Nurses’ perspective is an important indicator of the quality of care in pediatric sedation practice. This is an interesting and understudied area of work. In the literature, few studies are available about caregivers’ perception of pediatric peri-procedural sedation and in most of the cases parents’ satisfaction is high regardless of the sedative drug used 4,7,8. While several factors are reported to influence parental satisfaction, such as environment, timeliness and communication issues, the most relevant one is the quality of the child’s recovery from sedation 4,8,9. However, parents' perceptions may be limited by a lack of knowledge about the different available drug regimens and by the experience of only one or limited types of sedation in their child. Very few data are available on nurses' perception of periprocedural sedation. In a study performed to implement guidelines for the management and treatment of pain in the pediatric cardiac intensive unit, team members (physicians and nurses) were surveyed before and after the implementation of guidelines, and improvements in teamwork and patient care were demonstrated 10. To our knowledge, this is the first study analyzing nurses’ satisfaction for peri-procedural sedations in children comparing different sedative drugs. We believe that nurses’ perception plays a relevant role whenever different choices are available, since a teamwork between physicians and nurses can be the key to a more successful patient and family-centered care.
This study shows that in the nurses’ opinion the best sedation regimens are propofol, dexmedetomidine and midazolam, whereas all nurses were dissatisfied with the use of ketamine. In addition, we found that the nurses’ satisfaction for propofol increased with the number of sedations per month attended by the responding nurse. Regarding the nurses' preferred route of administration of sedative drugs, the IV route and the IN combined with the OS route were favored in this survey.
The 74.5% of the surveyed nurses rated the distraction techniques as important. The latter are simple, cost effective, easy to learn, and not time-consuming. Previous studies analyzed non-pharmacological interventions in pediatric patients to reduce the pain associated with minimally painful procedures, such as venous cannulation, and showed that these techniques, alone or in association with pharmacological treatments, can reduce pain and fear, beside promoting the cooperation of the child and their parents 11. Nurses’ awareness of the relevance of non-pharmacological techniques and adequate communication with patients and parents is a strong reminder for all physicians of the importance of this pivotal component of care.
Regardless of the pharmacological regimen used, nurses reported to feel safe during procedural sedation, even if the latter is not completely risk-free 12. This result should encourage the systematic use of sedative drugs in adequate settings with defined levels of training and monitoring, for children who undergo diagnostic or therapeutic procedures causing pain or excessive stress. The AE most frequently reported by nurses are the ones widely known in literature12,13. Interestingly, when assessing which AE reduced nurses’ satisfaction more, respiratory distress, hallucinations and nausea/vomiting had the largest impact.
The low appreciation of ketamine by nurses in this study should prompt some considerations. As a matter of fact, ketamine is considered a gold standard by pediatricians due to its safety and effectiveness. However, in the setting of minimally to moderately painful procedures, propofol may be equally effective and safe. This evidence further suggests that nurses’ opinion should be endorsed in the setting of a teamwork when defining a sedation strategy for a specific patient.
This study has some limitations. Firstly, a non-validated questionnaire was used, as a validated instrument to measure the specific outcome of this study was not available in the literature. Secondly, the number of surveyed nurses was relatively small as the study was limited to our single center. In addition, many nurses may not have enough experience with all types of sedative drugs, so their satisfaction may also have been biased by this limit.
The points of strength are the enrolment of pediatric nurses with relevant experience in peri-procedural pediatric sedation outside the operating room, and the use of a questionnaire developed in two steps through a joint effort of physicians, nurses, and parents. Finally, it offers an interesting insight into why nurses favor one drug regimen over another. The aspects of the sedation process that seem to influence the nurses’ satisfaction most are the presence of AE and parental/children satisfaction, suggesting that these areas should be targeted to enhance the quality of children’s care.
Drugs will change over the years but understanding the components of the quality of care is an enduring piece of knowledge.