Conference Coverage

Smooth sailing for pediatric hospitalists in nitrous oxide, ketamine sedation



NEW ORLEANS – Pediatric hospitalists were able to safely and effectively deliver nitrous oxide and ketamine sedation to children of all ages in a review of more than 8,000 sedations.

The procedure completion rates were more than 99%.

No patient experienced a major complication defined as death, need for CPR, unplanned intubations, suspected aspirations, or emergency anesthesia consultations. Two unplanned admissions occurred each for nitrous oxide and ketamine, putting the overall rate of major complications at 0.05%.

"This is comparable to the rates by other providers such as pediatric ED physicians or pediatric intensivists in other studies," Dr. Mythili Srinivasan said at Pediatric Hospital Medicine 2013.

Although several studies have illustrated the safe use of ketamine and nitrous oxide for procedural sedation by ED physicians and intensivists, this is the first study to demonstrate the safe and effective use of these agents by pediatric hospitalists.

Patrice Wendling/IMNG Medical Media

Dr. Mythili Srinivasan

"This is important to show since there are barriers in many institutions for pediatric hospitalists to provide deep sedation," she said. "These barriers result in procedures, such as incision and drainage of abscesses, being performed in the operating room by anesthesiologists, which not only raises costs significantly, but also exposes patients to the unnecessary risks of general anesthesia."

The retrospective study was based on the hospitalist sedation program at St. Louis Children’s Hospital, which consists of 50 pediatric hospitalists who provide procedural sedation at multiple settings in the hospital including the emergency department, ambulatory procedure center, and pediatric acute wound service. A variety of sedation agents are used depending on the hospitalist’s training and sedation credentialing.

Dr. Srinivasan analyzed all 8,870 sedations performed by pediatric hospitalists using ketamine and nitrous oxide in the hospital’s quality improvement database from February 2007 to February 2013. Of these, 5,339 involved ketamine (60%) and 3,531 nitrous oxide.

Almost all sedations were deep se­dations, with either inhaled 70% nitrous oxide or IV ketamine, usually after pre-medication with a high dose of oxycodone,
said Dr. Srinivasan of Washington University in St. Louis.

Sedation was used in a wide age range of children (6 months through 18 years), with about 72% of children between 1 and 12 years. Almost half of ketamine sedations and more than three-fourths of nitrous oxide sedations were performed in the pediatric acute wound clinic.

Abscess incision and drainage was the most common procedure requiring sedation, followed by other wound debridement/laceration repair, fracture reduction/casting, and radiologic imaging.

Only 0.12% of sedations were not completed due to inadequate sedation, Dr. Srinivasan said at the meeting, cosponsored by the Society of Hospital Medicine, American Academy of Pediatrics, and Academic Pediatric Association. The desired sedation level was not achieved in 1.71% of sedations.

The overall rate of respiratory events was 2.15% for ketamine and 0.91% for nitrous oxide, with airway obstruction reported in 0.97% and 0.57% of patients, respectively. To put this in perspective, a large, pooled analysis involving 8,282 pediatric ketamine sedations by ED physicians reported an airway and respiratory event rate of 3.9% (Ann. Emerg. Med. 2009;54:158-68.e1-4), she said.

Overall rates for airway interventions were low for both ketamine and nitrous oxide including airway repositioning (4% and 1%, respectively), blow-by oxygen/oxygen by nasal cannula/flow mask (2.3%, 0.33%), and mask ventilation or continuous positive airway pressure (0.43%, 0.08%).

During a discussion of the study, an attendee questioned the generalizability of the results noting that the St. Louis group probably does more pediatric sedations than any other hospitalist group in the United States. It was also noted that the hospital has an extensive training program for pediatric hospitalist sedation (J. Hosp. Med. 2012;7:335-9).

Dr. Srinivasan said a collaborative relationship with anesthesia is important, and that clinicians who don’t do many sedations can find it difficult to judge which patients to sedate.

"I think the most important thing is to judge when you should be sedating and when you should be sending them over to anesthesia, and I think that knowledge comes with experience from sedating more and more children," she said.

As pediatric hospitalists take on more and more sedations, however, they may find this collaborative relationship has its limits. When asked whether hospitalists get reimbursed differently for sedations than anesthesiologists, Dr. Srinivasan said deep sedations by pediatric hospitalists are billed as deep sedations, but likely generate less income than those performed by anesthesiologists.

"We were generating the same income when we were doing our propofol sedations, and so that’s how we had a conflict; they really wanted that revenue back," she added, to a round of laughter.


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