Adjunctive Nitrous Oxide During Emergency Department Propofol Sedation in Adults

Adjunctive Nitrous Oxide During Emergency Department Propofol Sedation in Adults, a Pilot Study

The purpose of this study is to describe the safety and efficacy of nitrous oxide administration for pain and anxiety before propofol in patients requiring any procedure under sedation in the Emergency Department. Procedural sedation is the use of sedative, analgesic, and/or dissociative agents to relieve anxiety and pain associated with diagnostic and therapeutic procedures. Propofol is commonly used and is a sedative and amnestic, but provides no analgesia. Short acting opioids may be used for pain relief, but come with the risk of respiratory depression. An optimum analgesic to relieve pain in patients who need procedural sedation should be short acting, easy to administer and safe. Nitrous oxide may be a suitable agent, but literature supporting or rejecting its use in adults is lacking. This study aims to fill this gap. Adult patients capable of consenting, coming to the Emergency Department with painful condition requiring procedural sedation are the targeted population. Eligible patients who consent to the study will receive Nitrous Oxide gas delivered through a hand held mask before they receive propofol for the procedure. Information regarding their vitals, pain scores and medical condition will also be collected.

Study Overview

• Status: Completed
• Conditions: Abscess; Perianal Abscess; Joint Dislocation
• Intervention / Treatment: Drug: Nitrous Oxide arm; Drug: Propofol; Drug: Oxygen

Detailed Description

This pilot study will be conducted in a prospective, non-randomized fashion using a convenience sample of 100 subjects undergoing sedation for Emergency Department procedures.

Recruitment Methods The research associates as well as the health care team (both residents and attending physicians) will screen patients who may need procedural sedation in the Emergency Department and may qualify for the study. Research associates will use the Medical Record

Procedures Involved in the Research Initial medical assessment will be made in accordance with established clinical procedures, including the history, physical examination, and vital signs. If by clinical assessment the patient meets eligibility criteria, then they will be approached by a research associate for enrollment in the study. After informed consent is obtained and prior to starting the sedation, standard vital sign monitoring will be placed on the patient (electrocardiogram, non-invasive blood pressure monitoring, pulse oximetry, and capnography). Level of consciousness will be determined using the modified Ramsay scale, which will be assessed at baseline. The Entitled Carbon Di Oxide (CO2) monitor will be used as the primary device to measure Entitled Carbon Di Oxide (CO2), with a nasal cannula capable of delivering supplemental oxygen and measuring Entitled CO2.

The Nitrous Oxide gas mixer system will be used as the primary nitrous oxide delivery device. It will mix and deliver nitrous oxide and oxygen in a 1:1 ratio, at a fixed concentration of 50%/50%. It uses a patient driven demand valve system that is hand held. This device provides a consistent, fixed 50%/50% blend of nitrous oxide (N2O) and oxygen (O2), eliminates the need to titrate, and provides fixed concentrations for controlled and consistent dosing. The device comparator detects dosing imbalance to protect against hypoxic mixtures, it cannot deliver nitrous gas without concurrent oxygen, and the device has an anti-asphyxia valve override. The on demand valve requires patient inspiration to trigger dosing. This portable device scavenges exhaled waste gases for environmental safety, as well as a key mechanism that renders the system inoperable without it for security.

After informed consent, the patient will fill out a pre procedure questionnaire and a 100 mm VAS baseline pain scale. The patient will be given the mask for delivery of nitrous oxide, and instructed on its use. The research associate will mark the time the patient began using the device electronically. Once IV access is established, and the team and patient are ready to begin the procedure, the nitrous oxide mask will be removed, and a 100% non rebreather mask delivering 15 liters a minute of supplemental oxygen will be placed on the patients face. The loading dose of propofol will then be administered immediately. All sedations in this trial will use propofol 1.0 mg/Kg initial dose, with 0.5 mg/Kg doses titrated to deep sedation. Once the patient is deeply sedated, the procedure will begin.

The subject's clinical data and sedation information (refer to data management) will be entered into a standardized data collection form. The data will be continuously recorded throughout the sedation and recovery periods. Study will end when the subjects recovers back to baseline mental status.

Vital signs will be flagged electronically when a physician intervenes for clinical respiratory depression. Respiratory depression will be defined as peripheral Oxygen saturation below 92%, Entitled CO2 level above 50, a rise or decrease of 10% above or below baseline, the loss of the Entitled CO2 waveform for more than 15 seconds. Level of consciousness will be determined using the modified Ramsay scale, which will be recorded at baseline and at the point of deepest sedation. Once the procedure is complete, and the patient is deemed back to their mental status baseline, they will fill out a post procedure satisfaction questionnaire, and a 100 mm VAS scale. They will be asked about procedure recall. The physician and nurse involved will also fill out a post procedure questionnaire.

System for screening, and they will be in charge of informed consent, enrollment, placement of the capnography monitor, as well as data collection. The health care team will be in charge of the procedural sedation and all other management.

