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

• Published in: European journal of pediatrics Vol. 180; no. 6; pp. 1799 - 1813
• Main Authors: Sahyoun, Cyril, Cantais, Aymeric, Gervaix, Alain, Bressan, Silvia, Löllgen, Ruth, Krauss, Baruch
• Format: Journal Article
• Language: English
• Published: Berlin/Heidelberg Springer Berlin Heidelberg 01-06-2021; Springer Nature B.V
• Subjects: Ambulatory surgical procedures; Analgesia; Anestesi och intensivvård; Anesthesiology and Intensive Care; Anesthetics; Anxiety; Carbon dioxide; Catheterization; Check lists; Child; Children; Chloral hydrate; Clinical Medicine; Conscious Sedation; Departments; Emergency medical care; Emergency medicine; Emergency Service, Hospital; Europe; Fentanyl; Humans; Hypnosis; Hypnotics; Hypnotics and Sedatives; Ibuprofen; Intravenous administration; Ketamine; Klinisk medicin; Medical and Health Sciences; Medicin och hälsovetenskap; Medicine; Medicine & Public Health; Midazolam; Nitrous oxide; Non-pharmacological approaches; Original; Original Article; Pain - drug therapy; Pain - etiology; Pain perception; Paracetamol; Pediatrics; Pediatrik; Procedural sedation and analgesia; Propofol; Safety; Sedatives; Statistical analysis; Surveys and Questionnaires; Europe; Pediatrics; Ambulatory surgical procedures; Procedural sedation and analgesia; Non-pharmacological approaches; Emergency medicine; Hypnotics and sedatives
• ISSN: 0340-6199; 1432-1076; 1432-1076
• DOI: 10.1007/s00431-021-03930-6

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:
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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.
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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:
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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.
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Other identified barriers to PSA implementation include staff shortage, control of sedation medications by specialists outside the emergency department, and lack of space.