Using nitrous oxide to help pediatric patients

Although the use of nitrous oxide (N2O) has been used in dentistry for over 150 years, its use in pediatrics for sedation and mild analgesia for procedures outside of the operating room has been gaining favor over the last several decades. Nitrous oxide’s inherent properties, including the induction of euphoria, amnesia, mild analgesia, quick onset of action and rapid removal from the body through exhalation, make it ideal for use in the pediatric population.

Initially, limitations in delivery of nitrous oxide made its use outside of the operating room challenging. However, over the last several years development of delivery systems and full face masks has allowed the use of lower concentrations of nitrous oxide and administration to younger patients to achieve adequate anxiolysis, amnesia and mild analgesia.

When nitrous oxide inhalation is coupled with guided imagery and distraction therapy, patient experience with painful procedures is greatly improved. As Swedish, nitrous oxide is delivered by a comprehensive care team including the parent/caregiver, nursing, child life specialist and LIP. Nitrous oxide can be delivered wherever patients are treated, from the emergency department (ED) to inpatient units or even during endoscopy. We utilize nitrous oxide for both inpatient and outpatient procedures: venipuncture for blood sampling and IV catheter placement, nasogastric tube placement, bladder catheterization, lumbar puncture, PICC insertion, wound care, laceration repair, joint aspiration/injection, EEG lead placement and vaccine administration for children with needle phobia.

During nitrous oxide delivery, patients are monitored with pulse oximetry. While complications are exceedingly rare, the most common one is nausea, occurring in approximately 4% of our patients. Other minor side effects include vomiting, tearing, crying, agitation, dizziness and hiccups. Serious side effects such as apnea, stridor, bradycardia, aspiration, laryngospasm, bronchospasm and hypotension are quite rare and have not been seen in our patient population. Nitrous oxide is not for everyone, and all patients at Swedish are screened for known contraindications such as pneumothorax, bowel obstruction, emphysema, impaired level of consciousness, intoxication, vitamin B12 deficiency, MTHFR deficiency, recent craniectomy or eye surgery, and treatment with bleomycin.

Since implementation in 2010, more than 2,000 patients have received nitrous oxide anxiolysis and both parent and patient feedback has been excellent. Our very first patient was a young preschooler who required frequent blood sampling and her mother struggled with her for days to get her here for each appointment. After her first venipuncture under nitrous oxide, her first words were…”can we do that again?”