Nitrous Oxide Analgesia Research Articles

Analgesic effect of nitrous oxide during manual therapy after anterior cruciate ligament reconstruction: a study protocol for a randomized controlled trial

BackgroundMany patients during manual therapy after anterior ligament reconstruction will experience severe pain, which has a negative impact on their rehabilitation. However, there is rarely an analgesic method for these patients during rehabilitation. Nitrous oxide with rapid analgesic and sedative effects is often used to relieve pain in minor procedures. The purpose of this study is to determine whether or not nitrous oxide analgesia decreases pain compared to oxygen during manual therapy after anterior ligament reconstruction.Methods/designThis single-center, randomized, double-blind and controlled trial will recruit 120 patients. Patients ≥ 18 years old undergoing manual therapy after anterior ligament reconstruction (1 month post-operative) with acute pain (VAS ≥ 4) are included. The main exclusion criteria included the following: pulmonary embolism, intestinal obstruction, pneumothorax. Patients will be randomly allocated to the intervention group (A) and the control group (B) in a ratio of 1:1. Doctors, therapists, patients, and data collectors are all blind to the study. The manual therapy will be performed by therapists. Nurses who implemented the intervention handed the doctors envelopes containing the patients’ codes and allocation of A or B. Group A will receive a pre-prepared nitrous oxide/oxygen mixture plus conventional treatment (no analgesic) given as 30-min treatment sessions, once daily, and group B will receive oxygen plus conventional treatment (no analgesic) under the same conditions. Assessments will be taken 2 min before the intervention (T0), 5 min after the beginning of the intervention (T1), and 5 min after the intervention finished (T2). The primary outcome is pain score. Secondary outcomes include vital signs, side effects, joint range of motion, adjuvant analgesia need, therapist and patient satisfaction, and whether willing to receive the same gas again.Expected outcomesWe expect nitrous oxide inhalation to have a beneficial effect on the pain of patients who receive manual therapy after anterior ligament reconstruction.DiscussionIf this treatment appears beneficial, it could improve patients’ satisfaction and quality of life potentially and even be implemented widely in hospital and rehabilitation settings.Trial registrationClinicalTrials.gov identifier, ChiCTR2200061175 (Version 2.0 June 15, 2022), https://www.chictr.org.cn.

Women’s perspectives of nitrous oxide for labour and procedural analgesia: A prospective clinical audit and cross-sectional study. “It’s the best thing”

ProblemThere is limited data regarding dose and duration of nitrous oxide use by women in peripartum care. Experiences of using nitrous in Australian settings have not previously been explored BackgroundMore than 1:2 women use nitrous oxide analgesia during labour and birth, despite this, there are limited published data on nitrous oxide use for labour or procedural analgesia in Australia. AimTo explore the use of nitrous oxide during labour and birth or procedural care. MethodsA two-phased sequential design was used; clinical audit (n = 183) and cross-sectional survey (n = 137) approaches supported data collection. Quantitative data were analysed using descriptive and inferential statistics, qualitative data underwent content analysis. FindingsNitrous oxide was used by primiparous and multiparous women evenly. Duration of labour-use ranged from < 15 min (10.9%) to > 5 h (10.8%), with equal representation between > 50% concentration (43%) and < 50% (43%). At audit, 75% found nitrous useful; postpartum maternal satisfaction scores remained high, mean indicators were 75%. More multiparous women found nitrous oxide useful than primiparous (95%vs80%,p = 0.009). There was no association between perceived usefulness and whether women were in spontaneous, augmented or induced labour; regardless of concentrations reached. Three key themes described women’s perspectives of physical and psycho-emotional effects and challenges. DiscussionNitrous oxide plays an important role in the provision of analgesia during procedural or labour and birth care. Service provision, parent and professional education, and future service design will benefit from these novel findings confirming the utility and acceptability of nitrous oxide use in contemporary maternity care.

