Written by Seth Welsh
Spoon Feed
This RCT found fewer desaturation events with supplemental oxygen via both low- and high-flow nasal cannula during pediatric procedural sedation.
With which flow to go?
It’s logical that administering oxygen during sedation decreases desaturation but to what degree compared to no oxygen? If we are administering oxygen, is there a benefit to setting up a High-Flow (HF) system, or can we get the same benefits with a Low-Flow (LF)?
The authors analyzed 253 patients under 18 years, ASA class ≤ III, without respiratory disease. The groups were well balanced at baseline, including age distribution and sedation agent. The LF group used a nasal cannula at ≤ 2L/min for age ≤ 12 months and ≤ 6L/min for the others. The HF group received 2L/kg/min at 50% FiO2. Propofol was the most common sedative agent, followed by midazolam. An anesthesiologist performed the sedations in a procedural suite.
The primary outcome of oxygen saturation < 95% for > 5 seconds occurred in 24 (27.6%), 6 (7.2%), and 1 (1.2%) patients from the control, LF, and HF groups, respectively. Odds ratios for the outcome relative to control were 0.184 (95%CI 0.067-0.503) for LF and 0.026 ( 0.003-0.027) for HF. Comparing HF to LF, the OR was 0.151 (0.017 – 1.307, p=0.078). Secondary outcomes such as rescue interventions (increasing O2, adjusting airway, etc.) were lower with supplemental O2 and followed a similar trend of fewer HF events without statistical significance.
How will this change my practice?
The data clearly show reduced desaturations with both LF and HF oxygen support and similar benefits for secondary outcomes. It would be a special circumstance for me not to use LF at least. The authors anticipated more desaturation events when designing this trial, so it may be underpowered to compare LF to HF. Regardless, I like using high flow when available for its additional benefits of humidification, greater titrability, and a small amount of positive pressure. Should I need to intubate the patient, I will already have them on HF to aid apneic oxygenation.
Editor’s note: I use ketamine for pediatric sedation, don’t use oxygen, and can’t remember the last time I had a child with hypoxemia. This study won’t change my practice. However, propofol is very different, so consider your patient population. ~Clay Smith
Source
Oxygen supplementation in pediatric sedation-prospective, multicenter, randomized controlled trial. Anesthesiology. 2025 Apr 11. doi: 10.1097/ALN.0000000000005500. Epub ahead of print. PMID: 40215365
