Pediatric Sedation/Anesthesia for MRI: Results From the Pediatric Sedation Research Consortium.

BACKGROUND: Magnetic resonance imaging (MRI) is the most common imaging procedure requiring sedation/anesthesia in children. Understanding adverse events associated with sedation/anesthesia is important in making decisions regarding MRI vs. other imaging modalities. No large studies have evaluated the practice of pediatric sedation/anesthesia for MRI by a variety of pediatric specialists. PURPOSE: Utilize a large pediatric sedation database to characterize the patients and adverse events associated with sedation/anesthesia for pediatric MRI. STUDY TYPE: Retrospective analysis of prospectively collected data. SUBJECTS: The Pediatric Sedation Research Consortium (PSRC) has 109,947 entries for sedations for MRI from November 10, 2011 through December 18, 2017. ASSESSMENT: Patient demographics, sedative medications, interventions, and adverse events are described. Associations with adverse events were assessed. Trends in sedative medications used over time are examined. STATISTICAL TESTS: Descriptive statistics, Chi-Squared and Fisher's Exact tests for categorical variables, logistic regression and assessment of trend using logistic regression and other method. RESULTS: A total of 109,947 MRI-related sedations were examined. Most subjects (66.2%) were 5 years old or younger. Seizure or other neurologic issue prompted MRI in 63.7% of cases. Providers responsible for sedation/anesthesia included intensivists (49.3%), emergency medicine physicians (28.2%), hospitalists (10.2%), and anesthesiologists (9.8%). The most commonly used sedative agent was propofol (89.1%). The most common airway intervention was supplemental oxygen (71.7%), followed by head/airway repositioning (20.6%). Airway-related adverse events occurred in 8.4% of patients. Serious adverse events occurred in only 0.06% of patients, including three cases of cardiac arrest. No mortality was recorded. There was a statistically significant increase in the use of dexmedetomidine over time. DATA CONCLUSIONS: Overall, adverse event rates were low. Sedation/anesthesia with propofol infusion and natural airway was the most common method used by this varied group of sedation providers. The use of dexmedetomidine increased over time. EVIDENCE LEVEL: 4 TECHNICAL EFFICACY: Stage 5.

Sedatives used in children to obtain head CT in the emergency department.

OBJECTIVES: Children in the emergency department who require computerized tomography (CT) of the head often are given sedative medications to facilitate completion of the study with adequate imaging. A prior study found the two most common medications used to obtain head CT in children were pentobarbital and chloral hydrate; however, these medications have become less popular. We hypothesized that there was variability in medication choice amongst providers in the emergency department and there has been a change in the preferred sedatives used in the last decade. METHODS: We conducted a retrospective multicenter cross-sectional study of children 0-18 years old who received a medication with sedative properties and underwent head CT while in the emergency department from 2007 to 2018, using the Pediatric Health Information System (PHIS) database. The primary outcome measure was the frequency of administration of drugs within an individual sedative class. RESULTS: We analyzed 24,418 patient encounters, of whom 53% received an opioid and 41% received a benzodiazepine. There were statistically significant decreases in the use of barbiturates, chloral hydrate, anti-emetic sedatives, and opioids, while increases in barbiturate combination drugs, benzodiazepines and dexmedetomidine were observed over the study period. The majority of medications were administered parenterally. CONCLUSION: There is wide variability in sedatives used in children to obtain head CT and the preferred drugs have shifted over the last decade.

Radiologic Imaging in Trauma Patients with Cervical Spine Immobilization at a Pediatric Trauma Center.

BACKGROUND: Pediatric trauma patients with cervical spine (CS) immobilization using a cervical collar often require procedural sedation (PS) for radiologic imaging. The limited ability to perform airway maneuvers while CS immobilized with a cervical collar is a concern for emergency department (ED) staff providing PS. OBJECTIVE: To describe the use of PS and analgesia for radiologic imaging acquisition in pediatric trauma patients with CS immobilization. METHODS: Retrospective medical record review of all trauma patients with CS immobilization at a high-volume pediatric trauma center was performed. Patient demographics, imaging modality, PS success, sedative and analgesia medications, and adverse events were analyzed. Patients intubated prior to arrival to the ED were excluded. RESULTS: A total of 1417 patients with 1898 imaging encounters met our inclusion criteria. A total of 398 patients required more than one radiographic imaging procedure. The median age was 8 years (range 3.8-12.75 years). Computed tomography of the head was used in 974 of the 1898 patients (51.3%). A total of 956 of the 1898 patients (50.4%) required sedatives or analgesics for their radiographic imaging, with 875 (91.5%) requiring a single sedative or analgesic agent, and 81 (8.5%) requiring more than one medication. Airway obstruction was the most common adverse event, occurring in 5 of 956 patients (0.3%). All imaging procedures were successfully completed. CONCLUSION: Only 50% of CS immobilized, nonintubated patients required a single sedative or analgesic medication for their radiologic imaging. Procedural success was high, with few adverse events.

