 |
|
The Safety of Conscious Sedation in Peritonsillar Abscess Drainage
Paul W. Bauer, MD;
Judith E. C. Lieu, MD;
Dana L. Suskind, MD;
Rodney P. Lusk, MD
Arch Otolaryngol Head Neck Surg. 2001;127:1477-1480.
ABSTRACT
| |
Objective To demonstrate the safety of conscious sedation in draining peritonsillar
abscesses (PTAs).
Design Children diagnosed as having a PTA in the pediatric emergency department
were identified, and their medical records were retrospectively reviewed.
Results of the present study were compared with those of a previous report.
Setting A tertiary referral children's hospital pediatric emergency department.
Participants Ninety-one consecutive children initially evaluated in the emergency
department and managed for a PTA.
Interventions Peritonsillar abscess incision and drainage with or without sedation.
A team of physicians whose activities were documented on a formal conscious-sedation
record was present. Patients were monitored for major and minor complications.
Outcome Measures The primary outcome measures were major and minor complications. Secondary
outcome measures were recurrence of PTA and the need for admission.
Results There were 62 episodes of conscious sedation for drainage of a PTA.
Among the 91 patients, 3 had a recurrence and 24 were admitted after the procedure.
A previous study evaluated 30 episodes of conscious sedation for drainage
of a PTA. No major complications occurred in either series. Combining the
previous data with the present data produced 92 episodes of conscious sedation
for drainage of a PTA. The 1-sided upper 95% confidence limit for the rate
of major complications is 3.2%.
Conclusion Our series, when combined with previously published data, demonstrates
that conscious sedation can be safely used when draining a PTA in pediatric
patients.
INTRODUCTION
MANAGEMENT of a peritonsillar abscess (PTA) in the pediatric emergency
department is a common consultation seen by the otolaryngologist. Management
options include admission for intravenous antibiotic therapy, needle aspiration
with or without incision and drainage, or immediate (quinsy) tonsillectomy.
Transoral incision and drainage has been an accepted approach to managing
PTAs.1 The efficacy of transoral incision and
drainage to treat PTAs in children has been documented, as has the safety
and efficacy of managing these children in the outpatient setting.2-4 Unfortunately, transoral
incision and drainage is not tolerated well by children and traditionally
requires restraint, creating a frightening and painful experience for the
child and the parent. The risks of transoral incision and drainage of PTAs
in children include vascular, neural, and soft tissue injury. There is also
a significant risk of aspiration of purulence in a restrained, combative child.
Conscious sedation is defined as a medically controlled state of depressed
consciousness that allows maintenance of protective reflexes, the ability
to maintain a patent airway, and appropriate response by the patient to physical
stimulation or verbal command.5 The goal of
sedation is to guard the patient's safety and welfare, while reducing his
or her pain and psychological stress. Sedation represents a continuum between
full alertness and general anesthesia, which may result in the loss of the
patient's protective reflexes.
Conscious sedation has been increasingly used in the pediatric population
for invasive procedures in the outpatient setting.6-8
The efficacy and safety of intravenous midazolam hydrochloride and ketamine
hydrochloride as agents to induce conscious sedation have been reported for
a range of procedures, including lumbar puncture, bone marrow aspiration,
reduction of fractures, and closure of lacerations.6-7
A previous report9 described the use of conscious
sedation in the drainage of PTAs in children. Management of PTAs in properly
sedated children results in better compliance, maintenance of their protective
reflexes, reduced pain, and some amnesia. Although this approach has become
the standard of care at our institution, concern persists regarding airway
patency and the risk of aspiration.
The objective of this study was to demonstrate the safety of conscious
sedation in draining PTAs.
PATIENTS AND METHODS
Children diagnosed as having a PTA in the pediatric emergency department
of a tertiary referral children's hospital (St Louis Children's Hospital,
St Louis, Mo) from March 1, 1998, until March 31, 2001, were identified through
medical records (International Classification of Diseases,
Ninth Revision, Clinical Modification code 475). Records were reviewed
retrospectively for the patient's age, sex, symptom duration, type of treatment,
findings of the procedure, sedation complications, and need for hospitalization.
The Washington University School of Medicine (St Louis) Human Studies Committee
approved the study.
