We also have used nitrous successfully in the PED for 7 years.
1-we did not select an age limit ( but have never used in anyone <2 years)
2-we titrate from 50-70%
3-all patients are on pulse ox and have full VS before use
4-it is considered an anxiolytic/ minimal sedation by Department of
5-We advise parents and staff in 1st trimester to not be be present in room
6- we do not use in any patient with suspected trapped air ( PTX)
7- A single dose of narcotic is allowed 20 minutes before administration
for painful procedures (usually PO or IN)

Good luck. Its a great adjuvant for minor procedures.

Susan Duffy,MD
Hasbro Childrenšs Hospital
Providence, RI

On 6/8/17, 5:31 PM, "Pediatric Emergency Medicine Discussion List on
behalf of Goetz, Kathleen" <[log in to unmask] on behalf of
[log in to unmask]> wrote:

>We've been using nitrous oxide for inpatient,  ED, and outpatient
>procedures for 6 or 7 years.
>1 - we use nitrous oxide down to 6 months of age
>2 - we use 50-70% and went through the same anesthesia and sedation
>committee approval route.  Any concentration is classified as
>Anxiolysis/Minimal Sedation.
>3 - We do not use nitrous if suspected increased ICP associated with
>medical or traumatic etiologies.
>Good luck.  It has really decreased our use procedural sedation.
>Kathleen Goetz, M.D.
>Medical Director, Swedish Pediatric Emergency Medicine
>Seattle, WA
>Sent from my Verizon, Samsung Galaxy smartphone
>-------- Original message --------
>From: "Jackson, Benjamin F" <[log in to unmask]>
>Date: 6/8/17 12:49 PM (GMT-08:00)
>To: [log in to unmask]
>Subject: Nitrous Oxide in PED
>Hello all:
>We're soon to go live with Nitrous Oxide in our PED with a delivery
>system offering up to 70% N2O, and we're finalizing the policy, which
>must be reviewed by anesthesiology and the sedation committee outside of
>our department (no need or interest in taking us on journey into that
>tangential, potentially frustrating matter - it's simply the way it is
>and we have favorable collaboration in this project).
>I have seen a few sample policies but am trying to get a broader sense of
>what others are doing:
>1) Do you have a minimum age (2 or 3 years, for instance) below which you
>do not provide Nitrous Oxide for procedural facilitation?
>2) Are you defining delivery of nitrous oxide  < 50% when not combined
>with an opioid, benzo, or other potentially sedating agent as MINIMAL
>sedation (anxiolysis) and >50 - 70% MODERATE sedation?
>Or, are you defining the level of sedation based on intent as well as on
>patient effect?
>I recognize the arbitrariness of 51 % vs 50 %.
>I'm familiar with the 2008 Pediatrics paper by Babl et al in which the
>vast majority of patients receiving either 50% or 70% scored in the
>minimal sedation range according to the CH-Wisconsin Sedation Scale and
>that there was no significant difference in adverse events between the
>50% group and the 70% group.
>As such, I'm interested in how you are classifying it in terms of policy
>3) I have seen where increased ICP is listed as a contraindication for
>some to the provision of nitrous oxide, but I also know that nitrous
>oxide is often provided for lumbar puncture in the outpatient non-ED
>procedural settings for oncology patients, who presumably have normal
>ICP. Is anyone in ED settings using nitrous oxide for LPs for meningitis
>or idiopathic intracranial hypertension or Guillain-Barre?
>Happy to receive any feedback directly to my email address
>[log in to unmask]
>Thanks so much.
>Benjamin F. Jackson, MD, FAAP, FACEP
>Associate Professor of Pediatrics
>Pediatric Emergency Medicine
>PEM Director of Procedural Sedation
>Medical University of South Carolina
>135 Rutledge Avenue, PO Box 250566
>Charleston, SC 29425
>Phone: 843-876-0795
>Fax: 843-876-0962
>Email: [log in to unmask]
>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:
>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:

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