Use of labor analgesia in trials of labor after previous cesarean section: A nationwide register-based analysis in Finland

ObjectivesThe literature concerning the overall use of labor analgesia among women with trials of labor after cesarean section (TOLAC) is lacking. The primary aim of this study is to report the rate of different labor analgesia methods among women with TOLAC. The secondary aim was to compare the use of labor analgesia between women with the first TOLAC and control group consisting of nulliparous women.Study design.Data from the National Medical Birth Register was used to evaluate the usage of labor analgesia in TOLACs. The use of labor analgesia in the first TOLAC is compared to the pregnancies of nulliparous women. The analgesia methods were stratified into neuraxial analgesia, pudendal, paracervical, nitrous oxide, other medical, other non-medical, and no analgesia. These are analyzed as categorized dichotomy (yes or no) variables. ResultsA total of 38 596 TOLACs as second pregnancy of the mother was found during our study period. The control group consisted of a total of 327 464 pregnancies of nulliparous women. Epidural analgesia (61.6% vs 67.1%), nitrous oxide (56.1% vs 62.0%), and non-medical analgesia (30.1% vs 35.0%) were less consumed among women with TOLAC. The rate of spinal analgesia was higher among women with TOLAC (10.1% vs 7.6%) when compared to the control group. However, when only vaginal deliveries were included, the rate of labor analgesia increased especially in the TOLAC group. ConclusionsThe main finding of this study is that women with TOLAC had a generally lower rate of labor analgesia. However, the rate of spinal analgesia was higher among women with TOLAC when compared to the control group, however. The results of this study inform midwives, obstetricians, and anesthesiologists on current practices and how to improve the analgetic treatment in TOLAC.

Prevention and treatment of pediatric pain and anxiety caused by botulinum neurotoxin A injections: Inadmissible without nitrous oxide analgesia and sedation?

This commentary is on the original article by Ostojic et al. on pages 1507–1516 of this issue.

Development of entrustable professional activities for post-doctorate pediatric dentistry education.

To identify the core components of pediatric dentistry defining entrustable professional activities (EPAs) representing the profession. Potential core components of pediatric dentistry and corresponding domains were identified through review of literature and existing pediatric dentistry standards. A modified Delphi technique was utilized to rate these candidate EPAs to achieve consensus around prioritized EPAs. Eleven participants participated in all three rounds of the Delphi. After three rounds, 16 candidate EPAs reached consensus for pediatric dentistry. Each EPA fell into one of four domains: "assessment and planning," "provision of care," "behavior guidance," and "professional development." An original candidate EPA focused on non-pharmacological behavior guidance was deemed too broad by the Delphi. This EPA was subsequently developed into three separate components on nitrous oxide analgesia, moderate sedation, and general anesthesia. Prioritized EPAs will help define the essential activities of the profession and provide a framework for creating assessments to ensure that graduating pediatric residents are ready for unsupervised practice.

The Problem of Pain, the Power of Presence, and the Appeal of Nitrous

Many believe that better pain relief in labor is significant to increased patient satisfaction. Exploring and prioritizing patients’ values and expectations for pain relief and labor coping, however, may involve several options. Our hospital faced the challenge of offering an option for women other than neuraxial anesthesia and intravenous narcotics. A nursing leader was tasked with the initiation of nitrous oxide analgesia in a regional perinatal center's labor and delivery unit. This was a new initiative for nitrous use in our inpatient hospital setting outside of the operating rooms. Our novel approach implemented more than providing information and training on nitrous oxide use, but rather a reinvigoration of the essential role of the nurse in labor support with a presentation and discussion exploring The Problem of Pain, The Power of Presence and the Appeal of Nitrous. Research was explored on labor pain, coping, suffering, patient satisfaction, and the impact of nursing care in those areas. The project involved consultation and collaboration among multiple team members, including nursing leaders, obstetric providers, anesthesia personnel, hospital administration, accreditation and quality, facilities, clinical engineering, fire safety, legal representatives, and information technology liaisons. Additionally, guidelines, patient agreement forms, educational materials, competencies, training, and inservices on the equipment were completed. After 1 year of preparation, nitrous oxide use began August 29, 2018. Approximately 150 patients have since used it. We provide this alternative option for patients who desire alternative analgesia to intravenous medications or neuraxial anesthesia for their labor and birth. Key lessons learned and hurdles encountered in the nitrous journey are explored. Nursing leaders and educators should take advantage of captive audiences with new initiatives to reinvigorate key nursing principles of clinical excellence, integrity, and compassion. Gathering the support of key stakeholders and interested team members is essential to the effective and safe implementation of nitrous oxide. Guidelines and tools related to nitrous oxide that clearly outline contraindications for use, patient counseling and monitoring, equipment set-up, and appropriate patient use are imperative to patient and staff safety.

