics. Monitoring should be available in all locations. Observation by means of video camera should be used in hazardous environments (e.g., where magnetic resonance imaging or radiation therapy is performed).
In general, only credentialed practitioners who are knowledgeable and experienced should undertake procedural sedation and analgesia.
6 ReferencesBrenda C. McClain, M.D.
Charlotte Bell, M.D.
Zeev N. Kain, M.D.
Yale–New Haven Children's Hospital, New Haven, CT 065201
Krauss B ,Green SM . Sedation and analgesia for procedures in children. N Engl J Med 2000;342:938-945
Full Text | Web of Science | Medline2
Malviya S ,Voepel-Lewis T ,Tait AR . Adverse events and risk factors associated with the sedation of children by nonanesthesiologists. Anesth Analg 1997;85:1207-1213[Erratum, Anesth Analg 1998;86:227.]
CrossRef | Web of Science | Medline3
Neal JM ,Owens BD . Hazards of antagonizing narcotic sedation with naloxone. Ann Emerg Med 1993;22:145-146
CrossRef | Web of Science | Medline4
Jones RDM ,Lawson AD ,Andrew LJ ,Gunawardene WMS ,Bacon-Shone J . Antagonism of the hypnotic effect of midazolam in children: a randomized, double-blind study of placebo and flumazenil administered after midazolam-induced anaesthesia. Br J Anaesth 1991;66:660-666
CrossRef | Web of Science | Medline5
Ghouri AF ,Ruiz MAR ,White PF . Effect of flumazenil on recovery after midazolam and propofol sedation. Anesthesiology 1994;81:333-339
CrossRef | Web of Science | Medline6
Karl HW ,Keifer AT ,Rosenberger JL ,Larach MG ,Ruffle JM . Comparison of the safety and efficacy of intranasal midazolam or sufentanil for preinduction of anesthesia in pediatric patients. Anesthesiology 1992;76:209-215
CrossRef | Web of Science | Medline
To the Editor:
Krauss and Green recommend chloral hydrate for sedation in children less than three years of age who are undergoing diagnostic imaging, citing its “well-established safety profile.” However, there have been numerous case reports of fatal cardiac dysrhythmias,1-4 unpredictable central nervous system depression,1-4 laryngospasm,4 and transient hepatorenal insufficiency,2 all in children after the administration of therapeutic doses (<100 mg of chloral hydrate per kilogram).1-4
Chloral hydrate increases myocardial sensitivity to catecholamines, shortens refractory time, and decreases contractility, resulting in cardiotoxicity. This triad of effects can result in potentially fatal dysrhythmias such as torsade de pointes, ventricular tachycardia or fibrillation, and asystole.1-3 Such events may be more likely to occur in children who are receiving stimulants. Unfortunately, these dysrhythmias do not respond to standard therapy. Short-acting beta-blockers such as esmolol have demonstrated efficacy in treating such life-threatening dysrhythmias.2
The sedative–hypnotic effects of chloral hydrate are unpredictable in duration and intensity. The half-life of its active metabolite, trichloroethanol, can range from 8 to 12 hours in older children and from one to two days in neonates. In addition, children with concomitant cerebral disorders may have increased sensitivity to the depressive effects of chloral hydrate on the central nervous system and respiratory system. These depressive effects on the central nervous system are not pharmacologically reversible.2
Midazolam is a better choice for sedation in children, for several reasons. Midazolam is a short-acting benzodiazepine that can be titrated and that may be administered orally, rectally, intravenously, intramuscularly, or intranasally. In addition, if necessary, its effects can be reversed with flumazenil.
4 ReferencesEric Nazziola, M.D.
Adhi N. Sharma, M.D.
Robert S. Hoffman, M.D.
New York City Poison Control Center, New York, NY 100161
Sing K ,Erickson T ,Amitai Y ,Hryhorczuk D . Chloral hydrate toxicity from oral and intravenous administration. Clin Toxicol 1996;34:101-106
CrossRef | Web of Science2
Pershad J ,Palmisano P ,Nichols M . Chloral hydrate: the good and the bad. Pediatr Emerg Care 1999;15:432-435
CrossRef | Web of Science | Medline3
Engelhart DA ,Lavins ES ,Hazenstab CB ,Sutheimer CA . Unusual death attributed to the combined effects of chloral hydrate, lidocaine, and nitrous oxide. J Anal Toxicol 1998;22:246-247
Web of Science | Medline4
Granoff DM ,McDaniel DB ,Borkowf SP . Cardiorespiratory arrest following aspiration of chloral hydrate. Am J Dis Child 1971;122:170-171
Web of Science | Medline
To the Editor:
The use of supplemental oxygen during procedural sedation is common; in fact, many hospitals have policies on procedural sedation that specifically call for it. The danger here lies in the mistaken belief that the best oxygen saturation is the highest one that can be obtained. It is not uncommon to find a heavily sedated patient receiving high-flow supplemental oxygen who is breathing slowly and shallowly, but who has an oxygen saturation in the high 90s. The pulse oximeter provides an indirect measure of the patient's ventilatory status. When the pulse-oximetry reading drops, it is not a signal to administer more oxygen to the patient. Instead, it is a signal for the caregiver to prompt the patient to breathe more rapidly and deeply, either by stimulating the patient or by reversing the effects of the sedative agent or agents (assuming that they are reversible).
