Oranges and Apples: Sedation and Analgesia

To the Editor. The vitriolic comments by Drs Freeman and Vining regarding various sedation/analgesia guidelines and Dr Cote's critical incident analysis of sedation-related adverse events underscore the need for the utilization of evidence in the evaluation of the safety of such practices.1 ,2 Drs Freeman and Vining contend that sedation alone for a nonpainful procedure such as an electroencephalogram (EEG) is inherently safe. They therefore suggest that the use of chloral hydrate alone for an EEG does not warrant any monitoring or attendance by qualified medical personnel as mandated by the Joint Commission on Accreditation of Healthcare Organizations and recommended by the American Academy of Pediatrics. Furthermore, they contend that such mandates are unnecessary and fiscally onerous. The evidence does not support their contention. We agree that the majority of children who receive sedation, analgesia, or both for a diagnostic or therapeutic procedure experience good outcomes with no long-term sequelae. However, the fortunately low incidence of adverse events should not lead to the conclusion that such guidelines are unnecessary. In fact, contrary to the conclusion of Drs Freeman and Vining, the literature is replete with reports of sedation-related adverse events.2–8 We would direct Drs Freeman and Vining to several large, well-conducted, prospective studies that have not only addressed the incidence of adverse events with chloral hydrate sedation but have also provided a denominator.3–8 These studies are not anecdotal, have appropriate statistical analysis, and include patients who had adverse events after the administration of chloral hydrate alone, without other sedative or analgesic agents. Indeed, it is reports such as these that have led to the development of monitoring guidelines and personnel mandates to promote the safety of sedated children. Although chloral hydrate in therapeutic doses is purported not to cause significant respiratory depression, it may still cause respiratory …