Pediatric Scott

Keeter,

PhD

Sedation of Current

#{149} Richard

M. Benator,

in Pediatric Practice’

To document current sedation practices in computed tomographic (CT) examination of children, a questionnaire was sent to a random sample of 2,000 hospitals with CT scanners in the United States. Responses were received from 834 hospitals (42%). Of these, 450 were reported to conduct pediatric CT with sedation. Approximately one-half of the examinations were conducted in pediatric hospitals or medical schools. Most hospitals did not require signed consent for CT with light sedation, even when intravenously or orally administered contrast medium was used. Signed consent for CT with deep sedation was required in 62% of hospitals. Monitoring techniques and personnel present during CT with sedation varied greatly, as did oral intake protocols for examinations with oral contrast material or no contrast material. Use of intubation during CT with oral contrast medium was rare. Orally administered chloral hydrate was the most frequently used first-line drug for sedation in most types of CT studies. The great variation in practices indicates a lack of settled standards for sedation during pediatric diagnostic examinations. Many procedures reported for pediatric CT with sedation are at variance with recommendations of the American Academy of Pediatrics. Index

terms:

raphy (CT), ed tomography Radiology

I

23284

Anesthesia #{149} Computed in infants and children (CT), technology 1990;

tomog#{149} Comput-

S

#{149} Stuart

CT:

M. Weinberg,

MD

computed tomography (CT) been used for pediatric evaluation, sedation has often been necessary for adequate imaging. Various methods of sedation have been used, ranging from general anesthesia to light conscious sedation (1-7). These techniques vary from institution to institution and even from physician to physician within the same institution. To our knowledge, there is currently no consensus about the best

of Anesthesiology,

Mercy

Medical

Center,

MATERIALS

has

sedation protocol, non do we know what techniques are most frequently used in the national medical community. In addition, conflicting medical concerns are present when contrast material is orally administered in the presence of sedation. The standard protocol for anesthesia requires that the patient have an empty stomach before elective sedation is performed, to minimize risk of aspiration (8), while adequate technique for CT with oral contrast medium in pediatnc patients requires administration of the contrast medium approximately 20 minutes to 4 hours before the examination, to optimize the image (1,2). Presently, we know little about how physicians resolve this conflict. To document current sedation practices for pediatric CT examinations, during 1988 we conducted a mail survey of a lange sample of U.S. hospitals with CT scanners and outpatient departments. The results indicate considerable variation in drug regimens, monitoring, and airway

Commonwealth Hospital, Baltimore

A. Hartenberg,

MD

Survey

INCE

The

data

based

on

May

AND

reported a mail

oped

CT

10,

by

made

tnibution The plex,

University, St Petersburg, (5MW.);

and

Richmond, Fla (R.M.B.); Department

VA De-

hospidedevel-

preliminarily

at institutions States. After

basis

mailing

of study questionnaire

prelimi-

was

prepared with a

packaged

return for

results. was of

sample throughmodifications

of the

label

consisting

from U.S.

outpatient was

postage-paid

and

are

a convenience

the questionnaire format and

letter,

lope,

of 834

and

with

on the

nary test, in booklet

cover

1988,

authors

mail

of 12 radiologists out the United

were

article

conducted

scanners and The questionnaire

by the

tested

this

survey,

1 to July

tals with partments.

in

METHODS

enve-

eventual long

13 pages

dis-

and and

corn-

30 ques-

tions, some of which had multiple pants. Separate sections were used to gather data

on a variety

of topics:

the responding ities, caseload, practices

characteristics

of sedation

in

pediatric

cluding staff in attendance, practices, drug regimens, the patient had received mouth (ie, NPO ties of questions

CT with

oral

plications

of

hospitals, including faciland affiliations; standard

status); an on sedation

contrast

resulting

CT,

in-

monitoring and whether anything by extended practices

material; from

sein

and

sedation

cornin

pe-

diatric CT with oral contrast material. Because the questionnaire is too lengthy to reproduce in this paper, a copy is available on request author. Completed an extensive ing before puterized items,

from

the

corresponding

questionnaires

underwent

process of review being keypunched

data questions

ened missing and were not Additionally,

and into

file for analysis. left blank were data for purposes entered in any when respondents

value

was

were

excluded

To

requested,

ensure

terms

these

from that

the

conscious

(or

the

of analysis calculations. providon gave a single

responses

analysis.

meaning light)

coda corn-

For all consid-

ed ambiguous answers to items multiple responses when only

175:745-752

Virginia All Children’s

#{149} Michael

National

management.

From the Survey Research Laboratory, (5K.); Department of Radiology,

partment

MD

Radiology

of the sedation,

deep

of Radi-

ology, Henrico Doctor’s Hospital, Richmond, Va (M.A.H.). Received July 10, 1989; revision requested August 9; revision received November 6; accepted December 7. Supported by an AD. Wilhams grant from the Medical College of Virginia and by the Survey Research Laboratory, Virginia Commonwealth University. Address reprint requests to 5K. © RSNA, 1990 See also the editorials by Cohen (pp 611-612) and Fisher (pp 613-615) in this issue.

Abbreviations:

AAP

Pediatrics, tion, gy,

AHA

ASA ECG

= =

American

American

American

Society

Academy

Hospital

of

Associa-

of Anesthesiolo-

electrocardiograph.

