Nitrous oxide analgesia during intra-articular injection for juvenile idiopathi arthritis. (Original Article)

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From: Archives of Disease in Childhood(Vol. 86, Issue 6)
Publisher: BMJ Publishing Group Ltd.
Document Type: Article
Length: 2,546 words

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Aims: To evaluate the efficacy and safety of nitrous oxide--oxygen for children with juvenile idiopathic arthritis (JIA) undergoing intra-articular corticosteroid injection.

Methods: A total of 55 consecutive patients with JIA undergoing intra-articular corticosteroid injection, using self administered nitrous oxide--oxygen for analgesia were studied. Patient, nurse, and parent pain scores were compared using a 0-10 cm visual analogue scale (VAS) immediately after the procedure.

Results: A total of 70 joints were injected in 55 patients (median age 13.54 years). The median pain score for patient, nurse, and parent was 1 (0-10 cm VAS). The mean rank patient score was 2.12, which was greater than the nurse score (1.97), which was greater than the parent score (1.91). These differences were significant. There were no serious adverse events in any patient.

Conclusions: Nitrous oxide--oxygen provides safe and effective analgesia for intra-articular injection in children. In some cases, nurses and parents underestimated pain related to the procedure compared to the child.


Inhaled nitrous oxide at a concentration of 30-70% in oxygen has been used to alleviate pain associated with a variety of procedures in children, such as laceration repair, (1) gastrointestinal endoscopy, (2) venous cannulation, (3) and burns dressing. (4) A recent national survey of the use and safety of inhaled nitrous oxide in France evaluated prospectively the procedure characteristics, pain evaluations, and adverse effects in 1019 painful procedures, including lumbar puncture, bone marrow aspiration, minor procedures, minor surgery, fractures, dental care, and pulmonary endoscopy. (5) The nitrous oxide-oxygen was tolerated in 87.3% of procedures, with optimum results in children 3 years of age and older.

The behavioural response of children undergoing a painful procedure using inhaled nitrous oxide-oxygen have been assessed using the Observational Scale of Behavioural Distress--Revised. (6) Children over the age of 6 years showed a lower level of distress, with the additional benefit of procedural amnesia reported in 65% of subjects. There have been no serious adverse effects associated with the use of inhaled nitrous oxide--oxygen mixture. Common adverse effects reported include euphoria, nausea and vomiting, clinically insignificant hypoxia, abnormalities of peripheral sensation, dizziness, restlessness, and hallucinations. (5 6) All were transient, with recovery time less than five minutes.

We report here our experience with the use of nurse supervised self administered nitrous oxide-oxygen mixture during intra-articular steriod injection in 55 children with juvenile idiopathic arthritis (JIA). The use of nitrous oxide--oxygen in this setting was prompted by perceived problems associated with the use of intravenous sedation with benzodiazepines including patient distress during venous cannulation, failure to achieve adequate hypnotic effect, and safety of nitrous oxide-oxygen inhalation in our units we performed a prospective study of intra-articluar injections in children with JIA.


All children over the age of 7 years with JIA listed for intra-articular injection in two paediatric rheumatology centres were studied. Patients were selected consecutively and providing they were capable of self administration of the nitrous oxide-oxygen mixture there were no exclusion criteria. In each centre the intra-articular injection was performed by the same physician....

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Gale Document Number: GALE|A87145594