The Impact of Procedural Sedation on Diagnostic Errors in Pediatric Echocardiography

Abstract

Background Infants and young children frequently have difficulty remaining still for an echocardiogram, potentially leading to poor study quality, increasing the likelihood of diagnostic errors. Sedation is believed to improve echocardiography quality; however, its effectiveness has not been demonstrated. We hypothesized that sedation would improve study quality and reduce diagnostic errors. Methods We examined outpatient echocardiograms in children ≤ 36 months from January 2008 – June 2009. We collected variables related to image quality, report completeness and sedation use. Diagnostic errors were identified and categorized. Multivariable analysis identified the odds ratio (OR) and 95% confidence interval (CI) for risk factors for potentially preventable diagnostic errors and the impact of sedation on these errors. Results Among 2,003 echocardiograms, sedation was used in 498 (25%). The overall diagnostic error rate was 6.5%. Most errors (66%) were potentially preventable. Multivariable analysis identified the following risk factors for potentially preventable errors: pre-cardiac procedure (OR 2.19, 95% CI 1.05 to 4.59, P=0.04); moderate anatomic complexity (OR 3.91, 95% CI 2.25 to 6.81, P<0.001); and high anatomic complexity (OR 8.36; 95% CI 3.57 to 19.6, P<0.001). Sedation was independently associated with lower odds for potentially preventable diagnostic error (OR 0.47, 95% CI 0.27 to 0.80, P=0.006). Echocardiograms with sedation had fewer image quality concerns (22% vs. 60%) and fewer incomplete reports (3% vs. 20%) (P<0.001). Conclusions Most echocardiographic diagnostic errors among infants and young children are potentially preventable. Sedation is associated with a lower likelihood of these diagnostic errors, fewer imaging quality concerns, and fewer incomplete reports.

Efficacy of Reconstituted Oral Chloral Hydrate from Crystals for Echocardiography Sedation

“…Distraction techniques, such as video viewing can be successful to obtain complete echocardiographic studies(9) but more recent data have shown that sedation results in higher quality studies and reduces the risk of preventable diagnostic errors, particularly in patients with moderate or high complexity disease(1). It is our general policy to sedate patients needing complete echocardiograms between 1 month and 2 years of age and use distraction techniques above this age.…”

“…Use of sedation in this age group improves image quality and reduces diagnostic errors, particularly in those with more complex disease(1). Chloral hydrate has been the medication of choice for many pediatric echo labs due to its low cost, oral availability (100mg/mL solution) and safety profile.…”

Calculation of Pediatric Left Ventricular Mass: Validation and Reference Values Using Real-Time Three-Dimensional Echocardiography

“…In comparison, echocardiography is quick, less expensive, and widely available. Not infrequently, sedation must be administered to minimize diagnostic errors, 18 although in most cases there is no need for it even if small children are investigated. Established twodimensional techniques are lacking in accuracy to determine LVM because they rely on geometric assumptions and use equations that cannot entirely compensate for the individual shape of a chamber.…”

Predictors of inadequate initial echocardiography in suspected Kawasaki disease: Criteria for sedation

“…Predictor variables collected included the following: patient weight, age, KD criteria fulfilled, IVIG administration prior to TTE, recent antipyretic (ibuprofen, acetaminophen, aspirin [ASA]) use within 6 hours prior to initial TTE, fever within 1 hour of TTE, number of days since start of KD fever, and inflammatory laboratory markers. The age and weight variables were converted into binary variables (≤ or > 2.0 years and ≤ or > 10 kg) as has been done in similar literature and for ease‐of‐use in any resulting management criteria. KD type by criteria fulfilled (Complete, Incomplete) were assigned in accordance with the American Heart Association (AHA)‐endorsed KD diagnostic guidelines at the time of the initial KD TTE .…”