A team of physicians managed patients who underwent PTA incision and
drainage under conscious sedation. The team included an otolaryngologist who
performed the drainage procedure, a pediatric emergency medicine physician
trained in the administration of conscious sedation, and a registered nurse
who monitored and documented vital signs and sedation level. The activities
of this team were documented by the registered nurse on a formal conscious-sedation
record.
As part of the conscious-sedation regimen, each patient has intravenous
access and is taken to a procedure room that has airway stabilization and
advanced cardiac life support equipment readily available. Midazolam and ketamine
are the agents most commonly used for sedation, and glycopyrrolate is frequently
given to decrease oral secretions. During sedation, heart rate and rhythm,
oxygenation, airway patency, blood pressure, and level of consciousness are
continuously monitored and documented at least every 5 minutes. The patient
continues to be closely monitored until he or she achieves criteria for discharge,
which include being awake, verbalizing, and walking with minimal help.
The primary outcome measures were major and minor complications from
conscious sedation. Major complications included endotracheal intubation or
other assisted ventilation, administration of naloxone hydrochloride for reversal
of sedation, significant bleeding, and aspiration. Minor complications included
oxygen saturation below 90% that either corrected spontaneously or responded
to noninvasive techniques (verbal reminders, chin lift, jaw thrust, or supplemental
oxygen) and nausea and vomiting.6, 9
Secondary outcome measures that were considered were recurrence of PTA
and the need for hospital admission. Recurrence was defined as presentation
for a second PTA within 1 month of the original procedure.9
Outcomes of patients who were managed with conscious sedation were compared
with previously published data from our institution9
on the complications from PTA incision and drainage under conscious sedation.
Descriptive statistics, such as frequency counts, means, medians, and
ranges, were used to describe baseline characteristics of the sample and historical
populations.
RESULTS
Ninety-one patients underwent treatment of a PTA during the 36 months
of the review. Their demographic data appear in Table 1. Sixty patients underwent incision and drainage under conscious
sedation, 28 underwent incision and drainage without sedation, and 3 were
taken to the operating room for immediate tonsillectomy. The choice of sedation,
no sedation, or immediate tonsillectomy was dependent on several variables.
These included surgeon's preference, patient's age, and severity of illness.
|
|
|
|
Table 1. Clinical Characteristics of Patients Treated for PTA Drainage
(Present Study)*
|
|
|
Three patients had a recurrence of their PTA. The first was a 16-year-old
who underwent initial incision and drainage without conscious sedation and
returned 3 days later for a second incision and drainage under conscious sedation.
Two patients (both aged 15) underwent initial incision and drainage under
conscious sedation; one returned 2 days later and the other 3 days later for
a second incision and drainage under conscious sedation. The patient who returned
3 days later had received no antibiotics after the initial procedure, because
of medical noncompliance. A fourth patient aged 10 years underwent initial
incision and drainage under conscious sedation, returned 4 months later, and
because of the history of a prior PTA underwent immediate tonsillectomy.
In the present study, there were no major complications and 3 minor
complications (1 in the conscious-sedation group and 2 in the nonsedation
group). The minor complication in the conscious-sedation group involved a
15-year-old who had a transient oxygen desaturation to 89%, which resolved
immediately after verbal arousal. The 2 complications in the nonsedation group
involved 2 patients, aged 13 and 17, who were both given small doses of a
narcotic (morphine sulfate and meperidine hydrochloride, respectively) and
subsequently developed nausea and vomiting.
Nineteen patients from the conscious-sedation group and 2 from the nonsedation
group were admitted to the hospital after the procedure. The indications for
admission of these patients are outlined in Table 2. The primary reason for admission was dehydration. No patient
was admitted secondary to problems with the sedation. The time required until
discharge or admission after the procedure ranged from 30 to 150 minutes.
|
|
|
|
Table 2. Indications for Admission*
|
|
|
A previous report9 described 27 patients
who underwent conscious sedation and 25 who did not receive sedation. No major
complications and 1 minor complication were reported in that series. The minor
complication involved a 4-year-old who, during conscious sedation, had a temporary
oxygen desaturation to 88%, which immediately resolved with stimulation and
a shoulder roll. Table 3 contains
the previously published demographic data for this patient population.
|
|
|
|
Table 3. Clinical Characteristics of Patients Treated for PTA Drainage
(Previously Published Data9)*
|
|
|
Combining these previous data with the patients from the present study,
we obtained 92 episodes of conscious sedation for drainage of a PTA. The 1-sided
upper 95% confidence limit for the rate of major complications is 3.2%.10
COMMENT
Incision and drainage of a PTA in the pediatric population under conscious
sedation is safe. In 2 combined studies, there were no major and 4 minor complications.
