Intranasal Fentanyl and High‐concentration Inhaled Nitrous Oxide for Procedural Sedation: A Prospective Observational Pilot Study of Adverse Events and Depth of Sedation

Abstract

Objectives: Nitrous oxide (N 2 O) is an attractive agent for pediatric procedural sedation and analgesia (PSA) with rapid onset and offset of sedation. However, it has limited analgesic efficacy. Intranasal fentanyl (INF) provides nonparenteral analgesia. There are currently no data on the combined use of N 2 O and INF for PSA in children. The authors set out to prospectively assess the depth of sedation and incidence of adverse events when N 2 O and INF are used in combination in pediatric patients.Methods: This was a prospective observational pilot study of combined N 2 O and INF for PSA at a tertiary children's hospital emergency department (ED). INF was administered at a precalculated dose of 1.5 lg ⁄ kg for preascertained weight ranges. N 2 O concentration, dose, timing of INF, adverse events, and sedation depth were recorded. Sedation depth was recorded using the University of Michigan Sedation Scale (UMSS).Results: A total of 41 patients, aged 1 to 14 years, received INF within 2 hours prior to N 2 O. N 2 O was administered at a maximal concentration of 70% in 40 patients, and at 50% in one patient. Most patients (80%) were minimally to moderately sedated (sedation score 1 or 2). Deep sedation (sedation score 3) was recorded in 14.6% of patients (95% confidence interval [CI] = 3.4% to 24.6%). No patients had serious adverse events; vomiting was recorded in 19.5% (95% CI = 7.4% to 31.6%). There were two patients (4.9%) who were deeply sedated and vomited during the procedure.

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures

“…The powerful magnetic field and the generation of radiofrequency emissions necessitate the use of special equipment to provide 107,197,492,494,495 In this situation, the practitioner is advised to institute the guidelines for moderate or deep sedation, as indicated by the patient's response. 496…”

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016

“…If nitrous oxide in oxygen is combined with other sedating medications, such as chloral hydrate, midazolam, or an opioid, or if nitrous oxide is used in concentrations >50%, the likelihood for moderate or deep sedation increases. 107,197,492,494,495 In this situation, the practitioner is advised to institute the guidelines for moderate or deep sedation, as indicated by the patient's response. 496 …”

Paediatric procedural sedation within the emergency department

“…While vomiting is relatively common, there has been no association found with pre‐procedural fasting and rates of emesis . The combination of N2O and IN fentanyl provides deeper PSA; however, vomiting was more common . Other side effects include headache, dysphoria and restlessness.…”