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Background: Pediatric subspecialists routinely provide procedural sedation outside the operating room. No large study has reported trends in outpatient pediatric procedural sedation. Our purpose in this study was to identify significant trends in outpatient procedural sedation using the Pediatric Sedation Research Consortium., Methods: Prospectively collected data from 2007 to 2018 were used for trending procedural sedation. Patient characteristics, medications, type of providers, serious adverse events, and interventions were reported. The Cochran-Armitage test for trend was used to explore the association between the year and a given characteristic., Results: A total of 432 842 sedation encounters were identified and divided into 3 4-year epochs (2007-2011, 2011-2014, and 2014-2018). There was a significant decrease in infants <3 months of age receiving procedural sedation (odds ratio = 0.97; 95% confidence interval, 0.96-0.98). A large increase was noticed in pediatric hospitalists providing procedural sedation (0.6%-9.5%; P < .001); there was a decreasing trend in sedation by other providers who were not in emergency medicine, critical care, or anesthesiology (13.9%-3.9%; P < .001). There was an increasing trend in the use of dexmedetomidine (6.3%-9.3%; P < .001) and a decreasing trend in the use of chloral hydrate (6.3%-0.01%; P < .001) and pentobarbital (7.3%-0.5%; P < .001). Serious adverse events showed a nonsignificant increase overall (1.35%-1.75%)., Conclusions: We report an increase in pediatric hospitalists providing sedation and a significant decrease in the use of chloral hydrate and pentobarbital by providers. Further studies are required to see if sedation services decrease costs and optimize resource use., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

Objectives: Development and validation of the Pediatric Sedation State Scale (PSSS) is intended to specifically meet the needs of pediatric procedural sedation providers to measure effectiveness and quality of care., Methods: The PSSS content was developed through Delphi methods utilizing leading pediatric sedation experts and published guidelines on procedural sedation in children. Video clips were created and presented to study participants, who graded the state of patients during procedures by using the PSSS to evaluate inter- and intrarater reliability by determining the intraclass correlation coefficient. We also compared the PSSS to the Observational Scale of Behavioral Distress-revised during 4 clinically relevant phases of a laceration repair procedure., Results: Six sedation states were defined for the PSSS. Each state was assigned a numerical value with higher numbers for increasing activity states. We included behaviors associated with adequate and inadequate sedation and adverse events associated with excessive sedation. Analysis of interrater and intrarater reliability revealed an intraclass correlation coefficient of 0.994 (95% confidence interval: 0.986-0.998) and 0.986 (95% confidence interval: 0.970-0.995), respectively. Criterion validity was confirmed with respect to the Observational Scale of Behavioral Distress-revised (Spearman r = 0.96). Construct validity was indicated by significant differences in PSSS scores ( P < .001) between 4 phases of a procedure, each having a different degree of painful or distressing stimuli., Conclusions: The PSSS is a 6-point scale that is a valid measure of the effectiveness and quality of procedural sedation in children within the limits of the testing method used in this study., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2017 by the American Academy of Pediatrics.)

Background and Objectives: Preterm and former preterm children frequently require sedation/anesthesia for diagnostic and therapeutic procedures. Our objective was to determine the age at which children who are born <37 weeks gestational age are no longer at increased risk for sedation/anesthesia adverse events. Our secondary objective was to describe the nature and incidence of adverse events., Methods: This is a prospective observational study of children receiving sedation/anesthesia for diagnostic and/or therapeutic procedures outside of the operating room by the Pediatric Sedation Research Consortium. A total of 57,227 patients 0 to 22 years of age were eligible for this study. All adverse events and descriptive terms were predefined. Logistic regression and locally weighted scatterplot regression were used for analysis., Results: Preterm and former preterm children had higher adverse event rates (14.7% vs 8.5%) compared with children born at term. Our analysis revealed a biphasic pattern for the development of adverse sedation/anesthesia events. Airway and respiratory adverse events were most commonly reported. MRI scans were the most commonly performed procedures in both categories of patients., Conclusions: Patients born preterm are nearly twice as likely to develop sedation/anesthesia adverse events, and this risk continues up to 23 years of age. We recommend obtaining birth history during the formulation of an anesthetic/sedation plan, with heightened awareness that preterm and former preterm children may be at increased risk. Further prospective studies focusing on the etiology and prevention of adverse events in former preterm patients are warranted., (Copyright © 2016 by the American Academy of Pediatrics.)

