Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA; Department of Pediatric Emergency Medicine, Royal Belfast Hospital for Sick Children, Belfast, UK.Dr Cosgrove is currently affiliated with Wellcome-Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK.
Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA.
Ann Emerg Med. 2022 Dec;80(6):485-496. doi: 10.1016/j.annemergmed.2022.05.002. Epub 2022 Jun 23.
Laryngospasm is a rare but potentially life-threatening complication of sedation. The objective of this study was to perform a predictor analysis of biologically plausible predictors and the interventions and outcomes associated with laryngospasm.
Secondary analysis of prospectively collected data from consecutively sedated patients, less than or equal to 22 years of age, at multiple locations at 64 member institutions of the Pediatric Sedation Research Consortium. The primary outcome was laryngospasm. The independent variables in the multivariable model included American Society of Anesthesiologists category, age, sex, concurrent upper respiratory infection, medication regimen, hospital sedation location, whether the procedure was painful, and whether the procedure involved the airway. The analysis included adjusted odds ratios (aORs) and predicted probabilities.
We analyzed 276,832 sedations with 913 reported events of laryngospasm (overall unadjusted prevalence 3.3:1,000). A younger age, a higher American Society of Anesthesiologists category, a concurrent upper respiratory infection (aOR 3.94, 2.57 to 6.03; predicted probability 12.2/1,000, 6.3/1,000 to 18.0/1,000), and airway procedures (aOR 3.73, 2.33 to 5.98; predicted probability 9.6/1,000, 5.2/1,000 to 13.9/1,000) were associated with increased risk. Compared with propofol alone, propofol combination regimens had increased risk (propofol+ketamine: aOR 2.52, 1.41 to 4.50; predicted probability 7.6/1,000, 3.1/1,000 to 12/1,000; and propofol+dexmedetomidine: aOR 2.10, 1.25 to 3.52; predicted probability 6.3/1,000, 3.7,/1,000 to 8.9/1,000). Among patients with laryngospasm, the resulting outcomes included desaturation less than 70% for more than 30 seconds (19.7%), procedure not completed (10.6%), emergency airway intervention (10.0%), endotracheal intubation (5.3%), unplanned admission/increase in level of care (2.3%), aspiration (1.1%), and cardiac arrest (0.2%).
We found increased associations of laryngospasm in pediatric procedural sedation with multiple biologic factors, procedure types, and medication regimens. However, effect estimates showed that the laryngospasm prevalence remained low, and this should be taken into consideration in sedation decisionmaking.
喉痉挛是镇静相关的罕见但潜在危及生命的并发症。本研究的目的是对生物上合理的预测因素以及与喉痉挛相关的干预措施和结局进行预测分析。
对来自于 64 个儿科镇静研究联盟成员机构多个地点连续镇静的小于或等于 22 岁患者前瞻性收集的数据进行二次分析。主要结局为喉痉挛。多变量模型中的自变量包括美国麻醉医师协会类别、年龄、性别、并发上呼吸道感染、药物治疗方案、医院镇静地点、操作是否疼痛以及操作是否涉及气道。分析包括调整后的优势比（aOR）和预测概率。
我们分析了 276832 例镇静，报告了 913 例喉痉挛事件（总体未调整的患病率为 3.3:1000）。年龄较小、美国麻醉医师协会类别较高、并发上呼吸道感染（aOR 3.94，2.57 至 6.03；预测概率为 12.2/1000，6.3/1000 至 18.0/1000）以及气道操作（aOR 3.73，2.33 至 5.98；预测概率为 9.6/1000，5.2/1000 至 13.9/1000）与风险增加相关。与单独使用异丙酚相比，异丙酚联合治疗方案风险增加（异丙酚+氯胺酮：aOR 2.52，1.41 至 4.50；预测概率为 7.6/1000，3.1/1000 至 12/1000；异丙酚+右美托咪定：aOR 2.10，1.25 至 3.52；预测概率为 6.3/1000，3.7/1000 至 8.9/1000）。在发生喉痉挛的患者中，其结果包括 30 秒以上饱和度低于 70%（19.7%）、操作未完成（10.6%）、紧急气道干预（10.0%）、气管插管（5.3%）、计划外入院/护理级别增加（2.3%）、误吸（1.1%）和心脏骤停（0.2%）。
我们发现儿科操作镇静中喉痉挛与多种生物学因素、操作类型和药物治疗方案之间存在相关性增加。然而，效应估计表明，喉痉挛的患病率仍然较低，这应在镇静决策中加以考虑。
