Risk Factors for Adverse Events in Emergency Procedural Pediatric Sedation

MedicalResearch.com Interview with:

Maala Bhatt MD, MSc., FRCPC Director, Pediatric Emergency Research Staff Physician, Emergency Medicine  Children's Hospital of Eastern Ontario

Dr. Bhatt

Maala Bhatt MD, MSc., FRCPC
Director, Pediatric Emergency Research
Staff Physician, Emergency Medicine
Children’s Hospital of Eastern Ontario 

MedicalResearch.com: What is the background for this study?

Response: Procedural sedation, defined as the administration of medications to minimize pain and awareness, has become standard practice in pediatric emergency departments worldwide to facilitate short, painful procedures such as orthopedic reduction and complex laceration repairs. Although emergency department sedation is regarded as safe, serious adverse events have been reported. The incidence of these events has been difficult to determine due to the infrequency of their occurrence and lack of large, multi-center surveillance studies focused on systematic detection of adverse events. Previous studies of emergency department sedation have been limited by single-center design and small sample sizes. These studies have not been able to reliably predict sedation-related adverse events, their severity or impact on patients.

To improve understanding of the safety and comparative effectiveness of ED procedural sedation, we conducted a large multi-center cohort study using standardized outcome measures that are valid and relevant to clinical practice. Our primary objective was to determine which practices lead to the best outcomes in children undergoing emergency department procedural sedation.

MedicalResearch.com: What are the main findings?

Response: We enrolled 6,295 patients undergoing parenteral procedural sedation for a painful procedure in one of six Canadian pediatric emergency departments from July 2010 to February 2015.

The overall incidence of adverse events in our population was 11.7%. Oxygen desaturation (5.6%) and vomiting (5.2%) were the most common events. Serious adverse events and significant interventions in response to an adverse event were rare occurring in only 1.1% and 1.4% of patients respectively.

We found that choice of sedation medication had the biggest impact on the incidence of adverse events and need for significant interventions in response to those events. The incidence of serious adverse events and significant interventions was lowest among patients sedated with ketamine-alone and highest among patients sedated with combination drugs ketamine+propofol and ketamine+fentanyl. We also found that pre-procedural opioid administration was strongly associated with increased odds of oxygen desaturation, vomiting and need for significant interventions, regardless of sedation medication.

Higher doses of ketamine were associated with increased odds of oxygen desaturation and vomiting. These findings are in opposition to the common belief that ketamine does not exhibit a dose-response relationship.

We also found that pre-procedural anti-emetics were associated with a 50% reduction in the odds of vomiting. However, based on published evidence, use in children under five years may not be as advantageous as their baseline risk is much lower.

MedicalResearch.com: What should clinicians and patients take away from your report?

Response: Procedural sedation for children provided by Emergency Physicians in these tertiary care pediatric emergency departments is safe and effective with low rates of serious adverse events (1.1%) and significant interventions (1.4%). Ketamine, Ketamine and Propofol and Propofol alone are all effective and safe in the hands of competent/experienced providers, however using ketamine alone is associated with fewer serious adverse events and significant interventions.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Response: Our finding that administering opioids prior to sedation increases the odds of oxygen desaturation, vomiting and the need for significant interventions is interesting. Future work could focus on the timing of opioid administration and the incidence of adverse events. We are also interesting in understanding the longer term effects of sedation medications, controlling for age.

Disclosures: This study was supported by a Canadian Institutes of Health Research Team Grant in Pediatric Emergency Medicine.

MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.

Citation:

Bhatt M, Johnson DW, Chan J, Taljaard M, Barrowman N, Farion KJ, Ali S, Beno S, Dixon A, McTimoney CM, Dubrovsky AS, Sourial N, Roback MG, for the Sedation Safety Study Group of Pediatric Emergency Research Canada (PERC). Risk Factors for Adverse Events in Emergency Department Procedural Sedation for Children. JAMA Pediatr. Published online August 21, 2017. doi:10.1001/jamapediatrics.2017.2135

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Over 1/3 of Anesthesia Now Delivered Outside of Traditional Operating Rooms

MedicalResearch.com Interview with:
Dr. Richard Dutton, MD

Chief quality officer
U.S. Anesthesia Partners
Dallas

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: We wanted to document the change in national anesthesia practice over the past 5 years, specifically the increase in non-operating room anesthesia NORA. We found that non-operating room anesthesia now accounts for more than 1/3 of all anesthetics. The proportion continues to rise as minimally invasive procedures are developed in gastroenterology, cardiology, radiology and other non-surgical disciplines. These procedures are often performed in complex patients, and require anesthesia involvement to facilitate.