745

Table

1

of Hospital

Summary

Beds, Pediatric

Beds, and Pediatric

CT Performed

No. of Hos pital

with

Sedation

No. of Ped iatnic Beds

Beds

by Type

of Hospital

No. of Pediatric CT Studies Done with Sedation per Week

No. of Hospital

Hospitals

Mean

Median

Mean

Median

29

347

225

166

175

13.80

28

517

485

70

50

4.92

98 279

437 230

428 200

42

26

2.48

18

14

434

303

250

37

20

Pediatric Medical

school

Affiliated with Unaffiliated

medical

school

Total

Mean

Median

Percentage of All CT Studies

Total 400.25

36

1.16

7.00 3.50 1.50 1.00

142.75 238.56 321.97

13 22 29

2.56

1.00

1,103.53

100

Note.-The

mean number of hospital beds exceeds the number of pediatric beds for hospitals classified as pediatric hospitals. Because we accepted a characterization of the hospital, we presume this anomaly results from one of the three following sources: (a) Some nonpediatnic beds are located in pediatric hospitals. (b) Some respondents classified nonpediatnic hospitals as pediatric hospitals. (c)Some pediatric hospitals did not include neonatal beds as pediatric beds. * All CT studies reported in the entire sample. respondent’s

sedation,

and

general

anesthesia

or were

would

be the same for all respondents, the questionnaire included the following definitions, as provided by the Section on Anesthesiology of the American Academy of Pediatrics (AAP) (9): Conscious

(or light)

sedation-A

minimal-

ly depressed level of consciousness that retains the patient’s ability to maintain a patent airway independently and continuously and respond appropriately to physical

stimulation

mand their

(ie, patients eyes

on give

and/on

should similar

verbal

be able response

com-

to open

bal commands). Deep sedation.-A controlled state of depressed consciousness from which the patient is not easily aroused, which may be accompanied by a partial on complete loss of protective reflexes, including the ability to maintain a patent airway independently and respond purposefully to physical stimulation or verbal commands. General anesthesia-A controlled state of unconsciousness accompanied by a loss of protective reflexes, including the ability to maintain an airway independently and respond purposefully to physical stimulation or verbal command. A sample of 2,000 hospitals was randomly selected from the 1987 American Hospital Association (AHA) Abridged Guide. The survey packet was mailed to the chief radiologist at each hospital in the sample. One week after the first mailing, a reminder was sent by postcard to all hospitals in the sample, and approximately 3 weeks later a second questionnaire and cover letter were sent to all hospitals that had not yet responded. Responses were eventually received from 834 hospitals, for a response rate of 42%. In these 834 responses, 450 respondents reported that they conduct sedation in pediatric CT. To ascertain the nepresentativeness of the respondents, a telephone survey of 99 randomly selected nonresponding hospitals

was

conducted

from

June

23 to July

1988. In addition, a number of characteristics available in the AHA database were compared between responding and nonresponding hospitals. Responding and nonnesponding hospitals were similar in terms of overall size (number of beds), the percentages that were medical schools 746

Radiology

#{149}

hospitals atnic beds

5,

with

medical

schools,

had, and

on the average, fewer conducted a smaller

pedimean

number of pediatric CT examinations with sedation pen week than responding hospitals.

Overall,

however,

the sample due to nonresponse relatively minor. The analysis of the survey sists

to yen-

affiliated

the likelihood of sedation being conducted in pediatric CT, and the likelihood of oral contrast material being used with sedation in pediatric CT. Nonresponding

principally

of the

the

biases

in

appeared results

to differences

among

and

hospitals,

facilities

with

many

pediat-

a

asked

wheth-

ric beds. Similarly,

other

questions

en the hospital was a medical school or affiliated with a medical school. Hospitals were classified according to the answers to these items and were placed in only one category (eg, a pediatric hospital affiliated with a medical school was classified as a pediatric hospital). The resultant groupings included pediatric hospitals (n 29), medical schools (n 28), hospitals affiliated with medical schools (n 98), and unaffiliated hospitals (n

279).

The number of pediatric CT studies performed with sedation among different hospitals varied greatly. Reported practices of hospitals with a heavy caseload

survey

Because

for

tion

statistical test of significance is reported. For the purpose of comparing practices at different types and sizes of hospitals, respondents were grouped according to answers to several preliminary questions. The first item on our questionnaire was “Is the hospital in which you practice a pediatric hospital?” We accepted a mespondent’s own definition of a pediatric hospital, and an inspection of the hospital names showed that most were children’s hospitals; however, several were large multipurpose

tions.

of this,

the

results

are reported in two ways: In the Discussion section and in the numbers in all tables, the hospital is used as the unit of analysis. However, adjacent to most percentages or means cited in the text, a cornparable statistic in brackets is provided, with the reported caseload used as the bacomputation.

Thus,

bracketed

numbers are weighted by the reported weekly overall caseload. For example, 14% of hospitals reported that a pediatric radiologist performed most of the pediatric CT examinations that included seda-

comparison of percentages and means from the various items of interest. Because of the extensive volume of data gathered in the study, our article focuses on data chosen to summarize the current practices of hospitals with regard to sedation in pediatric CT and, when relevant, explores the differences in practices among types of hospitals. When reference is made

those in hospifew examina-

sis

con-

presentation

were often different than tals conducting relatively

and

oral

contrast

material.

On

a case-

load basis, however, one-half of all such CT examinations were supervised by a pediatric radiologist, since pediatric and medical school hospitals conducted a disproportionate share of such examinations and were more likely to have a pediatric radiologist on the staff. In the text, this finding is presented as follows: Fourteen percent of hospitals [50%] reported that a pediatric radiologist performed most of the CT examinations that included oral contrast

material

and

sedation.

For several questions, respondents were asked to provide data on their practices with respect to five different age groups

of patients:

young

infant

(0-4

months of age), older infant (4 months to 1 year of age), toddler (1-3 years of age), young child (3-5 years of age), and older child (more than 5 years of age). Realizing that these age categories might not constitute a universal standard for sedation decisions, we asked respondents to indicate if they preferred a different breakdown. Hardly anyone objected to these age groupings, but some respondents said they preferred to use the patient’s body weight or surface area as the major factor in choosing a drug regimen.

