Procedural pain in children: education and management. The approach of an Italian pediatric pain center

Abstract

Pain management should be warranted for all children in every situation. Italian legislation proposes a model for pain assistance based on specialized tertiary centers which provide direct clinical management for complex cases and assure continuous cooperation with hospitals and family pediatricians for managing painful conditions every day. The Procedural Pain Service of the University of Padua Department of Pediatrics applies such model for procedural pain management. We describe activities of Service since January 1, 2006 on two levels: education and training for territorial services and sedation-analgesia when required for invasive and painful procedures. Since 2006 to date, the Service team produced an internal protocol for procedural sedation, developed two master courses, and organized a training program for procedural pain management in the territorial context. Procedural sedation-analgesia service provided overall 10,832 sedations to perform 14,264 procedures for 3,815 patients, median age of 6 years old. The most frequently performed procedures were lumbar puncture and bone marrow aspiration, followed by gastroscopy and bronchoscopy. Most frequently administered drug combinations were local analgesia + intravenous midazolam alone or midazolam and propofol or midazolam and propofol and ketamine; most frequently used non-pharmacological methods were distraction using cartoons and bubbles. Minor adverse events were recorded in 281 cases (2.5%), the most common being desaturation (2.1%). In conclusion, our model functions on two integrated levels, and it can be considered generally applicable as a solution for pain management.

Improving postoperative pain management in children by providing regular training and an updated pain therapy concept

“…Other studies have demonstrated insufficient management of procedure‐related pain in children (Cramton and Gruchala, ; Morton, ). One possibility for the implementation of procedural sedation‐analgesia was shown by Po et al., who used a procedural pain service including an organized training programme with frontal education and experience‐based training (Po et al., ). That approach is, however, associated with high costs in terms of the requirements for highly skilled medical staff to dedicate substantial time to the training.…”

The development of a Consensus Conference on Pediatric Procedural Sedation in the Emergency Department in Italy: from here where to?

“…In the absence of a nationally recognized curriculum and training each institution is mandated with the task of certifying the skill-set and competencies of their emergency physicians and pediatric emergency physicians providers, as well as the maintenance of the above over time, in order to warrant safe and effective PSA to children in the ED. While Pediatric Elective Sedation Services run by pediatricians are well established entities in some tertiary-care pediatric centers in Italy [31,36,37], the practice of pediatric PSA in the ED is often hampered by the fear of potential sedation adverse events, neglecting that emergency physicians and PEM physicians have the skill-set required to handle airway, ventilation and cardiovascular emergencies, as these competencies are required to cover their professional role. However, in order to create a safe PSA environment in the ED the training of nursing staff is also paramount.…”

General anesthesia, conscious sedation, or nothing: Decision‐making by children during painful procedures

“…We understood that the fear of the procedure was not neutralized by GA for some patients and that GA itself was a source of additional anxiety and discomfort, potentially due to its symbolic association with death. [30][31][32][33][34] The existing literature examines pharmacological versus nonpharmacological support [35][36][37][38][39][40] and sedation versus no sedation, 30,[41][42][43][44][45][46][47][48][49][50] and describes different ways to prepare children for these procedures. 11,51,52 However, none of these studies included asking children directly about their preferences for the type of medical support.…”