ARTICLE

Physiologic Monitoring Practices

During Pediatric Procedural Sedation
A Report From the Pediatric Sedation Research Consortium
Melissa L. Langhan, MD; Michael Mallory, MD, MPH; James Hertzog, MD; Lia Lowrie, MD;
Joseph Cravero, MD; for the Pediatric Sedation Research Consortium

Objectives: To describe the frequency of different physi- events, medications, and physiologic monitors used are
ologic monitoring modalities and combinations of mo- entered into a web-based system.
dalities used during pediatric procedural sedation; to de-
scribe how physiologic monitoring varies among different Results: Data from 114 855 subjects were collected and
classes of patients, health care providers (ie, ranging from analyzed. The frequency of use of each physiologic moni-
anesthesiologists to emergency medicine physicians to toring modality by health care provider type, medica-
nurse practitioners), procedures, and sedative medica- tion used, and procedure performed varied signifi-
tions employed; and to determine the proportion of se- cantly. The largest difference in frequency of monitoring
dations meeting published guidelines for physiologic use was seen between providers using electrocardiog-
monitoring. raphy (13%-95%); the smallest overall differences were
seen in monitoring use based on the American Society
Design: This was a prospective, observational study from of Anesthesiologists classifications (1%-10%). Guide-
September 1, 2007, through March 31, 2011. lines published by the American Academy of Pediatrics,
the American College of Emergency Physicians, and the
Setting: Data were collected in areas outside of the op- American Society of Anesthesiologists for nonanesthe-
erating room, such as intensive care units, radiology, emer- siologists were adhered to for 52% of subjects.
gency departments, and clinics.
Conclusions: A large degree of variability exists in the
Participants: Thirty-seven institutions comprise the Pe- use of physiologic monitoring modalities for pediatric pro-
diatric Sedation Research Consortium that prospec- cedural sedation. Differences in monitoring are evident
tively collects data on procedural sedation/anesthesia per- between sedation providers, medications, procedures, and
Author Affil
formed outside of the operating room in all children up patient types. Department
to age 21 years. Section of Em
Arch Pediatr Adolesc Med. 2012;166(11):990-998. Yale Univers
Main Outcome Measures: Data including demo- Published online September 10, 2012. Medicine, N
graphics, procedure performed, provider level, adverse doi:10.1001/archpediatrics.2012.1023 Connecticut
Pediatric Em
Associates, C

C
Healthcare o
HILDREN UNDERGOING tion.1,2 More than a dozen professional or- Georgia (Dr
painful procedures or di- ganizations, including the American Acad- Department
agnostic imaging often are emy of Pediatrics (AAP), American and Critical
aided by the receipt of Academy of Pediatric Dentistry (AAPD), the duPont Hosp
medication to reduce their American College of Emergency Physi- Wilmington,
cians (ACEP), and the American Society of Hertzog); Di
pain and anxiety. Procedural sedation is pro- Critical Care
vided to children to facilitate a variety of pro- Anesthesiologists (ASA), have published University Sc
cedures in multiple settings. Furthermore, at Cardinal G
health care providers ranging from anes- For editorial comment Medical Cen
thesiologists to emergency medicine phy- Missouri (Dr
see page 1067 Department
sicianstonursepractitioners,workingwithin Anesthesiolo
different systems for sedation provision, are guidelines for physiologic monitoring dur- Dartmouth-H
Author Affiliations are listed at involved in the provision of this care. ing pediatric procedural sedation, while the Center, Leba
the end of this article. The safety of children who receive se- Joint Commission (formerly the Joint Hampshire (
Group Information: The dation is of paramount importance. Clini- Group Infor
member hospitals that comprise
Commission on Accreditation of Health- member hos
the Pediatric Sedation Research cal practice guidelines for the physiologic care Organizations) sets hospital stan- the Pediatric
Consortium are listed at the end monitoring of children during procedural dards for anesthesia and sedation care and Consortium
of the article. sedation vary by specialty and by institu- regulates this care.1-7 of the article

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 Table 1. Summary of Monitoring Recommendations by Professional Organization

Organization SpO2 Respiratory Rate Heart Rate Blood Pressure ETCO2

AAP/AAPD Continuous Intermittent Continuous Intermittent Encouraged
ASA for anesthesiologists Continual Continual Continuous Intermittent Continual
ASA for nonanesthesiologists Continuous Continuous Continuous Intermittent Consider
ACEP Unknown frequency Unknown frequency Consider Unknown frequency No

Abbreviations: AAP, American Academy of Pediatrics; AAPD, American Academy of Pediatric Dentistry; ACEP, American College of Emergency Physicians;
ASA, American Society of Anesthesiologists; ETCO2, end-tidal carbon dioxide; SpO2, pulse oximetry.

