ENTONOX®

Conquering procedural pain in children

BOC: Living healthcare

Pain and the perception of pain

“ Inadequate relief of pain and distressduring childhood painful medical proceduresmay have long-term negative effects onfuture pain tolerance and pain responses.”1

Despite the fact that children are known tobe just as vulnerable to pain as adults, if notmore so, deficiencies in child pain managementpersist even in developed countries.“Advances in health care, such as newknowledge of pain prevention strategies,have not been consistently translated intodecreased prevalence or intensity of painexperienced by children in hospitals.”2

The United Nations Convention on the Rightsof the Child recognises the entitlement ofchildren to special consideration in healthcare, but their ability to perceive, respondto and be harmed by pain is still widelyunderestimated3.

Painful procedures are a routine part ofmedical care in paediatric and emergencydepartments, such as venipunctures, bladdercatheterizations, lumbar punctures and bonemarrow aspirations.

Children who have experienced theunpleasantness of pain are understandablyreluctant to undergo further distressingprocedures. Even small children can accuratelyrecall details of painful procedures, and thesememories can easily become exaggeratedmaking subsequent procedures moredistressful1.

Younger children exposed to pain subsequentlydevelop behavioural disturbances in the formof increased crying, neediness and difficultysettling down. These changes may persist fordays or weeks5. The long-lasting effects of painin children have underlined the necessity ofproviding reliable pain management to reducetheir experience of pain at the first exposure.Pain-related behavioural changes havebeen shown to diminish after the use ofnitrous oxide/oxygen6.

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ENTONOX®answers the need for fast and effectivepain relief during minor procedures

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ENTONOX is a ready-to-use gas mixtureconsisting of 50% nitrous oxide and 50%oxygen. Its analgesic properties can help toreduce the pain and discomfort felt by childrenduring painful procedures7. ENTONOX is easy touse and can be administered by trained nurses,thereby avoiding more resource demandingoptions.

Certain procedures that were previously carriedout in operating departments can now, in manycases, be performed in regular wards oroutpatient clinics. The rapid offset of action andmild side-effects associated with the use ofENTONOX analgesia reduce the need forpostoperative monitoring8.

ENTONOX analgesia has repeatedly been shownto be an efficacious choice of pain relief forminor painful paediatric procedures4,9,10,11. Ithas also been shown to reduce treatment timesand ease recovery.

ENTONOX not only has a rapid onset of action(induction time is only a few minutes), butits effects diminish rapidly after cessation ofadministration. The administration of ENTONOXrequires no needles, stitches or bad tastingmedicine and minimal staff training and patientinstruction.

• Easy to administer, no IV lines

• Short induction time – only a few minutes

• Mild side-effects

• Shorter recovery time.

Proven to control pain and anxiety in children

The use of ENTONOX® analgesia to eliminateprocedural pain in children has been examinedin relation to lumbar puncture, bone marrowaspiration, laceration repair, minor procedures,puncture and repositioning of fractures,among other procedures4.

ENTONOX analgesia is seen as a valuable, ifunderused, method of pain relief in emergencyand paediatric care. In many emergency caresituations, as well as a variety of minor painfulprocedures, there is an obvious need for arapid and easy-to-use analgesic that can besafely administered.

The efficacy of nitrous oxide/oxygen inoutpatient surgical procedures is welldocumented7. The mixture has been shownto be highly effective in reducing the pain andanxiety felt by children and minimising theneed for postoperative monitoring8,12,13.Its use has been associated with highsatisfaction ratings among children, as well astheir parents and medical staff14. One studyshowed satisfaction among parents andnurses at more than 90%11.

The sedative properties of ENTONOX helpmake the child less apprehensive before andduring the procedure.

The side-effects associated with short-termuse of ENTONOX are mild and wear off quickly15,minimising the need for postproceduralmonitoring and enabling a more efficientuse of hospital resources. Dizziness and mildnausea are the most commonly seen side-effects and vanish shortly after exposure4.

• Analgesic and sedative properties

• Non-invasive, effective pain relief

• Easy to use

• Safe – minimises the need for post-procedural monitoring

• High patient/parent/staff satisfaction.

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Raising the bar in patient and user safety

BOC Healthcare has developed a completeENTONOX® analgesia solution to ensure safehandling and delivery.

ENTONOX is distributed in lightweight cylinders,which means less effort in lifting, carryingand operating the cylinder. The integratedcylinder valve ensures patient and user safety,with no need to change the regulators, norequirement to make connections at highcylinder pressure, and no risk of highpressure leaks.

The integrated valve provides you with themeans for safe, quick and easy connection ofequipment for the administration of ENTONOX.Quick coupling of the ENTONOX cylinder tothe demand valve makes it easier for childrento use.

