National Survey to Describe the Current Patterns of Procedural Sedation Practices Among Pediatric Emergency Medicine Practitioners in the United States

Abstract

Objective: Pediatric procedural sedation (PPS) is used to maintain children's safety, comfort, and cooperation during emergency department procedures. Our objective was to gather data describing PPS practice across the United States to highlight the variations in practice and adherence to National Guidelines. Methods:We performed a nationwide survey of PPS practitioners using a secure web-based software program. A link to the survey was sent to all subscribers of a pediatric emergency medicine listserv. We collected participant demographics, their PPS approach for personnel, monitoring, equipment, postsedation observation, and side effects, as well as providers' medication preferences for 3 common PPS scenarios. Results:We received 211 completed surveys from 34 States. There were 20.6% respondents that were based in New York, 83.4% were pediatric emergency medicine attendings, and 91.7% were based in the United States teaching hospitals. Our participants learned PPS by various methods, most commonly: observation of at least 10 PPS (29.9%); self-study (24.8%); and classroom lectures (24.5%). Seventy-seven percent of our participants reported no body mass index cutoff to do PPS. There were 31.5% of our participants that observe children after PPS up to 1 hour, 30.1% up to 2 hours. There were 67.7% of the PPS providers that were a separate person from the practitioner doing the procedure, and 98.2% required a separate trained nurse to be present for monitoring. There were 92.6% of PPS providers that measure end-tidal carbon dioxide (ETCO 2 ) during the sedation. Most PPS providers reported having no reversal agents (71.4%) and no defibrillator (65.9%) at bedside. For the abscess drainage scenario, 22% of participants preferred local anesthetic alone, and 22.5% preferred utilizing local anesthetic in combination with intravenous ketamine. For a forearm fracture reduction scenario, 62.8% of participants would choose intravenous ketamine alone. For the laceration repair scenario, the most favored drug combination was local anesthesia + intranasal midazolam by 39.8% of participants.Conclusions: Our study demonstrates a wide variability in several aspects of PPS and low adherence to national PPS guidelines.

A Survey on Procedural Sedation and Analgesia for Pediatric Facial Laceration Repair in Korea

“… 17 18 Additionally, ketamine is also used in combination with other drugs to increase their effects while reducing the side effects. 5 10 However, in most plastic surgery training hospitals in Korea, ketamine or chloral hydrate was mostly used as a standalone sedative agent. Therefore, it is important to find a safer sedation approach for pediatric laceration repair in Korea.…”

“…Drugs commonly used for pediatric sedation in Korea include chloral hydrate, ketamine, and midazolam. 2 According to the results of a national and cross-sectional electronic survey conducted in the United States (US), midazolam, ketamine, and fentanyl were used as sedatives for pediatric lacerations, 5 In addition, according to an online, multinational, cross-sectional survey in Europe, midazolam, ketamine, and propofol were used in emergency departments for children. 6 Chloral hydrate is one of the oldest sedatives still in use and is applied widely because of the high degree of familiarity with this drug and low cost.…”

The landscape of pediatric procedural sedation in UK & Irish emergency departments; a PERUKI study

“…Despite the inclusion of PPS as a core competency in Pediatric Emergency Medicine fellowship programs in North America, 17,18 a quarter of respondents (most of whom were consultant-level physicians) reported learning PPS through self-study in one survey. 19 Of those with formal PPS training, mode of delivery varied widely including classroom lectures, observation of at least 10 sedations, and online learning. Our findings are comparable to other European sites, with a recent research network survey reporting that half the sites performing PPS required sedation clinicians to have undertaken a pediatric sedation and analgesia course as well as hold advanced life support provider status.…”

Safety and quality in paediatric procedural sedation: what really matters?

“…Sedatives such as midazolam, propofol and dexmedetomidine may be combined with opioids or (es)ketamine. (Es)Ketamine causes dissociative sedation and has both sedative and analgesic effects, as a result of which it is also used as a sole sedative for painful procedures [45][46][47]. In many cases, combinations of two or more sedative and analgetic drugs are administered for nonpainful procedures.…”