RESULTS Prevalence CT Studies ied

As would greatly

and Types of Pediatric with Sedation be expected, hospitals varin their caseload of pediatric

June

1990

sedation

Table

2

Mean

Reported

regimen

sibility

of Pediatric

Percentages

Patients

Undergoing

Each Type

of

Sedation Sedation

Young

Older

Young

Older

Infant

Infant

Toddler

Child

Child

60 33 6

31 56 12

20 61 16

38 48 12

75 20 4

0

0

1

1

1 2

1 1

0 1

None Light Deep

General anesthesia Without intubation With intubation

100

Total Note-Data

are from

Table 3 Staffing,

all responding

Informed

100

100

100

100

hospitals.

Consent,

and

Monitoring

Procedures

in

Pediatric

CT with

Sedation

for

and

it (Table

assumes

3),

nespon-

while

37%

me-

ported that the primary care physician is in charge. A combination of personnel (usually the radiologist and the pnimany care physician) is responsible in 13% of hospitals responding; an anesthesiologist, in 3% [but less than 1% of overall caseload]; and a nurse anesthetist, in 1% [about 2% of overall caseload]. Four hospitals reported that a nurse

anesthetist

assumed

nesponsibil-

ity for pediatric sedation. Of these four, one stated that the nurse anesthetist meported to an anesthesiologist, two stated that the nurse anesthetist reported to a radiologist, and one stated that the nurse anesthetist was free-standing on independent (ie, did not report to anyone).

No.

Variable

Who decides the sedation Anesthesiologist

regimen

13(3)

208(47)

Primary

164(37) 4(1) 58(13)

care physician

Nurse Other

anesthetist personnel or combination Is a special room provided for preparation

and recovery?

Yes, for preparation only Yes, for recovery only Yes, for preparation and recovery No, no separate room Signed consent is needed for examinations Oral contrast medium iodinated

Light

sedation

Deep

sedation

contrast

General anesthesia Light sedation is performed Deep sedation is performed Note-Numbers

in parentheses

done

at each

of

hos-

Although pediatric hospitals accounted for less than 7% of all hospitals that reported conducting this type of CT study, they conducted 36% of all CT studies reported, with a mean weekly prevalence of 13.80, compared with 4.92 per week at medical schools, 2.48 at medical school-affiliated hospitals, and 1.16 per week at unaffiliated hospitals (the difference between pediatric hospitals and all others in mean numben of CT studies performed pen week was significant [P < .001], as was the difference between pediatric hospitals and medical school hospitals [P < .005]). When the data for pediatric (36% of all CT studies) and medical school hospitals (13%) are combined, about one-half of the CT studies performed with sedation in the United States are done in hospitals where the procedure routine;

one-half

occur

Volume

175

however,

in settings

Number

#{149}

about

where

3

14(3) 181 (42) 94(23) 230 (62) 361 (94) 374 (88) 151 (36)

are percentages.

type

a

one-fourth

of

hospitals

re-

varied

according

to

the

type

of

ex-

amination and the type of hospital. Only 3% [6%] of hospitals required signed consent for CT examinations with oral contrast material. This practice did not vary significantly among the types of hospitals. An overall average of 58% [63%] did not require signed consent for intravenously administered iodinated contrast material. For light sedation, most hospitals (77%) [79%] did not require signed consent, where-

requiring:

in CT examinations

pital.

is relatively

sent

63(14) 313(71)

in CT examinations

CT studies performed with sedation. Table 1 shows the mean number of hospital beds, pediatric beds, and pediatric CT examinations performed with sedation per week for each type of hospital. It also shows the percentage of all such examinations

40(9) 24 (5)

medium

than

ported having a separate room for sedation, but among pediatric and medical school hospitals, 40% had a separate room (difference was significant, P < .01). Overall, 29% reported having a separate recovery room. The practice of requiring signed con-

and is responsible?

Radiologist

Intravenous

Less

of Responses

mean of fewer than three per week are done: medical school-affiliated hospitals (22%), and unaffiliated hospitals (29%). Respondents were asked to estimate, for each age group, the percentage of patients undergoing CT who underwent no sedation, conscious (or light) sedation, deep sedation, general anesthesia without intubation, and general anesthesia with intubation. Table 2 shows the means for the reported pencentage of patients in each age group receiving each type of sedation. The mean percentage of patients undergoing deep sedation was generally higher for pediatric hospitals and medical

as for

schools

material, with intravenous contrast matenial, and with oral contrast material. Respondents were also asked which staff members were routinely in attendance during the CT examination and the recovery phase. The results for light and deep sedation in CT with oral

than

for

other

types

of

facili-

ties. For example, the mean percentage of olden infants receiving deep sedation at pediatric hospitals was 23% (22% at medical schools), compared with a mean of 9% at unaffiliated hospitals (differences were significant, P < .05, except in older children).

Informed Consent and Monitoring

About one-half ported that the

of hospitals (47%) neradiologist decides the

sedation

between

was

most

pediatric

respondents

hospitals

significant,

types

of

and

P < .01).

