Prolonged recovery and delayed side effects of sedation for diagnostic imaging studies in children

Objective. Although sedation-related adverse events in children in the hosp ital setting have been extensively reported, limited data are available reg arding adverse events after discharge home. Despite nationally recommended discharge criteria, in busy outpatient settings, children may be sent home into the care of their parents after a brief recovery from sedation, placin g them at risk for adverse events in an unmonitored setting. Previous studi es have not addressed issues such as requirement for escalation of care aft er discharge (ie, emergency department visits or hospitalization), or paren tal satisfaction with their child's sedation experience. This study was und ertaken to evaluate the recovery and delayed adverse events after discharge of children who received sedation for magnetic resonance imaging or comput ed tomography. Methods. With approval from the institutional review board and written info rmed consent from a parent, children (<18 years old) sedated for magnetic r esonance imaging or computerized tomography were studied. Sedative drugs we re ordered at the discretion of the radiologist responsible for the procedu re in accordance with institutional sedation guidelines and in consideratio n of the child's health status. Pediatric nurses in the diagnostic areas ad ministered the sedative agent(s) and monitored children according to preest ablished institutional guidelines. Demographics, sedative(s) administered, and adverse events including hypoxemia (decrease in SpO(2) by greater than or equal to 10% of baseline) and sedation events such as inadequate, failed , or excessive sedation, were documented on the institutional quality assur ance tool. Children were discharged from the hospital when they met the fol lowing preestablished discharge criteria: return to baseline vital signs, l evel of consciousness close to baseline, and the ability to maintain a pate nt airway. The following day, parents were telephoned and questioned regard ing the child's alertness, side effects, and whether medical follow-up had been sought. Parents also rated their overall satisfaction with the sedatio n experience. Results. Three hundred seventy six children comprised the sample. Eighty ni ne percent of children received chloral hydrate (CH; 64 +/- 13 mg/kg), and 11% midazolam (.15 +/- .13 mg/ kg) as the primary sedative. There was an 8% incidence of failed sedation, and a 1.6% incidence of hypoxemia during the procedure. Three children required prolonged monitoring in the postanesthe sia care unit before discharge; 1 child attributable to an allergic reactio n, a second attributable to wheezing and oxygen desaturation, and the third attributable to prolonged sedation from CH and midazolam. These children w ere discharged home from the postanesthesia care unit without additional se quelae. Side effects after discharge included: motor imbalance (31%), gastrointesti nal effects (23%), agitation (19%), and restlessness (14%). Agitation and r estlessness lasted greater than 6 hours in more than one third of children who experienced these effects. CH was more commonly associated with imbalan ce compared with midazolam, and restlessness and prolonged imbalance were a ssociated with younger age. Medical advice was sought after discharge for 1 5 (4%) children, 3 of whom required a visit to the emergency department for excessive or prolonged sedation. Each of these children had received CH as a sole sedative in recommended doses (61-77 mg/kg). In 1 of these cases, t he procedure had been aborted because of inadequate sedation in the hospita l, yet the child became difficult to arouse at home. Only 48% of children returned to baseline activity and behavior within 8 ho urs of the procedure; however, 89% were back to baseline status within 24 h ours. Notably, 5% of all children did not return to baseline activity until the second day after the procedure. Although not statistically significant , infants <12 months old experienced delayed recovery (ie, greater than or equal to 24 hours) more frequently compared with older children. Sixteen pe rcent of parents were dissatisfied with the sedation experience. Inadequate /failed sedation and agitation after discharge contributed to parent dissat isfaction. Conclusions. Our data demonstrate that children may experience prolonged re covery as well as a significant incidence of delayed side effects after sed ation for a diagnostic procedure. Specifically, we found a high incidence o f motor imbalance, agitation, gastrointestinal effects, and restlessness af ter discharge. Factors related to these side effects included younger age ( restlessness and prolonged imbalance) and use of CH (agitation and motor im balance). Failed sedation and agitation contributed significantly to parent al dissatisfaction with the child's sedation experience. These findings hig hlight the importance of careful presedation education and preparation of t he patient/family regarding the potential for delayed recovery, anticipated side effects, and how to obtain medical follow-up if necessary. Future stu dies should focus on sedation methods that reduce sedation-related adverse events and promote the safety of sedated children.