Original Contribution
A randomized controlled study in reducing procedural pain and anxiety using high concentration nitrous oxide

https://doi.org/10.1016/j.ajem.2017.04.076Get rights and content

Introduction

Over the past 10 years, pediatric emergency departments (PED) throughout the country have adopted the concept of an “ouchless” PED, using both pharmacologic and non-pharmacologic methods to achieve this goal [1]. Despite our interest in an “ouchless” PED, many routine procedures are performed without full attention to patient comfort. Some procedures, such as laceration repair, require local anesthesia, while others, such as intravenous catheter placement, are usually performed without local anesthesia. All of these minor procedures, however, are ones in which the risk of parenteral procedural sedation outweighs the benefit.

As the concept of creating a pain-free PED experience has grown, the use of high-concentration nitrous oxide [HC-N2O] (> 50%) in the pediatric outpatient setting and PEDs has increased throughout the country. N2O is a colorless, non-narcotic, analgesic gas and its efficacy and safety have been well documented in anesthesia and dental literature [2].

Several studies have been published on the use of HC-N2O in decreasing pain and anxiety in the pediatric emergency setting; however, previous investigations have been either observational, focused on a narrow age range, studied for use with a single procedure type, or included procedures associated with moderate to severe pain such as fracture reduction [1], [3], [4], [5].

The objective of this study was to assess whether the use of HC-N2O in addition to standard management increased the comfort level in pediatric patients undergoing minor procedures compared to standard management alone.

Section snippets

Study design and selection of participants

This was a randomized controlled trial conducted in an inner city, academic PED. Children 3–12 years of age presenting to the PED, who required a minor procedure were assessed for eligibility. Minor procedures were defined as any procedure in which the standard management involved providing local anesthetic and/or holding the child in order to successfully accomplish the procedure. These procedures are those in which the potential risks associated with parenteral anesthesia would outweigh the

Results

Eighty-two patients were enrolled and randomized, 39 to the standard care group and 43 to the HC-N2O group. Patient characteristics are demonstrated in Table 1. There was no difference between the groups in terms of procedure type. The majority of the procedures in both groups were laceration repairs and IV placement. There were 19 laceration repairs (49%) and 11 IV placements (28%) in the standard care group and 18 (42%) and 15 (35%) respectively in the N2O group. Among the entire sample, the

Discussion

Providers caring for children in PEDs and urgent care centers are aware of the increase of anxiety and pain associated with the medical environment. There is, however, a gap between the recognition of the increase in distress and active methods to reduce anxiety. N2O has been documented for use in dental procedures since 1844 [8]. Today, anesthesiologists and dentists routinely use HC-N2O when performing minor procedures on pediatric patients. Its safety has been demonstrated throughout the

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