Most

(94%)

indicated

hospitals

others

of all that

signed consent was required for genenal anesthesia. This practice did not vary significantly among the groups. A parallel set of questions was posed to evaluate the intensity of monitoring in

pediatric

CT

examinations

with

and deep evaluated

sedation. Techniques for specific types

ies:

performed

those

contrast

and

Staffing, Practices,

deep

(62%) [44%] did require signed consent. However, many pediatric hospitals (68%) and medical schools (54%) did not require signed consent (difference

with

material

are

light

were of CT studno

shown

contrast

in

Tables

4

5. For

light

without

sedation

contrast

in CT performed material,

CT technician staff member

was, most

in

during

attendance

the

regular

as expected, frequently the

CT

the listed study

Radiology

as (94%

#{149} 747

Table

4

Personnel

in Attendance

for

Pediatric

CT Examinations

Performed

with

Light

Sedation

and

Oral COntrast

Material

Type of Hospital

Pediatric (n 22)

Personnel

Affiliated with Medical School (a 78)

School 24)

Medical (n

Total (n

354)

=

18 (82) 6 (27)

21 (88) 8 (33)

72 (92) 28 (36)

Licensedpracticalnurse

1(5)

0(0)

5(6)

9(4)

15(4)

Registered

6 (27)

12 (50)

27 (35)

51 (22)

96(27)

Regular Additional

CT technician CT technician nurse care physician

Primary

Radiologist Anesthesiologist Nurse anesthetist

Note-Numbers

Table

327 (92)

86 (37)

0 (0)

1 (4)

3 (4)

2 (1)

12 (50) 0(0) 0 (0)

41 (53) 0(0) 0 (0)

127 (55) 2(1) 1 (0)

2(9)

12(50)

6 (27)

2 (8)

0(0)

1(4)

12(15) 17 (22) 1(1)

3(1) 49 (21) 1(0)

or parent

Volunteer Other

216 (94)

10 (45) 0(0) 1 (5)

Residettt

128(36) 6(2) 190(54)

2(1) 2(1) 29(8) 74(21) 3(1)

are percentages.

in parentheses

5

Personnel

in Attendance

Pediatric

for

CT Examinations

Performed

with

Deep

Sedation

Affiliated

Pediatric (n 17)

Personnel

Regular Additional

CT technician CT technician

presence

748 #{149} Radiology

an

(n

Total

74)

(n

=

146)

59(40) 11(8)

9(53) 0 (0)

13(65) 1 (5)

18(51) 2 (6)

28(38) 0 (0)

68(47) 3(2)

8 (47)

13 (65)

19 (54)

41 (55)

10 (29) 6(17)

31 (42)

81 (55) 52(36) 27(18) 28(19) 21(14) 3(2)

8 (40) 3(15) 14(70) 3(15)

10(29) 7(20) 1(3)

0(0)

1(6)

of

Unaffiliated

132(90)

16(22) 1(1) 8(11) 1(1)

are percentages.

the

per-

centage of other staff members was similar to that in CT performed with sedation, with or without oral contrast medium. The patterns of staff in attendance during CT performed with deep sedation were similar to those reported for CT with light sedation; however, with deep sedation, 38% overall [19%] methe

35)

29 (39) 5(7)

3(18) 3(18)

but

(n

69 (93)

3 (18) 2(12)

[73%],

20)

with School

16 (46) 5(14)

of hospitals), followed by the radiologist (55%) [52%], an extra CT technologist (36%) [38%], a registered nurse (27%) [29%], and a volunteer aide or parent (20%) [12%]. Pediatric hospitals differed little from the others. At medical school hospitals, however, a resident (54%; difference was significant, P < .001) on a registered nurse (50%; difference was significant for two of the three types of studies, P < .05) was much more likely to be in attendance. Staff in attendance during CT penformed with oral contrast medium was nearly identical to that during CT penformed with sedation and no contrast material. When intravenous contrast material was used, the overall frequency of a radiologist being in attendance 70%

Medical

29 (83)

Volunteerorparent Other

to

School

6 (30) 0(0)

Nurseanesthetist Resident

increased

Material

18 (90)

physician

in parentheses

Contrast

8 (47) 1(6)

Anesthesiologist

Note-Numbers

Oral

16 (94)

Licensedpraticalnurse Registerednurse Primary care Radiologist

Medical (n

and

of Hospital

Type

ported

Unaffiliated (n = 230)

anesthesiolo-

gist (compared with 1% for CT with light sedation) and/or a nurse anesthetist (19% [10%], compared with 1% for CT with light sedation). As in CT with light sedation, residents were more likely to be present at medical schools (difference was significant, P < .001). These practices did not vary with the type of contrast material used in the study.

Respondents were also asked which staff members were in attendance duning the recovery phase of CT examinations with light and deep sedation. The form of this question differed slightly from the one asking about staff in attendance during the examination, which provided respondents with a list to check. For this item, they were instructed to list the staff members. Among those who provided a list, for light sedation, one-half mentioned the regular CT technician; 43%, a registered nurse; 34%, the radiologist; 13%, a volunteen aide or parent; and less than 10% each for several other types of staff members. For CT with deep sedation, 57%

said

a registered

present; 25% [42%], 21%, an anesthesiologist;

nurse

the

was

radiologist; 13%, a nurse

anesthetist; and 12% [21%], a resident. For CT with light and deep sedation, the most common monitoring technique used by all respondents was visual inspection. Tables 6 and 7 present the monitoring techniques employed for CT examinations with light and deep sedation and oral contrast matenial (results were similar for CT with intravenous contrast material and no contrast material). For CT with light sedation, a pulse oximeter, electmocardiograph (ECG), respiratory monitor, or automatic blood pressure device was used routinely by 1%-5% of hospitals. For CT with deep sedation, an ECG (45%-46%) was the most common device used, followed by a respiratory monitor (25%-26%), a pulse oximeter (20%-22%), and an automatic blood pressure device (15%-l7%). Among pediatric hospitals, the most common device used in CT with light sedation was a pulse oximetem (27%-32%) [51%-53%J. In CT with deep sedation, the use of pulse oximeters was increased at pediatnic hospitals (47%-53%) [70%-73%]. Because the question about monitoring techniques allowed multiple answers, we reconfigured the data in an

