Efficacy Outcome Measures for Pediatric Procedural Sedation Clinical Trials

A scoping review of interventions and outcome measures in trials of dental behavior support

BACKGROUND

Dental behavior support (DBS) describes all techniques used by dental professionals to ensure that dental care is safe, effective, and acceptable. There is a need to standardize outcome measures across DBS techniques to reduce heterogeneity, limit selective reporting, promote consistency, and optimize outcomes across DBS research. A comprehensive review of existing measures is a prerequisite to understanding potential outcomes related to the area of interest.

AIM

This review had three aims: first, to identify the outcome measures (OMs) reported in trials of dental behavior support; second, to categorize the component DBS techniques reported within interventions according to emerging agreed terminology; and, third, to map outcome measures to intervention type.

METHODS

A scoping review of trials evaluating DBS techniques was undertaken from 2012 to 2022. The review was prospectively registered. Studies were identified through Medline, Embase, and PsycINFO. Study abstracts were screened by two reviewers. Data were extracted by single selector. Outcome measures were sorted according to measurement domains (physiological, behavioral, psychological, and treatment). Responses were assimilated and summed to produce a refined list of distinguishable outcome measures. Intervention types were categorized according to accepted descriptors. Frequencies were presented; associations between outcome domain and DBS type were also reported (Chi-square test of independence).

RESULTS

A total of 344 trials were included in the review from an initial 14,793 titles / title and abstracts screened. Most involved children (n = 215), most were from India (n = 104), involving basic dental care (n = 117). The median number of outcome measures per trial was four (range = 1-12); 1,317 individual outcomes were reported, categorized as: psychological (n = 501, 38.0%); physiological (n = 491, 37.3%), behavioral (n = 123, 9.3%) or, treatment-related (n = 202, 15.3%). DBS interventions were split between 239 (45.7%) pharmacological and 283 (54.1%) non-pharmacological; 96.6% of interventions mapped to accepted descriptors. A significant relationship was noted between the type of intervention and the outcome domain reported.

CONCLUSION

The findings demonstrate massive variation in outcome measures of DBS interventions that likely lead to unnecessary heterogeneity, selective reporting, and questionable relevance in the literature. A large range of DBS interventions were mapped according to BeSiDe list. There is a need for consensus on a core outcome set across the spectrum of DBS techniques.

Procedural sedation in pediatric dentistry: a narrative review

Procedural sedation and analgesia are now considered standard care for managing pain and anxiety in pediatric dental patients undergoing diagnostic and therapeutic procedures outside of the operating room. Anxiolysis, which combines both pharmacologic and non-pharmacologic approaches, plays a significant role in procedural sedation. Non-pharmacologic interventions such as Behavior Management Technology can help reduce preprocedural agitation, ease the transition to sedation, reduce the required amount of medication for effective sedation, and decrease the occurrence of adverse events. As the introduction of novel sedative regimen and methods in pediatric dentistry, the potential role of mainstay sedatives administered by new routes, for new indications, and with new delivery techniques, should be considered. The purpose of this paper is to examine and discuss the current state of sedation techniques in pediatric dentistry.

Outcomes in pediatric anesthesia: towards a universal language

PURPOSE OF REVIEW

The identification of valid, well defined and relevant outcomes is fundamental to provide a reliable and replicable measure that can be used to improve quality of clinical care and research output. The purpose of this review is to provide an update on what the pediatric anesthesia research community is pursuing on standardized and validated outcomes.

RECENT FINDINGS

Several initiatives by different research groups have been established during the last years. They all aim to find validated outcomes using the standardized methodology of COMET ( https://www.comet-initiative.org/ ). These initiatives focus on clinical and research outcomes on the field of anesthesia, perioperative medicine, pain and sedation in pediatric age.

SUMMARY

Clinical outcomes are measurements of changes in health, function or quality of life and they help evaluating quality of care. In order for them to be relevant in quantifying quality improvement, they need to be well defined, standardized and consistent across trials. A great effort from researchers has been made towards the identification of set of outcomes with these features.