Evaluation of methohexital as an alternative to propofol in a high volume outpatient pediatric sedation service.

BACKGROUND: Propofol is a preferred agent for many pediatric sedation providers because of its rapid onset and short duration of action. It allows for quick turn around times and enhanced throughput. Occasionally, intravenous (IV) methohexital (MHX), an ultra-short acting barbiturate is utilized instead of propofol. OBJECTIVE: Describe the experience with MHX in a primarily propofol driven outpatient sedation program and to see if it serves as an acceptable alternative when propofol is not the preferred pharmacologic option. METHODS: Retrospective chart review from 2012 to 2015 of patients receiving IV MHX as their primary sedation agent. Data collected included demographics, reason for methohexital use, dosing, type of procedure, success rate, adverse events (AE), duration of the procedure, and time to discharge. RESULTS: Methohexital was used in 240 patient encounters. Median age was 4years (IQR 2-7), 71.8% were male, and 80.4% were ASA-PS I or II. Indications for MHX use: egg+soy/peanut allergy in 93 (38.8%) and mitochondrial disorder 9 (3.8%). Median induction bolus was 2.1mg/kg (IQR, 1.9-2.8), median maintenance infusion was 4.5mg/kg/h (IQR, 3.0-6.0). Hiccups 15 (6.3%), secretions requiring intervention 14 (5.8%), and cough 12 (5.0%) were the most commonly occurring minor AEs. Airway obstruction was seen in 28 (11.6%). Overall success rate was 94%. Median time to discharge after procedure completion was 40.5min (IQR 28-57). CONCLUSION: Methohexital can be used with a high success rate and AEs that are not inconsistent with propofol administration. Methohexital should be considered when propofol is not a preferred option.

Experience with the use of propofol for radiologic imaging in infants younger than 6 months of age.

BACKGROUND: There is an increased risk associated with procedural sedation of infants younger than 6 months of age. The use of propofol for radiologic imaging of this age group is not well studied. OBJECTIVE: We hypothesize that adverse events are higher in the infant population receiving propofol for radiologic imaging. MATERIALS AND METHODS: A retrospective chart review was undertaken of 304 infants younger than 6 months old who received propofol for procedural sedation from October 2012 to February 2015. Patient demographics, propofol dosing, sedation-related adverse events and interventions were collected. Serious adverse events were defined as laryngospasm, aspiration, the need for admission, cardiac arrest or death. RESULTS: Procedural sedation for radiologic imaging was successful in 301/304 (99%) of infants using propofol. Of these 304 patients, 130 (42.8%) patients were female, and 240 of the 304 (79%) were between 3 and 6 months of age. The majority of patients (172/304 [56.6%]) were American Society of Anesthesiologists-Physical Status Class II. There were 57 sedation-related, minor adverse events in 39 out of 304 (12.8%) patients. Thirteen of the 304 (4.3%) patients had 14 serious adverse events, with airway obstruction the most common. Eighty interventions were required in 56/304 (18.4%) patients. The most common interventions were continuous positive airway pressure (CPAP) in 25/304 patients (8.2%) and jaw thrust in 15/304 (4.9%). The median induction propofol dose was 4.7 mg/kg. A need for an increase in the propofol infusion rate during the procedure was noted in 162/304 (53.3%) infants. No significant predictors of sedation-related adverse events were detected. CONCLUSION: Propofol can be used for radiologic imaging of infants younger than 6 months of age with a high success rate. Practitioners should be mindful of significantly higher dosing requirements and a higher incidence of airway events, which can be easily identified and managed by a team of experienced sedation providers.

Practice Patterns and Adverse Events of Nitrous Oxide Sedation and Analgesia: A Report from the Pediatric Sedation Research Consortium.