June

1990

Table

6

of Patients

Monitoring

Undergoing

Pediatric

CT with

Light

and Oral Contrast

Sedation

Type

Material

o f Hospital

Affiliated Monitoring

Pediatric (n 22)

or Device

Procedure

Visual From control room In room with patient Intermittent inspection with and respiratory measurements ECG Respiratory monitor

blood

Pulse

blood pressure device carbon dioxide monitor oximeten

or

and electromechanical Note-Numbers

visual device

in parentheses

=

Unaffiliated

79)

(n

228)

(n

Total 352)

22 (96) 6 (26)

76 (96) 10 (13)

216 (95) 54 (24)

335 (95) 76(22)

5 (23) 4(18) 3 (14)

11 (48) 4(17)

19 (24) 1(1)

53 (23) 7(3)

88(25) 16(5)

1 0 2 3

6 (27) 0(0)

Any type of electromechanical device Visual inspection and electromechanical device inspection

(a

21 (95) 6 (27)

1 (5) 0 (0)

Other

Intermittent

23)

(n

with School

pressure

Automatic Expired

Medical

MedicalSchool

(4) (0) (9) (13)

2(3) 3 (4) 0 (0) 0 (0)

7 5 0 6

(3) (2) (0) (3)

13(4) 9(3) 2(1) 15(4)

0(0)

0(0)

1(0)

1(0)

8 (36)

8 (35)

5 (6)

16 (7)

37(11)

7(32)

7(30)

5(6)

16(7)

35(10)

14 (61)

22(28)

monitoring 10(45)

61 (27)

107(30)

are percentages.

Table? of Patients

Monitoring

Undergoing

Pediatni

c CT with

Dee p Sedation

and Oral Contrast Type

Monitoring

Procedure

or Device

Pediatric (n 17)

Medical (n

=

School 19)

Material

of Hospital Affiliated with Medical School (ii = 34)

Unaffiliated (n = 72)

(n

Total = 142)

Visual

From control room In room with patient Intermittent

Respiratory Automatic

monitor blood pressure

Expired Pulse

with blood measurements

inspection

and respiratory ECG carbon

dioxide

device monitor

oximeter

of electromechanical device inspection and electromechanical

Intermittent

inspection

on visual

and electromechanical Note-Numbers

175

Number

#{149}

3

64 (89) 40 (56)

131 (92) 76(54)

8 (47) 11 (65)

10 (53) 10 (53)

19 (56) 17 (50)

43 (60) 26 (36)

5 (29)

5 (26)

9 (26)

17 (24)

80(56) 64(45) 36(25)

3 (18) 1 (6) 9 (53)

2 (11) 2 (11) 7 (37)

3 (9) 1 (3) 5 (15)

13 (18) 4 (6) 8 (11)

21 (15) 8(6) 29(20)

0(0)

0(0)

2(6)

1(1)

14 (82)

13 (68)

18 (53)

33 (46)

78(55)

3(2)

14 (82)

13 (68)

18 (53)

32 (44)

77(54)

15 (88)

16 (84)

23 (68)

52(72)

106(75)

are percentages.

effort to determine what percentage of hospitals followed the recommendations of the AAP regarding monitoring of CT with sedation (9). For examinations with deep sedation, the AAP necommends continuous observation of the patient with measurement and mecording of blood pressure and respiration at a minimum of every 5 minutes. Respondents were considered to be following the recommendations if intermittent patient inspection was conducted with blood pressure and respiration monitoring or if visual inspection of the patient was conducted (even if only from the control room) and some type of electromechanical monitoring device was used. Thus, if the respondent chose one or more of the electromechanical monitoring devices listed (ECG, respiratory motion monitor, automatic blood pressure monitor, ex-

Volume

32 (94) 18 (53)

monitoring

device

in parentheses

19 (100) 11 (58)

pressure

Other Any type

Visual device

16 (94) 7 (41)

pined carbon dioxide monitor, or pulse oximetem) plus visual inspection, we counted that respondent as meeting the AAP recommendations. Blood pressure monitoring was not considered necessary to meet AAP recommendations if some form of electromechanical monitoring was used. Our criteria for measuring compliance are generous in that the survey question did not specify a frequency for intermittent patient inspection, nor is it clear that visual inspection from the control room is sufficient to monitor a patient’s color. This analysis revealed that about 75% of hospitals [84%] meet the AAP necommendations for CT performed with deep sedation and no contrast material on with oral contrast material, and 78% [88%] did so for CT with intravenous contrast material. Because of the genenous assumptions we have made, the ne-

sults

likely

overstate

the

extent

of

corn-

pliance. Of the two ways of complying with the AAP recommendations, electromechanical monitoring plus visual inspection was reported by a little more than one-half of the hospitals. Depending on whether contrast material was used, pediatric hospitals (76%-82%) [96%-99%] and medical school hospitals (68%-75%) [72%-86%] were more likely than other types of hospitals to use electromechanical monitoring devices (differences were significant, P < .003). Intermittent patient inspection was reported by 56%-59% of hospitals, with relatively little variation among types of hospitals. Drug A key the drug

Regimen section regimen

of the survey covered practiced in pediatric

Radiolocv

#{149} 7slQ

CT studies with sedation that did not require oral contrast material. Respondents were asked to describe the most frequently used first-line and augmentation drug for each of five age groups of patients.

Orally administered chloral hydrate was the most frequently cited first-line drug used to sedate pediatric patients for CT. A majority of hospitals cited oral chlonal hydrate as the first-line drug for sedation of children in all age groups, except for infants and olden children. A plurality of hospitals meported that sedation is not performed in the latter two patient groups. Of those who augmented sedation with something other than chlonal hydrate, respondents reported they were most likely to administer the combination of Dememol (meperidine hydrochloride; Winthrop, New York), Phenengan (promethazine hydrochloride; WyethAyerst, Philadelphia), and Thorazine (chlorpromazine

hydrochloride;

Smith

Kline & French, Philadelphia) (hereaften, DPT) as a second-line drug. Although chlonal hydrate was the most common first-line drug, barbiturates and the DPT combination were also cited by a number of respondents. For example, 15% of hospitals administened barbiturates as the first-line drug for toddlers, and 1 1% gave the DPT combination.