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Opportunities for Improvement in Pediatric Resuscitation Across US EDs

MedicalResearch.com Interview with:
Marc Auerbach, MD, FAAP, MSc
Associate Professor of Pediatrics (Emergency Medicine) and of Emergency Medicine
Co-chair INSPIRE (International Network for Simulation Based Pediatric Innovation Research and Education)
Director, Pediatric Simulation
Yale Center for Medical Simulation;

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Severely ill infants and children present to any of over 5000 United States Emergency Departments every day. A direct comparison of the quality of resuscitative care across EDs is challenging due to the low frequency of these high stakes events in individual EDs. This study utilized in-situ simulation-based measurement to compare the quality of resuscitative care delivered to two infants and one child by 58 distinct interprofessional teams across 30 EDs. Composite quality scores correlated with annual pediatric patient volume, with higher volume departments demonstrating higher scores.

The pediatric readiness score measures compliance with guidelines created by the American Academy of Pediatrics, the American College of Emergency Physicians and the Emergency Nurses Association. The pediatric readiness score correlated with composite quality scores measured by simulation.

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Brain-Based Signatures May Help Optimize Anesthesia Dose

Srivas Chennu, PhD Senior Research Associate Clinical Neurosciences, University of Cambridge Visiting Scientist, MRC Cognition and Brain Sciences Unit College Research Associate, Homerton College

Dr. Srivas Chennu

More on Anesthesiology on MedicalResearch.com
MedicalResearch.com Interview with:
Srivas Chennu, PhD
Senior Research Associate
Clinical Neurosciences, University of Cambridge
Visiting Scientist, MRC Cognition and Brain Sciences Unit
College Research Associate, Homerton College

Medical Research: What is the background for this study?

Dr. Chennu:  Scientific understanding of how brain networks generate consciousness has seen rapid advances in recent years, but the application of this knowledge to accurately track transitions to unconsciousness during general anaesthesia has proven difficult. Crucially, one reason for this is the considerable individual variability in susceptibility to anaesthetic dosage. 

To better understand the factors underlying this variability, we measured interconnected, oscillatory brain activity (‘brain networks’), using non-invasive, high-density electroencephalography (EEG) from healthy volunteers while they were sedated with the common anaesthetic propofol. Alongside, we measured their behavioural responsiveness, and the actual concentration of the drug in their blood plasma.  Continue reading

Universal TXA During Hip/Knee Replacement Reduced Transfusions 40%

Dr. Gregory M.T. Hare MD PhD Department of Anesthesia St. Michael's HospitaMedicalResearch.com Interview with:
Dr. Gregory M.T. Hare MD PhD
Department of Anesthesia
St. Michael’s Hospital

Medical Research: What is the background for this study? What are the main findings?

Dr. Hare: While many randomized trials had demonstrated that tranexamic acid (TXA therapy) was effective at reducing surgical blood loss and red blood cell transfusion in patients undergoing hip and knee replacement surgery, our hospital and many other centers in Ontario were not fully utilizing this therapy. Part of the reason was a concern about drug safety and potential side effects. While no serious adverse events had been reported using TXA, we set out to assess the impact of a protocol designed to ensure that we administered TXA (20 mg/kg iv preoperatively) to all eligible patients undergoing hip and knee replacement and determining the effect on our red blood cell transfusion rate and adverse effects including blood clot, stroke, heart attack, kidney injury and death. We excluded patients at high risk of any thrombotic complication.

After implementing our protocol, we increased utilization of the drug from 46% to 95% of eligible patients. With this increase in TXA use, we observed a 40% reduction in red blood cell transfusion. The impact was greater in patients with pre-operative anemia, but was also effective in non-anemic patients. The threshold for transfusion was not different after initiating our protocol and patients were discharged with higher red blood cell counts. Length of hospital stay remained constant and the incidence of adverse events did not increase.