Appropriate physiologic monitoring does not guaran- data sharing group. There were no specific selection criteria for
tee desired outcomes. The goal of such monitoring is to participation in the consortium; however, any interested insti-
alert the practitioner of physiologic derangements during tutions were required to obtain institutional review board ap-
procedural sedation such that medical intervention may be proval for data collection, identify a primary investigator, and
agree to a standardized method for data collection on a con-
provided and adverse events avoided.8 The modes and fre-
secutive sample. Health care providers self-identified their spe-
quency of monitoring vary extensively in clinical practice. cialty on the data forms.
Evidence is lacking regarding optimal physiologic moni- The PSRC data tool is a web-based data collection tool. For a
toring during pediatric procedural sedation.6 While spe- more detailed description of the logic and questions used in this
cific monitors (eg, pulse oximetry) have been shown to be data instrument, please see “Web Tool Content” on the consor-
useful in alerting practitioners to dangerous patient states, tium website at http://www.pediatricsedationrc.org. The data col-
no data exist to indicate that specific monitoring systems lection tool consisted of 25 primary screens and dynamically gen-
actually change the outcomes of sedation encounters. erated an interface for each subsequent question based on the
To our knowledge, the present study represents an ef- responses from the previous question. Some items, such as medi-
fort to summarize the findings of the first large-scale, mul- cations used for sedation and locations in which sedation was
provided, may have more than one response per subject.
tispecialty study to report the monitors that are actually
Data gathered regarding monitoring during sedation in-
used during pediatric sedation across a wide spectrum of cluded the following: noninvasive pulse oximetry (SpO2), 3-lead
practices. We examined data from the Pediatric Sedation electrocardiography (ECG), noninvasive blood pressure moni-
Research Consortium (PSRC), which is a collaborative toring, capnography/end-tidal carbon dioxide monitoring
group of 37 institutions that prospectively collects data (ETCO2), precordial stethoscopy, temperature monitoring,
about pediatric procedural sedation/anesthesia outside of bispectral index monitoring, impedance plethysmography, and
the operating room to better understand this practice and other.
its safety. Using its large database, our primary goal is to All the participating institutions (and primary investiga-
describe the frequency of different physiologic monitor- tors) were blinded to the data submitted from any individual
ing modalities and combinations of modalities used dur- institution other than their own. Study authors were also blinded
to referring institution. All the site-specific primary investiga-
ing pediatric procedural sedation within the experience
tors were required to perform data audits on 10 medical rec-
of the PSRC. Our secondary goals are to describe how physi- ords every 6 months and report the accuracy of the data trans-
ologic monitoring varies among different classes of pa- mitted. In addition, the primary investigator was required to
tients, health care providers, procedures, locations, and review total counts of sedations performed in his or her insti-
sedative medications employed, as well as to determine tution (independently recorded) vs that of the number of rec-
the proportion of sedations that meet different published ords submitted to the PSRC. Any discrepancies in numbers pro-
guidelines within the experience of the PSRC. vided vs sedations performed or confirmed inaccuracies of data
at the institution required a complete review of the data-
gathering method at the institution.
METHODS
Definition of Guidelines
STUDY DESIGN
The recommendations published by the AAP/AAPD, ASA, and
We performed an analysis of consecutive pediatric sedations
ACEP are summarized in Table 1. The ASA has published
entered prospectively into a large multicenter database. Pedi-
guidelines for sedation by nonanesthesiologists as well as stan-
atric Sedation Research Consortium participants collected the
dards for basic anesthetic monitoring performed by anesthe-
data for this analysis from September 1, 2007, through March
siologists, which include some specifications for moderate and
31, 2011. We included subjects younger than 21 years old.
deep sedation. A variety of devices have the capability to moni-
tor either heart rate or respiratory rate. It is not stipulated within
DATA COLLECTION SETTING AND PROCESSING these guidelines that a specific monitor should be used to moni-
tor either heart rate or respiratory rate. Therefore, for analyz-
The PSRC Database ing adherence to guidelines, the use of SpO2, ECG, or stethos-
copy was consider a positive monitor for heart rate, and the
The data collection method used by the PSRC has been de- use of ETCO2, impedance plethysmography, or stethoscopy was
scribed in a report about the first 30 000 sedations that were considered a positive monitor for respiratory rate. For ex-
performed.9 Thirty-seven locations, including large children’s ample, an ECG monitor is not required by the AAP/AAPD to
hospitals, children’s hospitals within hospitals, and general/ continuously monitor heart rate, and thus SpO2 would be an
community hospitals, self-selected for involvement in the PSRC appropriate monitor of both oxygenation and heart rate.