Nitrous oxide analgesia for external cephalic version: A randomized controlled trial

Study objectiveOur study sought to determine whether or not nitrous oxide analgesia decreases pain compared to oxygen placebo during external cephalic version for breech presentation. Procedural success may be limited by pain and anxiety. Although neuraxial anesthesia has been studied extensively for these procedures, many centers lack resources for routine use. Nitrous oxide is noninvasive, has minimal side effects and requires limited facilities. We hypothesized that its analgesic properties would decrease pain compared to oxygen placebo during external cephalic version. DesignDouble-blinded randomized placebo-controlled trial. SettingLabor and delivery triage room. PatientsForty-eight patients, ≥18 years of age, 37-weeks' gestation or beyond, singleton pregnancy, breech presentation, and American Society of Anesthesiology physical status I-III, having an external cephalic version. InterventionsPatients undergoing external cephalic version were randomized to receive self-administered 50% nitrous oxide/50% oxygen versus 100% oxygen placebo. MeasurementsThe primary outcome measured was intra-procedural pain. Secondary outcomes were intra-procedural anxiety, patient satisfaction, and procedure difficulty. Main resultsForty-eight patients were enrolled; 23 received nitrous oxide and 25 received oxygen. No difference was noted in mean pain scores (nitrous oxide 5.5 ± 2.3, placebo 5.4 ± 2.7, [CI95% = −1.40, 1.51]; P = 0.943) or anxiety scores (nitrous oxide 1.6 ± 2.0, placebo 1.2 ± 1.8, [CI95% = −0.74, 1.45]; P = 0.515). Procedural difficulty (1–10 scale, 1 = very easy, 10 = extremely difficult) was not different between groups (nitrous oxide 6.1 ± 2.2, placebo 6.1 ± 3.2, [CI95% = −1.54, 1.66]; P = 0.944). There was a significant increase in the number of version attempts in the nitrous oxide group (nitrous oxide 3.9 ± 1.9, placebo 2.8 ± 1.4, [CI95% = 0.05, 2]; P = 0.046). Patient satisfaction was significantly lower in the nitrous oxide group (nitrous oxide 4.3 ± 4.0, placebo 6.9 ± 3.6, [CI95% = −4.93, −0.34]; P = 0.025). ConclusionDespite the desirable properties of nitrous oxide, there was no analgesic benefit over oxygen for external cephalic version. Its routine use for these procedures was not supported.

Nitrous Oxide Use During Labor: Satisfaction, Adverse Effects, and Predictors of Conversion to Neuraxial Analgesia.