Objective: Increasing demand for pediatric procedural sedation has resulted in a marked increase in provision of pediatric procedural sedation by pediatric critical care physicians both inside and outside of the ICU. Reported experience of pediatric critical care physicians-administered pediatric procedural sedation is limited. We used the Pediatric Sedation Research Consortium database to evaluate a multicenter experience with propofol by pediatric critical care physicians in all settings., Setting: Review of national Pediatric Sedation Research Consortium database to identify pediatric procedural sedation provided by pediatric critical care physicians from 2007 to 2012. Demographic and clinical data were collected to describe pediatric procedural sedation selection, location, and delivery. Multivariable logistic regression analysis was performed to identify risk factors associated with pediatric procedural sedation-related adverse events and complications., Measurements and Main Results: A total of 91,189 pediatric procedural sedation performed by pediatric critical care physicians using propofol were included in the database. Median age was 60.0 months (range, 0-264 months; interquartile range, 34.0-132.0); 81.9% of patients were American Society of Anesthesiologists class I or II. Most sedations were performed in dedicated sedation or radiology units (80.9%). Procedures were successfully completed in 99.9% of patients. A propofol bolus alone was used in 52.8%, and 41.7% received bolus plus continuous infusion. Commonly used adjunctive medications were lidocaine (35.3%), opioids (23.3%), and benzodiazepines (16.4%). Overall adverse event incidence was 5.0% (95% CI, 4.9-5.2%), which included airway obstruction (1.6%), desaturation (1.5%), coughing (1.0%), and emergent airway intervention (0.7%). No deaths occurred; a single cardiac arrest was reported in a 13-month-old child receiving propofol and ketamine, with no untoward neurologic sequelae. Risk factors associated with adverse event included: location of sedation, number of adjunctive medications, upper and lower respiratory diagnosis, prematurity diagnosis, weight, American Society of Anesthesiologists status, and painful procedure., Conclusions: Pediatric procedural sedation using propofol can be provided by pediatric critical care physicians effectively and with a low incidence of adverse events.

Background: Pediatric procedural sedation outside of the operating room is performed by a variety of pediatric specialists. Using the database from the Pediatric Sedation Research Consortium (PSRC), patient demographics, medications used, diagnoses, complications, and procedures involved when pediatricians provided sedation in this cohort, were described. 'Pediatrician' was defined as a general pediatrician, cardiologist, endocrinologist, gastroenterologist, hematologist/oncologist, neurologist, pulmonologist or hospitalist., Methods: Data were collected by the PSRC, a group of 35 institutions dedicated to improving sedation care for children. Members prospectively enrolled consecutive patients who received sedation or anesthesia for diagnostic or therapeutic procedures. Data on demographics, primary diagnoses, procedures, medications, interventions, and complications were collected and stored on a Web-based data collection tool., Results: A total of 12 113 sedations performed by pediatricians were submitted from 1 July 2004 to 31 December 2008, compared to 119 665 cases performed by non-pediatricians. Pediatrician patients were more frequently non-emergency American Society of Anesthesiologists (ASA) class I or II, aged 2-8 years old, with a neurologic primary diagnosis, being sedated for a radiologic procedure with a sedative. Distraction techniques were used more frequently in the pediatrician group (11.9% vs 3.1%). The most common complication encountered was inadequate sedation, which occurred 2.2% of the time., Conclusions: Pediatricians sedate for a variety of patients within the PSRC, but the patients tended to be younger, predominately ASA class I or II, non-emergency, and undergoing non-painful procedures when compared to non-pediatrician providers. The patient demographics, medications used, diagnoses, complications, and procedures involved varied between the groups significantly. Complication rates were similar between the groups., (© 2012 The Authors. Pediatrics International © 2012 Japan Pediatric Society.)