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 Table 2. Demographic Information of 114 855 Children a

Variable Value
Age, median (IQR), mo 48 (23-96)
Range ⬍1-252
Weight, kg 17.3 (11.8-29)
Range 1-280
Characteristics for ⬎1% of participants
Sex b
Female 51 339 (45)
Male 62 983 (55)
ASA (n = 112 343) c
1 29 603 (26)
2 63 319 (56)
3 19 046 (17)
4 372 (⬍1)
5 3 (⬍1)
Primary diagnosis
Neurological 43 214 (38)
Hematologic/oncologic 25 623 (22)
Gastrointestinal 11 567 (10)
Infection 6663 (6)
Renal 6088 (5)
Other 4794 (4)
Orthopedic 4775 (4)
Metabolic/genetic 1940 (2)
Cardiovascular 1873 (2)
Respiratory: lower airway 1781 (2)
Surgical/wound management 1487 (1)
Craniofacial abnormalities 1470 (1)
Trauma, in the last 24 h or reason for current hospitalization 1433 (1)
Type of procedure performed
Radiology 67 937 (59)
Hematology/oncology 16 546 (14)
Gastroenterology 10 406 (9)
Surgical or invasive procedure 9070 (8)
Nerve/brain/ear 6640 (6)
Bone/joint/skeletal 2489 (2)
Cardiology 1538 (1)
Airway/pulmonary 1156 (1)
Sedative used (n = 113 933)
Propofol 81 372 (71)
Midazolam 27 747 (24)
Ketamine hydrochloride 7725 (7)
Dexmedetomidine hydrochloride 7497 (7)
Pentobarbital sodium 7426 (7)
Chloral hydrate 6360 (6)
Provider responsible (n = 11 697)
Pediatric intensivist 57 752 (50)
PEM physician 24 926 (22)
Pediatrician/subspecialist 13 085 (11)
Pediatric anesthesiologist 10 390 (9)
Anesthesiologist/intensivist 2557 (2)
Radiologist 2545 (2)
Location of procedure
Radiology 58 772 (51)
Sedation unit 49 170 (43)
Pediatrics/specialty clinic 9202 (8)
Other 3889 (3)
Critical care, ICU/PACU 3754 (3)
Pediatric floor 2238 (2)
Emergency department 1819 (2)

Abbreviations: ASA, American Society of Anesthesiologists; ICU, intensive care unit; PACU, postanesthesia care unit; PEM, pediatric emergency medicine.
a Data are given as number (percent) unless otherwise indicated.
b Data were missing for sex and, therefore, do not total 112 343.
c The American Society of Anesthesiologists physical status classifications system is as follows: 1 indicates a normal healthy patient; 2, a patient with mild
systemic disease; 3, a patient with severe systemic disease; 4, a patient with severe systemic disease that is a constant threat to life; and 5, a moribund patient
who is not expected to survive without undergoing an operation.

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 Table 3. Physiologic Monitoring Modalities Used During Table 4. Use of Combinations of Monitoring Devices a
Sedation in 114 855 Children
Monitoring Combination No. (%)
Monitoring Modality No. (%)
SpO2, ECG, ETCO2, BP, impedance 5717 (5)
SpO2 109 297 (95) plethysmography
Noninvasive BP 99 840 (87) SpO2, ECG, BP, impedance plethysmography 19 711 (17)
ECG 76 977 (67) SpO2, BP, impedance plethysmography 20 246 (18)
ETCO2 51 318 (45) SpO2, ECG, ETCO2, BP 37 946 (33)
Impedance plethysmography 22 533 (20) SpO2, ETCO2, BP 44 863 (39)
Stethoscopy 253 (0.22) SpO2, ETCO2 50 734 (44)
SpO2, ECG, BP 71 658 (63)
Abbreviations: BP, blood pressure; ECG, 3-lead electrocardiography; SpO2, BP 98 780 (86)
ETCO2, end-tidal carbon dioxide; SpO2, pulse oximetry.
Abbreviations: BP, blood pressure; ECG, 3-lead electrocardiography;
In this analysis, adherence to guidelines was not stratified ETCO2, end-tidal carbon dioxide; SpO2, pulse oximetry.
a This information does not exclude the use of additional monitoring
based on the type of health care provider. For example, the fre- devices (N = 114 855).
quency of sedations that met the monitoring guidelines set forth
by the AAP/AAPD was analyzed across all the health care pro-
viders, not just pediatricians. However, subanalyses by health Table 5. Frequency of Monitoring Use by ASA Classification
care provider type were performed. for 112 343 Children a

