Scope for improvement: hospital wide sedation practice at a children's hospital

Pediatric Sedation in Dutch Dental Clinics: The Influence of Guideline Modifications on Adverse Events

Background: Dental fear and uncooperative behavior can hinder dental treatment quality. Pediatric Procedural Sedation and Analgesia (PPSA) is used to facilitate treatment when the coping capacity is exceeded. Out-of-hospital PPSA has been associated with more adverse outcomes compared to when it is used in hospital-based settings. The updated Dutch PPSA guidelines have increased costs and raised concerns about the accessibility of specialized high-quality dental care for children in the Netherlands. This study aimed to investigate the impact of the updated 2017 guidelines on the occurrence rate of adverse events during PPSA in twelve Dutch dental clinics. Methods: The data of 25,872 children who were treated at twelve dental clinics between 1997 and 2019 were analyzed. A logistic two-level mixed-effects model was used to estimate the updated guidelines' impacts on adverse events. Results: The OR of the occurrence rate of an adverse event adjusted for age, weight, and duration of treatment was 0.75 (95% CI 0.64-0.89) after the implementation of the updated guidelines. This outcome was significant with p = 0.001, indicating a protective effect. Conclusions: Our findings demonstrate that there was a significant reduction in adverse events after the implementation of the updated guideline and highlight the importance of adhering to evidence-based practices in out-of-hospital dental clinics.

Professional skills and competence for safe and effective procedural sedation in children: recommendations based on a systematic review of the literature

Objectives. To investigate which skills and competence are imperative to assure optimal effectiveness and safety of procedural sedation (PS) in children and to analyze the underlying levels of evidence. Study Design and methods. Systematic review of literature published between 1993 and March 2009. Selected papers were classified according to their methodological quality and summarized in evidence-based conclusions. Next, conclusions were used to formulate recommendations. Results. Although the safety profiles vary among PS drugs, the possibility of potentially serious adverse events and the predictability of depth and duration of sedation define the imperative skills and competence necessary for a timely recognition and appropriate management. The level of effectiveness is mainly determined by the ability to apply titratable PS, including deep sedation using short-acting anesthetics for invasive procedures and nitrous oxide for minor painful procedures, and the implementation of non-pharmacological techniques. Conclusions. PS related safety and effectiveness are determined by the circumstances and professional skills rather than by specific pharmacologic characteristics. Evidence based recommendations regarding necessary skills and competence should be used to set up training programs and to define which professionals can and cannot be credentialed for PS in children.

Agitation during procedural sedation and analgesia in children

BACKGROUND

Agitation that occurs in children receiving standard procedural sedation regimens may indicate inadequate patient comfort and compromise procedural success. Although agitation in uninterrupted pediatric procedures is recognized to occur, it is not generally tracked as an adverse event, and there have been no formal studies to determine its rate of incidence.

METHODS

We identified intraprocedural agitation in a large cohort of children undergoing standardized sedation regimens in a tertiary care pediatric hospital over a calendar year and compared it with rates of well-accepted quality measures of sedation using odds ratio analysis, with 95% confidence intervals (CIs). All analyses excluded those patients who were documented to fail to sedate or to wake before the procedure was over-2 tracked adverse events that involve agitation and aborted, interrupted, or incomplete procedures.

RESULTS

Agitation occurred in 433 of 5045 (8.6%) procedures during the study period, including 306 (6.1%) who had an uninterrupted, complete procedure. In contrast, severe adverse events during sedation, including cardiovascular resuscitation and allergic reactions, were exceedingly rare (0.9 %). When excluding patients who woke during the procedure or who failed to sedate, we found that the odds ratio for the association between agitation and tracked adverse events was 2.9 (95% CI = 1.7-4.8; P < .001).

DISCUSSION

A clinically significant number of children appear agitated during standard procedural sedation and analgesia. In addition, agitation in children undergoing uninterrupted procedures was associated with other adverse events. Identifying risk factors for agitation is fundamental to improving the quality of procedural sedation in children.