Pride, Prejudice, and Pediatric Sedation:

Pride, Prejudice, and
Pediatric Sedation:
A Multispecialty Evaluation
of the State of the Art
Report from a
Dartmouth Summit
on Pediatric Sedation
The information contained in Pride, Prejudice, and Pediatric
Sedation: A Multispecialty Evaluation of the State of the Art came
from the Dartmouth Summit on Pediatric Sedation held at the
Dartmouth Hitchcock Medical Center (September 9th, 2000). This
summit brought together a group of health care professionals from a
variety of specialties to discuss pediatric sedation. The meeting was
organized and coordinated by Joseph P. Cravero, MD, Associate
Professor of Anesthesiology and Pediatrics at Dartmouth Medical
School and his colleague, George T. Blike, MD, Associate Professor
of Anesthesiology at Dartmouth Medical School and Director of the
Dartmouth Medical Interface Laboratory, along with the
departments of Anesthesiology, Pediatrics and the Center for
Continuing Education in the Health Sciences at Dartmouth
Hitchcock Medical Center.
The complete report is 52 pages long. It is available for online
viewing at http://www.npsf.org.

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Pride, Prejudice, and
Pediatric Sedation:
A Multispecialty Evaluation
of the State of the Art
Report from a
Dartmouth Summit
on Pediatric Sedation
George T. Blike
Dartmouth Medical School
Joseph P. Cravero
Dartmouth Medical School
Supported by grants from:
Agency for Healthcare Research and Quality
National Patient Safety Foundation

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Author information
George T. Blike, MD is an Associate Professor in the Departments of Anesthesiology
and Obstetrics and Gynecology at Dartmouth Medical School in Hanover, NH. He is
Director of the Dartmouth Medical Interface Laboratory, Dartmouth-Hitchcock
Medical Center, Lebanon, New Hampshire. His e-mail address is:
George.Blike@Hitchcock.org.
Joseph P. Cravero, MD, is an Associate Professor in the Departments of
Anesthesiology and Pediatrics at Dartmouth Medical School in Hanover, NH. He is
Director of Pediatric Anesthesiology, Children’s Hospital at Dartmouth, Dartmouth-
Hitchcock Medical Center, Lebanon, New Hampshire and Director of the Children’s
Hospital at Dartmouth PainFree Children’s Hospital Initiative. He is also a liaison
member of the Executive Committee of the American Academy of Pediatrics Section
on Anesthesiology. His e-mail address is: Joseph.Cravero@Hitchcock.org.
The authors gratefully acknowledge funding/support from sponsors of this work:
the Agency for Healthcare Quality and Research and the National Patient Safety
Foundation.
© 2001 National Patient Safety Foundation. Permission to reprint portions of this
publication is granted subject to prior written consent and appropriate credit given
to the National Patient Safety Foundation.
This article represents the views of the authors and does not represent an official
position of the National Patient Safety Foundation.

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Foreword This report on pediatric sedation marks the second in a series of
workshops on patient safety convened by the National Patient Safety
Foundation (NPSF). The first workshop, sponsored by the NPSF, the
Agency for Healthcare Research and Quality, and the Department of
Veterans Affairs, led to the report “A Tale of Two Stories”
(http://www.npsf.org/exec/toc.html). That workshop surveyed the
landscape of patient safety and identified productive and unproductive
approaches to learning more about how safety is created and eroded in
healthcare. A recurring theme in that report is that insight into safety
comes from close examination of the conflicting goals and pressures
present at the sharp end of practice and detailed study of the technical
work that occurs there. This current report, “Pride, Prejudice, and
Pediatric Sedation: A Multispecialty Evaluation of the State of the Art”
describes such a close, detailed look and demonstrates how the approach
envisioned in “A Tale of Two Stories” can work.
Within the landscape of patient safety, pediatric sedation is positioned
close to the organizational and institutional fault lines that lie below the
visible surface of healthcare. Because pediatric sedation is conducted by
people from different professions, with different experiences, and on
patients with a wide variety of diseases and physiological derangements,
exploring pediatric sedation issues necessarily creates a map of the fault
lines, their depth and character, and their consequences.
Typically, the consequences of these fault lines often leads an organization
to search for some compromise that can balance the demands for
production, the cost of personnel and facilities, and the perceived and
demonstrated risks of sedation. Such compromises are enshrined in
sedation “policies.” The tortuous legal language of such policies is itself a
demonstration of the fragility and ad hoc character of the compromises.
These policies are like the complicated building codes that prescribe
design and construction practices to be used when building in earthquake
prone areas. Pediatric sedation takes place near the fault lines and
sedation policies reflect the difficulty of working there.
Make no mistake about it, there is uncertainty about virtually every aspect
of pediatric sedation: Who should do it? What drugs should be used?
Where should it be done? When? How should the patient be recovered? –
all these questions are contested, and some hotly. The workshop did not
resolve the issues surrounding pediatric sedation. Instead it traced the fault
lines, showing how the visible surface of polices and institutional care
patterns are formed by forces buried within the structure of healthcare.
This report describes an exploration of the deep geology of healthcare.
It helps us understand where healthcare earthquakes originate.
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The significance of “Pride, Prejudice, and Pediatric Sedation” extends far
beyond pediatrics. While we may read the report narrowly with a view
towards pediatric sedation, the workshop and report together serve as a
model of the kind of detailed study needed to make real progress on patient
safety. It shows how we may come to grips with the “second stories” that
underlie success and failure in healthcare. As the authors of this report
point out, making progress on patient safety does not mean giving up pride
and prejudice but rather understanding their sources and, most of all, their
consequences.
Richard I. Cook, MD
David D. Woods, PhD
University of Chicago
The Ohio State University
ii