STATISTICAL ANALYSIS ASA 3,

ASA 1 or 2 4, or 5
We performed descriptive analyses using Intercooled STATA/SE Monitoring Modality (n = 92 922) b (n = 19 421) b P Value
11.2 (StataCorp LP). ␹2 Analyses were performed to assess the SpO2 89 034 (96) 18 534 (95) .01
differences in the use of each monitoring modality on the ba- BP 80 028 (86) 18 229 (94) ⬍.001
sis of ASA physical status classification groups (1-2 vs 3-5) as ECG 61 017 (66) 14 359 (74) ⬍.001
well as by each type of practitioner. These comparisons were ETCO2 41 693 (45) 8440 (43) ⬍.001
impossible for type of drug or procedure because choices in these Impedance 16 904 (18) 5361 (28) ⬍.001
categories were not mutually exclusive. plethysmography
Stethoscopy 167 (0.18) 73 (0.38) ⬍.001
RESULTS
Abbreviations: ASA, American Society of Anesthesiologists; BP, blood
pressure; ECG, 3-lead electrocardiography; ETCO2, end-tidal carbon dioxide;
Data from 114 855 sedations were reviewed. There were SpO2, pulse oximetry.
a Data are given as number (percent).
a wide variety of sedation procedures, health care pro- b The American Society of Anesthesiologists physical status classifications
viders, medications administered to provide sedation, pri- system is as follows: 1 indicates a normal healthy patient; 2, a patient
mary diagnoses, and locations where sedation was pro- with mild systemic disease; 3, a patient with severe systemic disease; 4, a
vided (Table 2). More than one administered medication patient with severe systemic disease that is a constant threat to life; and 5, a
moribund patient who is not expected to survive without undergoing an
or location for sedation procedure was possible for each operation.
subject. The most common procedures within the cat-
egories listed include magnetic resonance imaging for
radiology, lumbar puncture with intrathecal medica- 13 259 health care providers who identified them-
tion administration and bone marrow biopsy for hema- selves as anesthesiologists (a group including anesthe-
tology/oncology, upper endoscopy and colonoscopy for siologists, pediatric anesthesiologists, and anesthesi-
gastroenterology, brainstem auditory response test and ologists/intensivists) used a monitoring combination
lumbar puncture for nerve/brain/ear, fracture reduction that met requirements of the guidelines set forth by the
and botulism toxin injection for bone/joint/skeletal, AAP and ASA for nonanesthesiologists. However, 56 772
catheter insertion or removal, incision and drainage, as- (55.9%) of the 101 596 health care providers not identi-
pirations or biopsy specimens for surgical, echocardi- fied as anesthesiologists were adherent to the guidelines
ography for cardiology, and bronchoscopy for airway/ (unadjusted odds ratio [OR], 0.176; 95% CI, 0.168-
pulmonary. 0.185). While the overall rate of adherence to ACEP
The overall frequencies of use for each monitoring mo- guidelines was 52%, among physicians who identified
dality are provided in Table 3 and frequencies of vari- as emergency medicine physicians (emergency medicine
ous combinations of devices are given in Table 4. A physicians or pediatric emergency medicine physicians),
minimum of SpO2, heart rate monitoring, respiratory this rate was 71.8% (17 922 of 24 952) (unadjusted OR,
monitoring, and intermittent blood pressure monitor- 3.0; 95% CI, 2.9, 3.1). The rate was 45.9% among those
ing as recommended by the AAP/AAPD and ASA not identifying themselves as an emergency medicine
for nonanesthesiologists was used in 52% of children. physician (P ⬍ .001).
ACEP standards were similarly met in 52% of chil- There was statistically significant variation in monitor-
dren. The stricter ASA guidelines for anesthesiologists, ing used when patients were considered by ASA classifi-
which require ECG and ETCO2 monitoring in addi- cation (Table 5); however, these groups had the small-
tion to Sp O 2 and blood pressure monitoring, were est differences in frequency of use of each monitoring type
adhered to in 33% of cases. Only 2421 (18.3%) of the (maximum difference 10% for plethysmography). There

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 100
Anesthesiologist
90 PEM Physician
Pediatric Intensivist
80
Pediatric Anesthesiologist
70 Pediatrician
Radiologist
60
Use, %

50

40

30

20

10

0
SpO2 BP ECG ETCO2 Plethysmography
Monitoring Modality

Figure 1. Percent use of each monitoring modality by health care provider type. Refer to Table 2 for frequencies of health care providers. All the P values for the
comparison of each monitoring modality by health care provider are less than .001. BP indicates blood pressure; ECG, 3-lead electrocardiography; ETCO2,
capnography/end-tidal carbon dioxide; PEM, pediatric emergency medicine, and SpO2, noninvasive pluse oximetry.