• Study Type: Interventional
• Enrollment (Actual): 43
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • Pennsylvania
    • Philadelphia, Pennsylvania, United States, 19141
      • Albert Einstein Medical Center

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Spontaneous respirations
• 18 years of age and older
• American Society of Anesthesiologists (ASA) Physical Status Classification 1 or 2, who will be receiving sedation for an Emergency Department procedure.
• Ability to provide informed consent.

Exclusion Criteria:

• Comorbidities that affect ventilation, perfusion, or metabolism
• Intubated
• Cardiopulmonary instability
• Major trauma
• Sepsis
• American Society of Anesthesiologists (ASA) class 3, 4, and 5.
• Inability to provide informed consent
• Nursing home residents
• Age less than 18 years
• Non English speaking
• Pregnant women
• Under police custody

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm

Intervention / Treatment

Experimental: Nitrous Oxide Arm; Patients undergoing procedural sedation with propofol will undergo an initial medical assessment including the history, physical examination, and vital signs. The patients will then receive Nitrous Oxide gas via a gas mixer device before receiving propofol. The device will mix and deliver nitrous oxide and oxygen in a 1:1 ratio, at a fixed concentration of 50%/50%. The on demand valve requires patient inspiration to trigger dosing.

Drug: Nitrous Oxide arm; Patients undergoing procedural sedation with propofol will undergo an initial medical assessment including the history, physical examination, and vital signs. The patients will then receive Nitrous Oxide gas via a gas mixer device before receiving propofol. The device will mix and deliver nitrous oxide and oxygen in a 1:1 ratio, at a fixed concentration of 50%/50%. The on demand valve requires patient inspiration to trigger dosing.; Other Names: Nitrous Oxide; Sedera Gas Mixer; Propofol Sedation; Procedural Sedation; Drug: Propofol; The loading dose of propofol will be administered immediately after nitrous oxide discontinuation. All sedations in this trial will use propofol 1.0 mg/Kg initial dose, with 0.5 mg/Kg doses titrated to deep sedation. Once the patient is deeply sedated, the procedure will begin.; Other Names: Diprivan; Drug: Oxygen; If pulse oximetry declines to less than 92%, subject will be placed on nasal cannula with administration of 2 liter flow of oxygen and titrated in increments of 1 L flow to maintain pulse oximetry greater than 92%; Other Names: O2

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Total Number of Respiratory Depression Events	End tidal CO2 and SpO2 measured every 20 milliseconds seconds captured by a monitoring device. Events of respiratory depression are defined as peripheral SaO2 below 92%, ETCO2 level above 50, a rise or decrease of 10% above or below baseline, and/or the loss of the ETCO2 waveform for more than 15 seconds	day 1

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Total Number of Airway Repositioning Events	Presence or absence of physician intervention requiring airway repositioning by provider due to decreased oxygen saturation less than 92%	day 1
Total Number of Events Requiring Additional Oxygen	Presence or absence of physician intervention requiring additional oxygen via nasal cannula or non rebreather by the provider due to oxygen saturation less than 92%	day 1
Total Number of Positive Pressure Ventilation Events	Presence or absence of physician intervention requiring positive pressure ventilation via a bag valve max due to decreased oxygen saturation less than 92%	day 1
Total Number of Endotracheal Intubation Events	Presence or absence of physician intervention requiring endotracheal intubation by provider due to decreased oxygen saturation less than 92%	day 1
Total Number of Physical Stimulation Events	Presence or absence of physician intervention requiring physical stimulation by the provider due to decreased oxygen saturation less than 92%	day 1
Patient, Physician, and Nurse Satisfaction Surveys	Patient satisfaction with use of Nitrous Oxide in anxiolysis and pain control	day 1
Post-Procedure VAS Pain Score	Visual Analog Scale (0-100mm), where 0 mm is minimum pain, and 100 mm is maximum pain.	day 1

Collaborators and Investigators

• Sponsor: Albert Einstein Healthcare Network
• Investigators: Principal Investigator: Joseph Herres, DO, Albert Einstein Medical Center

Study record dates

Study Major Dates

• Study Start: February 1, 2015
• Primary Completion (Actual): February 1, 2018
• Study Completion (Actual): February 1, 2018

Study Registration Dates

• First Submitted: February 11, 2015
• First Submitted That Met QC Criteria: April 7, 2015
• First Posted (Estimate): April 8, 2015

Study Record Updates

• Last Update Posted (Actual): April 8, 2020
• Last Update Submitted That Met QC Criteria: March 27, 2020
• Last Verified: March 1, 2020

More Information

Terms related to this study

• Keywords: procedural sedation; procedural pain; procedural anxiolysis
• Additional Relevant MeSH Terms: Pathologic Processes; Infections; Inflammation; Wounds and Injuries; Disease Attributes; Joint Diseases; Musculoskeletal Diseases; Suppuration; Emergencies; Abscess; Joint Dislocations; Physiological Effects of Drugs; Central Nervous System Depressants; Peripheral Nervous System Agents; Analgesics; Sensory System Agents; Anesthetics, Intravenous; Anesthetics, General; Anesthetics; Analgesics, Non-Narcotic; Hypnotics and Sedatives; Anesthetics, Inhalation; Propofol; Nitrous Oxide
• Other Study ID Numbers: HN4641

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO