Pediatric Sedation Newsletter – Winter 2006
Departments of Anesthesiology and Pediatrics, Children’s Hospital at Dartmouth,
Dartmouth Hitchcock Medical Center, Lebanon, NH
Editors: Joseph Cravero MD (joseph.cravero@hitchcock.org),
George Blike MD george.blike@hitchcock.org
Website = http://an.hitchcock.org/PediSedation/
Estimated Circulation 4208
Housekeeping:
We would like to begin this newsletter by notifying you of a pediatric sedation conference that will
occur May 31-June 1 in Columbus Ohio sponsored by the Columbus Children’s Hospital. The conference
is being organized by Marc Leder MD – an emergency physician – and features a diverse faculty from a
variety of specialties and includes a variety of interesting topics. The brochure for the conference can be
viewed at www.columbuschildrens/conferences.
The presentation of this conference once again causes us to consider the idea of initiating a larger
organization of individuals and institutions that would like to further the practice and science of pediatric
sedation. We suggest that a larger group could coordinate activities such as these conferences – exploring
new clinical practice models and research in the area of pediatric sedation. In our last newsletter we
suggested the formation of an International Society for Pediatric Sedation. We received several positive
responses (none negative) to this suggestion but not an overwhelming mandate to carry this forward. The
conference in Columbus will offer an opportunity to discuss the idea with a large number of individuals
interested in the concept – so we will inform you of progress on this topic after that meeting.
We will devote this issue of the newsletter to technologies in pediatric anesthesia. We will start with an
exploration of the use of the BIS monitor in pediatric sedation – through an editorial with commentary and
two new papers on the validity of this monitor in pediatric sedation practice. We will then continue with a
report on the use of human patient simulation and what its implications are for pediatric sedation in the
foreseeable future.
Commentary:
We have discussed the BIS monitor in past issues of the newsletter. While the impact in sedation
practice has not been great to date, we are seeing an increasing number of papers that evaluate its
usefulness for pediatric procedural sedation. For the uninitiated, we feel it is important to provide some
perspective on the use of this monitor once again.
We will start with the basics. The bispectral index monitor (BIS) has been around for many years at this
point. It is essentially a small bedside monitor that connects easily to the forehead of a patient using a
“strip” with three sticky skin connections. After a brief warm-up period, the monitor displays a reading that
indicates the “depth” of sedation or anesthesia for the patient. The scale varies from 0 to 100. As you will
read below, there has been some debate over the years as to the exact utility of this monitor – and the
debate continues…….
The following editorial appeared in Anesthesia and Analgesia this month. While the editorial is addressed
to anesthesiologists there is clearly a lot of reference to non-anesthesiologists and that is where the new
market is perceived to be for this monitor.
To BIS or Not to BIS? That Is the Question
Chantal Kerssens, PhD, and Peter S. Sebel, MBBS, PhD, MBA, Anesth Analg 2006;102:380-382
This editorial accompanies two papers (1,2) on the use of the Bispectral Index (BIS) as a sedation index in
children. Before discussing the salient elements and findings of these papers, it is instructive to consider
what processed electroencephalogram (EEG) monitors actually measure.
As an analogy, consider the dark days before the introduction of pulse oximetry into clinical practice, when
clinicians generally used something that might approximate to a four-point scale (pink/slightly blue/dark
blue/black) to assess oxygenation. The introduction of pulse oximetry gave a continuous measure of oxygen
saturation as a percentage of saturated hemoglobin and quickly became the gold standard for measuring
oxygenation, despite the lack of prospective randomized trial evidence of improved outcomes (3).
Similarly, we have multiple discontinuous clinical scales for describing sedation levels in adults, including
the Observer’s Assessment of Alertness and Sedation (OAAS) and the Ramsay scales. The purpose of
processed EEG monitors is to provide a continuous measure that encompasses the full range of sedation
levels measured by the discontinuous scales.
Pulse oximetry measures a physiological parameter that most physicians can readily understand (oxygen
saturation). In contrast, processed EEG monitors calculate a mathematical abstraction of the
electroencephalogram, a concept less familiar and less accessible to the practicing clinician. BIS was
derived by empirically estimating the EEG parameters that best predicted OAAS measurements in a large
patient and volunteer database of subjects receiving hypnotics and opioids. As a continuous measure that
correlates to OAAS measures obtained from subjects receiving hypnotic drugs, BIS may be described as a
"probability of state" measure, reflecting the complex nature of consciousness (4).
Being derived from the OAAS, BIS should be expected to correlate well with the OAAS. The correlation
would probably be less strong with other rating scales, such as the Ramsay scale, the modified maintenance
of wakefulness test (MMWT) scale used in pediatrics, or the University of Michigan sedation scale
(UMSS). These latter scales were not part of the database used to develop the BIS monitor, and the original
database was entirely constructed from adult EEG data. Normal pediatric EEG differs markedly from adult
EEG, displaying more variation than adult EEG (5,6). This may make processed EEG parameters less
reliable in children. In general, the electrical activity of the brain changes during growth and development,
warranting age-specific considerations and cautious interpretation of EEG data in the pediatric population.
Despite such theoretical concerns, studies suggest that the performance of BIS in pediatric patients older
than 6 months of age may be similar to that of adults (7–9). In younger infants, brain maturation and
development may render processed EEG measures unreliable. However, McDermott et al. (8) still found a
significant correlation between BIS and the UMSS in patients younger than 6 months of age in a small
group of patients.
In this issue of Anesthesia & Analgesia, Malviya et al. (1) report on the observed relationship between BIS
and two observational measures, the UMSS and MMWT, in children 1 month to 17 years conceptual age. In
lieu of clinical guidelines that call for delineation of sedation states, the investigators were particularly
interested in the ability of different measures to discriminate conscious from deep sedation. Data from 39
patients were included, comprising repeated measurements (about 8 per individual on average) of sedation
indices after unspecified procedures that required sedation/analgesia or general anesthesia. The authors
report good correlation between UMSS and BIS (–0.73), indicating reasonable concordance between these
discontinuous and continuous scales. This supports the validity of BIS as a pediatric sedation monitor and
complements similar reports by this group (10) and others (8). MMWT scores, by contrast, correlated
weakly (0.36) with BIS, in contrast to earlier reports (10). On the basis of receiver operator characteristic
curves, they conclude that BIS = 80 is the best cutoff for determining deep sedation.
In our view, the proposed cutoff of 80 should be interpreted cautiously. It is inconsistent with the available
literature in adults supporting a cutoff of 70 (11–14). If this threshold were used to guide drug dosing, it
would have important ramifications in that it calls for more modest drug dosing in young individuals. This
is at odds with the notion of increased anesthetic requirements in pediatrics and the relatively high estimates
of pediatric awareness during general anesthesia compared with adults (15). Furthermore, Motas et al. (9)
have warned that the UMSS may underestimate the number of patients in deep sedative stages, since the
actual measurement requires physical stimulation of the patient. The arousal from the measurement itself
disrupts the "true" mental state of the subject, a commonly noted limitation of sedation scales that rely on
stimulation. Consequently, many more patients may be denoted as deeply sedated in the absence of
stimulation, as Motas et al. (9) observed. Since UMSS depends on stimulation, application of the stimulus
will tend to shift subjects from a deeper level of sedation to a lighter level (they wake up in response to
stimulation). This will then skew the cutoff number used to distinguish deep from light sedation. For
instance, consider Malviya et al. (1) (Table 2 in their article). Stimulation will tend to shift a number of
patients from deep sedation to a lighter level (e.g., UMSS = 2). Conversely, BIS values may be expected to
increase due to stimulation, which would also increase the cutoff value for deep sedation. Generally,
sedation scales focus on a narrow range of responsiveness based on response to voice or tactile stimuli.
Therefore, they tend to mix cortical responses (open your eyes) with spinal cord responses (movement). BIS
was specifically developed to reflect the cortical state, which may account for limited accordance with
tactile movement responses.
To circumvent part of the problem surrounding stimulation in sedation studies, it is generally recommended
that BIS be measured just prior to stimulation, as in the study by Malviya et al. (1) However, BIS should be
measured immediately before stimulation to be contemporaneous with the subsequent UMSS measurement.
Of course, all physiological variables, including BIS, should be captured by computer, rather than recorded
by hand, to provide reliable and accurate data acquisition (16). We agree with the authors that these results
should be treated cautiously due to the limited sample size. Malviya et al. (1) separately analyzed data for
children younger than 1 year of age and noted limited discriminative value of BIS in this group. This may
reflect an inability of BIS to capture true physiology in the immature brain, or merely a lack of statistical
power to demonstrate differences. Given the wide variation in normal pediatric EEG, specific hypotheses
should be studied in specific age groups of appropriate size (determined by power analysis). In our view,
the recommendation of Malviya et al. (1) that the cutoff for deep sedation in pediatric patients should be 80
requires prospective validation before it is adopted as a clinical guideline.
Also in this issue, Sadhasivam et al. (2) adequately address most of the methodological issues raised here
and elsewhere (17). They studied a larger group of children (n = 96) who varied less in age, and excluded
young infants (<1 year). Besides the UMSS, these authors incorporated the OAAS as a sedation measure to
test the hypothesis that BIS is a valid measure of pediatric sedation depth. BIS was automatically and
electronically recorded, and only values immediately (40 s) preceding observational scores were considered
for paired-data analyses. A further feature of this report is the distinct consideration of BIS values when the
two observers rated the sedation level equally. This eliminates interrater variability (occurring about 50% of
the time in the Sadhasivam et al. report (2)), another common limitation of observational scales, and allows
for a more accurate assessment of the BIS value across sedation levels. Given observational agreement,
Sadhasivam et al. (2) found reasonably good prediction probabilities for BIS and the clinical sedation
scores. Prediction probability is a nonparametric statistical measure of association that takes data limitations
into account (18). This finding again supports the feasibility of BIS as a pediatric sedation monitor. In
addition, BIS values were strong predictors of OAAS and UMSS scores independent of drug regimen, an
issue that could not be addressed by Malviya et al. (1). Sadhasivam et al. (2) explicitly excluded children
receiving ketamine, a drug that is known to affect BIS in a paradoxical manner (8,19).
Pediatric populations pose particular challenges, especially when delicate information is to be abstracted
and traumatic experiences may be involved (20). The utility of BIS to monitor depth of sedation should not
be interpreted as suggesting that BIS can substitute for a vigilant, trained anesthesiologist caring for
children receiving sedation. Deep sedation should only be administered by trained anesthesia personnel.
When nonanesthesiologists sedate children, general anesthesia is induced in up to 35% of patients, and 8%
of patients have adverse airway events including desaturation (9).
As investigators with an interest in awareness and memory function during anesthesia, and the interplay
between awareness and processed EEG parameters, we welcome the recent interest in pediatric sedation
monitoring. It took more than a decade of research to understand the issues involved in adult sedation
monitoring. The database in children is relatively sparse compared with the adult database. But the same
research issues and clinical concerns arise with children as with adults: What is the appropriate clinical
response measure to compare to processed EEG? Many still argue that movement is the gold standard (17),
but we disagree when it comes to measuring sedation. What are the effects of different drugs? What does a
single BIS value mean in different patients?
In adults, BIS monitoring reduces drug usage without jeopardizing primary clinical end-points (13,21).
Similar results have been obtained in the pediatric population (22). Brain monitoring facilitates early
recovery from anesthesia (13), reduces the risk of awareness in high risk patients (23), and reduces
postoperative nausea and vomiting (24). BIS may even provide information about the anesthetic state that
relates to the risk of postoperative mortality (25).
To BIS or not to BIS? More generally, should we monitor the EEG intraoperatively or not? We can answer
this in adults by asking whether the cost of the technology is reasonable (yes), whether it provides the
caregiver with useful information (yes), and do available data suggest the technology influences short-term
or long-term outcome (yes). Are the data sufficiently strong in the pediatric population to endorse a similar
recommendation? In pediatric patients older than 1 year of age, the technology appears to perform in a
similar manner to the adult population but further data are needed to support this conclusion. The results are
less convincing for patients in their first year of life. However, in the pediatric population older than 1 year
of age, we answer the question posed in our title with a cautious "Yes."