• Lightweight cylinders

• Integrated valve

• Controlled gas release.

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Caring for the working environment

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According to the American Society ofAnesthesiologists’ task force on traceanesthetic gases there is insufficientevidence to recommend any routine medicalsurveillance of personnel exposed to traceconcentrations of waste anesthetic gases aslong as routines are followed that ensurecompliance with existing occupationallimits16.

To minimise the potentially negative effectson health from chronic exposure to traceconcentrations in the working environmentmost authorities have set clearrecommendations on ambient air quality.

The maximum limits set in the UK and Irelandfor the average exposure level, measured overan eight hour period is 100 ppm.

This is well below the limits that are likely tohave any effect on the midwives and medicalpersonnel working within the hospital or atthe patient's home. These levels should beadhered to wherever ENTONOX is used16.

• ENTONOX should be administered in roomswith proper ventilation and/or air exchangesystems set to the proper levels.

• National air quality guidelines shouldbe followed.

References

BOC HealthcareCustomer Service Centre, Priestley Road, Worsley, Manchester, M28 2UTPhone: 0800 111 333, Mail: bochealthcare-uk@boc.comwebsites: www.bochealthcare.co.uk, www.entonox.co.uk

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1. Young KD. Pediatric procedural pain. Ann EmergMed 2005; 45(2):160-171.

2. Hain RD, Campbell C. Invasive procedures carriedout in conscious children: contrast between NorthAmerican and European paediatric oncologycentres. Arch Dis Child 2001; 85(1):12-15.

3. Finley GA, Franck LS. Grunau RE, von Baeyer CL.Why children’s pain matters. Pain Clinical Updates(International Association for the Study of Pain).2005, Vol. XIII (4).

4. Annequin D, Carbajal R, Chauvin P, et al.Fixed 50% nitrous oxide mixtures for painfulprocedures: a French survey. Pediatrics 2000;105(4):47-58.

5. Kotiniemi LH, Ryhanen PT, Moilanen IK. Behavioralchanges in children following day-case surgery:a 4-week follow-up of 551 children. Anaesthesia1997 Oct; 52(10): 970-6.

6. Kanagasundaram SA, Lane LJ, Cavalletto BP, et al.Efficacy and safety of nitrous oxide in alleviatingpain and anxiety during painful procedures. ArchDis Child 2001; 84:942-95.

7. Ekbom K, Jakobsson J, Marcus C. Nitrous oxideinhalation is a safe and effective way to facilitateprocedures in pediatric outpatient departments.Arch Dis Child 2005; 90:1073-6.

8. Burnweit C et al. Nitrous oxide analgesia for minorpediatric surgical procedures: An effective alternativeto conscious sedation? J Pediatr Surg 2004;39:495-499.

9. Beh T, Splinter W, Kim J. In children, nitrous oxidedecreases pain on injection of propofol mixedwith lidocaine. Can J Anesth 2002; 49(10):1061-3.

10. Lembert N, Wodey E, Geslot D, Ecoffey C. Preventionof pain on injection of propofol: comparisonof nitrous oxide with lidocaine. Ann Fran AnesthReanim 2002; 21(4):263-70.

11. Bourgois, C, Kuchler H. Gebrauch von MEOPA furschmerzhafte Eingriffe in der Pädiatrie Paediatrica2003; 14(2):18-21.

12. Burton JH, Auble TE, Fuchs SM. Effectiveness of50% nitrous oxide/50% oxygen during lacerationrepair in children. Acad Emerg Med 1998;5(2):112-117.

13. Hee HI, Goy RW, Ng AS. Effective reduction ofanxiety and pain during venous cannulation inchildren: A comparison of analgesic efficacyconferred by nitrous oxide, EMLA and combination.Pediatric Anaesthesia 2003; 13:210-216.

14. Griffin GC, Cambell VD, Jones R. Nitrous oxide-oxygensedation for minor surgery. Experience ina pediatric setting. JAMA 1981; 245:2411-13.

15. Gall O, Annequin D, Benoit G, et al. Adverseevents of premixed nitrous oxide and oxygenfor procedural sedation in children. Lancet 2001;358:1514-15.

16. McGregor DG, Baden JM, Bannister C, et al. Taskforce on trace anesthetic gases – Information formanagement in anesthetizing areas and thepostanesthetic care unit (PACU). American Society ofAnesthesiologists. 1999, Park Ridge, IL, USA

BOC Gases Ireland, PO Box 201, Bluebell, Dublin 12Phone: 01 409 1827, Mail: sales@bocgases.iewebsites: www.entonox.co.uk, www.bocgases.ie