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Table of Contents
Foreword
i
Table of Contents
iii
Acknowledgements
iv
Introduction
1
Summary of Proceedings
5
Plenary Session Overview
5
Topic 1 Current Safety and Efficacy of Pediatric Sedation
6
Topic 2 The Role of Error in Negative Pediatric Sedation Outcomes
7
Topic 3 Sedation Guidelines, Terminology, and Regulations
8
Topic 4 Rationale for Providing a Specialized Sedation Service
9
Topic 5 Evaluating Different Systems of Sedation Care
12
for “Best Practice”
Topic 6 Ethics of Using Force to Perform a Pediatric Procedure
13
Expert Panel Session Overview
15
Theme 1 Goals of Sedation (Risks of Under Sedation)
17
Theme 2 Sedation Care System Efficacy
21
(Performance in Achieving Goals)
Theme 3 Risks of Sedation
26
Theme 4 Sedation Safety
28
(Expertise in Managing Respiratory Depression)
Theme 5 Team Coordination and Communication in Sedation Care 32
Theme 6 Barriers to Sedation Safety
33
Conclusion and Summary Statement
42
References
43
iii

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Acknowledgements
A great many people contributed to make the summit possible and
successful. We would like to express our deepest appreciation and
thanks to the many participants in the workshop who gave of their time,
energy, and intellect to wrestle with the difficult questions that underlie
safety in the complex and changing world of health care:
Stuart Lieblich, DMD/MD; Lia Lowrie, MD; Charlotte Bell, MD;
Thomas Mancuso, MD; Shobha V. Malviya, MD; Richard Towbin, MD;
Michael Girardi, MD; Charles J. Cote, M.D; Mary George, DMD; Ralph
Epstein, DDS; Constance Houck, MD; George Bisset, MD; Mark Rockoff,
MD; Myron Yaster, MD; Lynne Maxwell MD; David Polaner, MD; Baruch
Krauss, MD.
Special thanks to members of the Department of Anesthesiology and
Continuing Education Department at Dartmouth Hitchcock Medical
Center for their tireless work in making this summit possible. In
particular we would like to thank: David Glass, MD, Mary Robinson,
Linda Jellison, Lisa Wirth, Ray Kulig, Deborah Holmes and Jens Jensen.
Also members of the NPSF staff and Board of Directors who supported
the publication of this manuscript: Asta Sorensen, MA; Jay Callahan,
PhD; Jeff Cooper, PhD; David Woods, MD; Richard Cook, MD; and
Joanne Turnbull, PhD.
George T. Blike
Joseph P. Cravero
iv

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Introduction
Every year hundreds of thousands of children across the country are
given sedation for diagnostic and therapeutic procedures in hospital
settings and in physician or dental offices. The personnel that
provide the sedation vary from briefly trained nursing personnel to
experienced pediatric anesthesiologists. The sedative drugs used,
techniques employed, and safety standards vary greatly from one location
to another, and even within a given institution.1 The care provided
depends on the caregivers administering sedation, the time of day, and the
area within the hospital that sedation is being provided. In essence,
practitioners who are attempting to achieve the same result – that of a
calm, generally still, child for a procedure – use widely varying techniques
and medications to produce this outcome. Few areas of medical practice
remain as non-standardized as pediatric sedation. Our challenge with this
conference was to search beyond the preconceived notions, “turf battles”,
and ignorance that exist among various specialists in order to explore the
current state of this art in medicine.
Hospitals and dental practices struggle with the logistical concerns of how
to provide an adequate service for all pediatric patients who require
sedation/anesthesia. We firmly believe (based on our own experience and
reports from around the United States) that with increasing education of
parents and a generalized awareness of patients rights, that a paradigm
shift is occurring in terms of what parents find acceptable in the care of
their children. Requests for high quality sedation services have increased
as the public becomes more aware of new pain management techniques
for children. Unfortunately, sedation services are required in widely
varying locations within an institution. In addition, pediatric sedation
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Introduction
may be required at any time of the day or night. Expert sedation
providers are not always available to provide this service given these
demands. This mismatch of supply and demand for sedation care fosters
such an eclectic approach resulting in a myriad of different sedation
protocols and drug combinations being used in various hospitals and
offices (even different departments in the same hospital).2 Possibly most
concerning is the lack of communication between various specialties that
provide sedation for children. For example, when reviewing protocols for
sedation in the emergency department, anesthesiologists may seek to
restrict the use of certain medications (like ketamine) by pediatric
emergency medicine physicians, without engaging in a constructive
discussion with these physicians as to their needs and qualifications.
Similarly, pediatric sedation research published in dental journals is
almost never read or appreciated by radiologists, who are high users
of sedation services.
As if to underscore this lack of “cross pollination”, advisory panels from
various professional organizations have produced guidelines for sedation
of pediatric patients that differ in key concepts and recommendations.
An example of this is the fact that the current guidelines from the
American Academy of Pediatrics, the American Academy of Pediatric
Dentistry, and the American Society of Anesthesiologists do not even
agree on definitions of the different levels of sedation that exist in
children.3,4,5,6
With this background, the Dartmouth Summit on Pediatric Sedation was
organized to help convene leaders in pediatric sedation research and
policy development to facilitate a high level discussion of the challenges
that face practitioners of pediatric sedation. We sought to recognize
pediatric sedation as a single field of endeavor practiced by a wide
variety of specialists. In addition to the logistical barriers of bringing
together an outstanding group of sedation experts from various
specialties, we understood that we would be inviting a clash of cultures.
True “agreement” and firm “conclusions” would be elusive. Inevitably,
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