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Erythomycin Allows Gastric Emptying To Prevent Aspiration In ER Patients

MedicalResearch.com Interview with:
Christoph Czarnetzki MD, MBA
Division of Anesthesiology
Geneva University Hospitals
Geneva, Switzerland

Medical Research: What is the background for this study? What are the main findings?

Dr. Czarnetzki: In the US, about 40 million patients undergo a general anesthetic each year, and approximately 12,000 broncho-aspirate. Broncho-aspiration of gastric juice may lead to acute respiratory distress syndrome, carrying a 40% mortality rate. The risk is increased 10-fold in patients undergoing emergency surgery. Trauma patients may have ingested food before their accident, or have swallowed blood from oral or nasal injuries. Also, gastric emptying is delayed due to head injury, stress, pain, and opioid medication. Non-trauma patients may have delayed gastric emptying due to paralytic ileus and critical illness, leading to significant residual stomach content even after long fasting periods. Erythromycin, a macrolide antibiotic, and motilin receptor agonist induces antral contractions, and increases the lower esophageal sphincter tone, which is an important barrier against gastro-esophageal reflux. Although gastric emptying properties of erythromycin are well known, its efficacy in patients undergoing emergency surgery has never been investigated before to our knowledge.

In our study we included 132 patients undergoing general anesthesia for emergency procedures and we could show that erythromycin increased the proportion of clear stomach and decreased acidity of residual gastric liquid. Dependent of the definition of empty stomach (less than 40 ml and absence of solid food or completely empty stomach) the absolute risk reduction ranged from 17% to 24%, equivalent to a number needed to treat of four to six patients to produce one completely cleared stomach. Erythromycin was particularly efficacious in non-trauma patients. Adverse effects were minor.

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Pre-Operative Low Blood Pressure Linked To Increased Mortality After Surgery and Anesthesia

Prof. Dr. Robert Sanders MD Assistant Professor, Anesthesiology & Critical Care Trials & Interdisciplinary Outcomes Network (ACTION) Department of Anesthesiology University of Wisconsin, Madison, WIMedicalResearch.com Interview with:
Prof. Dr. Robert Sanders MD
Assistant Professor, Anesthesiology & Critical Care Trials & Interdisciplinary Outcomes Network (ACTION)
Department of Anesthesiology
University of Wisconsin, Madison, WI

Medical Research: What is the background for this study? What are the main findings?

Dr. Sanders: While it is known that chronic raised blood pressure exerts important effects on long term health outcomes, it is unclear how pre-operative blood pressure levels effect risk from surgery. In this study we show that after adjustment for other diseases, high blood pressure does not increase perioperative risk. Rather low blood pressure is associated with an increase in risk of death following surgery and anesthesia.
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Study Links Intraoperative Hypothermia and Transfusion Requirements

Daniel Sessler, M.D. Michael Cudahy Professor and Chair of the Department of Outcomes Research Cleveland ClinicMedicalResearch.com Interview with:
Daniel Sessler, M.D.
Michael Cudahy Professor and Chair of the Department of Outcomes Research
Cleveland Clinic

Medical Research: What is the background for this study? What are the main findings?

Dr. Sessler: That intraoperative hypothermia is well established. However, temperature patterns during surgery are not. We thus evaluated core temperature in more tan 50,000 surgical patients, all of whom were actively warmed with forced air.

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Predictors of Survival from Perioperative Cardiopulmonary Arrests: A Retrospective Analysis of 2,524 Events from the Get With The Guidelines-Resuscitation Registry

Satya Krishna Ramachandran MD FRCA Director, Quality Assurance Department of Anesthesiology University of MichiganMedicalResearch.com eInterview with
Satya Krishna Ramachandran MD FRCA
Director, Quality Assurance
Department of Anesthesiology
University of Michigan

MedicalResearch.com: What are the main findings of the study?