Two of these occurred in patients with conscious sedation and 2 without conscious
sedation. Both minor complications in patients with sedation involved a brief
episode of decreased oxygen saturation that responded promptly to verbal stimulation.
Our institution uses a formal protocol that has been established for conscious-sedation
reporting. Although this is a retrospective review, it is unlikely that the
most minor of negative symptoms would not be reported on this document. It
is possible, however, that perceived benign intervention, such as verbal reminders,
may have occurred with greater frequency than was reported. Irrespective,
there were no major complications related to either the conscious sedation
or the actual drainage procedure.
How certain are we that conscious sedation is a safe procedure for the
drainage of a PTA? In our small series of patients, the frequency of major
complications was 0%. Therefore, only 1-sided confidence limits can be determined.
Rümke10 showed that the certainty with
which a particular effect can be assumed to be present or absent was dependent
on the total number of observations in the series. We arbitrarily chose a
95% confidence limit for the rate of major complications in our study. By
applying Rümke's rule to our series of patients, we know that the probability
of a major complication occurring is between 0% and 3.2%. Some observers of
this series may not accept the upper limit of 3.2% as an acceptable rate of
complications; this is a valid argument. However, we would predict that as
our experience increases our rate of complications would decrease.
In our review, 2 minor complications occurred in the group that did
not receive sedation. These were both related to the attempted use of small
doses of narcotics instead of using a formal sedation protocol. In neither
series of patients is there a major complication directly related to the incision
and drainage procedure. Complications from transoral incision and drainage
of a PTA may include bleeding; failure to fully evacuate the abscess, leading
to a recurrence; and pulmonary aspiration of the abscess contents. There are
several reports1-4
in the literature on the recurrence rate after needle aspiration or incision
and drainage of a PTA. We could find no reports of bleeding complications
or pulmonary aspiration after incision and drainage; nonetheless, they remain
potential risks of this transoral procedure. In the combined series of patients,
there were 145 drainage procedures, with 6 recurrences, for an overall recurrence
rate of 4.1%. This recurrence rate is well within the 10% rate of recurrence
cited in the literature.1 There were no episodes
of significant bleeding or pulmonary aspiration documented in these cases.
Historically and now, pediatric patients have received poorer pain control
in the emergency department setting than adult patients.11
The reluctance to provide analgesia for pediatric patients is often related
to fears of respiratory depression. Studies6-8
on conscious sedation have reported the adverse events and complications.
Adverse events have included oxygen desaturation, apnea, stridor, laryngospasm,
bronchospasm, cardiovascular instability, paradoxical reactions, aspiration,
and emesis. Complications are defined as adverse events that negatively affect
outcome or delay recovery. The adverse event rate in a recent report8 from a large tertiary pediatric emergency department
for conscious sedation performed by pediatric emergency–trained physicians
on 1180 patients was 2.3%, and no serious complications occurred.
As experience is gained in the administration of pediatric conscious
sedation for other invasive and therapeutic procedures, consideration should
be given to its use in the management of PTAs. Pediatric patients who need
incision and drainage of a PTA provide an optimal situation in which conscious
sedation can improve the care of the patient. In the management of a PTA,
conscious sedation properly administered provides a cooperative patient whose
airway protective reflexes are intact.
Sedation represents a continuum from fully alert to general anesthesia,
and as the level of sedation deepens, the patient may lose his or her airway
protective reflexes. This has led to the institution of strict guidelines
for the monitoring and management of pediatric patients during and after conscious
sedation.5 We have shown that conscious sedation,
when administered by trained personnel, is a safe means of managing a PTA
in pediatric patients. Conscious sedation, however, remains a specialized
undertaking that requires the presence of appropriate emergency department
physicians and nursing staff trained in its administration in the pediatric
setting. The vigilant monitoring and specialized training required may limit
the safe use of this technique. However, in facilities in which pediatric
conscious sedation is undertaken for other procedures, it would be appropriate
to consider its use in the management of PTAs.