100
Propofol
90 Ketamine
Midazolam
80
Dexmedetomidine
70 Pentobarbital
Chloral hydrate
60
Use, %

50

40

30

20

10

0
SpO2 BP ECG ETCO2 Plethysmography
Monitoring Modality

Figure 2. Percent use of each monitoring modality by medication used for sedation. Refer to Table 2 for frequencies of medication use. BP indicates blood
pressure; ECG, 3-lead electrocardiography; ETCO2, capnography/end-tidal carbon dioxide; and SpO2, noninvasive pluse oximetry.

were also significant variations in the use of each moni- for all the medications used. Notably, ETCO2 monitoring
toring device among health care providers (Figure 1). was used most frequently during sedation for magnetic
Stethoscopy was used in 4.8% of cases by anesthesiolo- resonance imaging and pentobarbital sodium sedation;
gists but in less than 1% of cases for all the other health however, pentobarbital had the least frequent monitor-
care providers. The overall largest difference in monitor- ing with SpO2, blood pressure, and plethysmography.
ing use was seen in the frequency of ECG monitoring be-
tween anesthesiologists, those in general practice or in a COMMENT
subspecialty other than pediatrics (95%), and those who
self-identified as pediatric anesthesiologists (13%). Gen-
erally, radiologists were the least frequent users of all the To safely and comfortably perform diagnostic or thera-
monitoring devices with the exception of ECG. Notably, peutic studies in children, sedation has become a part of
radiologists did not use any monitor in more than 40% the comprehensive care provided to this population.10-12
of children, and only 33% of radiologists used SpO2. Simi- Guidelines concerning the provision of sedation (in par-
lar differences were seen when plotting monitoring use ticular monitoring during sedation) are intended to im-
by medications used (Figure 2) and by type of proce- prove the safety and effectiveness of this care. Because
dure for which sedation was required (Table 6). Stethos- large, randomized controlled trials that evaluate out-
copy was reportedly used in less than 1% of all the cases comes of sedation activity related to monitoring sys-

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 Table 6. Frequency of Utilization for Each Monitoring Modality by Type of Procedure a

Hematology/ Nerve/ Bone/Joint/ Airway/

MRI Radiology Oncology Gastroenterology Surgical Brain/Ear Skeletal Cardiology Pulmonology
Monitoring Modality (n=50 904) (n=17 033) (n=16 546) (n=10 406) (n=9070) (n=6640) (n=2489) (n=1538) (n=1156)
SpO2 49 076 (96) 15 592 (92) 15 743 (95) 10 154 (98) 8909 (98) 6520 (98) 2462 (99) 1008 (66) 1093 (95)
BP 43 062 (85) 13 315 (78) 15 526 (94) 10 150 (98) 8725 (96) 6097 (92) 2359 (95) 963 (63) 1035 (90)
ECG 34 089 (67) 9364 (55) 12 050 (73) 7761 (75) 6883 (76) 4406 (66) 2068 (83) 593 (39) 795 (69)
ETCO2 38 964 (77) 3201 (19) 2745 (17) 2987 (29) 1562 (17) 1962 (30) 217 (9) 268 (17) 138 (12)
Impedance 5611 (11) 2592 (15) 5250 (32) 3536 (34) 3107 (34) 1631 (25) 514 (21) 402 (26) 549 (47)
plethysmography

Abbreviations: BP, blood pressure; ECG, 3-lead electrocardiography; ETCO2, end-tidal carbon dioxide; MRI, magnetic resonance imaging; SpO2, pulse oximetry.
a Data are given as number (percent).