Women desire safe and effective choices for pain management during labor. Currently, neuraxial and opioid analgesia are the most common methods used in the United States. The purpose of this study was to investigate demographic characteristics, safety, and satisfaction in a cohort of parturients who used inhaled nitrous oxide (N2 O) analgesia and to determine predictors of conversion from N2 O to neuraxial analgesia. This was a prospective chart review study. Individuals aged at least 18 years who used inhaled N2 O during the first or second stage of labor between March 1, 2016, and July 23, 2017, on the labor and delivery unit of one academic medical center (N = 463) and their neonates were included. Data describing maternal and neonatal factors are reported. Logistic regression and chi-square tests were used to model the effects of oxytocin augmentation, labor induction, parity, prior cesarean birth, pre-N2 O cervical dilatation, and post-N2 O cervical dilatation on the odds of conversion from N2 O to neuraxial analgesia. In this cohort, 31% who chose N2 O for analgesia did not convert to any other analgesic method. Significant positive predictors for conversion from N2 O to neuraxial analgesia included labor induction (odds ratio [OR], 2.9; 95% CI, 1.7-5.0), oxytocin augmentation (OR, 3.1; 95% CI, 1.6-6.0), and labor after cesarean (OR, 6.4; 95% CI, 2.5-16.5). Multiparity (OR, 0.4; 95% CI, 0.2-0.6) and post-N2 O cervical dilatation (OR, 0.8; 95% CI, 0.7-0.9) were negative predictors. Adverse effects related to N2 O use during labor were rare (8%) and were not a significant reason for conversion to neuraxial analgesia. Parturients had moderately high satisfaction with N2 O for pain management (11-point scale, mean [SD], 7.4 [2.9]). Five-minute Apgar scores were 7 or greater in 97.8% of the newborns. Understanding predictors of conversion from inhaled N2 O to neuraxial analgesia may assist perinatal care providers in their discussions with women about analgesia options during labor. N2 O is a useful, safe option for labor analgesia in the United States.

A Nurse-Driven Nitrous Oxide Program

The clinical educator and nursing staff explored development of a nurse-driven initiative to offer nitrous oxide to intrapartum women at a magnet-designated community hospital. A clinical nurse attended an AWHONN convention, learned about nitrous oxide during a specialty session, and returned to enthusiastically share this finding with key stakeholders and query whether this would be possible in the hospital. The purpose for the program is to disseminate how this was accomplished in a community hospital setting. Nitrous oxide as a pain-management option will supplement, not replace, the choices already offered to women who are in labor. The medical librarian was enlisted to assist with conducting a review of the current literature, which was obtained, reviewed, and critically analyzed. The evidence was shared with obstetrics and anesthesia providers. After thoughtful review by all stakeholders, the decision was made to focus on a nurse-driven program for delivering nitrous oxide to appropriate women in labor. Nitrous oxide analgesia system vendors presented to the nursing staff as well as to the interprofessional departmental meeting. A nursing steering committee was convened. Monthly meetings were held to develop the required elements of a new pain-management offering. A consent form, safety checklist, policy, provider order, and education plan were developed and implemented. Various hospital committees and senior administrators were required to review elements of the proposed program. The program has been in existence for 2 months. During that time, outcome measurements, using a standard numeric pain-management scale, have demonstrated the effectiveness of nitrous oxide. All women who have used nitrous oxide have given lower pain scores after initiation of inhalation. To date, no adverse outcomes have been identified. There is inherent value in hospital support of nurses attending AWHONN programs. Professional sharing of evidence-based practices helps to advance the practice of nursing. The provision of nitrous oxide as a nurse-driven program is safe and effective and ultimately offers intrapartum women an additional choice in the management of their birth experience.

