Table 5.

Summary of existing gaps in pediatric procedural sedation and analgesia (PSA) practice in European emergency departments (italics represent the explanation of the recommendation in nontechnical terms)

1. Sedation medications • Gap: Restricted pharmacopeia with limited appropriate medication options, in part due to external constraints: i. Limited availability of intranasal fentanyl and nitrous oxide ii. Restrictions on use of Ketamine and Propofol • Recommendation: PSA sites should work on increasing the availability of the full range of PSA agents, prioritizing intranasal fentanyl, nitrous oxide and ketamine, in order to deliver optimal care for patients. • Fentanyl is a medication used for immediate relief from severe pain. Its nasal spray form is safe and makes the use of needles unnecessary. Nitrous oxide is a widely available gas used to sedate anxious children for mild–moderately painful procedures. Ketamine is a safe and highly effective medication in emergency sedation, especially for very painful procedures. Increasing the availability of these medications and training for emergency department/site staff in their use is an essential part of improving the care of children in emergency situations. 2. Procedural pain management • Gap: Lack of adequate pain control for children undergoing painful procedures • Recommendation: Every child should have an appropriate assessment of their baseline pain, an assessment of the anticipated pain and anxiety of the procedure, and a sedation plan for providing adequate relief of pain and anxiety. • Children continue to receive inadequate treatment for painful procedures. All children should receive adequate control of their pain and anxiety during emergency department procedures. This requires both the availability of appropriate medications for sedation and analgesia and comprehensive staff training. 3. Triage analgesia protocols • Gap: Limited availability of nurse-directed triage analgesia protocols and limited use of topical anesthetics • Recommendation: Universal establishment of triage analgesia protocols for systemic analgesics and for topical anesthetics for venipuncture, intravenous catheter placement, and laceration repair. • The patient experience is improved by the use of protocols for the triage area, which allow nurses to rapidly and safely treat children’s pain using pain medications, as well as to prepare patients for needle sticks or wound repair, using anesthetic ointments or creams, without having to consult a physician. The use of a topical gel applied to the laceration before suturing allows many wounds to be stitched without discomfort or the need for an injection of lidocaine. The use of a topical cream before a needle stick for a blood draw or placement of an intravenous line also helps minimize the discomfort or pain experienced by the patient. We advocate for the universal use of these measures. 4. Safety and monitoring protocols • Gap: Limited implementation of standardized PSA safety and monitoring guidelines • Recommendation: Universal implementation of evidence-based PSA guidelines (risk assessment and contraindications to PSA, fasting status, preparation for adverse events, continuous oxygenation and ventilation monitoring, post-procedural care, and discharge criteria). • We encourage the universal use of PSA guidelines and continuous electronic patient safety monitoring which help ensure maximum safety during PSA through early recognition and management of the adverse effects related to treatment. 5. Staff training • Gap: Limited staff training in pediatric advanced life support and in PSA skills • Recommendation: Physicians administering PSA should be trained in pediatric advanced life support. Specific PSA curricular training (such as didactics on pain and anxiety recognition, assessment, and management, evidence-based utilization of analgesics and sedatives, incorporation of simulation PSA training, and implementation of a rigorous, supervised sedation practice) should also be instituted to provide safe and effective PSA. • All physicians performing sedation should be trained in rescuing patients from the adverse effects of sedation, should they occur. We advocate for universal training in pediatric life support courses as well as specific analgesia and sedation training to improve the patient experience. 6. Staff availability • Gap: Limited availability of PSA-trained staff • Recommendation: Emergency sites should employ developmentally appropriate approaches to frightened children and devise a plan for 24-h access to sedation services. In resource-limited settings, this can be achieved using multispecialty partnerships. • The management of pain, fear and anxiety in children should be consistent whether during normal daytime hours, on the weekend or during the night. In hospitals that have too low a volume to dedicate the care of such issues to one specialty, partnerships with other specialties should be sought to ensure around-the-clock adequate procedural pain relief and sedation care for children.