tems are not generally available, these guidelines are var- diopulmonary disease.3 As alterations in rhythm are rare
ied and rely on expert opinion based on review of the in children, ECG monitoring may be best used in those
available literature rather than strong, evidence-based patients with specific cardiac pathologic features or when
data.8 To our knowledge, we present the first study to a rhythm disturbance is present. It is logical to suspect
describe the monitoring practices of a large, multispe- that with the ubiquitous use of SpO2, many health care
cialty group of sedation health care providers. This is providers are using this device as the monitor for heart
meant provide general information on the types of moni- rate in place of an ECG. Similarly, false-positive ECG alerts
toring that is being used by high-functioning pediatric due to artifact for life-threatening disturbances, such as
sedation systems. Our data suggest that large variations ventricular tachycardia, in a stable patient may steer health
exist in the physiologic monitoring applied to children care providers away from this modality. Our data indi-
who are sedated outside of the operating room based on cate that ECG use is not prevalent and that, in fact, se-
the health care providers involved, the medications used, dation health care providers seem to use this monitor se-
and the tests performed. lectively based on the specific needs of the patient or risk
The reasons for the differences in monitoring choices involved in the procedure or depth of sedation. Having
can only be elucidated through extensive qualitative re- noted this, health care providers should also consider the
search that considers multiple factors relating to the pa- potential serious adverse effects of medications being ad-
tient, the procedure, the sedation technique, and the health ministered, such as dysrhythmias seen with dexmedeto-
care providers involved. In clinical practice among the midine hydrochloride administration or cardiac toxic-
members of the PSRC, monitoring options seem to be tai- ity associated with lidocaine hydrochloride, as well as the
lored to the individual patient on the basis of his or her potential for undiagnosed conditions, such as long-QT
medical history, the procedure he or she is undergoing, syndrome.
and the safety profile of the medications that he or she Literature has supported the use of SpO2 to reduce the
will be receiving during sedation. A standard set of guide- frequency of more severe hypoxic events.17,18 It is not sur-
lines does not consider all the variables that the experi- prising that this is the modality used most frequently across
enced clinician acknowledges prior to the initiation of all types of sedations. The exception within this study is
sedation. On the other hand, unknown diagnoses and iat- among radiologists, who only used this device in 33% of
rogenic errors are difficult, if not impossible, to account their patients compared with more than 90% usage among
for even by the most experienced clinician and argue for all the other health care providers. This may be due to
the standardization of this process. As such, guidelines use of oral medications or minimal sedation techniques;
need to set standards and allow for clinical judgment on however, we cannot determine the depth of sedation
how to achieve the monitoring goals of safe and effec- among study patients in this data set. When SpO2is not
tive care. used as a monitoring device, the development of hypox-
Despite the fact that most pediatric sedations occur emia may not be apparent until either cyanosis develops
in a relatively healthy population (ASA 1 or 2) that is free or more serious consequences of respiratory depression
of heart disease, a 3-lead ECG is still recommended by and hypoxemia, such as bradycardia and cardiac arrest,
many organizations as a routine part of monitoring.13 In ensue. Mild hypoxemia, defined as pulse oximetry lower
fact, after reviewing quality assurance records of 1140 than 95% for longer than 60 seconds, has been reported
children receiving sedation, Malviya et al14 reported only to precede more serious adverse events and, thus, may
3 cases of altered heart rate, one of which occurred dur- be a prompt for interventions that prevent deteriora-
ing cardiac catheterization. In addition, Coté et al15 re- tion.17 Similarly, critical event analyses have docu-
ported that bradycardia was never the first observed event mented that hypoxemia secondary to depressed respira-
even among those with serious adverse events, al- tory activity is a principal risk factor for near misses and
though cardiac arrest was described. Even among those death during sedation, and thus early detection of these
patients with heart disease, changes in heart rate and blood events through the use of SpO2 is vital.14,15
pressure requiring any intervention are rare.16 The ACEP While the ASA only recently incorporated monitor-
guidelines do not recommend this monitor as a stan- ing with capnography into its recommendations for an-
dard practice if there is no evidence of underlying car- esthesiologists who are providing moderate sedation, our