OBJECTIVES: To describe practice patterns and adverse events associated with nitrous oxide (N2O) administration as the primary sedative outside the operating room in varied settings by a diverse range of providers, and to identify patient and sedation characteristics associated with adverse events. STUDY DESIGN: Data prospectively collected by the Pediatric Sedation Research Consortium, which is comprised of 40 children's and general/community hospitals, was retrospectively analyzed for children who received N2O as the primary sedative. Descriptive measures of patient and sedation characteristics and adverse events were reported. A multivariable regression model was used to assess potential associations between patient and sedation characteristics and adverse events. RESULTS: A total of 1634 N2O administrations were identified. The majority was performed in sedation units, and most by advanced practice nurses or physician assistants. The most common adjunct medication was midazolam. There was a low prevalence of adverse events (6.5%), with vomiting as the most common (2.4%) and only 3 (0.2%) serious adverse events reported. The odds of vomiting increased when concomitant opioids were administered (OR 2.89, 95% CI 1.14, 7.32) and when nil per os (NPO) clear fluids <2 hours (OR 4.16, 95% CI 1.61, 10.76). NPO full meal <6 hours did not change the odds of vomiting (OR 1.42, 95% CI 0.57, 3.57). There were no aspiration events. CONCLUSIONS: There was a very low prevalence of serious adverse events during N2O administration in children outside of the operating room and by nonanesthesiologists. The odds of vomiting increased when concomitant opioids were administered and NPO clear fluids <2 hours.

The impact of obesity on pediatric procedural sedation-related outcomes: results from the Pediatric Sedation Research Consortium.

OBJECTIVES: To evaluate the impact of obesity on adverse events and required interventions during pediatric procedural sedation. METHODS: The Pediatric Sedation Research Consortium database of prospectively collected procedural sedation encounters was queried to identify patients for whom body mass index (BMI) could be calculated. Obesity was defined as BMI ≥95th percentile for age and gender. Sedation-related outcomes, adverse events, and therapeutic interventions were compared between obese and nonobese patients. RESULTS: For analysis, 28,792 records were eligible. A total of 5,153 patients (17.9%) were obese; they were predominantly male and older and had a higher median American Society of Anesthesiologists Physical Status classification (P < 0.001). Total adverse events were more common in obese patients (odds ratio [OR] 1.49, 95% confidence interval [1.31, 1.70]). Respiratory events (airway obstruction OR 1.94 [1.54, 2.44], oxygen desaturation OR 1.99 [1.50, 2.63], secretions OR 1.48 [1.01, 2.15], laryngospasm OR 2.30 [1.30, 4.05]), inability to complete the associated procedure (OR 1.96 [1.16, 3.30]), and prolonged recovery (OR 2.66 [1.26, 5.59]) were increased in obese patients. Obese patients more frequently required airway intervention including repositioning, suctioning, jaw thrust, airway adjuncts, and bag-valve-mask ventilation. Multivariate regression analysis demonstrated obesity to be independently associated with minor and moderate but not major adverse events. CONCLUSIONS: Obesity is an independent risk factor for adverse respiratory events during procedural sedation and is associated with an increased frequency of airway interventions, suggesting that additional vigilance and expertise are required when sedating these patients.

Emergency physician-administered propofol sedation: a report on 25,433 sedations from the pediatric sedation research consortium.

STUDY OBJECTIVE: We describe the adverse events observed in a large sample of children sedated with propofol by emergency physicians and identify patient and procedure characteristics predictive of more serious adverse events. METHODS: We identified sedations performed by emergency physicians using propofol as the primary sedative, included in the Pediatric Sedation Research Consortium database from July 2004 to September 2008. We describe the characteristics of the patients, procedures, location, adjunctive medications, and adverse events. We use a multivariable logistic regression model to identify predictors of more serious adverse events. RESULTS: Of 25,433 propofol sedations performed by emergency physicians, most (76%) were performed in a radiology department. More serious adverse events occurred in 581 sedations (2.28%; 95% confidence interval 2.1% to 2.5%). There were 2 instances of aspiration, 1 unplanned intubation, and 1 cardiac arrest. Significant predictors of serious adverse events were weight less than or equal to 5 kg, American Society of Anesthesiologists classification greater than 2, adjunctive medications (benzodiazepines, ketamine, opioids, or anticholinergics), nonpainful procedures, and primary diagnoses of upper respiratory illness or prematurity. CONCLUSION: We observed a low adverse event prevalence in this largest series of propofol sedations by emergency physicians. Factors indicating greater risk of more serious adverse events are detailed.

Propofol vs pentobarbital for sedation of children undergoing magnetic resonance imaging: results from the Pediatric Sedation Research Consortium.

