Nitrous Oxide



Nitrous Oxide – It’s Not Just for Dentists!

We are all very aware that many of the necessary procedures that need to be done in the Emergency Department, particularly the Pediatric ED, are painful and often scary.  We are very accustomed to performing procedural sedation for significant fracture reductions and laceration repairs.  I think that I order more Ketamine than antibiotics (actually, I am almost positive of that).

Unfortunately, we are also aware of the “issues” that surround procedural sedation.  Let’s be honest: it can be a pain in the rear-end.  You have to get consent, ensure that the room is set up per your protocol (find that End-Tidal CO2 monitor), and ensure that you have enough staff.  This always seems to occur when you are short staffed, with 34 in the waiting room, and two other full sepsis work-ups occurring. Additionally, you need to consider how long the child will be in your department after the procedure.  And then go back and ask when the last time the kid ate something was.

This often leads to many painful procedures (ex., lumbar puncture, incision and drainage) being done with Brutane. Interestingly, dentists don’t have the luxury of using Brutane – they might lose a finger – so they have maximized use of a very effective sedation strategy: Nitrous Oxide.

So the next time you are getting ready to do a “minor” procedure and begin to contemplate using a benzo and ask for extra hands to hold the patient… stop… and get the Laughing Gas!

Who Can’t Have Nitrous?

  • Anyone who is having respiratory distress (obviously)
  • Anyone who has a Pneumothorax, Bowel Obstruction, or Pulmonary Blebs
    • Nitrous has the ability to diffuse from the bloodstream into air-filled cavities faster than nitrogen and will cause these cavities to expand dramatically… potentially critically.
  • Patient’s with B12 deficiency
    • Nitrous interfers with B12 and folate metabolism…. I’m not smart enough to remember the biochemical reason for this one.
  • Relatively contraindicated in pregnant patients
    • Known to have teratogenic effects.
    • Bigger issue with your staff… make sure no one who is pregnant is in the room.

Who Won’t Nitrous Work On?

  • Essentially those who won’t take it.
    • If the patient is uncooperative … and won’t keep the mask on… it won’t work.
    • If the patient is going to cry vigorously… and you use a nasal mask to deliver the Nitrous… then the kids will be breathing out of his/her mouth and it won’t work.

Why Use Nitrous?

  • It is safe!
  • It works!
    • It provides analgesia, anxiolysis, and anesthesia! (THE BIG THREE!)
    • Analgesic properties similar to opiates.
    • Anxiolytic properties like benzos.
    • No FASTING Necessary!
      • OK, so this still may be dependent upon your hospital protocols, but…
      • The National Guideline Clearinghouse notes the following:
        • “Fasting is not needed for:
          • Minimal sedation
          • Sedation with nitrous oxide (in oxygen)
          • Moderate sedation during which the child or young person will maintain verbal contact with the healthcare professional”
      • Plus you can always determine that the procedure was an emergency and the risk:benefit ratio is in favor of performing the procedures.
  • It’s Fast!
    • Again, it diffuses fast… so it doesn’t take long to see an effect.
    • Equally important is the fact that once you turn it off, the effect of nitrous stops.
    • Additionally, there is no residual effect… so they don’t remain intoxicated, stumbling around and occupying your room for hours!

 Zier JL, Liu M. Safety of High-Concentration Nitrous Oxide by Nasal Mask for Pediatric Procedural Sedation. Pediatr Emerg Care 2011; 27: 1107-1112.

National Institute for Health and Clinical Excellence (NICE). Sedation in children and young people. Sedation for diagnostic and therapeutic procedures in children and young people. London (UK): National Institute for Health and Clinical Excellence (NICE); 2010 Dec. 30 p. (Clinical guideline; no. 112).

Sean M. Fox
Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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  1. Hi Dr. Fox my son is 2 years old. He gets croup all the time, he starts off with a fever, the first day, runny nose the second day, the third day the runny nose will stop, the fourth day he will cough maybe 4 times all day. the fifth day he is coughing more and the sixth day his cough is full blown, he coughs every 5 to 10 to 15 seconds all day every day and does stop. We have had to rush him to the ER because he is struggling to breath, he is coughing so violent that sometimes he throws up and continues to cough after he throws up. He gets an IV because by the 9 or 10th day he is dehydrated. I dont have a problem with the croup is the cough that is so aggressive. He has a bronchoscopy, Laryngoschopy and scheduled. Where is the stupid cough comming

    • I am sorry to hear of your son’s illness. I obviously cannot comment specifically about any person’s specific condition or symptoms, but what I would say is that it sounds like you are doing all of the correct things. Discuss your concerns openly with your child’s pediatrician and specialists who did the bronchoscopy.
      All the best,

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