Should We Preemptively Start Oxygen for Pediatric Sedations?

August 15, 2024

Written by Joshua Belfer

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A large retrospective registry analysis finds no difference in rates of additional respiratory interventions with preemptive administration of supplemental oxygen during pediatric sedation.

Oxygenation for every sedation?
Though uncommon, adverse events of pediatric procedural sedation are often respiratory related¹. Preemptively starting supplemental oxygen could be a simple intervention to reduce the risk of a respiratory event.

A retrospective review of the Pediatric Sedation Research Consortium sought to elucidate the effect of preemptive oxygen on additional respiratory interventions. It included 85,599 pediatric sedations across all settings from 45 institutions . Preemptive oxygen was started before or during induction in 50.5% (43,242/85,599) and analyzed as a “preprocedural oxygenation” group. Overall, some form of preemptive oxygen via nasal cannula, facemask, or blow-by was started before or at any point in the procedure and continued throughout, without an inciting respiratory event, in 61.0% (52,219/85,559). This comprised the “procedural oxygenation” group. These groups were compared to the 39.0% with no preemptive oxygenation.

The probability of an additional respiratory intervention was calculated via a weighted inverse probability of treatment. No significant difference was observed with preprocedural (-0.06%, 95%CI -4.26 to 4.14%) or procedural (-1.07%, 95%CI -6.44 to 4.30%) vs. no preemptive oxygen. Subgroups also lacked significant differences. A sensitivity analysis removing three outlier sites with higher hypoxemia rates and limiting the analysis to emergency physicians (n=10,859) found an increased probability of respiratory intervention with both preprocedural (4.03%, 95%CI 0.16 to 7.9%) and procedural oxygenation (4.05%, 95%CI 0.10 to 8.00%).

Limitations include a lack of some data points, such as oxygen flow rates, medication dosages, and oxygen saturation, which are thus not weighted. Interventions were recorded at the provider’s discretion and may be biased endpoints.

How will this change my practice?
The results suggest, with limitations, that preemptive oxygenation does not reduce – and possibly increases – additional interventions. My preference remains to minimize supplemental oxygen, as it may blunt the respiratory response to hypoventilation and delay recognition of the underlying cause of a hypoxemic event.

Source
Preprocedural Oxygenation and Procedural Oxygenation During Pediatric Procedural Sedation: Patterns of Use and Association With Interventions. Ann Emerg Med. Published online June 12, 2024. doi:10.1016/j.annemergmed.2024.04.014.

Work Cited

1. Selbst SM. Adverse sedation events in pediatrics: a critical incident analysis of contributing factors. Pediatrics. 2000;105(4 Pt 1):864-865. doi:10.1542/peds.105.4.864