Paediatric out-of-theatre procedural sedation at a tertiary children’s hospital: A prospective observational study

Abstract

This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.Procedural sedation and analgesia (PSA) describes the use of agents, such as sedatives and analgesics, to alleviate anxiety, pain and fear during diagnostic and therapeutic procedures. [1] The South African Society for Anaesthesiologists (SASA) defines the goals of procedural sedation as reducing the patient's fear, anxiety and distress while minimising physical discomfort, pain and psychological trauma, maintaining control of physiological parameters and ensuring patient safety. [2] Inadequate pain management in the paediatric population has the potential for lasting negative consequences and therefore adequate pain management is an essential part of PSA. [3,4] The use of PSA has been validated and extensively researched as an adjunct to facilitate procedures in the paediatric population. [4][5][6] Procedural sedation is a continuum. It ranges from mild sedation, through to moderate and deep sedation, and finally culminates in the induction of general anaesthesia. [2] Sedation should be considered as a dose-dependent change in the level of consciousness that should be titrated according to the patient's response by administration of the minimum amount necessary to avoid unintended deeper levels of sedation. [7] Diagnostic and therapeutic procedures are often facilitated with the performance of moderate to deep sedation, with the patient or the procedure dictating the intended level of sedation required. [4] Unfortunately there is currently no single risk-free sedative that fulfils all the criteria as the perfect agent for PSA. [8] PSA has been performed in various locations throughout our paediatric tertiary referral hospital by anaesthetists and nonanaesthetists. This study sought to understand the nature and extent of PSA provision in the hospital as a precursor to setting up a formalised out-of-theatre sedation service. MethodsA prospective observational study of all consecutive patients <13 years of age requiring PSA for diagnostic or therapeutic indications outside the operating theatre was performed at Red Cross War Memorial Children's Hospital (RCWMCH), a paediatric, tertiary-level referral centre in Cape Town, South Africa (SA). The primary objective was to determine the number of sedations performed. PSA performed in the intensive care unit and the trauma unit were excluded from this study as they would not fall within the remit of an out-of-theatre sedation service were it to be established.During the time of the study, the number of cases was measured by a twice-weekly audit of the scheduled drug books in each ward and outpatient area. Medications known to be used for PSA in each area (dexmedetomidine, propofol, ketamine, midazolam, etomidate, fentanyl or chloral hydrate) were audited and patient hospital numbers correlated with records of procedural sedations kept by the unit manager in each area/ward. The hospital identification numbers were not recorded to preserve anonymity.Attending clinicians completed a data cap...

Paediatric procedural sedation and analgesia in a South African emergency centre: a single-centre, descriptive study

“…Some of the most precious resources are time, beds, space, and the specialists available. It is therefore essential to provide PSA safely to the paediatric patient outside of theatre [ 1 , 2 , 4 ]. Applying evidence-based medicine and newly developed guidelines can provide PSA safely with minimal delays and thus save time, money, and other resources [ 27 , 28 ].…”

“…The Red Cross War Memorial Children`s Hospital (RCWMCH) is the largest paediatric hospital in Africa and is situated in Cape Town. The hospital identified the need for an out-of-theatre sedation service due to the increased need for PSA [ 4 ]. They did an observational study in 2019 with the primary aim of defining the number of cases of PSA performed outside of operating theatre.…”

“…They reviewed 288 sedations; the overall complication rate was low and in line with international literature. These complications included the following: airway obstruction (4.9%), desaturation (4.2%) (defined as saturation < 90% for > 60 s), laryngospasm (0.3%) and nausea and vomiting (2.4%) [ 4 ].…”

Pediatric procedural sedation in African clinical settings: A mixed methods study of African providers’ sedation practices

“…There is currently limited information on procedural sedation practices in LMICs, with published research on pediatric procedural sedation in Africa almost non-existent. A recent prospective observational study at Red Cross War Memorial Children's Hospital in Cape Town, South Africa reported performing ∼200 pediatric procedural sedations per month [12] . However, the study was limited to one city in one country, at one of the largest children's hospitals in Africa.…”