1.
Malviya S, Voepel-Lewis T, Tait AR. A comparison of observational and objective measures to differentiate
depth of sedation in children birth to 18 years of age. Anesth Analg 2005;102:389–94.
2.
Sadhasivam S, Ganesh A, Robison A, et al. Validation of the bispectral index monitor for measuring depth of
sedation in children. Anesth Analg 2005;102:383–8.
3.
Moller JT, Johannessen NW, Espersen K, et al. Randomized evaluation of pulse oximetry in 20,802 patients:
II. Perioperative events and postoperative complications. Anesthesiology 1993;78:445–53.
4.
Crick F, Koch C. A framework for consciousness. Nat Neurosci 2003;6:119–26.
5.
Mizrahi EM. Avoiding the pitfalls of EEG interpretation in childhood epilepsy. Epilepsia 1996;37:S41–51.
6.
Eeg-Olofsson O, Petersen I, Sellden U. The development of the electroencephalogram in normal children
from the age of 1 through 15 years: paroxysmal activity. Neuropadiatrie 1971;2:375–404.
7.
Agrawal D, Feldman HA, Krauss B, Waltzman ML. Bispectral index monitoring quantifies depth of sedation
during emergency department procedural sedation and analgesia in children. Ann Emerg Med 2004;43:247–
55.
8.
McDermott NB, VanSickle T, Motas D, Friesen RH. Validation of the bispectral index monitor during
conscious and deep sedation in children. Anesth Analg 2003:97:39–43
9.
Motas D, McDermott NB, Vansickle T, Friesen RH. Depth of consciousness and deep sedation attained in
children as administered by nonanaesthesiologists in a children’s hospital. Pediatr Anesth 2004;14:256–60
10. Malviya S, Voepel-Lewis T, Ludomirsky A, et al. Can we improve the assessment of discharge readiness? A
comparative study of observational and objective measures of depth of sedation in children. Anesthesiology
2004;100:218–24.
11. Flaishon R, Windsor A, Sigl J, Sebel PS. Recovery of consciousness after thiopental or propofol: bispectral
index and the isolated forearm technique. Anesthesiology 1997;86:613–9.
12. Glass PS, Bloom M, Kearse L, et al. Bispectral analysis measures sedation and memory effects of propofol,
midazolam, isoflurane, and alfentanil in healthy volunteers. Anesthesiology 1997;86:836–47.
13. Johansen JW, Sebel PS. Development and clinical application of electroencephalographic bispectrum
monitoring. Anesthesiology 2000;93:1336–44.
14. Kerssens C, Klein J, Bonke B. Awareness: monitoring versus remembering what happened. Anesthesiology
2003;99:570–5.
15. Davidson AJ, Huang GH, Czarnecki C, et al. Awareness during anesthesia in children: a prospective cohort
study. Anesth Analg 2005;100:653–61.
16. Rampil I, Mychaskiw GI, Horowitz M. False negative BIS? Maybe, maybe not! Anesth Analg 2001;93:798–
9.
17. Shields CH, Creamer KM. Validation of the BIS monitor during conscious sedation and deep sedation in
children [letter]. Anesth Analg 2004;98:277–8.
18. Smith WD, Dutton RC, Smith NT. Measuring the performance of anesthetic depth indicators. Anesthesiology
1996;84:38–51.
19. Overly FL, Wright RO, Connor FAJ, et al. Bispectral analysis during pediatric procedural sedation. Pediatr
Emerg Care 2005;21:6–11.
20. Davis PJ. Goldilocks. The pediatric anesthesiologist’s dilemma. Anesth Analg 2005;100:650–2.
21. Johansen JW, Sebel PS, Sigl JC. Clinical impact of hypnotic-titration guidelines based on EEG bispectral
index (BIS) monitoring during routine anesthetic care. J Clin Anesth 2000;12:433–43.