The Emerging Role of Virtual Reality as an Adjunct to Procedural Sedation and Anesthesia: A Narrative Review

Over the past 20 years, there has been a significant reduction in the incidence of adverse events associated with sedation outside of the operating room. Non-pharmacologic techniques are increasingly being used as peri-operative adjuncts to facilitate and promote anxiolysis, analgesia and sedation, and to reduce adverse events. This narrative review will briefly explore the emerging role of immersive reality in the peri-procedural care of surgical patients. Immersive virtual reality (VR) is intended to distract patients with the illusion of "being present" inside the computer-generated world, drawing attention away from their anxiety, pain, and discomfort. VR has been described for a variety of procedures that include colonoscopies, venipuncture, dental procedures, and burn wound care. As VR technology develops and the production costs decrease, the role and application of VR in clinical practice will expand. It is important for medical professionals to understand that VR is now available for prime-time use and to be aware of the growing body in the literature that supports VR.

Post-Discharge Effects and Parents' Opinions of Intranasal Fentanyl with Oral Midazolam Sedation in Pediatric Dental Patients: A Cross-Sectional Study

The aim of this study was to evaluate the post-discharge effects of oral midazolam with intranasal fentanyl sedation in pediatric patients who had dental treatment and to evaluate parents’ preference regarding sedation visits. Methods: A total of 32 uncooperative healthy pediatric patients aged 3–6 years old who met the inclusion criteria were included. In the first visit, one group received oral midazolam (0.7 mg/kg) with intranasal fentanyl (1 μg/kg) sedation (M/F) and the other group received oral midazolam with intranasal placebo (M), and in the second visit each group received the other type of sedation in a cross-over type. In this cross-sectional study, a post-discharge phone-call questionnaire was carried out 24 h after both sedation visits with the parents to evaluate the children’s behavior, function, balance, eating pattern, sleeping pattern, vomiting incidents, and any possible side effects, as well as parents’ satisfaction and preference. The Wilcoxon signed-rank test was used to analyze the categorical variables, and the Chi-square test was performed to analyze the parents’ preference. Result: A total of 32 parents responded to the phone-call questionnaire after 64 sedation visits. All of them were mothers. There was no statistically significant difference between the two groups with respect to recovery to normal function and balance, behavior, incidents of fever, vomiting, sleep disturbance, oversleeping, and adverse behavioral changes (p > 0.05). Children required a significantly longer amount of time until the first meal after M/F sedation (p = 0.04). No significant difference was found between parents’ preferences regarding the sedation visits (p > 0.05). Conclusion: Intranasal fentanyl added to oral midazolam sedation could have an effect on post-discharge adverse behavioral changes, prolonged sleeping, and prolonged recovery time. Children sedated with midazolam/fentanyl required a longer amount of time until the first meal. Vomiting and fever occurred similarly in both sedation regimens with a low incidence. There was no difference in parents’ preferences regarding the two sedation regimens.

Design and reporting characteristics of clinical trials investigating sedation practices in the paediatric intensive care unit: a scoping review by SCEPTER (Sedation Consortium on Endpoints and Procedures for Treatment, Education and Research)

OBJECTIVES

To conduct a scoping review of sedation clinical trials in the paediatric intensive care setting and summarise key methodological elements.

DESIGN

Scoping review.

DATA SOURCES

PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature and grey references including ClinicalTrials.gov from database inception to 3 August 2021.

STUDY SELECTION

All human trials in the English language related to sedation in paediatric critically ill patients were included. After title and abstract screening, full-text review was performed. 29 trials were eligible for final analysis.

DATA EXTRACTION

A coding manual was developed and pretested. Trial characteristics were double extracted.

RESULTS

The majority of trials were single centre (22/29, 75.9%), parallel group superiority (17/29, 58.6%), double-blinded (18/29, 62.1%) and conducted in an academic setting (29/29, 100.0%). Trial enrolment (≥90% planned sample size) was achieved in 65.5% of trials (19/29), and retention (≥90% enrolled subjects) in 72.4% of trials (21/29). Protocol violations were reported in nine trials (31.0%). The most commonly studied cohorts were mechanically ventilated patients (28/29, 96.6%) and postsurgical patients (11/29, 37.9%) with inclusion criteria for age ranging from 0±0.5 to 15.0±7.3 years (median±IQR). The median age of enrolled patients was 1.7 years (IQR=4.4 years). Patients excluded from trials were those with neurological impairment (21/29, 72.4%), complex disease (20/29, 69.0%) or receipt of neuromuscular blockade (10/29, 34.5%). Trials evaluated drugs/protocols for sedation management (20/29, 69.0%), weaning (3/29, 10.3%), daily interruption (3/29, 10.3%) or protocolisation (3/29, 10.3%). Primary outcome measures were heterogeneous, as were assessment instruments and follow-up durations.