BACKGROUND: Pentobarbital and propofol are commonly used to sedate children undergoing magnetic resonance imaging (MRI). The Pediatric Sedation Research Consortium (PSRC) was created in 2003 to improve pediatric sedation process and outcomes. OBJECTIVE: To use PSRC records to compare the effectiveness, efficiency and adverse events of propofol vs pentobarbital for sedation of children undergoing MRI. METHODS: Pediatric Sedation Research Consortium records of children aged 6 months to 6 years who were primarily sedated with either i.v. pentobarbital or propofol were included. Participating PSRC investigators obtained institutional review board approval before data collection. RESULTS: Of 11 846 sedations for MRI, 7079 met inclusion criteria (propofol: n = 5072; pentobarbital: n = 2007). Demographic details were similar between the two groups. Ideal sedation was produced in 96.45% of the pentobarbital group and in 96.8% of the propofol group (P = 0.478), but pentobarbital was more likely to result in poor sedation cancelling the procedure (OR 5.88; CI 2.24, 15.40). Propofol resulted in physiologic changes more frequently than did pentobarbital (OR 5.69; CI 1.35, 23.97). Pentobarbital was associated with prolonged recovery (OR 16.82; CI 4.98, 56.8), unplanned admission (OR 5.60; CI 1.02, 30.82), vomiting (OR 36.76; CI 4.84, 279.2) and allergic complication (OR 9.15; CI 1.02, 82.34). The incidence of airway complications was not significantly different between the two. The median recovery time for patients receiving propofol was 30 min, whereas for pentobarbital it was 75 min (P < 0.001). CONCLUSION: Among institutions contributing data to the PSRC, it is found that propofol provides more efficient and effective sedation than pentobarbital for children undergoing MRI. Although apnea occurred with a greater frequency in patients who received propofol, the rate of apnea and airway complications for propofol was not statistically different from that seen in patients who received pentobarbital.

Procedural Sedation Outside the Operating Room and Potential Neurotoxicity: Analysis of an At-Risk Pediatric Population.

OBJECTIVES: To determine the characteristics of children who met the risk criteria for potential neurotoxicity defined by the US Food and Drug Administration (FDA; 2016 warning) in a procedural sedation (PS) service. STUDY DESIGN: A single-center retrospective review of all infants and children aged <3 years receiving PS outside the operating room from 2014 to 2016. Demographics, duration of, and the reason for PS were analyzed. RESULTS: A total of 2950 patients with 3653 sedation encounters were included. Median age was 19 (range, 11-26) months. Most PS (86.4%) were for magnetic resonance imaging (MRI). The median number of sedation procedures per patient was 1 (25th-75th: 1-7), and median duration of sedation was 72 minutes (25th-75th: 55-98 minutes). Forty patients (1.4%) required prolonged sedations >3 hours, in a single encounter (median, [25th-75th] of 196 minutes [185-214 minutes]), and 298 patients (10.1%) had multiple sedation exposures during the study period. Overall, 327 patients, 11.1% (95% confidence interval, 10.0%-12.3%) required repeated and/or prolonged sedation. The most common reasons for repeated or prolonged sedation were MRI of the brain and neurologic concerns. CONCLUSIONS: Multiple and prolonged PS commonly occurs outside the operating room in this young and potentially vulnerable population. Although certain imaging cannot be avoided, other cases may have the potential to be delayed until the child is >3 years old or to have alternate imaging that may not require prolonged PS. Family and provider awareness of the FDA warnings regarding potential neurotoxicity of sedation in all settings, both inside and outside the operating room, is critical.

Etomidate versus pentobarbital for computed tomography sedations: report from the Pediatric Sedation Research Consortium.

OBJECTIVE: To compare efficacy, sedation duration, and adverse events after administration of etomidate or pentobarbital for diagnostic computed tomography (CT) scans. METHODS: A cohort of children sedated for CT scans between July 2004 and October 2005 was identified from a prospectively generated Pediatric Sedation Research Consortium database. The 24 Pediatric Sedation Research Consortium institutions prospectively record consecutive sedation data and adverse events on a Web-based tool. This study included all patients of American Society for Anesthesiologists (ASA) class I or II, between 6 months and 6 years old, sedated with etomidate or with intravenous pentobarbital with or without midazolam. Outcomes included sedation efficacy, duration (time from drug administration until cessation of monitoring), and complication rate. RESULTS: Of 3397 pediatric sedations for CT scans, 2587 met age and ASA criteria. Etomidate was administered by pediatric emergency physicians as the sole sedative for 446 sedation service cases; pentobarbital with or without midazolam was used in 396 sedations by a variety of providers. Sedation was "not ideal" for 11 pentobarbital sedations and 1 etomidate sedation. Median etomidate dose was 0.33 mg/kg (intraquartile rank, 0.30-0.44 mg/kg); median pentobarbital dose was 4 mg/kg (intraquartile rank, 3.2-4.8 mg/kg). Mean etomidate sedation (34 minutes; 95% confidence interval [CI], 32-36 minutes) was shorter than pentobarbital (144 minutes; 95% CI, 139-150 minutes). Etomidate patients were younger (24 vs. 29 months), whereas pentobarbital patients were more often of ASA class II (52% vs. 34%), both P < 0.001. Adverse events were more common with pentobarbital (4.5% vs. 0.9%; relative risk, 3.38%; 95% CI, 1.28%-9.45%). One etomidate and 2 pentobarbital patients experienced apnea. CONCLUSIONS: Etomidate as given by emergency physicians was more effective and efficient than pentobarbital, with rare adverse events.

Upper Respiratory Infections and Airway Adverse Events in Pediatric Procedural Sedation.

BACKGROUND: Upper respiratory infections (URIs) are associated with airway adverse events (AAEs) during general anesthesia. There have been no large studies examining the relationship between URIs and AAEs during pediatric procedural sedation. We hypothesized that there would be a relationship between URI status and AAEs in pediatric procedural sedation. METHODS: We examined prospectively collected data from the Pediatric Sedation Research Consortium database. Specific questions regarding URI status were added to the database to facilitate our analysis. Characteristics of patients, procedure types, adjunctive medications, adverse events, and airway interventions (AIs) were reported. We performed bivariate analysis of adverse events and URI status, then used a multivariable logistic regression model to assess the relationship between URI status and adverse events. We examined the secondary outcome of AI similarly. RESULTS: Of the 105 728 sedations entered into the Pediatric Sedation Research Consortium database during the study period, we were able to use 83 491 for analysis. Controlling for multiple patient, drug, and procedure characteristics, recent and current URI were associated with increased frequency of AAEs. In general, the frequency of AAEs and AIs increased from recent URI, to current URI-clear secretions to current URI-thick secretions. We did not find a relationship between URI status and non-AAEs. CONCLUSIONS: URI status is associated with a statistically significant increase in frequency of AAEs and AI during pediatric procedural sedation for the population sedated by our consortium. Although URI status merits consideration in determining potential risk for sedation, rates of some AAEs and AIs remained low regardless of URI status.

Use of a pediatric observation unit for treatment of children with dehydration caused by gastroenteritis.

OBJECTIVE: Observation units (OUs) have emerged as a cost-saving alternative to traditional ward admission for many pediatric illnesses. Dehydration caused by gastroenteritis is a common reason for admission to a pediatric OU. In this study, we describe characteristics of patients with presumed gastroenteritis admitted to a pediatric OU and seek to identify factors associated with unplanned inpatient admission, defined as the inability to discharge an OU patient within 24 hours. METHODS: Retrospective cohort chart review with nested case-control study of children admitted to a pediatric OU from August 2000 to July 2001 for treatment of dehydration caused by vomiting or diarrhea from presumed gastroenteritis. Controls were defined as patients in the cohort who were successfully discharged within 24 hours from the OU; cases were defined as those requiring unplanned inpatient admission. RESULTS: Four hundred sixty-seven admissions were reviewed; 430 OU admissions involving 417 patients met criteria for inclusion. Patients' mean age was 1.8 years (median, 1.2 years), and 55% were boys. Patients presented with both diarrhea and vomiting in 77% of cases, and 72% had experienced symptoms for 48 hours before presentation. Nineteen percent of patients had temperatures greater than 38 degrees C; 25% had an anion gap of greater than 14; 37% had serum bicarbonate less than 15 mmol/L, and 10% had serum sodium less than 135 or greater than 145 mmol/L. Unplanned inpatient admission was required in 19% of patients. We found no significant association between specific historical, physical examination, and laboratory characteristics and need for an unplanned inpatient admission. CONCLUSION: Most patients with dehydration caused by gastroeneritis who need more treatment and observation than can reasonably be offered in an emergency department setting should be considered for OU admission regardless of their historical or laboratory characteristics.

A clinical decision tool for predicting patient care characteristics: patients returning within 72 hours in the emergency department.

The primary purpose of this study was to develop a clinical tool capable of identifying discriminatory characteristics that can predict patients who will return within 72 hours to the Pediatric emergency department (PED). We studied 66,861 patients who were discharged from the EDs during the period from May 1 2009 to December 31 2009. We used a classification model to predict return visits based on factors extracted from patient demographic information, chief complaint, diagnosis, treatment, and hospital real-time ED statistics census. We began with a large pool of potentially important factors, and used particle swarm optimization techniques for feature selection coupled with an optimization-based discriminant analysis model (DAMIP) to identify a classification rule with relatively small subsets of discriminatory factors that can be used to predict - with 80% accuracy or greater - return within 72 hours. The analysis involves using a subset of the patient cohort for training and establishment of the predictive rule, and blind predicting the return of the remaining patients. Good candidate factors for revisit prediction are obtained where the accuracy of cross validation and blind prediction are over 80%. Among the predictive rules, the most frequent discriminatory factors identified include diagnosis (> 97%), patient complaint (>97%), and provider type (> 57%). There are significant differences in the readmission characteristics among different acuity levels. For Level 1 patients, critical readmission factors include patient complaint (>57%), time when the patient arrived until he/she got an ED bed (> 64%), and type/number of providers (>50%). For Level 4/5 patients, physician diagnosis (100%), patient complaint (99%), disposition type when patient arrives and leaves the ED (>30%), and if patient has lab test (>33%) appear to be significant. The model was demonstrated to be consistent and predictive across multiple PED sites.The resulting tool could enable ED staff and administrators to use patient specific values for each of a small number of discriminatory factors, and in return receive a prediction as to whether the patient will return to the ED within 72 hours. Our prediction accuracy can be as high as over 85%. This provides an opportunity for improving care and offering additional care or guidance to reduce ED readmission.

Bronchiolitis management preferences and the influence of pulse oximetry and respiratory rate on the decision to admit.

OBJECTIVE: High incidence, rising admission rates, and relatively ineffective therapies make the management of bronchiolitis controversial. Since 1980, the rate of hospitalization for children with bronchiolitis has increased by nearly 250%, whereas mortality rates for the disease have remained constant. It has been speculated that the increasing use of pulse oximetry has lowered the threshold for admission and may have contributed to the rise in bronchiolitis-related admissions. The objective of this study was to describe pediatric emergency medicine physicians' management preferences regarding infants with moderately severe bronchiolitis and to assess the influence of specific differences in oxygen saturation as measured by pulse oximetry (SpO2) and respiratory rate (RR) on the decision to admit. METHODS: Physicians who are members of the American Academy of Pediatrics Section of Emergency Medicine and living in the United States were randomized into 4 groups and mailed a survey that contained 1 of 4 vignettes. Vignettes were identical except for given SpO2 values (94% or 92%) and RR (50/min or 65/min). Subjects were asked to answer questions regarding laboratory tests, treatment options, and the decision to admit for the patient in their vignette. RESULTS: We received completed surveys from 519 (64%) of the 812 physicians contacted. Most respondents recommended use of bronchodilators (96%), nasal suction (82%), and supplemental oxygen (57%). Few respondents recommended decongestants (9%), steroids (8%), or antibiotics (2%). When asked to rank therapies, respondents gave nasal suction 182 number 1 votes; bronchodilators received 164. The decision to admit varied with SpO2 and RR. Forty-three percent of respondents who received a vignette featuring SpO2 of 94% and a RR of 50/min recommended admission for the infant in their vignette. Fifty-eight percent recommended admission when the vignette SpO2 was 94% and RR was 65/min (chi2 = 5.021). Respondents who received a vignette with SpO2 of 92% were nearly twice as likely to recommend admission: 83% recommended admission when vignette RR was 50/min, and 85% recommended admission when vignette RR was 65/min (chi2 = 0.126). CONCLUSIONS: When treating infants with moderately severe bronchiolitis, pediatricians who work in emergency departments frequently use bronchodilators and nasal suction, 2 practices for which supporting data are either conflicting (bronchodilators) or nonexistent (nasal suction). In addition, their decisions to admit differ markedly on the basis of only a 2% difference in SpO2. It is possible that increased reliance on pulse oximetry has contributed to the increase in bronchiolitis hospitalization rates seen during the past 2 decades.