Nurses Pioneer Practice in the Use of Nitrous Oxide for Labor Analgesia

The purpose was to expand options for pain management by offering nitrous oxide analgesia to women through a process that allows nurses to implement and manage administration, independent from anesthesia oversight. We applied the Texas Board of Nursing Six-Step Decision-Making Model and found that the provision of nitrous oxide for patient self-administration after a provider order was within nursing scope of practice. Our goal was to develop a nurse-managed nitrous oxide policy and procedure guideline for self-administration by obstetric patients, thereby removing the “middle man” (i.e., the anesthesia department). All stakeholders agreed that research evidence and expert opinion supported implementation of a nurse-managed model after an order was obtained, with no necessity to consult or involve the anesthesia services department. After addressing self-administration issues, occupational hazards, and environmental risks, we proceeded with a nurse-led nitrous oxide protocol. It took 14 months to develop and guide the protocol throughout our health system committees to gain approval. Entity-specific professional competencies were developed and implemented within the obstetrics department. To date, 56% of our patients have used nitrous oxide as an analgesia option at some point between the antepartum and postpartum periods. The response by patients to nitrous oxide administration has been overwhelmingly positive in regard to meeting their expectations for pain management. There have been no safety concerns related to this analgesia option. Nitrous oxide was also used for its anxiolytic properties for bedside procedures, such as external cephalic versions, cervical ripening, intravenous catheter insertions, indwelling urinary catheter insertions, perineum repairs, and postpartum incisional care, as well as in cases of fetal demise. Babies born after nitrous oxide administration show less sedation and fewer potential respiratory issues compared with those born after intravenous narcotics have been administered during birth. A nurse-managed policy and procedure allows registered nurses to practice at the top of their licensure and to support the autonomy of their patients without delay; it also helps decrease health care costs by giving patients an expensive, noninvasive option for pain management.

Mini-Review: A Brief History of Nitrous Oxide (N2O) Use in Neuropsychiatry.

Background:Joseph Priestley’s discovery of nitrous oxide (N2O) was recorded in 1772. In the late 1790’s, Humphry Davy experimented with the psychotropic properties of N2O, describing his observations in a book, published in 1800. A dentist, Horace Wells discovered anaesthesia with N2O in 1844. Over a century after Davy, its potential usefulness in psychiatry was first recognised. The seminal researches in neuropsychiatry, between 1920 and 1950, mainly used anaesthetic concen-trations of the gas. The psychotropic actions of N2O, at non-anaesthetic doses, were first used by den-tists, mainly for its anxiolytic action. In modern dentistry, N2O is always mixed with at least 30% ox-ygen and titrated to doses rarely exceeding 40% of N2O. At these lower concentrations, untoward ef-fects are almost always avoided, including over-sedation and/or anaesthesia. In the early 1980’s, the low-dose dental titration technique was first used to investigate and treat psychiatric conditions, includ-ing substance abuse. Until then, most physicians regarded the gas only as an anaesthetic agent. An ex-ception was obstetricians who used a fixed 50% concentration of N2O diluted with oxygen for analge-sia during parturition. In 1994, to clearly distinguish between anaesthetic and non-anaesthetic concen-trations (as used in dentistry), the term Psychotropic Analgesic Nitrous oxide (PAN) was introduced.Objective:This paper will give a brief history of the use of the N2O in psychiatry since the psycho-tropic actions were first recognised in the 18th century until the present.Conclusion:The role of other non- opioid systems, and the extent to which they contribute to the psy-chotropic properties of N2O, still remains to be established.

Inhaled Nitrous Oxide Analgesia for Labor

This paper reviews the history, efficacy, safety, and administrative concerns for nitrous oxide analgesia during labor. While pain relief is inferior to that provided by neuraxial analgesia, maternal satisfaction is equivalent to that of neuraxial techniques, and better if analgesia is reported to be poor. A recent systematic review reports good safety for mother and child, that some women report excellent pain relief and others not, and that minor side effects are infrequent. Qualitative research summarizing patient comments on their experience suggests that numerous factors other than pain relief affect maternal satisfaction with their analgesia for labor. Only one study has examined patient factors that predict conversion from nitrous oxide to neuraxial analgesia for labor. Inhaled nitrous oxide offers a safe and effective means for labor analgesia for many women. Maternal satisfaction is not as dependent on effective pain relief as with neuraxial analgesia.