Douglas S. Binder, M.D.
University of New Mexico, Albuquerque, NM 87131Author/Editor Response
The authors reply:
To the Editor: The article cited by McClain et al. to portray a high complication rate for pediatric procedural sedation and analgesia by nonanesthesiologists is instead supportive of this increasingly common practice. Only 2 of 1140 children (0.17 percent) required assisted ventilation, and none had adverse sequelae. The complication rate is exaggerated to the stated 20 percent by defining inadequate sedation and minor events as complications. A wide margin of safety for procedural sedation and anesthesia by nonanesthesiologists who meet the qualifications detailed in our article has been well documented.
McClain et al. dispute our recommended dose of naloxone by citing case reports of exceedingly rare complications for which a dose relation remains speculative.1 The dose we recommend is widely accepted,2 has been endorsed by the American Academy of Pediatrics,3 and has an extensive track record of safety. We did not recommend flumazenil in place of ventilatory support, and Table 3 of our article clearly indicates that serial doses of reversal agents may be required. We clearly stated that not enough data are available to recommend the use of sufentanil.
McClain et al. blur the distinction between complete immobility — which usually requires general anesthesia — and relative motion control, which is sufficient for most indications for procedural sedation and anesthesia. We did not recommend that only three sets of vital signs be obtained during procedural sedation and anesthesia; instead, we recommended five sets at “a minimum,” with the exact frequency dependent on the specific clinical situation. We certainly agree with McClain et al. that monitoring should be available in all locations and did not mean to suggest otherwise.
Finally, McClain et al. state that only “credentialed practitioners” should engage in procedural sedation and anesthesia. Our article delineates the cognitive and procedural skills necessary for practitioners to undertake procedural sedation and anesthesia.
The case reports of adverse events with chloral hydrate cited by Nazziola et al. are at odds with decades of widespread use, and the safety of chloral hydrate is supported by the American Academy of Pediatrics.4 Midazolam does not appear to be as effective as chloral hydrate for noninvasive procedures (e.g., neuroimaging) and can be associated with paradoxical agitation, which may preclude the motion control necessary for these procedures.5
We agree with Binder that supplemental oxygen should not be considered mandatory during procedural sedation and anesthesia, and we tried to point out that its use may delay recognition of respiratory depression by pulse oximetry.
5 ReferencesBaruch Krauss, M.D.
Children's Hospital, Boston, MA 02115Steven M. Green, M.D.
Loma Linda University Medical Center, Loma Linda, CA 923541
Bailey PL, Egan TD, Stanley TH. Intravenous opioid anesthetics. In: Miller RD, ed. Anesthesia. 5th ed. Vol. 1. Philadelphia: Churchill Livingstone, 2000:348-9.
2
Siberry GK, Iannone R, eds. The Harriet Lane handbook. 15th ed. St. Louis: Mosby, 2000:783.
3
American Academy of Pediatrics Committee on Drugs
Web of Science | Medline4
American Academy of Pediatrics Committee on Drugs and Committee on Environmental Health
Web of Science | Medline5
D'Agostino J ,Terndrup TE . Chloral hydrate versus midazolam for sedation of children for neuroimaging: a randomized clinical trial. Pediatr Emerg Care 2000;16:1-4
CrossRef | Web of Science | Medline
- Citing Articles (2)
Citing Articles
1
Sharon E. Mace, Lance A. Brown, Lisa Francis, Steven A. Godwin, Sigrid A. Hahn, Patricia Kunz Howard, Robert M. Kennedy, David P. Mooney, Alfred D. Sacchetti, Robert L. Wears, Randall M. Clark. (2008) Clinical Policy: Critical Issues in the Sedation of Pediatric Patients in the Emergency Department. Annals of Emergency Medicine 51:4, 378-399.e57
CrossRef2
Robert J. Hoffman, Kevin C. Osterhoudt. (2002) Evaluation and Management of Pediatric Poisonings. Pediatric Case Reviews 2:1, 51-63
CrossRef