Purpose of Review: To illustrate the changes that are occurring in the rapidly growing field of pediatric sedation. In the USA and throughout the world, children receive sedation from a multitude of specialists with varying levels of training. The current pediatric sedation literature reflects a growing body of sedation literature by medical specialists other than anesthesiologists. This article will review the controversial use of propofol by nonanesthesiologists and the manner in which this varied group of providers along with government entities, regulatory agencies, and national organizations contribute to the continuing evolution of sedation practices., Recent Findings: The number of diagnostic and therapeutic procedures performed on children outside of the operating room continues to increase. The growing body of pediatric sedation literature suggests anesthesiologists are no longer at the forefront of pediatric sedation training, education, and research. Articles published by nonanesthesiologists describe pediatric sedation services, safety, and quality initiatives, drugs, and original sedation research. Medications that were considered under the realm of anesthesiologists are utilized by nonanesthesiologists to provide sedation to children. Regulating and government agencies, including the Joint Commission and the Center for Medicaid and Medicare Services have recently issued statements on the oversight and practice of sedation., Summary: The direction of pediatric sedation is no longer solely under the leadership of anesthesiologists. The use of anesthetic agents, including propofol, have been administered by nonanesthesiologists and reported as safe and effective agents. Nonanesthesiologists and governmental and regulatory agencies influence the delivery of sedation services. The future direction of pediatric sedation will ultimately depend upon the ability of anesthesiologists to collaborate with specialists, hospital administrators, credentialing committees, and oversight agencies in order to provide high-quality efficient sedation services to children.

Study Objective: We describe the adverse events observed in a large sample of children sedated with propofol by emergency physicians and identify patient and procedure characteristics predictive of more serious adverse events., Methods: We identified sedations performed by emergency physicians using propofol as the primary sedative, included in the Pediatric Sedation Research Consortium database from July 2004 to September 2008. We describe the characteristics of the patients, procedures, location, adjunctive medications, and adverse events. We use a multivariable logistic regression model to identify predictors of more serious adverse events., Results: Of 25,433 propofol sedations performed by emergency physicians, most (76%) were performed in a radiology department. More serious adverse events occurred in 581 sedations (2.28%; 95% confidence interval 2.1% to 2.5%). There were 2 instances of aspiration, 1 unplanned intubation, and 1 cardiac arrest. Significant predictors of serious adverse events were weight less than or equal to 5 kg, American Society of Anesthesiologists classification greater than 2, adjunctive medications (benzodiazepines, ketamine, opioids, or anticholinergics), nonpainful procedures, and primary diagnoses of upper respiratory illness or prematurity., Conclusion: We observed a low adverse event prevalence in this largest series of propofol sedations by emergency physicians. Factors indicating greater risk of more serious adverse events are detailed., (Copyright © 2011 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.)

Aim: To compare the quality between 2 commonly used sedation practices for upper endoscopic ultrasound (EUS) by using expert observational analysis of the sedation practice., Methods: After institutional review board approval, 50 adults undergoing EUS had videotape observation of the procedural sedation: 25 received benzodiazepine/opiate administered by the endoscopy team as per the standard protocol at our institution, and 25 received propofol administered by a dedicated anesthesiologist. Quantitative analysis of the video was performed using the Dartmouth Operative Conditions Scale (DOCS). The DOCS is a tool previously developed to quantify the adequacy of procedural sedation through an objective measurement of the patient state during the sedation process. In this study, the DOCS was used in a novel way to compare the quality of sedation provided by different sedation protocols. Data were collected on patient demographics, patient and provider satisfaction, efficiency, side effects, and safety measures., Results: Videotape analysis using the DOCS revealed that 52% (13/25) of the standard group exhibited an uncontrolled patient state (significant undersedation and/or oversedation) on 1 or more occasion during their EUS procedure compared with 28% (7/25) of the propofol group. Patients in the standard group spent 7.1% of the procedure in an uncontrolled patient state, whereas patients in the propofol group experienced an uncontrolled state approximately 1.0% of the procedure time. Overall efficiency as measured by time in both the procedure room and in recovery was superior in the propofol group. These patients spent 12 less minutes on average in the procedure room and were ready for discharge in about half the time (56 minutes versus 109 minutes). The propofol group experienced significantly less in-hospital and at-home nausea and vomiting and felt back to baseline status more quickly. Finally, patient satisfaction was improved in the propofol group: 60% felt the procedure was better than anticipated versus 21% in the standard group., Conclusions: Expert videotape analysis of the patient state during procedural sedation allows direct comparison of sedation methodologies using small numbers of patients. In our institution, endoscopist-directed sedation using a midazolam/narcotic combination for EUS proved inferior to sedation using propofol given by an anesthesiologist. Specifically, a midazolam/narcotic combination provided less effective intraprocedural conditions, was less efficient both before and after the procedure, and was less satisfactory to patients as compared with propofol. Results of this type of analysis can be used to drive appropriate system redesign and improve patient care.