Dental Concerns of Children with Down’s Syndrome - An Overview

Down’s syndrome is a condition known to be associated with a chromosomal abnormality. This is usually in the form of three in place of a pair of chromosomes 21, hence the name ‘trisomy 21’ the incidence of Down’s syndrome in the population has been variably estimated between 1 and 4 per 1000 and which occurs in all races. These children are mentally retarded to some degree, they are generally smaller than average in height for their age, Midface dysplasia, flat broad bridge of the nose, “lop” ears, Epicanthal folds with slanting almond-shaped eyes which was responsible for the term mongoloid. The majority of the children exhibit brachycephaly (broad, short head) and lack of supraorbital ridges and hypotelerism, Absence of frontal sinuses and absent or reduced maxillary sinuses, nasal septum or nasal conchl deviations are often observed which can produce a partially obstructed or narrow air passage and can contribute to the problem of mouth breathing, prone to infections especially upper respiratory tract infections. They have congenitally missing lateral incisors, the morphology of the teeth may also be affected. Teeth are smaller than normal, peg shaped and tend to be rounded or bulbous, roots of the incisors are short and most of the children are having tongue thrusting habit with lack of lip seal and high frenal attachment. They have a remarkable resistance to dental caries and at least half of them are caries free, preventive procedures along with chlorhexidine mouth wash may be beneficial and they suffer from a moderate to severe degree of periodontal disease. Down’s syndrome children with congenital heart disease extractions and deep scaling should be done under antibiotic coverage and pulp treatment in primary teeth is contraindicated in patients with cardiac problems because of the risk of bacteremia whereas in permanent teeth it can be considered if an adequate apical seal can be obtained. Both orthodontic and prosthodontics appliances are usually contraindicated. Nitrous oxide analgesia or Tell show do in mildly apprehensive patients can be used, general anesthesia in severe resistance to dental treatment. This article discusses about etiological factors, clinical features and management aspects.

Nitrous Oxide During Labor: Maternal Satisfaction Does Not Depend Exclusively on Analgesic Effectiveness.

Evidence on the analgesic effectiveness of nitrous oxide for labor pain is limited. Even fewer studies have looked at patient satisfaction. Although nitrous oxide appears less effective than neuraxial analgesia, it is unclear whether labor analgesic effectiveness is the most important factor in patient satisfaction. We sought to compare the relationship between analgesic effectiveness and patient satisfaction with analgesia in women who delivered vaginally using nitrous oxide, neuraxial analgesia (epidural or combined spinal-epidural [CSE]), or both (neuraxial after a trial of nitrous oxide). A standardized survey was recorded on the first postpartum day for all women who received anesthetic care for labor and delivery. Data were queried for women who delivered vaginally with nitrous oxide and/or neuraxial labor analgesia over a 34-month period in 2011 to 2014. Parturients with complete data for analgesia quality and patient satisfaction were included. Analgesia and satisfaction scores were grouped into 8 to 10 high, 5 to 7 intermediate, and 0 to 4 low. These scores were compared with the use of ordinal logistic regression across 3 groups: nitrous oxide alone, epidural or CSE alone, or nitrous oxide followed by neuraxial (epidural or CSE) analgesia. A total of 6507 women received anesthesia care and delivered vaginally. Complete data were available for 6242 (96%) women; 5261 (81%) chose neuraxial analgesia and 1246 (19%) chose nitrous oxide. Of the latter, 753 (60%) went on to deliver with nitrous oxide alone, and 493 (40%) switched to neuraxial analgesia. Most parturients who received neuraxial analgesia (>90%) reported high analgesic effectiveness. Those who used nitrous oxide alone experienced variable analgesic effectiveness, with only one-half reporting high effectiveness. Among all women who reported poor analgesia effectiveness (0-4; n = 257), those who received nitrous oxide alone were more likely to report high satisfaction (8-10) than women who received epidural analgesia alone (OR 2.5; 95% CI 1.4-4.5; P = .002). Women who reported moderate analgesia (5-7) and received nitrous oxide only were more likely to report high satisfaction compared with the other groups. Among women who reported a high level of analgesic effectiveness, satisfaction with anesthesia was high and not different among groups. Patients who received nitrous oxide alone were as likely to express satisfaction with anesthesia care as those who received neuraxial analgesia, even though they were less likely to report excellent analgesia. Although pain relief contributes to the satisfaction with labor analgesia care, our results suggest that analgesia is not the only contributor to maternal satisfaction.

