Alotaibi, Badriyah
(2016)
The use of procedural sedation in children.
PhD thesis, University of Nottingham.
Abstract
The use of sedation for diagnostic and therapeutic procedures in children is common and leads to considerable debate. Evaluating this subject is complicated by differences in the methods and the outcomes used for sedation assessment in children reported in the literature which are large. This thesis used systematic literature reviews, a prospective study and a national survey to evaluate several aspects of paediatric sedation.
A systematic review of the safety and effectiveness of chloral hydrate in three categories of procedural sedation was conducted. For painless procedural sedation, chloral hydrate was more effective for shorter imaging procedures, such as CT scanning. The incidence of adverse events was 1,951 occurring in 14439 patients (13.5%), with hypoxia the most frequent. Moderate hypoxia (SpO2 85%–90%) was seen in 281 cases of 14439 patients (1.9%) of children.
For painful procedural sedation, the success rate of chloral hydrate was variable (35%–100%). Hypoxia was the most common adverse event, occurring in 95 of 1810 patients (5.2%). Most (66 cases/1810 patients, 3.6%) were mild however moderate hypoxia occurred in 29 of 1810 patients (1.6%). The incidence of adverse events was higher during painful procedures than during painless procedures: 313AEs/1810 patients (17.3%) versus 1,951AEs/14439 patients (13.5%).
The most frequent use of chloral hydrate as a treatment was to reduce agitation during mechanical ventilation, followed by treatment of neonatal diseases and treatment of neurological disorders. The reported success rate was high throughout all treatment procedures (86%–100%). The incidence of hypoxia was found to be the highest, when it was used for the treatment of agitation 71 cases/438 patients (16.2%).
Due to the heterogeneity between the studies it was not possible to perform meaningful statistical analysis.
The effectiveness and safety of triclofos (a chloral hydrate derivative) was evaluated for procedural sedation in children, in a systematic review of the literature. The success rate was variable (ranging from 50 to 100%), shorter procedures such as CT scanning were more likely to be successful. Vomiting and hypoxia were the most frequently reported adverse events, 10% (62/613) and 7.8% (48/613) respectively.
A systematic literature review of the safety and effectiveness of paraldehyde as a sedative agent for children was performed, as it was named as a second line agent in the sedation policy of the Derbyshire Children's Hospital. The literature is scant; only five studies were located and involved 157 patients. The reported effectiveness of paraldehyde ranged from 75- 93%. Vomiting was the most commonly reported adverse event (2 cases/8 patients, 25%). Due to the small numbers of patients and poor methodology of studies, its clinical use cannot be supported.
A further systematic literature review of 29 studies involving 6342 children on the safety and effectiveness of midazolam for imaging procedures was conducted. The procedural success rate was variable (0%–100%, median 82%). Hypoxia was the most commonly reported adverse event (74 cases/2046 patients, 3.6%) with (32 cases/2046 patients) 1.6% of cases being reported as moderate hypoxia.
Palatability of the two most commonly used sedative agents, chloral hydrate and midazolam, was evaluated by conducting a literature review and a prospective study at the Derbyshire Children's Hospital. Only 9 studies were identified during the literature review. Of these, 8 studies evaluated the palatability of midazolam, while only 2 evaluated the palatability of chloral hydrate. Midazolam was reported as more acceptable to patients than chloral hydrate. The prospective study supported this, and showed that patient acceptance of midazolam was good, while it was poor for chloral hydrate. The success rate of procedures was lower with midazolam, then chloral hydrate.
A further literature review evaluated the use of sedation in Middle Eastern countries. Limited numbers of reports were found. Of the 37 studies, the majority (43%) were conducted in Turkey, within single centres and only examined a single procedure. Very limited evidence on the use of sedation guidelines was reported.
Further exploration of the current sedation practice in the Kingdom of Saudi Arabia was done using a national survey. The questionnaires were completed by 81 health care professionals. Only 61% documented the use of sedation guidelines, although 91% reported monitoring of patients during procedural sedation. The most commonly reported agents for both painless and painful procedures were chloral hydrate and midazolam.
This research aimed to add to the evidence base for paediatric sedation. The results suggest a need for future research to cover further areas, including the safety and effectiveness of other drugs, worldwide practice and patient monitoring.
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