Pediatric procedural sedation and analgesia in the emergency setting in community hospitals in Italy: current status and challenges

Background: We investigated the use of mild procedural sedation/analgesia in children at community hospitals to describe current practices and identify challenges to its effective implementation. Methods: Cross-sectional survey among all medical and nursing staff of the Paediatric, Emergency, Anesthesiology and Surgical Units of four secondary care hospitals in Italy, in the years 2021–2022. Results: The response rate was 80% (range across centers 57%-100%); 346 complete questionnaires were analyzed (52.6% physicians; 47.4% nurses). Overall, procedural pain in children was considered a relevant topic by 90.8% of staff. Procedural sedation/analgesia was considered helpful for procedural success (97.4%) and for improving children’s experience of pain/anxiety (98.6%). However, 47.7% were not satisfied with the management of procedural pain/anxiety at their workplace and 56.9% reported a lack of adequate knowledge. In fact, only 22.8% demonstrated adequate knowledge on fasting times and 39.6% on correct patient monitoring during procedural sedation. From a pharmacological perspective, midazolam was the most accessible (80.9%) and used (58.7%) medication, while intranasal fentanyl and nitrous oxide were less available (15.3% and 2.9% respectively) and used (7.2% and 2.6% respectively). Procedural sedation was generally practiced by anesthesiologists (65.9%). Overall, 91.9% of respondents performed/participated in < 4 pediatric sedations per month. For 64.3% lack of training represented the greatest barrier to pediatric sedation/analgesia implementation. Conclusions: Despite staff awareness about the importance of pediatric procedural sedation/analgesia, lack of specific knowledge and training, as well as limited availability of sedative/analgesic medications represent current challenges to procedural sedation implementation in community hospitals without a pediatric emergency room.