Pediatric hospitalists are frequently and increasingly asked to provide sedation for a variety of painful procedures in children. There are a wide variety of agents available for sedation including ketamine, fentanyl, ketofol, and nitrous oxide. Nitrous oxide is attractive agent because of rapid onset, ability to deliver the agent without intravenous access, and short recovery time as compared to other agents, including ketamine and fentanyl. The use of 50% nitrous oxide to provide minimal sedation has been described in several studies. However, there has been little data on the use of 70% nitrous oxide combined with oral opioids to achieve moderate or deep sedation for painful procedures outside of the operating room.
A retrospective chart review of all outpatient pediatric patients seen in a pediatric acute wound clinic from July 1 2009 to Jun 30 2010 was performed. Data was collected on patient demographics, nature and location of wound, and procedure performed. Sedation records were reviewed to identify the sedation agents utilized, premedications given, length of sedation and procedure, maximal depth of sedation achieved, complications, and, when documented, recovery times.
During the study period, 1157 outpatients were seen for 2154 visits to the wound unit. To date, we have analyzed 68 patient charts and 114 nitrous sedations during this period. The average age of the patients was 16.5 yrs. Abscess care (I&D or dressing change) comprised 60% of visits; 19.4% of visits were for burn debridement and dressing changes. 19.7% of visits were for other wounds including wound vac changes. Deep and moderate sedation was achieved in 37.7% and 50% of nitrous oxide sedations respectively. Complications were seen in 13.7% of patients and included emesis in 9.4% of patients and crying/agitation was seen in 3.4% of patients. One patient had transient elevation in blood pressure.
We describe a hospitalistled sedation program utilizing 70% nitrous oxide coupled with oral opioids to achieve moderate to deep sedation in an outpatient population undergoing painful procedures including abscess incision and drainage and burn debridement. In many institutions such procedures are performed with no to minimal sedation. Alternatively, in some cases they undergo general anesthesia in the operating room, with the associated risks and costs. The use of nitrous oxide and oral opioids for these patients provides an attractive and effective alternative for painful procedures on outpatients with minimal complications.
To cite this abstract:Wallace C, Carlson D, Hamlin K, Srinivasan M, Daud Y. Moderate to Deep Procedural Sedation with Nitrous Oxide for Painful Procedures in a Pediatric Acute Wound Clinic by Pediatric Hospitalists. Abstract published at Hospital Medicine 2012, April 1-4, San Diego, Calif. Abstract 97635. Journal of Hospital Medicine. 2012; 7 (suppl 2). https://www.shmabstracts.com/abstract/moderate-to-deep-procedural-sedation-with-nitrous-oxide-for-painful-procedures-in-a-pediatric-acute-wound-clinic-by-pediatric-hospitalists/. Accessed May 27, 2019.