22. Bannister CF, Brosius KK, Sigl JC, et al. The effect of BIS index monitoring on anesthetic use and recovery
in children anesthetized with sevoflurane in nitrous oxide. Anaesth Analg 2001;92:877–81.
23. Myles PS, Leslie K, McNeil J, et al. Bispectral index monitoring to prevent awareness during anaesthesia: the
B-Aware randomised controlled trial. Lancet 2004;363:1757–63.
24. Liu SS. Effects of Bispectral index monitoring on ambulatory anesthesia: A meta-analysis of randomized
controlled trials and a cost analysis. Anesthesiology 2004;101:311–5
25. Monk TG, Saini V, Weldon BC, Sigl JC. Anesthetic management and one-year mortality after noncardiac
surgery. Anesth Analg 2005;100:4–10.
Commentary:
Many possible points to make here but we will try to keep this brief and to the point. We should begin by
recognizing that Dr. Sebel is a paid consultant for the Aspect Corp – makers of the BIS monitor. Having
said this we are a little concerned about the concluding paragraph of this editorial which sounds a little like
an endorsement of the use of this monitor for pediatric patients. Almost all of the references the authors
cite to bolster their argument for the utility of the BIS monitor in adults and children in this editorial refer
its use in anesthesia – not sedation. On the other hand the authors refer to the two accompanying articles
concerning pediatric sedation to promote the idea of the validity of the BIS monitor in children. We are
concerned that there is some mixing of information here in a context that might make some sedation
providers think that the monitor has been shown to be effective or useful in the sedation venue.
Let’s consider the final paragraph of this editorial which poses several questions about the BIS in adults
and tries to make a conclusion about applicability to children.
1) Is it worth the money? The disposables for this machine cost $17.50 a piece for our institution.
The answer to this question could only come from a complete knowledge of how the monitor will
be used by individuals; so we can not comment on this issue other than to say the cost per patient
is not insignificant but not excessive.
2) Does the monitor give useful information? We would question this (somewhat). Part of the
confusion here may reflect the difference between statistically significant correlation and
clinically useful correlation. If we consider the Sadhasivam paper (2 above) we calculate that for
patients in their cohort with levels of sedation considered “deep” or “anesthesia” by the UMSS
criteria (minimally or not arousable with stimulation) - fully 20% had BIS levels that were above
80 – indicating moderate or mild sedation. Likewise for patients with UMSS scores indicating
minimal or moderate sedation – 36% had BIS values lower than 80 – (the cut off the Malviya et al.
suggest should be used to determine “deep” sedation given desired specificity and sensitivity).
While there may well be statistical correlation between the two measures of sedation depth, with
this amount of inaccuracy compared to clinical indicators of sedation depth, one must ask is the
information clinically useful?
3) Do available data suggest the technology influences short-term or long-term outcome? We would
remind readers that there are no data from pediatric sedation studies that the use of this monitor
influences outcomes such as nausea and vomiting or even speed of emergence. Issues concerning
“awareness” during anesthesia have only been accounted for in the operating room environment
and there are no data on this problem for sedation activity in children. So there really are no data
to specifically address this question.
This editorial also includes a comparison of the BIS monitor with some aspects of pulse oximetry. We find
this comparison interesting, but there are a couple of points that should be raised concerning clinical utility
of these two monitors. 1) While we all recognize that there are a considerable number of ways in which the
pulse oximeter can be inaccurate, generally (if we have a good wave form) we believe that a saturation
reading below 90% means just that – oxygenation is compromised. Our concern with the BIS is that while
statistical correlation with sedation depth exists, “scatter” in the reading is so large that at least 20% of the
time it is not accurate in differentiating deep sedation from minimal or moderate sedation. Utility and
safety in a sedation application is suspect. 2) When the pulse oximeter was introduced for wide clinical
application approximately 25 years ago, clinicians readily appreciated its usefulness. In fact where we
worked, there were daily arguments over who could use the available machines based on patient acuity etc.
Interestingly, in spite of the fact that we are very familiar with BIS technology and the BIS machines are
readily available at our institution, it is simply not used for monitoring of sedation except in extraordinary
circumstances – such as the ICU patient on muscle relaxants for prolonged periods of time. Clearly the
evident utility of the two monitors is very different and we find the comparison a bit of a stretch.
