Age, Glycopyrrolate Spotted as Pediatric Propofol Risks

KANSAS CITY, MO. – Improved patient selection and reduced use of oral midazolam are being credited with a fivefold decrease in adverse events associated with pediatric propofol sedation.

The rate of respiratory events, airway interventions, and any other event dropped from 11% in 2005 to 2.3% in 2009 among patients sedated with propofol (Diprivan) by hospitalists in an ambulatory procedure center at St. Louis Children’s Hospital, according to an analysis of 1,649 patients.

Multivariate analysis showed that age more than 12 years (odds ratio 4.0), American Society of Anesthesiologists (ASA) 3 status (OR 2.3), premedication with oral midazolam (Versed) (OR 1.9), use of glycopyrrolate (Robinul) during sedation (OR 4.7), and history of snoring (OR 2.4) increased the likelihood of respiratory events.

All of these, except for ASA 3 status, also significantly increased the likelihood for airway interventions, Dr. Mythili Srinivasan and her colleagues reported in a poster at Pediatric Hospital Medicine 2011.

Although snoring and midazolam were the two most prevalent risk factors, the use of adjuvant glycopyrrolate was found to be the single greatest risk factor for both respiratory events (OR 4.7) and airway interventions (OR 5.8).

"However, a history of recent or ongoing upper respiratory infection was not a significant risk factor, raising the question of whether glycopyrrolate itself may be a risk factor for propofol sedation similar to that reported for ketamine sedations," said Dr. Srinivasan, a pediatric hospitalist at Washington University in St. Louis, Missouri.

A previous analysis of risk factors for ketamine sedation also showed that use of glycopyrrolate was associated with significantly more airway and respiratory complications in the emergency department than either atropine or no anticholinergic in an individual patient-data meta-analysis of 8,282 children (Ann. Emerg. Med. 2009;54:158-68).

In the current analysis, propofol dose, procedure time, and the diagnostic category of the patients were not significant risk factors for adverse events.

The higher likelihood of respiratory events and airway interventions in patients 12 years or older was described by the authors as an unexpected finding. The increase was not related to higher doses of propofol normalized to body weight, nor did older patients have a higher incidence of risk factors such as history of snoring, ASA 3 status, premedication with midazolam, or use of glycopyrrolate compared with patients younger than 12 years. Further studies are needed to explain the surprise finding, the authors suggested.

Declines during the study period in three of the five risk factors – age more than 12 years, ASA 3 status, and premedication with oral midazolam – were significantly correlated with the overall decrease in rates of adverse events, Dr. Srinivasan reported at the meeting, which was sponsored by the Society of Hospital Medicine, American Academy of Pediatrics, and Academic Pediatric Association.

The percentage of patients older than 12 years dropped twofold from 8% in 2005 to 3.8% in 2009, while patients in the ASA 3 category decreased from 10% to 2%, and the use of oral midazolam fell from 41% to 3.3%.

Finally, the increased expertise of hospitalists in the use of propofol also likely contributed to the decrease in adverse events, she noted.

Dr. Srinivasan and her coauthors reported no relevant financial disclosures.

KANSAS CITY, MO. – Improved patient selection and reduced use of oral midazolam are being credited with a fivefold decrease in adverse events associated with pediatric propofol sedation.

The rate of respiratory events, airway interventions, and any other event dropped from 11% in 2005 to 2.3% in 2009 among patients sedated with propofol (Diprivan) by hospitalists in an ambulatory procedure center at St. Louis Children’s Hospital, according to an analysis of 1,649 patients.

Multivariate analysis showed that age more than 12 years (odds ratio 4.0), American Society of Anesthesiologists (ASA) 3 status (OR 2.3), premedication with oral midazolam (Versed) (OR 1.9), use of glycopyrrolate (Robinul) during sedation (OR 4.7), and history of snoring (OR 2.4) increased the likelihood of respiratory events.

All of these, except for ASA 3 status, also significantly increased the likelihood for airway interventions, Dr. Mythili Srinivasan and her colleagues reported in a poster at Pediatric Hospital Medicine 2011.

Although snoring and midazolam were the two most prevalent risk factors, the use of adjuvant glycopyrrolate was found to be the single greatest risk factor for both respiratory events (OR 4.7) and airway interventions (OR 5.8).

"However, a history of recent or ongoing upper respiratory infection was not a significant risk factor, raising the question of whether glycopyrrolate itself may be a risk factor for propofol sedation similar to that reported for ketamine sedations," said Dr. Srinivasan, a pediatric hospitalist at Washington University in St. Louis, Missouri.

