Children with upper respiratory infections (URIs) are at greater risk of adverse events and airway interventions during procedural sedation – though the rates are low, researchers say.
Dr. Joseph Cravero of Boston Children’s Hospital in Massachusetts and colleagues analyzed data on 83,491 sedations in children with a mean age of 4.5 years (about 44 percent girls) performed between November 2012 and July 2015.
They looked at procedures done in children without a URI (70,830), with a recent URI (3,354), with current URI (8,649) and with a current URI with thick secretion (658).
Propofol was the most commonly used sedative in all groups, followed by ketamine. Opioid analgesics were given in 23.3 percent of cases, and were more commonly used in patients with no URI (P<0.001). Atropine and glycopyrrolate were administered to 2.7 percent and 6.5 percent of all children, respectively, regardless of URI status (P<0.001).
As reported in Pediatrics, online June 29, the rate of any adverse airway event – e.g., wheezing, cough, stridor, laryngospasm – increased progressively from 6.3 percent for those with no URI to 22.2 percent for those with current URI with thick and/or green secretions.
Similarly, most airway interventions – e.g., endotracheal tube, nasopharyngeal airway, suction – increased from no URI status to recent URI, to current URI with thin and/or clear secretions, and then to current URI with thick and/or green secretions.
A statistically significant association was seen between recent URI and current URI with thick and/or green secretions with seven of 10 adverse airway events when compared with no URI.
Current URI with thin and/or clear secretions had a statistically significant association with eight of 10 adverse airway events compared with no URI. Odds ratios varied for both sets of associations based on the characteristics and timing of the URIs.
“Although URI status merits consideration in determining potential risk for sedation,” the authors observe, rates of some adverse airway events and airway interventions were low regardless of URI status. Experts not involved in the study commented on the findings for Reuters Health.
Dr. Juan Gutierrez, director of the pediatric ICU at Atlantic Health System Goryeb Children’s Hospital in Morristown, New Jersey, said, “Ultimately, practitioners and parents should weigh the risk/benefit balance of any procedure. This study confirms the general safety of doing procedures under sedation in children with mild upper respiratory infections, and provides valuable information to help practitioners and parents make a more informed decision.”
“If respiratory secretions are thick and/or green, practitioners should consider this an added risk – though low,” he said by email. “In many cases, including those that are time-sensitive or emergent, delaying a procedure could pose a larger risk than those associated with sedation.”
“A critical point to stress is that sedation must be provided with adequate monitoring by practitioners skilled in managing potential emergencies, particularly related to airway and breathing,” Dr. Gutierrez cautioned. “Though rare, adverse events related to sedation can have devastating consequences. In skilled hands and with adequate monitoring, this study indicates that sedation is very safe.”
Dr. Desmond Henry, chief of pediatric anesthesiology at Children’s Health in Dallas, Texas, observed, “Having the results of this study to share with families will assist in the informed consent process prior to a procedure requiring sedation.”
“This study also reinforces the importance of a thorough history and physical exam prior to a sedation procedure,” he said by email. “We are confident this study will allow families to play an active and more informed role in decision making, knowing their child is at increased risk if recently or currently affected by an upper respiratory infection, while also being reassured that overall risk of an adverse event is still very small.”
Dr. Gordana Stjepanovic, director of the division of pediatric anesthesiology at NYU Langone Medical Center in New York City noted, “the authors recognize that the clinical relevance of the findings is questionable. The rates of adverse airway reactions and airway interventions remain relatively low, less than 1 percent, regardless of URI status.”
“In addition to the study findings, in a clinical setting, the sedation plan has to be tailored to every individual patient,” she wrote in an email. “Factors to keep in mind include the severity of their URI, type of the procedure, urgency of the procedure, patient age, and concurrent comorbidities – especially facial malformations, obstructive sleep apnea, and obesity.”
Study authors Drs. Mallory and Cravero did not respond to requests for a comment.