CONCLUSIONS

There is substantial heterogeneity in methodological approach in clinical trials evaluating sedation in critically ill paediatric patients. These results provide a basis for the design of future clinical trials to improve the quality of trial data and aid in the development of sedation-related clinical guidelines.

Parents' satisfaction with paediatric dental treatment under sedation: A cross-sectional study

BACKGROUND

Patient-reported outcomes are under-investigated in the field of paediatric dental sedation.

AIM

To evaluate the satisfaction of parents/guardians with their children's dental sedation, compare it to the dentist's satisfaction, and identify associated factors.

DESIGN

This study was performed with parents/guardians of young children treated under sedation and dentists. Participants' satisfaction was measured using the visual analogue scale (0-100). Child's behaviour was classified using the Ohio State Behavioural Rating Scale. Other information was collected during interviews and from patient charts. The Spearman's, Mann-Whitney and Kruskal-Wallis tests were performed (P < .05).

RESULTS

A total of 167 parents/guardians and ten dentists participated in the study. Protective stabilisation and atraumatic restorative treatment (ART) were used in 69.9% and 51.5% appointments, respectively. The parents/guardians (median: 91 [25-75 percentile: 75-96]) and dentists (76 [23-98]) were satisfied. Parental/guardian satisfaction was higher than dentist satisfaction (P ≤ .001). Parental/guardian satisfaction was positively correlated with quiet child behaviour (r = 0.347, P ≤ .001) and was associated with the non-use of protective stabilisation (P ≤ .001), no previous toothache (P = .019), and the use of ART (P = .018).

CONCLUSION

The participants were satisfied with treatment under sedation. Parents/guardians were more satisfied, especially, when the child had cooperative behaviour.

Evaluating Patient-Centered Outcomes in Clinical Trials of Procedural Sedation, Part 2 Safety: Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations

The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research, established by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks, a public-private partnership with the US Food and Drug Administration, convened a second meeting of sedation experts from a variety of clinical specialties and research backgrounds to develop recommendations for procedural sedation research. The previous meeting addressed efficacy and patient- and/or family-centered outcomes. This meeting addressed issues of safety, which was defined as "the avoidance of physical or psychological harm." A literature review identified 133 articles addressing safety measures in procedural sedation clinical trials. After basic reporting of vital signs, the most commonly measured safety parameter was oxygen saturation. Adverse events were inconsistently defined throughout the studies. Only 6 of the 133 studies used a previously validated measure of safety. The meeting identified methodological problems associated with measuring infrequent adverse events. With a consensus discussion, a set of core and supplemental measures were recommended to code for safety in future procedural clinical trials. When adopted, these measures should improve the integration of safety data across studies and facilitate comparisons in systematic reviews and meta-analyses.

Engaging Stakeholders to Promote Safe Anesthesia and Sedation Care in Young Children

An important aspect of any research endeavor is engaging various stakeholders to work toward the common goal of pushing knowledge forward about the question at hand. Research into pediatric anesthetic neurotoxicity could benefit greatly from interventions designed to improve the efforts and dedication of government agencies, pharmaceutical companies, research communities, and most importantly, patients. The Pediatric Anesthesia Neurodevelopment Assessment (PANDA) symposium is a biennial meeting where updates in research in the field are presented, and issues relevant to the community are discussed in round table discussions. Here, we summarize a discussion that took place at the 2018 meeting regarding new methods of engaging various stakeholders, as well as perspectives from other stakeholders. Topics discussed included an online portal to better reach patients, experiences with a public-private partnership, steps by the National Institutes of Health to improve engagement with research and improve the dissemination of results, and the experiences of the United States Food and Drug Administration attempting to improve stakeholder engagement following the passage of a new law to promote drug development. The round table discussion provided interesting insights into a critical research topic, and shared first-hand experience of attempts to improve engagement with a variety of stakeholders.