A previous analysis of risk factors for ketamine sedation also showed that use of glycopyrrolate was associated with significantly more airway and respiratory complications in the emergency department than either atropine or no anticholinergic in an individual patient-data meta-analysis of 8,282 children (Ann. Emerg. Med. 2009;54:158-68).

In the current analysis, propofol dose, procedure time, and the diagnostic category of the patients were not significant risk factors for adverse events.

The higher likelihood of respiratory events and airway interventions in patients 12 years or older was described by the authors as an unexpected finding. The increase was not related to higher doses of propofol normalized to body weight, nor did older patients have a higher incidence of risk factors such as history of snoring, ASA 3 status, premedication with midazolam, or use of glycopyrrolate compared with patients younger than 12 years. Further studies are needed to explain the surprise finding, the authors suggested.

Declines during the study period in three of the five risk factors – age more than 12 years, ASA 3 status, and premedication with oral midazolam – were significantly correlated with the overall decrease in rates of adverse events, Dr. Srinivasan reported at the meeting, which was sponsored by the Society of Hospital Medicine, American Academy of Pediatrics, and Academic Pediatric Association.

The percentage of patients older than 12 years dropped twofold from 8% in 2005 to 3.8% in 2009, while patients in the ASA 3 category decreased from 10% to 2%, and the use of oral midazolam fell from 41% to 3.3%.

Finally, the increased expertise of hospitalists in the use of propofol also likely contributed to the decrease in adverse events, she noted.

Dr. Srinivasan and her coauthors reported no relevant financial disclosures.

KANSAS CITY, MO. – Improved patient selection and reduced use of oral midazolam are being credited with a fivefold decrease in adverse events associated with pediatric propofol sedation.

The rate of respiratory events, airway interventions, and any other event dropped from 11% in 2005 to 2.3% in 2009 among patients sedated with propofol (Diprivan) by hospitalists in an ambulatory procedure center at St. Louis Children’s Hospital, according to an analysis of 1,649 patients.

Multivariate analysis showed that age more than 12 years (odds ratio 4.0), American Society of Anesthesiologists (ASA) 3 status (OR 2.3), premedication with oral midazolam (Versed) (OR 1.9), use of glycopyrrolate (Robinul) during sedation (OR 4.7), and history of snoring (OR 2.4) increased the likelihood of respiratory events.

All of these, except for ASA 3 status, also significantly increased the likelihood for airway interventions, Dr. Mythili Srinivasan and her colleagues reported in a poster at Pediatric Hospital Medicine 2011.

Although snoring and midazolam were the two most prevalent risk factors, the use of adjuvant glycopyrrolate was found to be the single greatest risk factor for both respiratory events (OR 4.7) and airway interventions (OR 5.8).

"However, a history of recent or ongoing upper respiratory infection was not a significant risk factor, raising the question of whether glycopyrrolate itself may be a risk factor for propofol sedation similar to that reported for ketamine sedations," said Dr. Srinivasan, a pediatric hospitalist at Washington University in St. Louis, Missouri.

A previous analysis of risk factors for ketamine sedation also showed that use of glycopyrrolate was associated with significantly more airway and respiratory complications in the emergency department than either atropine or no anticholinergic in an individual patient-data meta-analysis of 8,282 children (Ann. Emerg. Med. 2009;54:158-68).

In the current analysis, propofol dose, procedure time, and the diagnostic category of the patients were not significant risk factors for adverse events.

The higher likelihood of respiratory events and airway interventions in patients 12 years or older was described by the authors as an unexpected finding. The increase was not related to higher doses of propofol normalized to body weight, nor did older patients have a higher incidence of risk factors such as history of snoring, ASA 3 status, premedication with midazolam, or use of glycopyrrolate compared with patients younger than 12 years. Further studies are needed to explain the surprise finding, the authors suggested.

Declines during the study period in three of the five risk factors – age more than 12 years, ASA 3 status, and premedication with oral midazolam – were significantly correlated with the overall decrease in rates of adverse events, Dr. Srinivasan reported at the meeting, which was sponsored by the Society of Hospital Medicine, American Academy of Pediatrics, and Academic Pediatric Association.

The percentage of patients older than 12 years dropped twofold from 8% in 2005 to 3.8% in 2009, while patients in the ASA 3 category decreased from 10% to 2%, and the use of oral midazolam fell from 41% to 3.3%.

Finally, the increased expertise of hospitalists in the use of propofol also likely contributed to the decrease in adverse events, she noted.

Dr. Srinivasan and her coauthors reported no relevant financial disclosures.