Answer:

  • Background: A cardiac arrest is a life-threatening condition where the heart has stopped beating. This remains one of the biggest fears of patients undergoing anesthesia and surgery. This is a rare complication around anesthesia, with only seven arrests per 10,000 patients undergoing surgeries unrelated to the heart. Although this is a rare complication nowadays, previous research has provided limited understanding of risk factors and outcomes.  Cardiac arrests that happen during or soon after anesthesia and surgery may present themselves in different ways and have differences in survival or further complications. By studying these arrests in a large national database of cardiac arrests called the “Get With The Guidelines – Resuscitation” registry, we were able to identify over 2,500 instances of cardiac arrest occurring during or soon after anesthesia. This database is supported by the American Heart Association and has specific information on patient conditions, life-saving treatments and recovery from the arrests.
  • Findings: Cardiac arrests that happen during or immediately after anesthesia are rare events. But we have found that recovery from these events is much better than previous reports of arrests from other hospital locations. We have also found that life-saving treatment is given extremely rapidly in the operating room and the post-anesthesia care unit. These are two locations that anesthesiologists and peri-anesthesia nurses closely monitor patients for complications. We believe that the better recovery seen in these places is because of the immediate availability of these trained caregivers.

MedicalResearch.com: Were any of the findings unexpected?

Answer:

  • Specifically, recovery from asystole (a type of cardiac arrest where the electrical activity of the heart completely stops) in the operating room is at least three times better than previous reports from other hospital locations. We also found that life-saving treatment was given much faster in these locations. We think this improved survival is mainly because of the presence of trained anesthesiologists and nurse providers who directly monitor and respond quickly to any cardiac arrest situation.
  • Patients developing arrests during or immediately after anesthesia (in the post-anesthesia care unit) were more likely to survive with good brain function than other hospital locations.  We believe that the presence of trained anesthesiologists in both locations improve chances of good recovery due to careful monitoring and immediate responses to these uncommon events.

MedicalResearch.com: What should clinicians and patients take away from your report?

Answer:

  • We found that one out of every three patients who develop a perioperative cardiac arrest survives to hospital discharge. We also found that two out of every three patients who survived had no signs of brain damage after the arrest.
  • We also identified several risk-conditions during hospital admission that reduce the chance of successful recovery from a perioperative cardiac arrest. These include major trauma, heart failure, low blood pressure, electrolyte disturbances, kidney failure, late stage cancer, major infection of the blood, and breathing difficulties. Patients with older age and longer arrest times had reduced chance of successful recovery.
  • The following conditions improved chances of successful recovery from arrests: presence of a heart rhythm abnormality, ventricular fibrillation arrest, and difficulty in keeping open the breathing passage. We showed that patients recover better from cardiac arrests that happen during or immediately after anesthesia, compared to other hospital locations. However, we also found that arrests that happen during weekends and at night have worse outcomes.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Answer:

  • Research into the role of monitoring in preventing postoperative complications including cardiac arrests is essential. There are concerns about inadequate monitoring of postoperative patients in US hospitals. On the other hand, there are concerns that increasing the level of monitoring also increases nursing fatigue to alarms, similar to a “cry-wolf” situation. As most monitoring strategies are potentially associated with immense healthcare benefits, costs and risks, good quality research into the value and effectiveness of monitoring postoperative patients is essential.
  • We also found that patients who had signs of brain damage at the time of hospital admission had the lowest chance of surviving the arrest and recovering their brain function. In these patients, the chance of good recovery was low, even if they did not have any other major risk-conditions listed above. On the other hand, patients who had good brain function at the time of hospital admission had a good chance of recovery even if they had many risk-conditions listed above.  Future research into do-not-resuscitate orders needs to incorporate this finding.

Citation:

Predictors of Survival from Perioperative Cardiopulmonary Arrests: A Retrospective Analysis of 2,524 Events from the Get With The Guidelines-Resuscitation Registry

Ramachandran, Satya Krishna; Mhyre, Jill; Kheterpal, Sachin; Christensen, Robert E.; Tallman, Kristen; Morris, Michelle; Chan, Paul S.; for the American Heart Association’s Get With The Guidelines-Resuscitation Investigators

Anesthesiology., POST AUTHOR CORRECTIONS, 30 April 2013
doi: 10.1097/ALN.0b013e318289bafe