Randomized clinical trial on the efficacy of intranasal or oral ketamine-midazolam combinations compared to oral midazolam for outpatient pediatric sedation

Purpose

The optimal sedative regime that provides the greatest comfort and the lowest risk for procedural sedation in young children remains to be determined. The aim of this randomized, blinded, controlled, parallel-design trial was to evaluate the efficacy of intranasal ketamine and midazolam as the main component of the behavioral guidance approach for preschoolers during dental treatment.

Materials and methods

Children under seven years of age, with caries and non-cooperative behavior, were randomized into three groups: (KMIN) intranasal ketamine and midazolam; (KMO) oral ketamine and midazolam; or (MO) oral midazolam. The dental sedation appointments were videotaped, and the videos were analyzed using the Ohio State University Behavioral Rating Scale (OSUBRS) to determine the success of the sedation in each group. Intra- and postoperative adverse events were recorded. Data analysis involved descriptive statistics and non-parametric tests (P < 0.05, IBM SPSS).

Results

Participants were 84 children (28 per group; 43 boys), with a mean age of 3.1 years (SD 1.2). Children’s baseline and the dental sedation session characteristics were balanced among groups. The success of the treatment as assessed by the dichotomous variable ‘quiet behavior for at least 60% of the session length’ was: KMIN 50.0% (n = 14; OR 2.10, 95% CI 0.71 to 6.30), KMO 46.4% (n = 13; OR 1.80, 95% CI 0.62 to 5.40), MO 32.1% (n = 9) (P = 0.360). Adverse events were minor, occurred in 37 of 84 children (44.0%), and did not differ among groups (P = 0.462).

Conclusion

All three regimens provided moderate dental sedation with minor adverse events, with marked variability in the behavior of children during dental treatment. The potential benefit of the ketamine–midazolam combination should be further investigated in studies with larger samples.

Trial registration

ClinicalTrials.gov, identifier: NCT02447289. Registered on 11 May 2015, named “Midazolam and Ketamine Effect Administered Through the Nose for Sedation of Children for Dental Treatment (NASO).”

Future of paediatric sedation: towards a unified goal of improving practice

This review offers a perspective on the future of paediatric sedation. This future will require continued evaluation of adverse events, their risk factors, and predictors. As the introduction of new sedatives with paediatric applications will remain limited, the potential role of mainstay sedatives administered by new routes, for new indications, and with new delivery techniques, should be considered. The role of non-pharmacological strategies for anxiolysis, along with the application of non-mainstay physiologic monitoring, may aid in the improvement of targeted sedation delivery. Understanding the mechanism and location of action of the different sedatives will remain an important focus. Important developments in paediatric sedation will require that large scale studies with global data contribution be conducted in order to support changes in sedation practice, improve the patient experience, and make sedation safer.

Psychometrics: Trust, but Verify

There is a continued mandate for practicing evidence-based medicine and the prerequisite rigorous analysis of the comparative effectiveness of alternative treatments. There is also an increasing emphasis on delivering value-based health care. Both these high priorities and their related endeavors require correct information about the outcomes of care. Accurately measuring and confirming health care outcomes are thus likely now of even greater importance. The present basic statistical tutorial focuses on the germane topic of psychometrics. In its narrower sense, psychometrics is the science of evaluating the attributes of such psychological tests. However, in its broader sense, psychometrics is concerned with the objective measurement of the skills, knowledge, and abilities, as well as the subjective measurement of the interests, values, and attitudes of individuals-both patients and their clinicians. While psychometrics is principally the domain and content expertise of psychiatry, psychology, and social work, it is also very pertinent to patient care, education, and research in anesthesiology, perioperative medicine, critical care, and pain medicine. A key step in selecting an existing or creating a new health-related assessment tool, scale, or survey is confirming or establishing the usefulness of the existing or new measure; this process conventionally involves assessing its reliability and its validity. Assessing reliability involves demonstrating that the measurement instrument generates consistent and hence reproducible results-in other words, whether the instrument produces the same results each time it is used in the same setting, with the same type of subjects. This includes interrater reliability, intrarater reliability, test-retest reliability, and internal reliability. Assessing validity is answering whether the instrument is actually measuring what it is intended to measure. This includes content validity, criterion validity, and construct validity. In evaluating a reported set of research data and its analyses, in a similar manner, it is important to assess the overall internal validity of the attendant study design and the external validity (generalizability) of its findings.