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 study reveals that anesthesiologists and pediatric emer- include “assessment of blood pressure, pulse rate, respi-
gency medicine physicians use this device more regu- ratory rate and pulse oximetry,” but the nature of this
larly than other health care providers.7 A relatively low monitoring, be it continuous or intermittent, is not speci-
use of ETCO2 monitoring has been documented for pe- fied.3 Furthermore, not all the patients may receive the
diatric emergency medicine physicians in previous stud- same monitoring under this policy. The use of SpO2 is
ies, but the data from this study point to a more global recommended in emergency department patients at in-
lack of use by nonanesthesiologists.19-21 The frequent use creased risk of developing hypoxemia or with signifi-
of this monitor by anesthesiologists is likely due to the cant comorbidities, and cardiac monitoring can be for-
fact that it has been readily available in the operating room gone in patients without a history of cardiopulmonary
environment for more than 30 years, yet this device has disease.3 Later policies, in fact, defer to departmental
only recently become routinely available in other clini- guidelines for monitoring practices.5
cal settings.7,19,20,22 There has long been evidence that cap- There are many difficulties when it comes to devel-
nography improves detection of hypoventilation and ap- oping evidence-based guidelines for the safe and effec-
nea earlier than current monitoring devices (Sp O 2 , tive monitoring of pediatric patients undergoing seda-
impedance plethysmography, and/or direct observa- tion. First, serious adverse outcomes are rare. More
tions). More recent literature indicates the use of this common complications, such as oxygen desaturations and
monitor can reduce the frequency of oxygen desatura- hypoventilation, may have various definitions and are of
tions—one of the more common adverse events seen dur- uncertain clinical significance.29 Second, many compli-
ing sedation.23-25 These studies support the claims that cations or interventions depend on the threshold and be-
capnography provides an early warning to health care pro- havior of the health care provider and, thus, are subject
viders about hypoventilation, which they can then act on to their own inherent variability.9
effectively and noninvasively before further sequelae de- Despite the variability in monitoring shown herein,
velop. Likewise, when supplemental oxygen is rou- serious adverse outcomes during procedural sedation were
tinely administered to patients receiving sedation, SpO2 uncommon within this large database. The PSRC has pre-
cannot accurately detect changes in higher levels of ar- viously published data concerning rates of complica-
terial oxygenation content until they begin to precipi- tions arising from sedations with a total incidence rate
tously decline below normal, which may be delayed for of 340 per 10 000 cases.9 The most common complica-
several minutes.26,27 In this circumstance, capnography tions were oxygen desaturations less than 90% (157 per
yields even more value in the detection of hypoventila- 10 000 cases), secretions requiring suctioning (47 per
tion and apnea. Data from this study of sedation health 10 000 cases), and vomiting during the procedure (42 per
care providers in the PSRC indicate who this monitor is 10 000 cases). Serious adverse events were found to be
used most commonly by health care providers that ad- rare with no reported deaths and a single case of cardiac
minister the deepest levels of sedation and in cases in arrest among this large cohort.9 Continuing rigorous re-
which the most potent drugs for sedation are used. search on the use of monitoring modalities during pro-
Our study highlights variability in adherence to pub- cedural sedation with a focus on the detection of ad-
lished clinical guidelines on monitoring during seda- verse events and prevention of serious outcomes, as well
tion. Strict adherence to guidelines is not universal for as cost-effectiveness, will be key in developing evidence-
many reasons. Evidence-based guidelines for physi- based guidelines for this population.
ologic monitoring during sedation may be difficult to de- There are inherent limitations to the use of a large da-
velop.6,28 In some settings (eg, the magnetic resonance tabase, such as the inability to ensure complete consis-
imaging scanner), the environment itself may challenge tency in reporting over a large number of institutions and
the accuracy of many monitoring modalities. In other situ- health care providers. However, this is balanced by the
ations, the use of monitors themselves (eg, blood pres- ability to obtain a greater sample of participants with in-
sure cuffs) can disturb the sedated child and interfere with creased generalizability. Other limitations have been out-
procedures that require absolute motion control. Most lined in previous articles and include the self-selection
important, implementation of guideline-based monitor- of motivated institutions into this consortium.9,30 These
ing may not, in fact, reduce adverse events.6,7 Studies to groups likely have highly organized sedation systems and
evaluate the effect of the use of individual monitors on may represent best practice and, thus, they may have in-
serious adverse events while accounting for the multi- herent and unexplained differences from other organi-
tude of variables encountered would require a large and zations in which sedations occur that are not included
standardized collaborative effort and is not addressed in this cohort.30 Finally, we recognize that it is impos-
herein. From a human factors engineering perspective, sible to know the exact nature of the intended sedation
the current study is interesting in that it indicates which levels for every case in this database or the sedation level
monitors the high-performing sedation health care pro- that was achieved in every case. The monitoring data are
viders within the PSRC find useful enough to use on a clearly skewed by the fact that certain types of health care
day-to-day basis. providers were aiming for different sedation levels than
One difficulty in adherence to specific guidelines may other health care providers and, therefore, may have in-
be that the language used in these guidelines can be con- fluenced the monitoring needs. Even with this in mind,
fusing or difficult to interpret and implement. For in- we believe the presentation of the variety of monitoring
stance, in the ASA statement, a distinction is made be- choices that individual health care providers make for
tween the terms continual and continuous.7 In the ACEP their day-to-day work can help inform future research
clinical policy, it is stated that vital sign monitoring may into the issue of what monitors are most necessary.