For augmentation, the DPT combination, barbiturates, and chlomal hydrate were the most frequently mentioned drugs

(in

that

order).

For

toddlers,

of

drugs

(including

data

from

hospitals that did not use sedation or augmentation) were reported for the sedation of toddlers. When the different possible routes of administration of each drug were considered, the permutations were even more numerous. Benzodiazepine,

narcotics,

and

gen-

enal anesthetics were rarely cited as parts of a first-line regimen, although benzodiazepine and general anesthetics occasionally were somewhat more common as part of a backup regimen. In general, pediatric hospitals were more likely than other types of hospitals to report giving barbiturate denivatives as the first-line drug regimen and were correspondingly less likely to administer chloral hydrate, especially in toddlers,

young

children,

and

older

children (differences were significant for four of the five age groups, P < .01). Pediatric hospitals and medical schools were more likely than other hospitals to augment sedation when the first-line 750

Radiology

#{149}

38%

do

not

sedate

comparison, not

olden

only

sedate

5%

of

children.

In

hospitals

do

toddlers.

Management

of Sedation

Hospitals that conduct pediatric CT studies with light sedation were asked what percentage of examinations are completed (a) without the patient prognessing to a state of deep sedation, (b) with the patient progressing to deep sedation and snoring that is corrected by neck extension, and (c) with the patient progressing to deep sedation requining assisted mask on intubated yentilation. Approximately two-thirds of hospitals reported that over 90% of CT studies with light sedation are completed without the patient progressing to a state of deep sedation (mean percentage for all hospitals, 86%). Answers to this

item

varied

little

among

types

of

hospitals. Overall, hospitals reported that an average of 9% of CT examinations with light sedation resulted in progression to deep sedation; most (all but 0.5% of 1%) of these studies involved snoring that was corrected by neck extension.

19%

of respondents reported they administened DPT; 16%, chlonal hydrate; and 15%, barbiturates. The particular pairs of drugs used by respondents for first-line sedation and augmentation varied greatly from hospital to hospital. Twenty-five different pairs

regimen failed (differences were significant for all age groups except older children, P ranged from < .02 to < .01). Young infants and older children were less likely than children of other ages to be given any type of first-line drug. Forty percent of hospitals said they do not sedate young infants, and

NPO

Status

For CT studies performed with sedation and without oral contrast material, there was considerable variability among hospitals in the amount of time that pediatric patients are held NPO before routine sedation for CT. Overall, 42%

that

they

hold young infants of age) NPO, while

[32%]

(less 19%

than [17%]

young

for

2 hours;

infants

reported

NPO

did

not

1 month held 11%

[3%], for 3 hours; and 15% [37%], for 4 hours (mean, 103 minutes). Similar variation was seen for children of other ages, although the percentage of mespondents holding patients NPO increased as the age of the child increased; on a caseload basis, 61% of CT studies of children aged 5 years on oldem had an NPO time of 4 hours or more. There was no consistent variation in NPO time among types of hospitals. Respondents conducting CT with sedation and oral contrast material were asked when the last dose of oral contrast material was administered to pediatric

patients

less

than

5 years

of age.

Most responses were under 1 hour, with 67% [59%] stating within 30 mmutes before CT started; 23% [29%], 35 minutes to 1 hour; and 10% [12%], more

than 1 hour minutes).

Pediatric Contrast

(mean

for

all hospitals,

39

CT Studies with Oral Material and Sedation

The use of oral contrast material in abdominal pediatric CT with sedation varied by type of hospital. Respondents were asked what percentage of abdominal pediatric CT studies with sedation were performed with oral contrast material, and the overall mean percentage reported was 50% [68%]. However, 31% of hospitals in the sample, representing 13% of the caseload, reported they neven conducted such examinations, while 20% [16%] said all abdominal CT studies were performed with oral contrast agents.

Pediatric and medical school hospitals were considerably more likely than others to use oral contrast material in abdominal CT with sedation (differences were significant, P < .001). The mean percentages of CT studies performed with sedation and oral contrast material were 83% for hospitals defined

by respondents

as pediatric

hospitals

and 71% for medical schools. In cornparison, the mean percentages of these studies were 43% for hospitals affiliated with medical schools and 48% for unaffiliated hospitals. Only 8% of the hospitals [6%] stated that the drug regimen for sedation changed when oral contrast material was used. Only one pediatric hospital reported such a change. Of those stating that the regimen changed, about three-fourths did not sedate on did not augment sedation in CT with oral contrast material, compared with CT without oral contrast material. Most hospitals that performed any pediatric CT with sedation and oral contrast material reported that the NPO orders were the same as those for CT with sedation and without oral contrast material. Only 6% [3%] reported that the NPO orders differed. Among the hospitals that said the NPO orders differed, most reported a longer NPO time for each age group when oral contrast material was used, although two or three respondents reported a shorter time. Of the 46 respondents who reported having given general anesthetics with intubation for abdominal CT with oral contrast material, 61% [79%] administemed oral contrast material before intubation, while the rest did so after intubation. The median time of administration of oral contrast material before intubation was 60 minutes, but the reported range was 5-240 minutes. For all hospitals in the sample, 14% [50%] reported that a pediatric radiologist performed most of the CT studies in which sedatives and oral contrast

June

1990

material were that an adult such studies.

used; the radiologist Six percent

others reported performed did not an-

emergency

intubation

cases

of apnea

with

an

oxygen

was

requiring mask

indicated

in

ventilation or

ambu

bag.

swen.

