Use of operator-directed sedation (ODS) and anesthesiologist care in pediatric cardiac catheterization laboratory procedures may be safe and efficient, according to a study published Feb. 15 in JACC: Cardiovascular Interventions.

Using data from ACC's IMPACT Registry, Michael L. O'Byrne, MD, MSCE, et al., looked at procedures performed with either ODS or anesthesia at hospitals participating in the registry between 2011 and 2018 that used ODS for ≥5% of cases. The researchers compared risks for major adverse events (MAE) for ODS and anesthesia. Current recommendations were used to compare the ratio of observed to expected MAE for cases in which ODS was inappropriate with those for similar risk for anesthesia care cases, as well as for cases in which ODS or anesthesia care was appropriate.

During the study period, 28 hospitals used ODS for more than 5% of total case volume. These 28 hospitals performed 37,927 cases, 7,042 (23%) of which were performed using ODS. The percentage of cases using ODS decreased during the study period – from 19% in 2011 to 3.9% in 2018. The proportion of infants (age 30 days to 1 year) was lower in the ODS cohort, while the proportion of adults (≥18 years) was higher. Patients in the ODS cohort were less likely to have genetic syndromes, chronic lung disease, single ventricles, renal insufficiency and pre-procedural inotropes.

Overall, the total risk for all MAE was 7% and was higher in anesthesia cohort (7%) vs. the ODS cohort (4%). In-hospital deaths within 30 days were more common in patients receiving anesthesia (1.9%) vs. ODS (0.6%). In addition, anesthesia care was associated with higher risk for cardiac arrest, new arrhythmia, device malposition, vascular complications and miscellaneous adverse events. ODS was associated with higher risk for dialysis initiation, tamponade and airway events. After adjusting for pre-procedural risk, anesthesia care was associated with increased odds of MAE compared with ODS (odds ratio: 1.2; 95% confidence interval: 1.03-1.4; p=0.02).

The study shows that, "for a subset of [pediatric cardiac catheterization laboratory] procedures, that the use of ODS is associated with high-quality efficient care and that there is no evidence (for this subset of procedures) that the alternative use of [anesthesia care] would improve outcomes," the authors write. "These findings should inform future guidelines governing the use of procedural sedation," they conclude.

In an accompanying editorial comment, Lee Benson, MD, FACC, and Bruce Macpherson, MD, write that O'Byrne, et al., "rightly suggest that current recommendations do not accurately identify children who would be safe candidates for ODS use" but urge caution in generalizing "these findings to centers presently not using ODS in their case mix, as there will be an institutional learning curve in operationalizing the practice." They add that additional research "assessing the safety of the initiation of an ODS practice are needed before a general recommendation can be made."

Clinical Topics: Arrhythmias and Clinical EP, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Hospital Mortality, Renal Dialysis, Anesthesia, Anesthesiology, Arrhythmias, Cardiac, Heart Arrest, Renal Insufficiency, Registries, National Cardiovascular Data Registries, Diagnosis-Related Groups, Lung Diseases, Cardiac Catheterization, IMPACT Registry

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