Inside this Edition

Upcoming Pediatric Sedation Conference

Parental Presence:
The discussion

Literature Review:
Case-series of nurse-administered nitrous oxide for urinary catheterization
in children

Newsmakers Interview:
Judy Zier, MD
Children’s Hospital and Clinics of Minnesota

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Literature Review

Zier JL, Drake GJ, McCormick PC et al. 

Case-series of nurse-administered nitrous oxide for urinary catheterization in children.  Anesth Analg 2007; 104:876-9.

Background:  Children undergoing urologic imaging studies requiring urethral catheterization experience considerable discomfort and psychological distress.  Nitrous oxide sedation may mitigate these detriments but the requirement for physician administration has limited the applicability of this technique. 

Methods:  Registered nurses underwent nitrous oxide training requirements prescribed for state licensure of dentists and dental hygienists, with special emphasis on pediatric sedation principles.  To evaluate the safety of nurse-administered nitrous oxide, we consecutively enrolled all children (ASA PS I-II) sedated for urethral catheterization for urologic imaging in an observational trial designed to identify sedation-related adverse events. 

Results:  Nitrous oxide was administered on 1018 occasions.  There were no major adverse events (apnea, oxygen saturation <92%).  Minor adverse events (diaphoresis, nausea, vomiting) occurred in 4% of patients.  Eight patients (1%) were described as over-sedated.  In 11 (1%) patients, nitrous oxide provided insufficient sedation for completion of urologic imaging. 

Conclusions:  Nitrous oxide sedation can be provided by a nurse-administered program in pediatric radiology.  Administration of nitrous oxide for pediatric procedures by adequately trained nursing staff with appropriate multidisciplinary oversight may increase children’s access to this sedative/analgesic drug.

Commentary:  This is the largest observational study of the use of nitrous oxide for pediatric procedural sedation in the United States reported thus far, and this program is unique in its incorporation of nurse administration of the agent.  While the sample size is likely a bit small to compare safety with other agents, the lack of significant events and the low incidence of minor adverse reactions correlate well with other reports in the literature.  The vast majority of patients (94%) were sedated for less than or equal to 15 minutes, but most patients received 70% nitrous oxide during that time.  It’s unclear whether the incidence of adverse reactions correlated with length of time sedated.  Of the 8 patients described as over-sedated, none required any type of airway intervention.  While it would be helpful in the future to have some documented comparisons of recovery times, differences in staff and parental satisfaction, and cost savings with this regimen versus other agents, we can all imagine that these advantages are true.  For all the many pediatric sedation programs out there that are in the process of incorporating nitrous oxide into their armamentarium, this article provides valuable insight into program planning and likely expected outcomes.

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Joseph Cravero MD
George Blike MD

Departments of Anesthesiology
and Pediatrics,
Children’s Hospital
at Dartmouth,
Dartmouth Hitchcock
Medical Center,
Lebanon, NH

Editors Note:
Many thanks to guest
editor Trish Scherrer MD
from University of Virginia
Peds Critical Care,
who was instrumental
in putting together
the Nitrous Oxide review article and the interview
that are featured in
this issue.
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