DISCUSSION

The questionnaire included a series of questions about complications that had occurred as a result of pediatric CT performed with sedation and oral contrast material in the past 5 years. Respondents were asked how many cornplications had occurred; whether cornplications had involved respiratory arrest, aspiration, or death; what type of sedation technique was used; and whether cases had resulted in litigation. Two percent of hospitals that conduct CT with oral contrast material, representing 5% of the caseload (total of six hospitals), reported the occurnence of a complication from pediatric CT with sedation and oral contrast material in the past 5 years. Three hospitals-a medical school, an affiliate of a medical school, and an unaffiliated hospital-reported one complication each. A pediatric hospital reported three complications. The other two (a medical school and an unaffiliated hospital) did not report the number of complications.

Two of the complications involved respiratory arrest. No result was checked for the others. None of the mespondents indicated that litigation mesulted from the cases. Because of the sensitive nature of this

question

and

understandable

dif-

ferences in the respondents’ interpretations of what constitutes a complication, it is difficult to know the meliability of these results. In some instances, respondents who completed the survey could be unaware of complications that occurred at their hospitals in previous years.

Other

complications

may

have

resulted in ongoing litigation, which, on the advice of attorneys, might have been omitted from the survey.

Management

Airway

To gauge the sensitivity and aggressiveness of airway management by madiologists, respondents were asked their professional opinion regarding the circumstances in which emergency intubation was required for pediatric patients undergoing CT with sedation and oral contrast material. Eleven pencent of respondents said emergency intubation occurs

was that

indicated is partially

when relieved

snoring by

neck

extension. Fifty-four percent said it was indicated in hypoventilation requiring ventilation with an oxygen mask on “ambu bag” (ie, assisted mask ventilation device). Seventy-five percent said

Volume

175

AND

RECOMMENDATIONS

Complications

Number

#{149}

3

Many pediatric performed with those in which

CT examinations sedation, including oral contrast material is used, are conducted each week in U.S. hospitals. Although the procedunes appear to be relatively safe, there is considerable variation in the staffing, monitoring, drug regimen, NPO status, and airway management associated with these examinations. Relatively few hospitals-pediatric hospitals and medical schools-conduct about one-half of the CT studies with sedation that are performed. However, this also means that onehalf of all CT studies with sedation are performed in locations where the procedure is relatively rare and where the staff may be relatively inexperienced in managing the sedated pediatric patient (especially when oral contrast agents are used). In two areas examined in the sunvey, the sedation practices reported by many hospitals were at variance with recommendations of the AAP. First, reported NPO practices often contrasted sharply with the AAP guidelines (9). For elective use of sedation in pediatric patients, the AAP recommends NPO 4 hours before the scheduled procedure is performed in patients aged 0-3 years and 6 hours in patients aged 3-6 years. Our sunvey suggests that the practices of less than one-third-and for some age groups, as few as one-fifth-of hospitals were consistent with the AAP recommendations. Second, monitoring of CT with deep sedation appears to fall short of the AAP recommendations at a sizable minority of hospitals. Even when we used a relatively generous set of assumptions in configuring the monitoring data, one-fourth of hospitals do not appear to provide the 1evel of monitoring judged necessary for safety. Although hospitals that do not appear to meet the standards conduct relatively few CT examinations with sedation, the infrequency of the procedure at such locations may nesult in additional risks to patients. Considering the variance between sedation practices in pediatric CT and the AAP recommendations, we necommend that management practices be adjusted to conform as closely as reasonably possible to the standards and guidelines for sedation and mon-

itoring recommended by pediatric or anesthesia societies. Radiology departments should have a written po1icy on CT with sedation and an ongoing

quality

assurance

program.

Stan-

dands established by the American Society for Anesthesiology (ASA) (10) require that during administration of all anesthetics, including sedatives for CT examinations, the oxygenation, ventilation, circulation, and temperature of the patient should be continually evaluated. Although assessment of a patient’s color, observation of chest wall excursion, and appraisal of other qualitative clinical signs may be sufficient to evaluate the adequacy of oxygenation and ventilation when personnel are immediately present, intermittent remote observation of the patient during periods of radiation exposure requires the use of additional safeguards such as a pulse oximeter, apnea monitoring, or expired carbon dioxide monitoring. We suggest that a pulse oximeten be used because it has been proved to be a reliable and simple means to ensure the continuous adequacy of oxygenation. Although continuous ternperature and ECG display and determination of blood pressure at least every 5 minutes are recommended by the ASA (10), these monitoring techniques may lead to a compromised CT examination and probably are not necessary if a pulse oximeter is already being used. Most monitoring wires cause streak artifacts on CT scans. Manipulation during blood pressure monitoring may awaken a consciously sedated patient and thereby cause motion artifacts or premature termination of a CT study. It is interesting that the ASA guidelines do not differentiate conscious sedation, deep sedation, and general anesthesia (10), whereas the AAP does make a differentiation (9). The AAP guidelines for operative monitoning in conscious sedation require that a trained individual continuously monitor the patient, and, with the possible exception of very light sedation, the heart and respiratory rates should be continuously monitored and recorded at specific intervals (9). The AAP guidelines for operative monitoring in deep sedation require continuous monitoring of the heart rate, respiratory rate, and blood pressure and that visual monitoring of the patient’s color must be carried out and recorded at 5-minute intervals (9). In lieu of these recommendations, we suggest that the lightest possible

