We are using continuous flow nitrous (variable concentration 0-70%)
extensively in the PED. (I would not bother with demand valve fixed nitrous
50% - young children have difficulty creating the negative pressure to open
the valve and one cannot provide oxygen wash out).
It is very safe as a single agent- see our recent paper in PEC below - our
current data set is up to 800 sedations under nitrous without serious
safety issues. Patients are also immediately discharge ready. In addition
it is mainly administered by accredited ED nurses and therefore less a
drain on resources than ketamine etc.
In terms of efficacy as a single agent it is excellent for distressing
procedures but problematic for very painful procedures.
Royal Children's Hospital
Preprocedural Fasting State and Adverse Events in Children Receiving
Nitrous Oxide for Procedural Sedation and Analgesia.
Pediatric Emergency Care. 21(11):736-743, November 2005.
Babl, Franz E. MD, MPH; Puspitadewi, Ardita; Barnett, Peter MBBS; Oakley,
Ed MBBS; Spicer, Maureen PhD
Study Objective: Established fasting guidelines for analgesia and sedation
are difficult to follow in the emergency department (ED), and the
association between preprocedural fasting and adverse events has been
questioned. We characterize the fasting status of patients receiving
procedural sedation and analgesia with nitrous oxide (N2O) in a pediatric
ED and assess the relationship between fasting status and adverse events.
Methods: A prospective case series was conducted in a children's hospital
ED over an 8-month period. Patients receiving N2O for procedural sedation
and analgesia were enrolled and followed up by telephone call.
Preprocedural fasting state and adverse events, as well as N2O
concentration, adjunctive drugs, and deepest level of sedation, were
recorded. Adverse events were analyzed in relation to fasting status.
Results: Two hundred twenty children who underwent procedural sedation and
analgesia with N2O were enrolled. Fasting status was obtained in 218
patients (99.1%). Of these, 155 (71.1%; 95% confidence interval [CI],
64.5%-77.0%) did not meet fasting guidelines for solids There were no
serious adverse events and no episodes of aspiration (1-sided 97.5% CI,
0%-1.7%). While in the ED, 46 minor adverse events occurred in 37 patients
(16.8%; 95% CI, 12.1%-22.4%). Emesis occurred in 15 patients (7%),
including 4 (6.3%; 95% CI, 1.8%-15.5%) of 63 patients who met and in 11
(7.1%; 95% CI, 3.6%-12.3%) of 155 patients who did not meet fasting
guidelines for solids. There was no significant difference in median
fasting duration between patients with and without emesis.
Conclusion: Seventy-one percent of patients undergoing ED procedural
sedation and analgesia with N2O did not meet established fasting
guidelines. In this series, there was no association between preprocedural
fasting and emesis. There were no serious adverse events.
(C) 2005 Lippincott Williams & Wilkins, Inc.
At 02:03 PM 21/11/2005 -0600, Brandon Carr wrote:
>I am currently a second year fellow and I am looking into trying nitrous
>oxide in our pediatric emergency department along with another fellow. We
>are currently using ketamine and etomidate to sedate children for
>procedures such as incision and drainiage of abcesses and complicated
>lacerations. At this point, we don't have access to nitrous. I wanted to
>see if anyone is using it and the results you are having. I also wanted
>to see if anyone had any ideas on a good way to obtain a machine so that
>we can learn how to use it and see how it works for us here. I have heard
>conflicting opinions and wanted to get some more input before we relly
>start to pursue this. Thanks and I appreciate any input.
>University of Alabama at Birmingham
>For more information, send mail to [log in to unmask] with the
>message: info PED-EM-L
>The URL for the PED-EM-L Web Page is:
Franz E Babl, MD MPH FRACP FAAP
Consultant in Emergency Medicine
Royal Children's Hospital
Victoria 3052 Australia
Ph: +613-9345 6592
Fax: +613-9345 5938
For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is: