Pediatric procedural sedation and analgesia in the emergency department: surveying the current European practice

Abstract

Procedural sedation and analgesia outside the operating theater have become standard care in managing pain and anxiety in children undergoing diagnostic and therapeutic procedures. The objectives of this study are to describe the current pediatric procedural sedation and analgesia practice patterns in European emergency departments, to perform a needs assessment-like analysis, and to identify barriers to implementation. A survey study of European emergency departments treating children was conducted. Through a lead research coordinator identified through the Research in European Pediatric Emergency Medicine (REPEM) network for each of the participating countries, a 30-question questionnaire was sent, targeting senior physicians at each site. Descriptive statistics were performed. One hundred and seventy-one sites participated, treating approximately 5 million children/year and representing 19 countries, with a response rate of 89%. Of the procedural sedation and analgesia medications, midazolam (100%) and ketamine (91%) were available to most children, whereas propofol (67%), nitrous oxide (56%), intranasal fentanyl (47%), and chloral hydrate (42%) were less frequent. Children were sedated by general pediatricians in 82% of cases. Safety and monitoring guidelines were common (74%), but pre-procedural checklists (51%) and capnography (46%) less available. In 37% of the sites, the entire staff performing procedural sedation and analgesia were certified in pediatric advanced life support. Pediatric emergency medicine was a board-certified specialty in 3/19 countries. Physician (73%) and nursing (72%) shortages and lack of physical space (69%) were commonly reported as barriers to procedural sedation and analgesia. Nurse-directed triage protocols were in place in 52% of the sites, mostly for paracetamol (99%) and ibuprofen (91%). Tissue adhesive for laceration repair was available to 91% of children, while topical anesthetics for intravenous catheterization was available to 55%. Access to child life specialists (13%) and hypnosis (12%) was rare.Conclusion: Procedural sedation and analgesia are prevalent in European emergency departments, but some sedation agents and topical anesthetics are not widely available. Guidelines are common but further safety nets, nurse-directed triage analgesia, and nonpharmacologic support to procedural sedation and analgesia are lacking. Barriers to implementation include availability of sedation agents, staff shortage, and lack of space. What is Known:• Effective and prompt analgesia, anxiolysis, and sedation (PSA) outside the operating theatre have become standard in managing pain and anxiety in children undergoing painful or anxiogenic diagnostic and therapeutic procedures.• We searched PubMed up to September 15, 2020, without any date limits or language restrictions, using different combinations of the MeSH terms “pediatrics,” “hypnotics and sedatives,” “conscious sedation,” and “ambulatory surgical procedures” and the non-MeSH term “procedural sedation” and found no reports describing the current practice of pediatric PSA in Europe. What is New:• This study is, to the best of our knowledge, the first to shed light on the pediatric PSA practice in European EDs and uncovers important gaps in several domains, notably availability of sedation medications and topical anesthetics, safety aspects such as PSA provider training, availability of nonpharmacologic support to PSA, and high impact interventions such as nurse-directed triage analgesia.• Other identified barriers to PSA implementation include staff shortage, control of sedation medications by specialists outside the emergency department, and lack of space.

Cross-sectional evolution of pain management policies and practices in Portuguese pediatric emergency departments

“…Beyond sparse adherence to specific pain treatment with analgesics, the frequency of analgesia for various medical procedures remains uncommon, and incorrect practices continue. Notably, however, there is a slight reduction of hospitals that never use analgesics for these procedures, but analgesia remains rarely used for venipuncture, below the average in Europe and Canada(Ali et al, 2014; Sahyoun et al, 2021), but in line with other international reports(Ali et al, 2014; Kleiber et al, 2011). National and international recommendations, however, clearly suggest the implementation of analgesia when performing venipuncture(Bailey and Trottier, 2016; Bauman and McManus, 2005; Direção-Geral da Saúde, 2012a; Fein et al, 2012; Ruest and Anderson, 2016; Trottier et al, 2019).…”

Pediatric Procedural Sedation and Analgesia (PROSA) in the Leuven University Hospitals: An Audit on Efficacy and Safety

“…This is achieved by the above mentioned safety rules and structured approach (prescreening, structured contact before initiation of pharmacological sedation, structured training) Most patients with ASA 3 or 4 were excluded for sedation by PROSA, because sedation in these categories is prone to more adverse events [ 12 ]. According to a European survey in 2021 of senior physicians, a lack of protocol and training is the main reason for dissatisfaction with management of anxiety and pain in children in their hospital setting [ 13 ]. They also found that only a third of the sites had the complete staff certified in a Pediatric Advanced Life Support course.…”

Adolescents’ pain and distress during peripheral intravenous cannulation in a paediatric emergency setting

“…Topical and local anaesthesia through the application of anaesthetic creams or injecting buffered lidocaine is the most effective pain relief technique during peripheral intravenous cannulation [ 2 , 15 ]. Nevertheless, a recent survey focused on European paediatric EDs showed that their availability and use is still limited [ 19 ]. Notably in this study, only 3.2% percent of adolescents received EMLA cream compared to 43.8% of older children and 80% of young children.…”