Adverse Events Associated with Sedative and Anesthetic Drugs in Pediatric Patients

Abstract

OVERVIEW

The use of sedatives and anesthetics in pediatric critical care settings and operating rooms is inevitable. Sedation is required in critically ill pediatric patients to aid ventilation and decrease anxiety and pain. Sedative and anesthetics, high alert medications, are always associated with several adverse events that vary in incidence and severity. We aimed to study two common adverse drug events (ADE). About 60 – 80 % of bronchiolitis presentation is attributed to Respiratory Syncytial Virus (RSV), with an observed increasing trend of intensive care unit admission during the last decade. Dexmedetomidine (DMED) is a widely used sedative in pediatric critical care settings. Bradycardia is a prevalent DMED ADE (>10%). Asystole was observed with DMED in some children diagnosed with RSV bronchiolitis which is associated with bradycardia. The clinical course of bradycardia upon using DMED to sedate RSV bronchiolitis children is questionable. Therefore, we conducted a retrospective cohort study to investigate if RSV bronchiolitis during DMED administration is associated with clinically significant bradycardia. Among anesthetics, isoflurane and sevoflurane are commonly used inhalation anesthetics. Although emergence agitation (EA) is a probable ADE with both, there is conflicting data regarding this association. Understanding this association using up to date evidence can guide development of preemptive strategies to decrease EA burden. To accomplish this, we conducted a systematic review and meta-analysis comparing isoflurane versus sevoflurane for their association with EA. In summary, both studies are essential for pediatric clinicians to guide sedative medications use and mitigate these adverse events.

CONCLUSION In our first project: although both RSV and dexmedetomidine are associated with bradycardia, our results suggested that RSV bronchiolitis was no statistically significant association with additive clinically significant bradycardia during DMED administration in children of two years of age or younger. However, there was a significant decrease in the heart rate by an average 8 bpm in those with RSV bronchiolitis. We also explored effect modification by ventilation mode. These results contribute to the body of literature on this area by providing evidence that may guide clinicians’ decision for sedating children with RSV bronchiolitis in pediatric intensive care units. Close heart rate monitoring and clinical caution may be warranted, especially in specific groups, including the mechanically ventilated or those requiring high starting doses of DMED greater than 0.3 mcg/kg/h, or high peak doses greater than 1 mcg/kg/h. In the second project: our systematic review and meta-analysis evaluated the of isoflurane and sevoflurane and their association with emergence agitation incidence adverse event using the available evidence more comprehensively. Our results concluded that the incidence of emergence agitation among children who received sevoflurane was significantly higher than among isoflurane. Furthermore, we assessed the differences in emergence agitation incidence by using different scales, and studied the effect of the use of premedications, and intraoperative analgesics. There was a significant decrease in the risk of EA in the isoflurane group than sevoflurane group upon assessing EA with the PAED scale, using premeditations and intraoperative systemic analgesics. The need for extra nursing care and medications in post operative care and intensive care units to children who received sevoflurane should be anticipated. Overall, our findings highlighted the importance of studying the probable adverse events that impact clinical practice and may be life-threatening. Consequences should be anticipated upon using these drugs, and preemptive strategies of close monitoring should be established.