Radiology

#{149} 751

sedation be used and that pulse oximeter monitoring be applied in all cases. In addition, we suggest that the medical condition of the patient dictate the use of additional monitoring such as temperature, ECG measunements, and blood pressure. We also suggest that routine baseline pulse and respiratory rates, along with auscultation of the chest and a brief medical history, be performed before sedation to help ensure that the patient is a safe candidate for sedation. Unless medically indicated by the patient’s condition, routine baseline blood pressure measurements for infants and young children are deferred because the child is often crying and fighting throughout this

procedure. Visual inspection of patients remains an essential part of proper monitoring. In addition to the CT technologist, trained ancillary personnel such as a nurse should assist in the administration of sedatives and monitoring of the sedated patient. This is to be done under the supervision of a physician. If the institutional protocols for sedation are not sufficient to sedate a particular patient, then one should consult an anesthesiologist for further management, because risk increases with deepening sedation. Trained personnel should stay near the patient during all phases of sedation. Just before CT is performed, the patient’s depth of sedation should be assessed. Before leaving the side of the patient to perform the CT study, one should be sure that the sedation level has reached a plateau and then proceed with the examination. If intravenous contrast material is used, one should use the break in the scanning procedure to physically reinspect the patient’s sedation status. One can easily listen for signs of airway obstruction (such as snoring), obtain respiratory rate, inspect the color of the nail bed, and look for emesis without awakening the lightly sedated patient. A volunteer or guardian may be enlisted to help monitor obvious signs of untoward reactions to sedation but is not a substitute for trained personnel. Before a patient is discharged, be sure that he or she is awake and alert and that vital signs have returned to baseline. As our results indicated, no one drug regimen is predominant sedation in pediatric CT.

752

Radiology

#{149}

Many

in all dif-

fenent drug regimens are apparently being used safely (1-7,11,12). However, chloral hydrate is the most frequently cited first-line drug used to sedate pediatric patients for CT examinations. Pediatric hospitals were more likely than other types of hospitals to report the administration of barbiturate derivatives as the firstline drug regimen and were correspondingly less likely to give chloral hydrate, especially in toddlers, young children, and older children. Also, pediatric hospitals and medical schools were more likely than other hospitals to augment sedation when the first-line regimen failed. Of paramount importance is that the physican and medical personnel involved be adequately trained and expenienced in administering the chosen drug regimen. The use of oral contrast material in pediatric CT examinations presents a “full-stomach” consideration. Anesthesiologists, by their training, are generally cautious in using anesthetics in patients with full stomachs and are likely to be more aggressive in airway management than is the current practice documented by responses to this survey. Certain maneuvers that are safe in the absence of a full stomach, such as use of an ambu bag, are potentially lethal for a patient undergoing a CT examination with oral contrast material. Because oral contrast material is a necessary component in most abdominal CT examinations (1,2), it is unreasonable to deny its administration when conscious sedation is used, considering that the protective gag reflex is still preserved with this depth of sedation. However, one must exercise caution, because the point of transition to deep sedation in which the gag reflex may be lost is difficult to determine. With each examination requiring sedation and oral contrast material, one should ensure that the examination is indicated and necessary, because the patient is at risk of aspiration in this procedure, although the risk is theoretically minimal if conscious sedation is used. The management of children undergoing CT studies is an area of practice in which three medical specialties intersect: anesthesiology, pediatrics, and radiology. As in the situation requiring sedation of children receiving oral contrast material, there is occasionally a conflict among the goals of the various professions (ie,

the radiologist’s desire to obtain a high-quality definitive abdominal scan, and the goal of the anesthesiologist to protect the airway and prevent aspiration of gastric contents). Resolution of such conflicts may mequire some degree of compromise and accommodation among all parties, but always within the bounds of the overriding medical concern-the maintenance of the well-being and safety of the patient. With good cornmunication and further flow of ideas and information among the various disciplines, effective and safe management of children for diagnostic studies can be established for the benefit of all. #{149} Acknowledgments: Baron, MA, and

Anne

The assistance Harvell, MB,

of Carol is grateful-

ly acknowledged.

References 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

1 1.

12.

Kaufman PA. Technical aspects of abdominal CT in infants and children. AJR 1989; 153:549-554. Berger PE, Kuhn JP, Brusehaber J. Techniques for computed tomography in infants and children. Radiol Clin North Am 1981; 19:399-408. Strain JD, Campbell JB, Harvey LA, Foley LC. IV nembutal: safe sedation for children undergoing CT. AJR 1988; 151:975979. Burckart GJ, White TJ III, Siegle RL, Jabbour JT, Ramey DR. Rectal thiopental versus an intramuscular cocktail for sedating children before computerized tomography. Am J Hosp Pharm 1980; 37:2.22224. Varner

PD,

Ebert

JP,

McKay

RD.

Nail

CS,

Whitlock TM. Methohexital sedation of children undergoing CT scans. Anesth Analg 1985; 64:643-645. Thompson JR. Schneider 5, Ashwal 5, Holden BS, Hinshaw DB Jr. Hasso AN. The choice of sedation for computed tomography in children: a prospective evaluation. Radiology 1982; 143:475-479. Nahata MC. Sedation in pediatric patients undergoing diagnostic procedures. Drug Intell Clin Pharm 1988; 22:711-715. Salem

MR.

Wong

AY,

Collins

VJ.

The

pe-

diatric patient with a full stomach. Anesthesiology 1973; 39:435-440. Committee on Drugs, Section on Anesthesiology. Guidelines for the elective use of conscious sedation, deep sedation, and general anesthesia in pediatric patients. Pediatrics 1985; 76:317-321. Standards for basic intraoperative monitoring. In: Directory of Members, 54th ed. Park Ridge, Ill: American Society of Anesthesiologists, 1989; 609-610. Sander JE, Lo W. Computed tomographic premedication in children (letter). JAMA 1983; 249:2639. Strain JD, Harvey LA, Foley LC, Campbell JB. Intravenously administered pentobarbital sodium for sedation in pediatric CT. Radiology 1986; 161:105-108.

June

1990