Chronic postsurgical pain in the Evaluation of Nitrous Oxide in the Gas Mixture for Anaesthesia (ENIGMA)-II trial

BackgroundPrevious animal and clinical studies showed that nitrous oxide may produce long-term analgesia. The aim of this study was to evaluate the effect of nitrous oxide in preventing chronic postsurgical pain. We also explored whether methylenetetrahydrofolate reductase gene polymorphisms (1298A>C, 667C>T) would enhance nitrous oxide analgesia. MethodsWe conducted a telephone interview at 12 months after surgery on 2924 (41.1%) patients enrolled in the Evaluation of Nitrous Oxide in the Gas Mixture for Anaesthesia-II trial. Pain at the wound site was recorded using the modified brief pain inventory and the neuropathic pain questionnaire. General health status was measured using the EQ-5D questionnaire. Genotyping was performed in a subset of 674 Asian patients in Hong Kong. ResultsAt 12 months after surgery, 356 (12.2%) patients reported chronic postsurgical pain at the wound site and 112 (3.8%) patients had severe pain and required regular analgesic interventions. Nitrous oxide did not affect the rate of chronic postsurgical pain (11.8% nitrous oxide group; 12.5% no nitrous oxide group), relative risk (95% confidence intervals): 0.94 (0.75–1.17), P=0.57. However, in a planned subgroup analysis, nitrous oxide reduced the risk of chronic postsurgical pain in Asian patients, relative risk (95% confidence intervals): 0.70 (0.50–0.98), P=0.031. Patients who were homozygous for either gene polymorphism and who received nitrous oxide during surgery were less likely to report chronic postsurgical pain. ConclusionsNitrous oxide administration had no impact on chronic postsurgical pain, but benefits may still be possible in Asian patients and patients with variants in methylenetetrahydrofolate reductase gene. Clinical trial registrationNCT00430989.

Women’s Awareness and Attitudes towards Labor Analgesia Influencing Practice between Developed and Developing Countries

Childbirth experience is one of the most intense pain that majority of women will endure during their lifetime. Concerns about pain in labor remain a hot topic, and its popularity gets more common day by day as more women become aware of their rights to achieve a better quality of care during labor. There are various non-pharmacologic (transcutaneous electrical nerve stimulation, hydrotherapy, intradermal water injections and acupuncture) and pharmacologic treatments (nitrous oxide, opioids and regional analgesia techniques: spinal, epidural and combined epidural analgesia) available today. Among these, epidural analgesia offers the most effective form of pain relief and is considered to be the gold standard of labor analgesia. Despite having labor analgesic services, most women still go through painful labor due to lack of knowledge regarding it, particularly in developing countries. The main source of information regarding pain reliefs is from friends and relatives, revealing the lack of information from caregiver’s side. So this study reflects that there is a wide gap in the communication between pregnant women and obstetricians. It supports the fact that obstetricians through the practice of routinely offering labor analgesia can significantly improve the maternal and perinatal outcomes of pregnancy. Provision of standardized epidural analgesia information at an appropriate time in their pregnancy may benefit them by the practice of mutual decision-making. Thus, it may prevent women from making a difficult choice of cesarean section to avoid the fear of painful labor.

Practice Patterns and Adverse Events of Nitrous Oxide Sedation and Analgesia: A Report from the Pediatric Sedation Research Consortium