The authors conclude their editorial by endorsing the use of BIS in children over 1 year of age
“cautiously”. We would advise extreme caution! There is clearly a lot of work that needs to be done to
determine how the BIS could be used for procedural sedation and to determine if its use could improve the
safety or effectiveness of care.
The articles that accompanied this editorial include:
A Comparison of Observational and Objective Measures to Differentiate Depth of
Sedation in Children from Birth to 18 Years of Age Shobha Malviya, MD, Terri Voepel-Lewis,
MSN, RN, and Alan R. Tait, PhD, Anesth Analg 2006;102:389-394
Abstract:
Several observational and objective methods are available to assess sedation depth; however, data regarding
their accuracy in differentiating deep sedation are limited. In this study we compared 3 sedation tools in
children from birth to 18 yr of age and determined their relative value in detecting deep levels of sedation.
Bispectral index monitoring (BIS®), Modified Maintenance of Wakefulness Tests (MMWT), and the
University of Michigan Sedation Scale (UMSS) were used to assess sedation. Three-hundred-twenty-seven
observations were recorded in 39 children. The overall validity of each measure was supported by
appropriate changes after sedation administration through the observation period. There were moderate to
high correlations between UMSS and BIS (rho = –0.73) and UMSS and MMWT (rho = –0.59; P < 0.01).
The correlation between BIS and MMWT was significant but low (r = 0.36; P < 0.01). Measures of exact
agreement supported the reliability of the UMSS and MMWT across the sedation continuum. There were
significant decreases in BIS across UMSS scores except from scores 2–3. ROC curves suggested that BIS
80 and MMWT 14 min were most sensitive in delineating deep sedation. Our findings demonstrate the
overall validity of these observational and objective measures of sedation depth in children <18 yr of age
but show ongoing limitations distinguishing moderate from deep sedation.
Commentary: Please see commentary above. In this study patients who had clinical (UMSS) scores
associated with deep sedation would have been identified at minimal or moderate sedation 16% of the time.
Conversely, patients who had clinical markers of minimal or moderate sedation would have been
considered “deep” by BIS criteria 27% of the time. Not sure how we would apply this clinically.
Validation of the Bispectral Index Monitor for Measuring the Depth of Sedation in
Children Senthilkumar Sadhasivam, MD, Arjunan Ganesh, MBBS, Amy Robison, BA, Robin Kaye,
MD, and Mehernoor F. Watcha, MD Anesth Analg 2006;102:383-388
Abstract:
The Bispectral Index (BIS) is an empirically calibrated number derived from adult electroencephalograph
data that correlates with the depth of sedation in adults. We tested the hypothesis that the BIS score is a
valid measure of the depth of pediatric sedation in a study designed to avoid limitations of a previously
published report. BIS values from 96 healthy ASA physical status I–II children aged 1–12 yr undergoing
sedation were continually recorded and electronically transferred to a computer. Two independent observers
blinded as to BIS score evaluated sedation using the Observer’s Assessment of Alertness/Sedation (OAA/S)
and the University of Michigan Sedation Scale (UMSS) at 3–5 min intervals. There was a significant
correlation between BIS and UMSS and between BIS and OAA/S by both the Spearman’s rank correlation
test and by prediction probability (P < 0.001). In children <6 yr, there was a significant correlation between
BIS and the clinical sedation scores for subgroups undergoing invasive and noninvasive procedures (P <
0.001). There was also good agreement between the 2 independent observers who assessed clinical sedation
scores (kappa = 0.51, P < 0.001). We conclude that the BIS monitor is a quantitative, nondisruptive and
easy to use depth of sedation monitor in children.
Commentary: Once again, please see commentary following the editorial. This study was supported by a
grant from Aspect Medical. Statistical correlation between BIS and sedation scores exists, and the authors
conclusions that this is “an objective and non-disruptive tool for measuring depth of sedation in pediatric
patients older than 1 year who do not receive ketamine” may be accurate. None-the-less, we would
question the utility of BIS in clinical practice given the significant percentage of the time that the BIS fails
to correctly identify deep sedation from other depths of sedation.