In our series, the number of patients requiring hospital admission after
drainage of a PTA was higher in the group receiving conscious sedation. Inherent
bias in the selection of patients receiving conscious sedation over those
who do not receive sedation most likely accounts for this difference. Patients
who are perceived as having a larger PTA, appear more ill, or have a greater
degree of trismus may be selected for conscious sedation to maximize the drainage
of the PTA. Also, patients who are younger are less likely to tolerate the
procedure without the assistance of conscious sedation. The severity of the
illness and the age of the patient may have led to the increased incidence
of admission seen in our patient population who underwent conscious sedation.
CONCLUSIONS
Our series, when combined with previously published data, demonstrates
that conscious sedation can be safely used when draining a PTA in pediatric
patients. In institutions in which trained emergency personnel now administer
pediatric conscious sedation, we recommend consideration of its use in the
management of PTAs.
AUTHOR INFORMATION
Accepted for publication July 23, 2001.
Presented at the 16th Annual Meeting of the American Society of Pediatric
Otolaryngology, Scottsdale, Ariz, May 10, 2001.
Corresponding author: Paul W. Bauer, MD, Division of Pediatric Otolaryngology,
St Louis Children's Hospital, Washington University School of Medicine, One
Children's Place, Suite 3S-35, St Louis, MO 63110-1077 (e-mail: bauerp{at}msnotes.wustl.edu).
From the Division of Pediatric Otolaryngology, St Louis Children's
Hospital, Washington University School of Medicine, St Louis, Mo (Drs Bauer,
Lieu, and Lusk); and the Section of Otolaryngology–Head and Neck Surgery,
Department of Surgery, University of Chicago, Chicago, Ill (Dr Suskind).
REFERENCES
| |
1. Herzon FS. Peritonsillar abscess: incidence, current management practices, and
a proposal for treatment guidelines. Laryngoscope. 1995;105(suppl 74):1-17.
2. Apostolopoulos NJ, Nikolopoulos TP, Bairamis TN. Peritonsillar abscess in children: is incision and drainage an effective
management? Int J Pediatr Otorhinolaryngol. 1995;31:129-135.
FULL TEXT
|
ISI
| PUBMED
3. Holt GR, Tinsley PP. Peritonsillar abscesses in children. Laryngoscope. 1981;91:1226-1230.
ISI
| PUBMED
4. Stringer SP, Schaefer SD, Close LG. A randomized trial for outpatient management of peritonsillar abscess. Arch Otolaryngol Head Neck Surg. 1988;114:296-298.
ABSTRACT
5. American Academy of Pediatrics Committee on Drugs. Guidelines for monitoring and management of pediatric patients during
and after sedation for diagnostic and therapeutic procedures. Pediatrics. 1992;89:1110-1115.
FREE FULL TEXT
6. Graff KJ, Kennedy RM, Jaffe DM. Conscious sedation for pediatric orthopaedic emergencies. Pediatr Emerg Care. 1996;12:31-35.
ISI
| PUBMED
7. Parker RI, Mahan RA, Giugliano D, Parker MM. Efficacy and safety of intravenous midazolam and ketamine as sedation
for therapeutic and diagnostic procedures in children. Pediatrics. 1997;99:427-431.
FREE FULL TEXT
8. Pena BMG, Krauss B. Adverse events of procedural sedation and analgesia in a pediatric
emergency department. Ann Emerg Med. 1999;34:483-491.
FULL TEXT
|
ISI
| PUBMED
9. Suskind DL, Park J, Piccirillo JF, Lusk RP, Muntz HR. Conscious sedation: a new approach for peritonsillar abscess drainage
in the pediatric population. Arch Otolaryngol Head Neck Surg. 1999;125:1197-1200.
FREE FULL TEXT
10. Rümke CL. Uncertainty as to the acceptance or rejection of the presence of an
effect in relation to the number of observations in an experiment. Triangle. 1968;8:284-289.
PUBMED
11. Petrack EM, Christopher NC, Kriwinsky J. Pain management in the emergency department: patterns of analgesic
utilization. Pediatrics. 1997;99:711-714.
FREE FULL TEXT
RELATED ARTICLE
Archives of Otolaryngology–Head & Neck Surgery Reader's Choice: Continuing Medical Education
Arch Otolaryngol Head Neck Surg. 2001;127(12):1521-1522.
FULL TEXT
|
