PediatricsA randomized clinical trial of continuous-flow nitrous oxide and midazolam for sedation of young children during laceration repair*
Introduction
Lacerations requiring sutures contribute to as many as half of emergency department visits by injured children.1 Even with the availability of tissue adhesives, many still require suturing. Successful management in the ED requires effective relief of pain and anxiety as these visits are often stressful for the patient, parent, and health care worker. Advances in analgesic regimens such as the use of topical and buffered injected anesthetics can make suturing almost painless.2, 3, 4 However, anxiety during both wound preparation and suturing continues to be a significant problem, especially among young children and their parents.
Many agents for pharmacologic sedation during suturing in children have been studied.5, 6, 7, 8, 9, 10, 11, 12 Desirable characteristics include nonpainful routes of administration, predictable and titratable effects, lack of significant adverse effects, and rapid onset and recovery. Oral midazolam and inhaled nitrous oxide (N2O) are 2 agents that meet most of these criteria and have commonly been used for outpatient procedures.5, 6, 7, 8, 13, 14, 15, 16, 17 The purpose of this study was to compare the efficacy and complication profile of midazolam and continuous-flow N2O in alleviating anxiety during laceration repair in young children. Our primary study hypotheses were (1) N2O would produce more effective sedation than midazolam or standard care during wound preparation and suturing, and (2) differences in adverse effects between groups related to the known mechanisms of action would occur. In addition, our secondary hypotheses were (1) patients receiving N2O would recover more rapidly from sedation than patients receiving midazolam, and (2) suturers would be more satisfied with N2O sedations compared with midazolam or standard care.
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Materials and methods
To compare the efficacy and complication profile of midazolam and continuous-flow N2O, the following 4 treatment groups were defined: standard care alone, which includes comforting and topical anesthesia augmented with injected lidocaine if needed; standard care and oral midazolam; standard care and N2O; and standard care and oral midazolam plus nitrous oxide. Children ages 2 through 6 years who presented to the ED at St. Louis Children’s Hospital for repair of facial lacerations and met the
Results
Two hundred five subjects (83% of eligible) were enrolled in the study (Figure 1).Patients eligible but not enrolled were similar to those enrolled in terms of age, sex, race, and laceration length. One subject enrolled was given midazolam intravenously and was excluded from analysis because of protocol violation. The mean patient age was 4.1 years; 66% were boys; 66% were black; and 92% were in ASA class I. There were no differences in age, sex, race, ASA classification,
Discussion
This study demonstrates that in our sample, continuous-flow 50% N2O is more effective for relief of anxiety in young children during wound preparation and suturing, has fewer adverse effects, and shorter recovery times than oral midazolam. Although vomiting occurred more frequently in groups that received N2O, there were no incidents of clinically apparent aspiration. In addition, suturer satisfaction with the sedation was highest when N2O was used.
Few studies in children using N2O for anxiety
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2020, UrologyCitation Excerpt :Alternatively, a mask can be strapped to the patient's face and a clinician may titrate the gas. This is frequently used for children who may be unable to self-titrate.37,38 However, the risk of emesis and over-sedation is higher with continuous flow N2O.22
Efficacy, safety and satisfaction of sedation-analgesia in Spanish emergency departments
2019, Anales de PediatriaThe Benefits of Introducing the Use of Nitrous Oxide in the Pediatric Emergency Department for Painful Procedures
2018, Journal of Emergency NursingTen Practical Ways to Make Your ED Practice Less Painful and More Child-Friendly
2017, Clinical Pediatric Emergency MedicineCitation Excerpt :The onset is within 5 minutes, and recovery 3-5 minutes after discontinuation is optimal for use in the ED. There is growing evidence for its safe and effective use in the ED for suture-related distress, lumbar puncture, dressing changes, and IV catheter placement.127-130 Its safety profile is very appealing, with a 0.03% rate of severe adverse effects reported.
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Address for reprints: Jan D. Luhmann, MD, St. Louis Children’s Hospital, One Children’s Place, Room 4S50, St. Louis, MO 63110, 314-454-2341, fax 314-454-4345, E-mail [email protected].