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Nitrous oxide use in Canadian pediatric emergency departments: a survey of physician’s knowledge, attitudes, and practices

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Abstract

Objectives

Nitrous oxide (N2O) is an inhaled analgesic/ anxiolytic gas with evidence supporting its safety and efficacy for distressing procedures in children. Despite this, its use is not consistent across Canadian pediatric emergency departments (EDs). We aimed to characterize a) physicians’ knowledge and practices with N2O and b) site-specific N2O protocols in Canadian pediatric EDs to help optimize its use nationally.

Methods

This cross-sectional survey was distributed to physician members of Pediatric Emergency Research Canada (PERC) in early 2021. Survey items addressed practice patterns, clinician comfort, and perceived barriers/ facilitators to use. Further, a representative from each ED completed a site-specific inventory of N2O policies and procedures.

Results

N2O was available in 40.0% of 15 pediatric EDs, with 83.3% of these sites having written policies in place. Of 230 distributed surveys, 67.8% were completed with mean (SD) attending experience of 14.7 (8.6) years and 70.1% having pediatric emergency subspecialty training. Of the 156 respondents, 48.7% used N2O in their clinical practice. The most common indications for use were digit fracture/ dislocation reduction (69.7%), wound closure (60.5%), and incision & drainage (59.2%). Commonly perceived facilitators were N2O equipment availability (73.0% of 156) and previous clinical experience (71.7% of 156). Of the 51.3% of physicians who reported not using N2O, 93.7% did not have availability at their site; importantly, the majority indicated a desire to acquire access. They identified concerns about ventilation/ scavenging systems (71.2% of 80) and unfamiliarity with equipment (52.5% of 80) as the most common barriers to use.

Conclusions

Despite evidence to support its use, only half of Canadian pediatric ED physicians surveyed use N2O in their clinical practice for treating procedure-related pain and distress. Increased availability of N2O equipment, protocols, and training may improve clinicians’ abilities to better manage pediatric acute pain and distress in the ED.

Résumé

Objectifs

Le protoxyde d'azote (N2O) est un gaz analgésique/anxiolytique inhalé dont l'innocuité et l'efficacité ont été démontrées lors d'interventions pénibles chez l'enfant. Malgré cela, son utilisation n’est pas uniforme dans les services d’urgences pédiatriques (SU) du Canada. Nous avons cherché à caractériser a) les connaissances et les pratiques des médecins en matière de N2O et b) les protocoles de N2O spécifiques à un site dans les urgences pédiatriques canadiennes afin d'aider à optimiser son utilisation à l'échelle nationale.

Méthodes

Cette enquête transversale a été distribuée aux médecins membres de Recherche d’urgence pédiatrique Canada (PERC) au début de 2021. Les questions de l'enquête portaient sur les modes de pratique, l'aisance du clinicien et les obstacles/facilitateurs perçus pour l'utilisation. En outre, un représentant de chaque SU a dressé un inventaire des politiques et procédures N2O propres à chaque site.

Résultats

La N2O était disponible dans 40,0% des 15 services d'urgence pédiatriques, et 83,3% de ces sites avaient mis en place des politiques écrites. Sur 230 enquêtes distribuées, 67,8% ont été réalisées avec une expérience moyenne (SD) de 14,7 (8,6) ans et 70,1% ont suivi une formation en surspécialité pédiatrique d’urgence. Sur les 156 répondants, 48,7% utilisaient le N2O dans leur pratique clinique. Les indications les plus courantes étaient la réduction des fractures digitales et des luxations (69,7%), la fermeture des plaies (60,5%) et l'incision et le drainage (59,2%). Les facilitateurs généralement perçus étaient la disponibilité de l'équipement N2O (73,0% sur 156) et l'expérience clinique antérieure (71,7% sur 156). Parmi les 51,3% de médecins qui ont déclaré ne pas utiliser de N2O, 93,7% n'avaient pas de disponibilité sur leur site; il est important de noter que la majorité d'entre eux ont indiqué qu'ils souhaitaient y avoir accès. Ils ont identifié les préoccupations concernant les systèmes de ventilation/de récupération (71,2% sur 80) et la méconnaissance de l'équipement (52,5% sur 80) comme étant les obstacles les plus courants à l'utilisation de l'appareil.

Conclusions

Malgré les données probantes à l'appui de son utilisation, seulement la moitié des médecins canadiens des urgences pédiatriques interrogés utilisent le N2O dans leur pratique clinique pour traiter la douleur et la détresse liées à l'intervention. Une plus grande disponibilité de l'équipement N2O, des protocoles et de la formation peut améliorer les capacités des cliniciens à mieux gérer la douleur aiguë et la détresse pédiatrique aux urgences.

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Data sharing statement

Deidentified survey data can be made available, in addition to study protocols, and the statistical analysis plan. The data will be made available upon publication to researchers who provide a methodologically sound proposal for use in achieving the goals of the approved proposal. Proposals should be submitted to rjain0481@gmail.com.

Abbreviations

CHEO:

Children’s Hospital of Eastern Ontario

ED:

Emergency department

N2O:

Nitrous oxide

PERC:

Pediatric Emergency Research Canada

REDCap:

Research Electronic Data Capture

IV:

Intravenous

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Acknowledgements

We acknowledge Pediatric Emergency Research Canada (PERC) for providing physician database access for this study. We also thank Dr. Vik Sabhaney, Dr. Mohamed Eltorki, Dr. April Kam, Dr. Jennifer Smith, Dr. Margaret Boland, Dr. Amy Roeske, and Mr. Sylvain Morneau for their expertise in creating the survey tool.

Funding

This work received no specific funding support.

Author information

Authors and Affiliations

  1. Faculty of Medicine, Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada

    Rini Jain & Martin H. Osmond

  2. Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada

    Rini Jain & Martin H. Osmond

  3. Faculty of Medicine, Department of Pediatrics, Division of Emergency Medicine, Jim Pattison Children’s Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada

    Rini Jain

  4. Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada

    Summer Hudson

  5. Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada

    Evelyne D. Trottier

  6. Departments of Pediatrics, Internal Medicine, Epidemiology and Biostatistics, Western University, London, Ontario, Canada

    Naveen Poonai

  7. Faculty of Medicine and Dentistry, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada

    Samina Ali

  8. Women and Children’s Health Research Institute, Edmonton, Alberta, Canada

    Samina Ali

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  1. Rini Jain
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  2. Summer Hudson
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  4. Evelyne D. Trottier
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  5. Naveen Poonai
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  6. Samina Ali
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Pediatric Emergency Research Canada

Corresponding author

Correspondence to Rini Jain.

Additional information

Communicated by Brett Burstein.

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Jain, R., Hudson, S., Osmond, M.H. et al. Nitrous oxide use in Canadian pediatric emergency departments: a survey of physician’s knowledge, attitudes, and practices. Can J Emerg Med 26, 47–56 (2024). https://doi.org/10.1007/s43678-023-00602-2

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  • DOI: https://doi.org/10.1007/s43678-023-00602-2

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