A review of a journal article created by a Journal Watch contributor

It's time to stop using nitrous oxide for pediatric mask induction

Pediatric Anesthesia

Submitted October 2023 by Dr Andrew Chazan

Read by 154 Journal Watch subscribers

This short ‘perspectives essay’ is aimed at getting anaesthetists to reconsider the routine use of nitrous oxide in mask induction of anaesthesia. The points raised in the article include:

1. Greater time until desaturation in the event of laryngospasm if 100% oxygen is used rather than high concentration N20.
2. Turning the nitrous oxide off as soon as the child is asleep does not guarantee that you will achieve full preoxygenation before a potential laryngospasm event (as washout may take one or two minutes and laryngospasm may occur at any point)
3. Potential impacts of chronic N20 exposure on staff and also definite impacts on the environment, which could be significantly reduced by not routinely using N20 at induction
4. Nitrous oxide use does not guarantee a pleasant/ non traumatic induction in a child and there are many other techniques that can be used to increase the likelihood of a pleasant experience.
5. There is no accepted guidelines on how long one should use high concentration N20 before introducing volatile and some anaesthetists potentially add sevoflurane before euphoria has occurred, negating the potential benefit.
6. The notion that N20 will help speed up induction due to second gas effect is potentially flawed. The main studies looking at this phenomenon reportedly involved using halothane +/- N2O in adult patients. Anaesthesia of small children with sevoflurane is a different pharmacological and physiological scenario.

The article concludes with: “why should we continue a practice which is less safe for children, potentially harmful to ourselves and assuredly more harmful to the atmosphere- without any evidence of benefit to our patients?”

Take home messages/commentary:
I found this to be a very interesting and topical read and it has made me reconsider my practice. I feel that a better title to the article might be “It is time to reconsider the need for N20 in pediatric mask induction” as I suspect there are some occasions where it may still have a role to play. There can be no denying that N20 is harmful for the environment, it is also logical that desaturation will be more rapid if high concentration N20 has been used rather than 100% oxygen in the case of a lost airway (though the degree and relevance will be patient and scenario specific). What will continue to be debated is how much more or less likely the induction is to be peaceful if N20 is used vs if it is not used. A study specifically looking at this would be very useful to add weight to the argument made in this article. There are many other strategies that we can employ to increase the likelihood of peaceful induction other than the routine use of N20.

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