Abstract
Lumbar puncture (LP) is stressful and often painful. We evaluated the efficacy of a fixed 50% nitrous oxide–oxygen mixture (50%N2O-O2) versus placebo to reduce immediate procedural pain and anxiety during LP performed in an emergency setting. We conducted a randomized controlled trial involving adults who needed a cerebrospinal fluid analysis in an emergency department. Patients were randomly assigned to inhale either 50%N2O-O2 or medical air. The primary endpoint, assessed using a numerical scale, was the maximum pain felt by the patient during the procedure and the maximum anxiety and satisfaction as secondary outcomes. Eighty-eight patients were randomized and analyzed (ITT). The maximal pain was 5.0 ± 2.9 for patients receiving air and 4.2 ± 3.0 for patients receiving 50%N2O-O2 (effect-size = −0.27 [−0.69; 0.14], p = 0.20). LP-induced anxiety was 4.7 ± 2.8 vs. 3.7 ± 3.7 (p = 0.13), and the proportion of patients with significant anxiety (score ≥ 4/10) was 72.7% vs. 50.0% (p = 0.03). Overall satisfaction was higher among patients receiving 50%N2O-O2 (7.4 ± 2.4 vs. 8.9 ± 1.6, p < 0.001). No serious adverse events were attributable to 50%N2O-O2 inhalation. Although inhalation of 50%N2O-O2 failed to reduce LP-induced pain in an emergency setting, it tended to reduce anxiety and significantly increased patient satisfaction.
Highlights
Lumbar puncture (LP) was described in the late 19th century [1]
The purpose of this study was to evaluate the efficacy of 50%N2 O-O2 inhalation versus placebo for reducing pain and anxiety during LP in adults in an emergency setting in a randomized control trial
The exclusion criteria were a contraindication for nitrous oxide use [14], hemodynamic instability, a body-mass index >35 kg/m2, an ongoing pregnancy, confusion, a Mini Mental State Examination (MMSE) score < 24/30, and an inability to verbally communicate
Summary
Lumbar puncture (LP) was described in the late 19th century [1]. Over 130 years later, this technical procedure, which gives direct access to the cerebrospinal fluid at the lumbar level, has become an indispensable diagnostic method in clinical practice, used daily in many hospital departments [2]. The procedure is still stressful and possibly painful for most patients. The emergency department (ED) is among those in which LP is the most common, with an incidence of 0.8 per 100 admissions [2]. The LP technique is universal, the conditions under which LPs are performed and the indications are different between hospital departments and EDs. EDs are overcrowded [3], resulting in potential delays in receiving prescriptions and therapeutics [4]. Patients visiting an ED are often stressed [5]
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