CRISP score may not be best way to select who can skip anesthesia
Cardiac anesthesiologists may not have to be present in the pediatric and congenital catheterization lab to administer general anesthesia as often as recommended, one center found.
Operator-directed sedation actually had fewer adverse events than did general anesthesia (3.4% vs 6.6%, adjusted OR 0.66, 95% CI 0.45-0.95), according to propensity score-matched analysis from a group led by Michael O'Byrne, MD, MSCE, of The Children's Hospital of Philadelphia.
Sedation also had 17% shorter room time, 13% shorter sheath time, 40% faster exit time, 12% lower professional charges, and 16% lower hospital charges than did general anesthesia (all P<0.001), the researchers reported online in JACC: Cardiovascular Interventions.
"In combination, these findings suggest that the selective use of ODS [operator-directed sedation] can allow for greater efficiency and higher value care without sacrificing safety," they concluded.
O'Byrne and colleagues had reviewed all elective and urgent catheterizations at their center over almost 7 years among patients ages 30 days to 25 years (4,424 catheterization procedures in 2,547 patients).
Only 27% of cases were done with sedation administered by a registered nurse supervised by the interventional cardiologist. Just over 4% of those cases converted to general anesthesia because of a major adverse event.
Notably, despite the favorable outcomes found after adjustment for case mix, around 90% of operator-directed sedation cases would have been deemed inappropriate under current recommendations, the investigators found.
A consensus statement from the Society for Cardiac Angiography and Intervention, the Society for Pediatric Anesthesia, and the Congenital Cardiac Anesthesia Society recommended a cardiac anesthesiologist for cases with higher Catheterization Risk Score for Pediatrics (CRISP).
"This study suggests current recommendations for when/when not to use ODS may not accurately identify patients who are good candidates for its use. The results of the study also suggest there are clearly circumstances and cases for which ODS can be administered, presenting an efficient and cost-saving technique that would not compromise patient safety," according to an accompanying editorial by Natalie Jayaram, MD, of Children's Mercy Hospital and Clinics in Kansas City, Missouri, and colleagues.
However, a "one size fits all" approach to sedation wouldn't work in the pediatric and congenital catheterization laboratories, they wrote.
"We do not believe that this is evidence that treatment by an anesthesiologist increases the risk of a catheterization procedure or that these findings negate other aspects of the consensus statement. Rather, we propose that careful review of patient history can better identify patients in whom ODS is safe and effective and that its application can reduce resource utilization, specifically case times and costs," according to O'Byrne's team.
They said that they are switching to having more anesthesiologists in these cases to meet regulatory requirements, which call for a second qualified sedation practitioner to manage a patient when the goal of sedation is greater than moderate sedation.
In the study, the degree of sedation was not recorded in each case, so it is likely that some ODS patients achieved deeper levels of sedation, the group acknowledged.
Jayaram and colleagues called it "premature" to overhaul the sedation practices for these catheterizations based solely on this study. "While clinical judgment alone may be effective for deciding when to use ODS at a center with a well-established catheterization program and experience with ODS, other centers with less experience making this determination may not experience similar successes."
O'Byrne reported NIH research support.
Jayaram disclosed no conflicts of interest.
JACC: Cardiovascular Interventions
Source Reference: O'Byrne ML, et al "Operator-directed procedural sedation in the congenital cardiac catheterization laboratory" JACC Cardiovasc Interv 2019. DOI: 10.1016/j.jcin.2019.01.224.
JACC: Cardiovascular Interventions
Source Reference: Jayaram N, et al "Sedation in the pediatric and congenital catheterization lab: is it time we wake them up?" JACC Cardiovasc Interv 2019. DOI: 10.1016/j.jcin.2019.02.001.
Read the original article on Medpage Today: Sedation May Work for More Kids in Cath Lab Than Thought