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Push for safety in procedural sedation urged.

ANAHEIM, CALIF. -- Systems need to be developed between pediatricians and radiologists in individual communities to provide for safe procedural sedation for children undergoing procedures, Dr. Steven J. Weisman urged at a meeting sponsored by the Los Angeles Pediatric Society.

"You should not give sedating medications to kids at home and send them in a car to the hospital. Once in a while, a dead one's going to arrive at the hospital. You have to have them get the medication at the hospital, so that if, God forbid, something goes wrong, they can be attended to," said Dr. Weisman, chair of pain management at Children's Hospital of Wisconsin, and professor of anesthesiology and pediatrics at the Medical College of Wisconsin, Milwaukee.

The nature of medications used to sedate children for painless procedures fosters tension between radiology departments on tight schedules and busy pediatricians at their offices. "Everyone still uses chloral hydrate, a dirty drug that tastes disgusting," he said.

Even with its shortcomings, it has advantages. The drug is relatively safe and can be administered orally or rectally; however, it takes time to take effect and has a failure rate of 25%-30%. The "systems issue" about how to deliver chloral hydrate has to be addressed, and sometimes it can require a "'push" by community pediatricians, he said.

"You send your patients to a radiology department making a gazillion dollars off doing these procedures, and it behooves them to learn how to sedate patients."

That fact that it requires children to be "'in house" while it takes effect should be part of the development of a community-wide system focusing on safety, he asserted.

Pediatricians also need to be assured that if chloral hydrate fails to sedate a patient, radiologists will be willing to reschedule the procedure, using a new plan that may involve general anesthesia.

Again, Dr. Weisman said that may require assertiveness on the part of community pediatricians.

"If anesthesiology is not cooperative, everyone needs to rise up and make them get cooperative," he suggested. Obviously, it would be helpful if there were more safe drugs that could be used for procedural sedation during painless procedures.

Midazolam, a fast-acting drug commonly used for procedural sedation, is not a wise choice in this scenario because it lasts only 2030 minutes and will not cover MRI procedures that typically last 45-60 minutes. Dr. Weisman was careful to point out that sedation may not even be necessary in the radiology suite.

An MRI on a 1-month-old may require nothing more than a pacifier and swaddling in a warmed blanket.

Likewise, most 15-year-olds merely need reassurance, perhaps some relaxation training, and a set of headphones with their favorite tunes.


Los Angeles Bureau

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Title Annotation:Clinical Rounds
Author:Bates, Betsy
Publication:Pediatric News
Geographic Code:1USA
Date:Nov 1, 2006
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