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Moderate to Deep Procedural Sedation with Inhaled Nitrous Oxide and Oral Opioids for Painful Procedures

Sunday, October 21, 2012
Room 281-282 (Morial Convention Center)
Kim Hamlin, Mythili Srinivasan, Yasmeen Daud, Colleen Wallace and Doug Carlson, Pediatrics, Washington University, St. Louis Children's Hospital, St. Louis, MO


Pediatric hospitalists are frequnetly asked to provide sedation for painful procedures in children. Sedation frequently requires painful and sometimes difficult placement of an intravenous catheter for sedation medications and prolonged recovery. Inhaled nitrous oxide is an attractive agent because of its rapid onset, lack of need for an intravenous catheter, and short recovery time. The use of 50% nitrous oxide to provide minimal sedation has been previously described.  However, there is little data on the use of nitrous oxide coupled with other agents to achieve deeper levels of sedation adequate for the completion of painful procedures outside of the operating room. The purpose of this study was to describe the use of 70% inhaled nitrous oxide with orally administered opioids to achieve moderate to deep sedation sufficient to complete painful procedures such as abscess incision and drainage and burn debridement.


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.  Patients were premedicated with oral oxycodone approximately 1 hour prior to sedation with 70% inhaled nitrous oxide. Data was collected on patient demographics, wound type, procedure, sedation length, maximal depth of sedation, and complications.


During the study period, 1157 outpatients were seen for 2154 visits in the PAWS unit.  To date, we have analyzed 103 patient charts for 173 nitrous sedations during this period.

The average age of the patients was 14 years; there were 43 males and 60 females.  There were 81 sedations for abscess wound care (including incision and drainage and dressing change), 29 sedations for burn debridement and dressing change, and 30 sedations for care of pilonidal abscess/cyst. Of the 154 patients for which sedation depth was documented, moderate and deep sedation was achieved in 60% and 39%, respectively.. Complications were seen in 16% of patients. Nausea/vomiting occurred in 10% of patients and crying/agitation in 4%. In only one patient was the procedure not completed due to inadequate depth of sedation. Average duration of nitrous oxide delivery was 8 minutes; average procedure duration was 9.4 minutes.


Inhaled 70% nitrous oxide, delivered after premedication with oral opioids, is a safe and effective modality for short painful procedures, including incision and drainage of abscesses and burn debridement.  Using this combination of medications, moderate to deep levels of sedation can be consistently achieved. Nitrous oxide can be delivered without placement of an IV and has a rapid onset and recovery, making it an attractive option for short, moderately painful procedures. Complications appear to be mild and self-limited.