“Procedural sedation and analgesia in Italian pediatric emergency departments: a subgroup analysis in italian hospitals"

In this subgroup analysis of data extracted from a survey looking at the current pediatric PSA practice in Europe, we focused on the current practice of PSA in Italian pediatric EDs.

Our results show that a large proportion of children who require PSA do not get offered adequate sedation, that general safety and monitoring guidelines and preprocedural checklists are not always systematically available, and that additional barriers to implementation included staff shortage, lack of medications, absence of child life specialist services and hypnosis and lack of space. Furthermore, a point of concern emerged by our analysis is the restriction to the anesthesiologist of the administration of certain medications, such as ketamine, despite it has been proved to be the safest single agent for PSA, indicated even for urgent procedures, when pre-procedural fasting is not possible to perform [7].

A low level of satisfaction with their site’s management of pain and anxiety was also reported by respondents, which may be harnessed as a driving force for improvement.

In the following discussion we analyze the identified gaps and propose a problem-solving strategy of the major challenges emerged by this subgroup analysis.

Inadequate sedation to 27% of patients

As mentioned above, the most disconcerting result emerging from our analysis is that an adequate sedation plan is not used in 27% of patients who require it, in an era where pain assessment and management has been finally recognized as priority for the best patient quality of care, and backed by multiple international bodies, including the Joint Commission [8].

It is a known fact that a proportion of children who access the pediatric ED live a painful and unpleasant experience [1, 9, 10], not only related to the reason of the medical consultation, but also due to medical procedures performed during the clinical evaluation and treatment. At the same time, pain is one of the most frequent reasons of referral to pediatric EDs, especially in younger children and in those with special needs, a category in which undertreatment of pain (the so-called “oligoanalgesia”) is very frequent [1, 11, 12]. Given that oligoanalgesia is related to long-terms negative behavioral and psychological consequences, [1, 13, 14] and that the management of pain and anxiety could help the entire medical team in the evaluation and treatment of a child, we identify this gap as a major source of potential improvement, in a continued effort to make pediatric EDs pain-free or at the very least free of iatrogenic traumatic experiences.

Lack of availability of certain important medications

Our analysis also points to the low availability of certain types of medications such as nitrous oxide, and the non-systematic availability of topical anesthetics.

Lack of use of Nitrous oxide

NO is a safe and prompt-to-use gas, shown to be useful in performing many painful procedures as fracture reductions, sutures or placing an intravenous catheter, alone or in combination with other medications such as intranasal fentanyl or intranasal dexmedetomidine, especially in an emergency setting [15]. Despite that, NO was reported to be available only to less than a half of the children represented by this study. Since many studies showed the safety and efficacy of this medication, as much as a high degree of satisfaction of the patient and the parents, [16, 17] we firmly encourage an implementation of its use in Italian pediatric EDs.

Oral opioids, intranasal fentanyl and topical anesthetics: a useful tool since the triage

Intranasal medications as fentanyl and midazolam are available for almost the totality of the children represented in our study, confirming the growing importance and use of these agents in performing PSA in pediatric EDs, likely thanks to their ease of administration. However, another major issue concerns the absence of these medications in nurse-directed triage analgesia protocols. Furthermore, topical anesthetics are unexpectedly reported to be rarely used in Italian pediatric EDs.

The administration of an analgesic medication at the time of triage has been shown to improve the management of pain by reducing the time to reach adequate analgesia and by making the medical evaluation easier. Nurse-directed triage analgesia protocols were available in almost the totality of the Italian sites participating in this study, but they only included topical anesthetics, oral ibuprofen or similar non-steroidal anti-inflammatory drug and paracetamol. These are medications with a relatively long time of onset and adequate mainly for mild pain. Intranasal fentanyl, a very effective, safe and easy to administer medication with an onset of action of only 3–5 min, despite being available to almost the totality of children in our study, is not included in nurse-directed triage protocols [18,19,20,21]. To quickly ease severe pain, we would strongly encourage the introduction of oral opioids as well as intranasal fentanyl to nurse-directed triage analgesia protocols backed by a standing medical prescription, in conjunction with safety guidelines around their use (indications, contraindications, monitoring, etc.). These would help decrease the time to analgesia for painful conditions (such as fractures, vaso-occlusive crisis, severe abdominal pain) already at the first nurse evaluation, particularly when the ED is busy and a bed not immediately available.

Off label use of medications

Another barrier in access to and implementation of medications is that many drugs used for pain and anxiety control are off label for the pediatric age, or have limited applications [22]. Despite the recent increase in publications around PSA, specific studies in the pediatric age remain scarce. Consequently, the off-label use of such medications requires informed consent, and their use are under the responsibility of the practicing physician. Depending on the training and experience of that physician in pediatrics, and depending on the site of practice, such use may create a medico-legal concern, as should, inarguably, inadequate pain and anxiety relief during procedures. We believe that the creation of PSA national guidelines for pediatricians but also for staff intervening in emergency situations but without pediatric expertise, would help palliate such concerns.

Rare use of safety protocols and preprocedural checklists, lack of staff training and lack of space

PSA, in our study, was performed mainly by general pediatricians and anesthesiologists. Furthermore, several PSA medications (ketamine and propofol, particularly) are restricted for use, in the ED, without direct supervision or official approval by anesthesiology colleagues. In Italy, this heterogenous practice is probably the consequence of the fact that pediatric emergency medicine is not yet formally recognized as a board-certified subspecialty at a national level, while it is recognized as such in foreign settings. Then, PSA in the Italian pediatric reality is still a developing skill, and that in order to gain more independence, efforts should concentrate on homogeneous training of the pediatric staff in PSA, on the drafting and the systematic use of national safety guidelines, as well as on the universal training of pediatricians administering PSA in a PALS course. A latere, the improvement of the equipment in the EDs, such as capnography monitoring, may furthermore increase the safety of PSA, during ketamine and propofol sedations, for example.

Furthermore, the use of general safety and monitoring guidelines and checklists was reported in around half of the responding sites only, making the lack of a standardized approach an issue of concern, which could expose patients to possible adverse events related to patient or sedation characteristics. For this reason, the development and implementation of local, but also standardized national guidelines around PSA should be fostered.

Unavailability of child life specialists and hypnosis

Even if our data showed that the availability of Child Life Specialists among Italian pediatric EDs was the same as the average availability in Europe, the numbers remain small (11 vs 13%). Hypnosis, on the other hand, is reported to be completely unavailable among the respondent Italian sites. As described for the other European sites, this could be due to cultural beliefs, prioritization of resources and low experience with this field, particularly for the pediatric age.

Since children have more hypnotic ability than adults (measured by the Children’s Hypnotic Susceptibility Scale and the Stanford Hypnotic Scale for Children), several studies proposed hypnosis as a tool for procedural pain and chronic pain management in children, reporting a significative reduction in pain and anxiety and improving the patient experience [23,24,25,26,27,28].

For this reason, we recommend training in nonpharmacological techniques such as hypnosis, and increasing knowledge of the added value of child life specialists and similar professionals.

The aspects above, taken together, may explain the low satisfaction of the respondents with their site’s management of pain and anxiety in children.

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