Objective: We used a large database of prospectively collected data on pediatric sedation/anesthesia outside the operating room provided by a wide range of pediatric specialists to delineate the nature and frequency of adverse events associated with propofol-based sedation/anesthesia care., Patients and Methods: Data were collected by the Pediatric Sedation Research Consortium, a collaborative group of institutions dedicated to improving sedation/anesthesia care for children internationally. Members prospectively enrolled consecutive patients receiving sedation or sedation/anesthesia for procedures. The primary inclusion criterion was the need for some form of sedation/anesthesia to perform a diagnostic or therapeutic procedure outside the operating room. There were no exclusion criteria. Data on demographics, primary illness, coexisting illness, procedure performed, medications used, procedure and recovery times, medication doses outcomes of anesthesia, airway interventions and adverse events were collected and reported using web-based data collection tool. For this study, we evaluated all instances where propofol was used as the primary drug in the sedation/anesthesia technique., Results: Thirty-seven locations submitted data on 49,836 propofol sedation/anesthesia encounters during the study period from July 1, 2004 until September 1, 2007. There were no deaths. Cardiopulmonary resuscitation was required twice. Aspiration during sedation/anesthesia occurred four times. Less serious events were more common with O(2) desaturation below 90% for more than 30 s, occurring 154 times per 10,000 sedation/anesthesia administrations. Central apnea or airway obstruction occurred 575 times per 10,000 sedation/anesthesia administrations. Stridor, laryngospasm, excessive secretions, and vomiting had frequencies of 50, 96, 341, and 49 per 10,000 encounters, respectively. Unexpected admissions (increases in levels of care required) occurred at a rate of 7.1 per 10,000 encounters. In an unadjusted analysis, the rate of pulmonary adverse events was not different for anesthesiologists versus other providers., Conclusions: We report the largest series of pediatric propofol sedation/anesthesia for procedures outside the operating room. The data indicate that propofol sedation/anesthesia is unlikely to yield serious adverse outcomes in a collection of institutions with highly motivated and organized sedation/anesthesia services. However, the safety of this practice is dependent on a system's ability to manage less serious events. We propose that our data suggest variables for training and credentialing providers of propofol sedation/anesthesia and the system characteristics that promote safe use of this drug.

The application of sedation/analgesia in paediatric patients is rapidly expanding as less invasive, non-operative techniques of diagnosis and treatment are applied to the paediatric population. Medical providers who are asked to provide sedation may include radiologists, paediatricians, nurses and emergency physicians, as well as anaesthesiologists and intensive care physicians. At the same time, the range of drugs used in these settings has expanded considerably. As there is no single drug fulfilling the criteria for the ideal sedative (rapid-onset, rapid recovery, no adverse effects, immobility appropriate to procedure being performed), multiple drugs may be used in combination. It is imperative that practitioners using drugs for sedation/analgesia in children be aware of the adverse effect profile(s) of these drugs, both individually and in combination. The purpose of this review is to describe the adverse effects of sedative and reversal agents currently used in paediatric sedation/analgesia.