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.


Franz Babl
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.
>Brandon Carr
>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:

Consultant in Emergency Medicine
Emergency Department
Royal Children's Hospital
Flemington Rd
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: