Juan P. Boriosi

Auditory brainstem response testing is typically done under sedation in the pediatric sedation unit but often requires tympanostomy tube placement, typically done under general anesthesia in the operating room (OR), to be performed first to obtain accurate results. This is the first report on the feasibility of performing tympanostomy tube placement in combination with auditory brainstem response testing under sedation provided by pediatric critical care medicine and hospitalist physicians outside the OR. A retrospective review was performed of cases at two children’s hospitals in the United States, between July 2021 and February 2024. A total of 28 cases of tympanostomy tube placement in conjunction with auditory brainstem response testing under sedation provided by pediatric critical care medicine and hospitalist physicians outside the OR were identified. All the sedative regimens utilized propofol. All procedures were successful, but 6 patients experienced adverse events, with 5 patients experiencing only minor respiratory adverse events. One patient experienced laryngospasm, requiring unplanned intubation and Pediatric Intensive Care Unit admission. Lower direct facility costs and wait times were noted in a convenience sample of cases under sedation outside the OR compared to cases under general anesthesia in the OR.

Background: Our institution decided to implement an awake MRI scanning quality improvement project using audiovisual distraction (AVD) technology. Objective: To reduce the utilization of minimal/moderate sedation by at least 20% in children 4 to 18 years, while maintaining comparable diagnostic quality and adhering to allotted exam times, through the implementation of an awake MRI program. Materials and methods: This project was conducted at a pediatric sedation clinic between October 2021 and January 2024. We included patients 4 to 18 years of age, scheduled for an MRI at the pediatric hospital, and eligible for either minimal/moderate sedation or AVD. The outcome measure was the percentage of patients referred to our sedation clinic who completed an MRI with AVD and without sedation, analyzed on a statistical process control (SPC) P-Chart. Process measures were the number of children eligible for AVD per month, analyzed on an SPC C-Chart. Balance measures were the number of studies that exceeded allotted exam time or were non-diagnostic. Results: Of 734 MRI referrals aged 4 to 18 years, 320 patients met inclusion criteria. Two hundred twenty-eight (71.3%) received minimal/moderate sedation (mean age [SD] 9.7 years [± 3.0]) and 92 (28.8%) underwent AVD (mean age 10.0 years [± 2.7]). The average monthly decrease in minimal/moderate sedation use was 28.8 percentage points. The average number of children considered eligible for AVD increased by special cause variation from 3.8 to 7 patients per month. All 92 MRI referrals triaged to AVD completed their MRI successfully without sedation; all studies were diagnostic, and 96% of studies were within the allotted exam time. Conclusion: We implemented an awake MRI program with AVD that decreased monthly sedation needs by 28.8 percentage points while maintaining a high rate of diagnostic studies and no MRI delays.

Introduction: Distractions are a leading cause of disturbance to workflow during medical care. Distractions affecting the anesthetic team in the operating room are frequent and have a negative impact on patient care one-fifth of the time. The objective of this study was to evaluate the frequency, source, target, and impact of distractions during the induction phase of pediatric procedural sedation outside the operating room.Methods: Distractions were analyzed during propofol induction for oncology procedures from 45 video recordings. Distraction was defined as any event that disturbs or has potential to disturb the sedation team from performing their primary tasks. The type of distraction was cataloged into communication, coordination, extraneous events, equipment, layout, and usability. A five-point Likert scale was used to quantify the impact on the sedation team or its members.Results: All patients had a diagnosis of acute lymphocytic leukemia and had a mean age of 8.4 years. Five hundred and sixty-seven distractions occurred and averaged 12.6 events (+/- 5.6) per induction (mean induction time 3 min 12 s). Extraneous events were most common, accounting for 55% (312/567) of all distractions. Most distractions had an impact on the sedation team's workflow, resulting in multitasking (46%, n = 262), and in either brief or complete disruption from a primary task (17%). Sedation nurses were impacted most often, 62% of the time. Coordination and usability issues resulted in the greatest negative impact, mean +/- SD, 3.7 +/- 1.0 and 3.5 +/- 0.9, respectively. There was no significant association between distractions and adverse events or induction length.Discussion: Distractions are common during procedural sedation, with extraneous events being most frequent. Coordination issues within the team and usability problems had the greatest negative impact on sedation team workflow. Nurses were the most frequent target.Conclusion: Distractions impacted sedation team workflow but had no association with patient outcomes.

Background: Pediatric sedation is a clinical activity with potential for serious but rare airway adverse events, particularly laryngospasm. Anticholinergic drugs, atropine and glycopyrrolate, are frequently used with the intention to improve sedation safety by virtue of their antisialagogue effects.Aims: The objective of this study is to describe the current practice of anticholinergic use in pediatric sedation and to compare the frequency of serious sedation‐related adverse events in patients who received anticholinergics to those who did not.Methods: We examined prospectively collected data from the Pediatric Sedation Research Consortium database. Patient characteristics, procedure type, sedation provider, sedatives, location of sedation, anticholinergic administered, adverse events, and airway interventions were reported. Propensity score matching and multivariable logistic regression were used to test whether any association exists between anticholinergic use and serious sedation‐related adverse events.Results: Anticholinergics were administered in 7.1% (n = 18 707) of all cases (n = 263 883) reported between November 2011 and October 2017. When anticholinergics were used, atropine was used in 22% (n = 4111) and glycopyrrolate in 78.1% (n = 14 601) of sedations. Use of anticholinergics was more common in patients with well‐described risk factors for airway adverse events: active/history of upper respiratory infection, history of reactive airway disease/asthma, and exposure to smoke. However, infants and ASA 3 patients were not associated with higher rate of anticholinergic use. Anticholinergic use was independently associated with an increase in the odds of serious adverse events, OR 1.8 (95% CI 1.6–2.1), especially airway adverse events.Conclusions: In this large Pediatric Sedation Research Consortium study, we found the use of anticholinergic adjuvants independently associated with greater odds of serious adverse events, especially airway adverse events, after adjusting for well‐known sedation risk factors using propensity score matching and multivariate analysis.

OBJECTIVES: Intranasal, intramuscular, and intravenous (IV) dexmedetomidine routes have been used successfully for pediatric MRI studies. We designed this retrospective study to determine efficacy and safety of buccal dexmedetomidine for pediatric MRI sedation. METHODS: Medical records were reviewed of outpatient children ages 5 to 18 years who received buccal dexmedetomidine with or without oral midazolam for MRI sedation at a freestanding children’s hospital sedation program in 2015 and 2016. RESULTS: A total of 220 outpatient encounters received buccal dexmedetomidine for MRI. Mean age of the cohort was 10.1 ± 2.6 years (range: 5–18.7). Buccal dexmedetomidine dose administered was a mean of 2.20 ± 0.38 μg/kg (range: 0.88–3.19). Of the 220 sedation encounters, 179 (81.4%) patients had satisfactory sedation with buccal dexmedetomidine with or without oral midazolam: 84 had buccal dexmedetomidine as the sole sedative, 95 had satisfactory sedation when buccal dexmedetomidine and oral midazolam (mean: 0.33 ± 0.07 mg/kg; range: 0.21–0.53) were given together, 1 (0.4%) had satisfactory sedation when intranasal fentanyl and midazolam were administered in addition to buccal dexmedetomidine, and 35 (15.9%) required IV sedatives to achieve satisfactory sedation. All patients completed their MRI successfully except 5 (2.2%): 2 encounters were sedation failures, 2 IV sedations developed severe upper airway obstruction, and 1 IV sedation experienced MRI contrast anaphylaxis. CONCLUSIONS: In a selected population of pediatric patients, buccal dexmedetomidine with or without midazolam provides adequate sedation for most MRI studies with few adverse effects, but given a failure rate of almost 20%, modifications to buccal dexmedetomidine dosing should be investigated.

Background: Monitoring of ventilation with capnography or a stethoscope is recommended because the detection of ventilatory abnormalities can be significantly delayed by the use of pulse oximetry alone in patients receiving supplemental oxygen. The aim of this study was to evaluate the diagnostic performance of the pretracheal stethoscope with pulse oximetry and capnography in detecting adverse respiratory events during propofol sedation in nonintubated children. We hypothesized that use of the pretracheal stethoscope would facilitate earlier detection of adverse respiratory events.Methods: This was a prospective observational study of children undergoing procedural sedation at a pediatric sedation program. A pretracheal stethoscope, pulse oximetry, and nasal capnography were attached at the discretion of the sedation nurse and provider to monitor ventilation.Results: We enrolled 104 patient encounters (mean recorded time, SD 8.3 ± 5.3 minutes) from February, 2015 to March, 2017. The pretracheal stethoscope was the first monitor to detect adverse events in 64% (25/39) of patients compared to 18% (7/39) for capnography and 15% (6/39) for pulse oximetry. Auscultation performed best at detecting upper airway obstruction but capnography and pulse oximetry performed best at detecting hypoventilation. The positive predictive value for detecting a true ventilation abnormality and 95% CI of the pretracheal stethoscope, pulse oximetry, and capnography was 100% (90%‐100%), 18% (10%‐31%), and 27% (18%‐38%), respectively. The negative predictive value and 95% CI of the pretracheal stethoscope, pulse oximetry, and capnography was 88% (82%‐92%), 68% (59%‐75%), and 70% (61%‐78%), respectively. Limitations are short observation time, nonstandardized application of respiratory monitors, and too much focus on auscultation.Conclusion: A pretracheal stethoscope in conjunction with capnography and pulse oximetry detects most sedation‐related adverse events first. Auscultation performed best at detecting upper airway obstruction but capnography and pulse oximetry performed best at detecting hypoventilation.

Background and aim: Both propofol and dexmedetomidine have been found to be safe and effective sedation for magnetic resonance imaging (MRI). Our program experienced an increase in patients arousing and experiencing an adverse airway event during propofol sedation for MRI in the first months of using a new 3T (Tesla) MRI scanner that was found to have a longer reverberation time compared to the previous 1.5 T MRI. In an effort to decrease patient arousal and adverse airway events during MRI, we administered a dexmedetomidine load prior to our standard propofol protocol. The objective was to compare adverse events and other outcome measures of patients sedated with propofol alone (Pro) and propofol preceded by a dexmedetomidine load (D+P).Methods: We reviewed a sedation database and medical records for all children undergoing 3T MRI studies while sedated with propofol alone or propofol preceded by a dexmedetomidine load in 2014.Results: Two hundred and fifty‐six sedations were performed for MRI (87 Pro and 169 D+P). The two groups were comparable with regard to age, weight, gender, and American Society of Anesthesiologists status. Subjects in the D+P cohort had significantly fewer adverse events (10/169 patients (5.9%) vs 23/87 patients (26.4%) [OR 0.18, 95% CI: 0.08–0.39, P < 0.001]), particularly upper airway obstruction. Mean discharge time was longer in the D+P cohort compared to the Pro cohort (87.1, SD 26.3 min vs 69.7, SD 23.6; [mean difference 17.7 min, 95% CI: 10.6–24.8, P < 0.001]).Conclusions: The addition of a dexmedetomidine infusion prior to our propofol MRI sedation protocol resulted in fewer sedation‐related adverse events, particularly upper airway obstruction. Further studies are needed to evaluate the potential for a reduction on adverse events with this drug combination.

Summary: Spinal muscular atrophy (SMA), a lower motor neuron anterior horn cell disease, causes significant respiratory morbidity and mortality in children. Acute respiratory distress syndrome (ARDS) accounts for 1–4% of all Pediatric Intensive Care Unit (PICU) admissions. Management outcomes for ARDS in patients with SMA have not been described. We present the case of a 5‐year‐old boy with Type II SMA and ARDS requiring invasive mechanical ventilation. He improved with meticulous management of mechanical ventilation, airway clearance, fluid/nutrition, and sedation/analgesia. He was successfully extubated after 14 days of invasive mechanical ventilation and discharged home after a 20 day hospitalization. Pediatr Pulmonol. 2015; 50:E29–E31.