We asked 81 tertiary children’s hospitals and tertiary maternity and children hospitals to join the study; 17 did not respond, and 64 agreed to participate. Questionnaires were sent to representatives from each of the 64 hospitals, and valid questionnaires were retrieved from 63 (98.4%) of them. At least one hospital in each province and municipality in China was included, except for the Tibet Autonomous Region and the Ningxia Hui Autonomous Region. According to the National Health Commission of People’s Republic of China, there were no tertiary children's hospitals or tertiary maternity and children hospitals registered in these two regions.
Frequency of moderate- and deep-sedation use
Of the 63 hospitals, 58 (92.1%) provided moderate and deep sedation for non-invasive paediatric diagnostic procedures. A majority (N=36, 62.1%) of the hospitals performed moderate-to-deep sedation in fewer than 1,000 cases per year. Twelve (20.7%) hospitals performed it in 1,000-5,000 cases per year, and 10 (17.2%) hospitals performed it in more than 10,000 cases per year. The top 10 centres in terms of number of patients served were located in Shanghai, Chongqing, Guangzhou, Zhengzhou, Xuzhou, Hangzhou, Chengdu, Kunming, Qingdao, and Xining.
Dedicated sedation rooms and post-sedation recovery rooms were reported in only 14 (24.1%) and 19 (32.8%) hospitals, respectively. Of the 10 hospitals with more than 10,000 sedation cases per year, eight (80%) reported dedicated sedation rooms and all (100%) reported post-sedation recovery rooms. The availability of such a facility was less common in hospitals that managed less than 1,000 sedation cases per year (p<0.001; Figure 1).
Staff structure and prerequisite skills
Most sedations were performed by anaesthesiologists (69.0%). Other sedation providers included physicians-in-charge (13.8%), radiologists (6.9%), and nurses (10.3%) (Figure 2). Fifteen (25.9%) hospitals reported that they employed full-time sedation providers. Of those 15 hospitals, 13 used anaesthesiologists and two used nurses as full-time sedation providers. In China, full-time sedation providers are medical personnel whose only duty is to provide sedation service during that session. Ten of the 14 hospitals with sedation rooms had full-time sedation providers; however, only five of the 44 hospitals without sedation rooms had full-time sedation providers (p<0.001).
The ratio of physicians to nurses is shown in Table 1. A ratio lower than 1:1 was reported in 19 (52.8%) hospitals with less than 1,000 sedation cases per year and in two (20.0%) hospitals with more than 10,000 sedation cases per year. A ratio equal to or more than 1:4 was reported in two (5.6%) hospitals with less than 1,000 sedation cases per year and four (40%) hospitals with more than 10,000 sedation cases per year. The ratio was not specified in 12 (33.3%) hospitals with less than 1,000 sedation cases per year, but all hospitals with more than 10,000 sedation cases per year had explicit requirements regarding the ratio of physicians to nurses.
Prerequisite skills for sedation providers are shown in Figure 2. Ten (17.2%) hospitals indicated that Paediatric Advanced Life Support (PALS) training is required for staff involved in sedation service, and four (6.9%) hospitals replied that Paediatric Basic Life Support (PBLS) is required. More than half of the hospitals (51.7%) did not specify any training requirements.
Solid food or milk was stopped for at least 4 hours, 6 hours, 8 hours, and more than 8 hours before sedation in 27.6%, 37.9%, 25.9%, and 1.7% of hospitals, respectively. Clear liquids were stopped for at least 2 hours, 4 hours, and 6 hours before sedation in 44.8%, 43.1%, and 5.2% of hospitals, respectively. Four hospitals (6.9%) did not mention pre-sedation fasting requirements (Table 2).
Pulse oximetry was used in 65.5% and 77.6% of hospitals during magnetic resonance imaging and non-magnetic procedures, respectively; capnography was monitored in approximately 10% of hospitals during the sedation procedure (Table 3). Most hospitals monitored pulse oximetry in either a continuous or intermittent manner (Table 4).
Choice of sedatives
Chloral hydrate was commonly selected as the first-line sedative for children. For infants (i.e., younger than 1 year), the three most commonly used sedation agents were chloral hydrate (53.4%), dexmedetomidine (12.1%), and diazepam (8.6%). For older children, the use of chloral hydrate decreased and the use of dexmedetomidine and propofol increased. In children older than 4 years of age, the top three agents were chloral hydrate (24.1%), propofol (20.7%), and dexmedetomidine (17.2%) (Figure 3).
Rescue sedatives were considered by sedation providers if the patient remained awake 30 minutes after the first-choice agent was administered. The term ‘remained awake’ refers to a Modified Observer’s Assessment of Alertness and Sedation Scale score of ≥4 (Table 5). If the first-choice sedative failed, propofol (15.5%) and inhaled anaesthetics (15.5%) were most commonly used in infants, and an additional dose of chloral hydrate was also considered in 7 hospitals (12.1%). For older children, dexmedetomidine and propofol (instead of inhaled anaesthetics) were popular choices (Figure 3).