Dissociative and Deep Sedations Administered by Trained Unsupervised Pediatric Residents in Israeli Emergency Departments - 23/01/25

Doi : 10.1016/j.annemergmed.2024.12.020

Neta Cohen, MD ^a, Nitai Levy, MD ^b, Jordanna H. Koppel, MD ^c, Layah Alkoby-Meshulam, MD ^d, Nir Friedman, MD ^e, Gidon Test, MD ^f, Nachshon Buchshtav, MD ^g, Giora Weiser, MD ^h, Adi Klein, MD ⁱ, Irena Chistyakov, MD ^j, Itai Shavit, MD ^k,^⁎
Israel Pediatric Emergency Research Network (ISPERN)
^a Pediatric Emergency Department, Tel Aviv Sourasky Medical Center, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
^b Pediatric Emergency Department, Rambam Health Care Campus, Rappaport Faculty of Medicine, Technion - Institute of Technology, Haifa, Israel
^c Pediatric Emergency Department, Sheba Medical Center, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
^d Pediatric Emergency Department, Schneider Medical Center, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
^e Pediatric Emergency Department, Meir Medical Center, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
^f Pediatric Emergency Department, Soroka Medical Center, Faculty of Health Sciences, Ben Gurion University, Beer Sheva, Israel
^g Pediatric Emergency Department, HaEmek Medical Center, Afula, Israel
^h Pediatric Emergency Department, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
ⁱ Division of Pediatrics, Hillel Yaffe Medical Center, Rappaport Faculty of Medicine, Technion - Institute of Technology, Haifa, Israel
^j Pediatric Emergency Department, Bnei-Zion Medical Center, Rappaport Faculty of Medicine, Technion - Institute of Technology, Haifa, Israel
^k Division of Pediatrics, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel

^∗Corresponding Author.

Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Thursday 23 January 2025

Abstract

Study objective

To cover pediatric emergency physicians' off-hours, third-year pediatric residents in Israel are trained for unsupervised administration of emergency department (ED) dissociative and deep sedation. We assessed the frequency of critical sedation events associated with resident-performed sedations.

Methods

We conducted a retrospective chart review on all patients receiving intravenous sedation across 10 pediatric EDs between January 2018 and September 2022. We defined a critical sedation event as one or more of the following: chest compressions, tracheal intubation, neuromuscular blockers, vasopressors, atropine for bradycardia, aspiration syndrome, death, or unplanned hospital admission due to sedation. We liaised with the Ministry of Health’s reporting department and ED directors to verify complete identification of all sentinel events.

Results

Pediatric residents and pediatric emergency physicians performed 12,733 and 10,845 sedations, respectively, most frequently for fracture reduction (44.4%) and laceration repair (25.6%). Patients’ mean (SD) age was 6.9 (4.4) years. Residents and emergency physicians administered ketamine or propofol alone in 6,473 and 3,465 cases, respectively, with drug combinations for the remainder. We identified 6 critical sedation events, of which 3 were resident-performed sedations. The frequency of critical sedation events among pediatric residents and emergency physicians was 0.024% (95% CI, 0.005% to 0.069%) and 0.028% (95% CI, 0.006% to 0.080%), respectively.

Conclusion

We observed a low frequency of critical sedation events in this large sample of dissociative and deep sedations performed by pediatric residents and pediatric emergency physicians. Our findings suggest that ED sedation by unsupervised, trained pediatric residents is a safe practice in Israel.

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Keywords : Sedation, Pediatric residents, Deep sedation, Dissociative sedation

Plan

Introduction

Background

Importance

Goal of This Investigation

Materials and Methods

Study Design and Setting

Selection of Participants

Characteristics of Study Subjects

Main Results

Limitations

Discussion

	Supervising editor: Steven M. Green, MD. Specific detailed information about possible conflict of interest for individual editors is available at editors.
	Author contributions: NC conceived the idea for the study, extracted the data, analyzed and interpreted the data, reviewed the literature, and critically revised the article. NL, JHK, LA-M, NF, GT, NB, GW, IC, and AK extracted the data, carried out the initial analysis, and critically revised the article. IS analyzed and interpreted the data, reviewed the literature, drafted the manuscript, and supervised the study. NC and IS have full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. All authors approved the final manuscript as submitted and agreed to be accountable for all aspects of the work. IS takes responsibility for the article as a whole.
	Data sharing statement: The deidentified participant data of this study will be available from the corresponding author up on reasonable request, beginning 12 months and ending 36 months following article publication. To gain access, data requestors will need to sign a data access agreement and obtain approval from the institutional review board.
	All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
	Funding and support: By Annals’ policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org/). The authors of the paper report no such relationships. This study did not receive any funding.
	Ethics committee approval: The study was approved by the Tel Aviv Sourasky Institutional Review Board and the Review Boards of the participating centers (Ref # 0626-22-TLV).
	Please see page XX for the Editor’s Capsule Summary of this article.