Simulation Update:
Apnea is defined as the lack of air movement in and out of the lungs, whether due to obstruction or central
mechanisms. Apnea is a relatively rare event associated with pediatric procedural sedation that the sedation
team needs to manage. The potential risk for apnea is obviously dependent on the drug used and the
intended depth of sedation. Preventive measures can lower the risk of apnea. However, pediatric patients
are unpredictable and pharmacodynamics equally variable. We conclude that apnea will never be an
entirely preventable complication associated with sedation care. Therefore, safety in this domain will
require not just preventive measures, but rescue measures to detect and manage apnea.
We would like to update everyone on the growth of advanced immersive learning tools and mannequin
based pediatric simulation specifically. We have previously discussed modern human patient simulation as
a powerful tool for both training and assessment of competency in managing such rare events. We should
also disclose our bias that current simulation is an important tool for identifying flaws in sedation rescue
systems. [1]
The first development of a simulated patient dates back to the late 1960’s. David Gaba and others are
credited with driving the development of the modern model based interactive simulation in the 1980’s.
Now almost 20 years later, simulation is improving at an impressive rate resulting in more products from
more companies and representing more patient populations. Last month the newly formed Society for
Medical Simulation http://www.socmedsim.org/index.html met in San Diego for its annual meeting. Over
700 people attended the conference. This is a huge change from approximately 300 last year and more like
200 the year before. All specialties and expertise in education assessment were represented (surgeons,
obstetricians, general internists, pediatricians, human factors engineers, biomedical engineers, software elearning designers, companies making training tools, education assessment experts, etc.) Many countries
were represented as well, making the group international. Many vendors are now available supporting birth
simulation, trauma care, surgical simulation etc. Don’t let the company names scare you off (e.g., Limbs
and Things http://www.limbsandthings.com/ ). All of the vendors that were at the meeting are listed with
links on the SMS website. The scientific program was quite good and over 100 abstracts were presented
(http://www.socmedsim.org/meetings/smssponsor/upcoming/2006IMMSAbstracts.html ). While the quality
of research validating simulation remains somewhat immature, many high quality studies were presented.
Also of note, the first issue of the Journal Simulation in Medicine has been published.
Notably, pediatric simulation is improving
dramatically. Two major companies now
have neonatal and pediatric models
commercially available (Medical Education
Technologies Incorporated
http://www.meti.com and Laerdal
http://www.laerdal.com ). The simulated
babies are supposed to be 3-6month, but
height and weight put them on the high end
of the growth curve. The functionality of
these two products is somewhat different.
The METI simulator is model driven,
meaning that the physiology is automatic
and computer controlled. As the clinician
provides (or fails to provide) needed
therapies the patient condition is designed to
change automatically as it should in real-time. The Laerdal simulators are not model driven, but offer an
excellent task training platform. The reality is that these two products fill differing needs in simulation for
training and assessment. At this point we have utilized the more expensive and model driven platform for
research that assesses rescue performance in a standardized manner. On the other-hand, we are using the
Laerdal simulator for training due to its flexible software and portability.
We have included just a sample of the functionality supported by these simulators--various causes of
airway obstruction, patterns of breathing, cyanosis (blue LED that is in the mouth) etc. We have found the
models to be not entirely realistic, but they are quantum leap forward in allowing for the deliberate practice
that is require for novices to achieve competency in the skills, rules and knowledge associated with
expertise in pediatric procedural sedation.
We encourage those involved in training sedation providers to check the Society for Medical Simulation
and consider joining. The blog and list-serve are very active and a tremendous resource for a growing
community. While we are only glossing the surface in this update, the pace of change is staggering. We
will continue to review all relevant literature that will be of interest to our readership.
1. Blike GT, Christoffersen, K, Cravero JP, Andeweg SK, Jensen J. A method for measuring system safety
and latent errors associated with pediatric procedural sedation. Anesth Analg. 2005 Jul;101(1):48-58