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 In conclusion, there is significant variability in the fre- the Medical Center of Central Georgia, Macon; Chil-
quency of use of individual monitoring devices during dren’s Hospital of Alabama, Birmingham; Children’s Me-
the sedation of children outside of the operating room morial Hospital–Emergency Department, Chicago, Illi-
within the PSRC. These differences are seen among types nois; Children’s Memorial Hospital, Chicago; Children’s
of health care providers, medications used for sedation, Mercy Hospital–Emergency Department, Kansas City, Mis-
and the types of procedures for which sedation is needed. souri; Chris Evert Children’s Hospital, Fort Lauderdale,
There is also a lack of adherence to published guide- Florida; Columbus Children’s Hospital, Columbus, Ohio;
lines about monitoring children during sedation. De- Dartmouth Hitchcock Medical Center, Lebanon, New
spite these findings, the reported safety of sedation within Hampshire; East Tennessee Children’s Hospital, Knox-
our study consortium is excellent. Further research is ville; Eastern Maine Medical Center, Bangor; Florida Hos-
needed to develop evidence-based guidelines regarding pital for Children, Orlando; Gundersen Lutheran, La-
the appropriateness of various monitoring modalities and Crosse, Wisconsin; Helen DeVos Children’s Hospital,
their effect on adverse outcomes that are associated with Grand Rapids, Michigan; Holtz Children’s Hospital at the
sedation. University of Miami/Jackson Memorial Medical Center,
Miami, Florida; Joe DiMaggio Children’s Hospital, Hol-
Accepted for Publication: April 17, 2012. lywood, Florida; Kentucky Children’s Hospital, Lexing-
Published Online: September 10, 2012. doi:10.1001 ton; Kosair Children’s Hospital, University of Louisville,
/archpediatrics.2012.1023 Louisville, Kentucky; Medical University of South Caro-
Author Affiliations: Department of Pediatrics, Section of lina, Charleston; North Central Baptist Hospital, San An-
Emergency Medicine, Yale University School of Medi- tonio, Texas; Palmetto Health Richland Memorial Hos-
cine, New Haven, Connecticut (Dr Langhan); Pediatric pital, Columbia, South Carolina; Rainbow Babies and
Emergency Medicine Associates, Children’s Healthcare Children’s Hospital, Cleveland, Ohio; The Children’s Hos-
of Atlanta, Atlanta, Georgia (Dr Mallory); Department pital at Providence, Anchorage, Alaska; UMass Memo-
of Anesthesiology and Critical Care Medicine, A.I. du- rial Medical Center, Worcester, Massachusetts; UNC
Pont Hospital for Children, Wilmington, Delaware (Dr Healthcare, Chapel Hill, North Carolina; University of
Hertzog); Division of Pediatric Critical Care, St Louis Uni- Virginia, Charlottesville; Vanderbilt Children’s Hospi-
versity School of Medicine at Cardinal Glennon Chil- tal, Nashville, Tennessee; Yale New Haven Children’s Hos-
dren’s Medical Center, St Louis, Missouri (Dr Lowrie); pital, New Haven, Connecticut.
and Department of Pediatric Anesthesiology, Dartmouth- Financial Disclosure: Dr Langhan received an hono-
Hitchcock Medical Center, Lebanon, New Hampshire (Dr rarium to participate in an expert panel at an advisory
Cravero). board meeting of Oridion Capnography, Inc in Novem-
Correspondence: Melissa L. Langhan, MD, Department ber 2011 during the revising of the manuscript.
of Pediatrics, Section of Emergency Medicine, Yale Uni- Funding/Support: This study was supported in part by
versity School of Medicine, 100 York St, Ste 1F, New Ha- grant Clinical and Transitional Science Award UL1
ven, CT 06511 ([email protected]). RR024139 from the National Center for Advancing Trans-
Author Contributions: Drs Langhan, Mallory, Hertzog, lational Sciences, a component of the National Insti-
Lowrie, and Cravero had full access to all the data in the tutes of Health, and National Institutes of Health road-
study and take responsibility for the integrity of the data map for Medical Research (Dr Langhan).
and the accuracy of the data analysis. Study concept and Previous Presentations: An abstract from these data was
design: Langhan, Mallory, Hertzog, Lowrie, and Cravero. presented at the American Academy of Pediatrics Na-
Acquisition of data: Mallory and Cravero. Analysis and in- tional Conference and Exhibition; October 14, 2011; Bos-
terpretation of data: Langhan, Mallory, Hertzog, Lowrie, ton, Massachusetts; and the Society for Pediatric Seda-
and Cravero. Drafting of the manuscript: Langhan. Criti- tion Meeting; May 22, 2012; Cleveland, Ohio.
cal revision of the manuscript for important intellectual con- Additional Contributions: We would like to acknowl-
tent: Langhan, Mallory, Hertzog, Lowrie, and Cravero. edge the efforts of the PSRC in creating this database and
Statistical analysis: Mallory and Cravero. Administra- collecting data across multiple institutions.
tive, technical, and material support: Langhan. Study su-
pervision: Langhan and Cravero.
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