To describe practice patterns and adverse events associated with nitrous oxide (N2O) administration as the primary sedative outside the operating room in varied settings by a diverse range of providers, and to identify patient and sedation characteristics associated with adverse events. Data prospectively collected by the Pediatric Sedation Research Consortium, which is comprised of 40 children's and general/community hospitals, was retrospectively analyzed for children who received N2O as the primary sedative. Descriptive measures of patient and sedation characteristics and adverse events were reported. A multivariable regression model was used to assess potential associations between patient and sedation characteristics and adverse events. A total of 1634 N2O administrations were identified. The majority was performed in sedation units, and most by advanced practice nurses or physician assistants. The most common adjunct medication was midazolam. There was a low prevalence of adverse events (6.5%), with vomiting as the most common (2.4%) and only 3 (0.2%) serious adverse events reported. The odds of vomiting increased when concomitant opioids were administered (OR 2.89, 95% CI 1.14, 7.32) and when nil per os (NPO) clear fluids <2 hours (OR 4.16, 95% CI 1.61, 10.76). NPO full meal <6 hours did not change the odds of vomiting (OR 1.42, 95% CI 0.57, 3.57). There were no aspiration events. There was a very low prevalence of serious adverse events during N2O administration in children outside of the operating room and by nonanesthesiologists. The odds of vomiting increased when concomitant opioids were administered and NPO clear fluids <2 hours.

Nitrous oxide analgesia for bone marrow aspiration and biopsy – A randomized, controlled and patient blinded study

Background and aimsBone marrow aspiration and/or biopsy (BMAB), performed under local anaesthesia in adults, is a common and often painful procedure. Anxiety is known to intensify pain during the procedure. Nitrous oxide (N2O), known for its sedative and analgesic benefit in various short medical procedures and labour pain, could be advantageous also for pain relief during bone marrow examination. N2O acts rapidly and is eliminated in a couple of minutes once the inhalation is stopped, and occasional side effects (e.g. dizziness and nausea) are mild. The aim of this study was to compare the analgesic effects of inhaled 50% mixture of nitrous oxide and oxygen to 50% oxygen during bone marrow examination. MethodsIn this randomized, controlled, patient and observer blinded study patients received either 50% mixture of nitrous oxide and oxygen or 50% mixture of oxygen in air during bone marrow examination, in addition to local analgesia. Both patient groups comprised 35 adult patients. Pre-procedural anxiety and procedural pain were rated on the Numeral Rating Scale (NRS 0–10). Cognitive function was measured before and 30min after the procedure. Possible side effects were recorded. A telephone interview was performed 24h later. ResultsThere were no statistically significant differences in pain scores of the procedural steps (median NRS ranging 3.0–4.0) between the study groups. High pain scores of 8–10 comprised 0% vs. 8.6% of the scores during infiltration, 2.9% vs. 5.7% during puncture, 11.4% vs. 14.3% during aspiration and 2.9% vs. 2.9% during biopsy in N2O and 50% O2 groups, respectively (NS). Pre-procedural anxiety (median NRS 3.5 in both groups), measured in the outpatient clinic just prior to procedure, correlated with pain intensity during bone marrow aspiration (P=0.045). There were no significant differences between side effects. During the BMAB four patients (3 in N2O group, 1 in 50% O2 group) reported dizziness and one patient in the N2O group reported nausea. Gas inhalation did not affect the cognitive function of the participants. In both groups the majority (>80%) of the patients was satisfied with the inhalation technique. During the 24h interview, most of the participants were pain free and they did not report any serious adverse effects. ConclusionsIn spite of similar moderate to strong procedural pain in both groups and no benefit of N2O, most patients were satisfied with the inhalational techniques. We assume that the bedside presence of an anaesthesiologist and the distraction caused by the inhalational arrangements introduced positive context-sensitive therapeutic effect independent of the gas used. Pre-procedural anxiety predicted pain associated with bone marrow aspiration. ImplicationsInhaled 50% nitrous oxide was not an effective analgesic during bone marrow examination in our unselected outpatient population. Further studies should concentrate on its use with patients predicted to be at increased risk of suffering intense pain during the procedure, such as very anxious patients or those who have a painful history of previous bone marrow examinations.

598: The use of nitrous oxide analgesia during labor at a single institution in the United States

598: The use of nitrous oxide analgesia during labor at a single institution in the United States

New Evidence of Enhanced Safety of Nitrous Oxide in General Anesthesia

New Evidence of Enhanced Safety of Nitrous Oxide in General Anesthesia