Nitrous Oxide

What is nitrous oxide?

What are the side effects?

Before nitrous oxide, what did children receive as a sedative?

How long do most children receive nitrous oxide during a test or procedure?

How safe is nitrous oxide?

What is needed to properly maintain equipment?

Are there exposure risks to staff?

Why has nitrous oxide been available only in detist offices, not medical settings?

Is nitrous oxide used for medical care outside the U.S.?

What is nitrous oxide?

Nitrous oxide, a blend of two gases, nitrous oxide and oxygen, is a mild, fast-acting, safe sedative. The calming effect of nitrous oxide reduces anxiety and pain, sometimes causing patients to forget the procedure.

What are the side effects?

Children’s research on more than 4,800 patients from 2004 to 2008 showed that nitrous oxide has few side effects. Just over five percent of patients sedated with nitrous oxide experienced minor side effects. The most common were vomiting (2.5%) or nausea (2%). In comparison, up to 12 percent of patients have been reported to experience side effects from the oral sedative previously used for many of these procedures.

Before nitrous oxide, what did children receive as a sedative?

Some patients received the sedative Versed, which stayed in their systems for six hours and sometimes caused belligerent and combative behavior. Children who received Versed could not return to school after their procedure. Given the side effects, many parents decided against using Versed. Another sedative, Propofol, requires an IV for administration, causing additional distress to the patient.

How long do most children receive nitrous oxide during a test or procedure?

The average length of use at Children’s is 11 minutes. A nurse monitors the child at all times as they receive nitrous oxide. For longer tests or procedures, nurses adjust the amount of sedation based on the length of the procedure and the child’s need for pain management.

How safe is nitrous oxide?

It’s extremely safe. Among medical gases, nitrous oxide is considered to be very mild. Children’s equipment to administer nitrous oxide is fail-safe, so an overdose is impossible.

What is needed to properly maintain equipment?

Equipment should be inspected prior to clinical use. Ongoing maintenance (e.g., quarterly leak checks) can be coordinated by the hospital biomedical department. Flowmeter checks are routinely performed per manufacturer guidelines. Most recommend monthly checks (e.g., non-rebreathing valve check, emergency air valve check). Appropriate function of the fail-safe valve is confirmed with each use. Equipment is cleaned per infection control departmental guidelines.

Are there exposure risks to staff?

Risk to health care professionals administering nitrous oxide remains open for debate. Most data on adverse effects of occupational exposure were collected before scavenging systems were developed to decrease environmental nitrous oxide during administration. Good administration technique, proper equipment maintenance and appropriate use of the scavenging system will minimize staff occupational exposure. The hospital safety officer can ensure that regulatory standards from the National Institute of Occupational Safety and Health (NIOSH) and/or the American Conference of Governmental Industrial Hygienists (ACGIH) are met.

Why has nitrous oxide been available only in dentist offices, not medical settings?

Traditionally, dentists—not physicians—have been trained in the use of this gas. Although the first article on nitrous oxide use for general pediatric procedures appeared in the Journal of the American Medical Association 25 years ago, its use has remained mostly in dentistry. There are a few emergency departments that use nitrous, and the numbers continue to grow.

Is nitrous oxide used for medical care outside the U.S.?

Yes, it’s used in Europe, Israel, Australia, and New Zealand.

By Judith, a patient mom

Daniel is our 3 year old who was diagnosed by the doctors as having severe Hemophilia B and described by the nurses as having a “strong personality.” To date, he hasn’t had any joint bleeds or spontaneous bleeds so we haven’t gone the route of prophylaxis. This means that when he does have a bleed, we either head down to the clinic or just as often (because he likes to bleed on nights, weekends and holidays) to the Children’s Emergency Room in St. Paul. That is okay with him - he isn’t picky; the clinic has really cool toys and the ER has Stephanie who will play endless pretend games involving dinosaurs and tigers!

Several months ago, we went to the Emergency Room. My 15 year-old daughter Kelsey was with me. Because this was going to be her first time seeing Daniel get factor, I had spent time preparing her for how Daniel was going to react and by letting her know that he would probably get very upset.

Once we got back into a room, we were offered the option of giving Daniel some nitrous oxide. My own experience with nitrous oxide at the dentist’s office made me think that this might be a good idea because it would make him more relaxed. The nurse proceeded to go through a checklist with me to make sure that nitrous was a good option for him. Daniel was able to choose a “flavor” which was rubbed inside the mask (the elephant mask!) and he then proceeded to take some deep breaths. It was amazing!! We made it through the entire infusion without a single tear (although not without hearing various animal sounds and a rendition of “Rudolph the Red Nose Reindeer”). Kelsey was probably thinking that

I had completely exaggerated the trauma of past visits! I hadn’t – this was by far our best experience with getting an infusion as evidenced by the fact that it took only three staff to administer the factor versus five!

Since that first experience, we have had nitrous oxide in the clinic and just last week, in the ER again. Each time, the nitrous oxide has helped to make the process easier on all of us.

As Daniel continues to grow and mature, he’ll be able to make his own decisions on how he gets his factor. For now, the nitrous oxide makes things go more smoothly. I’m glad that this has become an option in both the ER and in the clinic.

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Video of the Sedation Program (4:10)

Children’s Hospitals and Clinics of Minnesota pioneered the development of a nurse-administered nitrous oxide sedation program designed to provide greater comfort for pediatric patients as they undergo stressful procedures. The following information highlights the unique components of the program, and offers tools and resources based on the success of Children’s program.

Why nitrous oxide?

Nitrous oxide (N2O) is a mild sedative anxiolytic, with analgesic and amnestic properties. Dentists have taken advantage of these properties since the 1840s. Although nitrous oxide sedation has been practiced in health care settings across Europe and Australia for years, studies on the use of nitrous oxide in pediatric patients in the United States began to appear in journals approximately 25 years ago (Griffen, G.C., Campbell, V.D., Jones, R. “Nitrous oxide-oxygen sedation for minor surgery – experience in a pediatric setting” JAMA 1981, Vol. 245:2411-3). More recent reports and studies conducted at Children’s Hospitals and Clinics of Minnesota confirm the safety and efficacy of nitrous oxide for pediatric patients.

Nitrous oxide produces “conscious sedation” with the patient remaining awake but calm throughout its administration. When children are relaxed, they are able to follow verbal instructions. Despite their “awake” state, up to 80 percent of children are unable to recall a painful procedure when nitrous oxide is used for sedation/analgesia.

Side effects

The relief provided by nitrous oxide administration is not accompanied by the side effects associated with other sedatives, including combativeness, which can occur in patients coming out of sedation. Additionally, when compared to other commonly used sedation drugs, nitrous oxide is shorter acting. Many children can walk out of their hospital visit without assistance after a brief recovery, and some older patients can actually return to activities, such as school, after a medical procedure.

In the first four years of the program, Children’s studied more than 4,800 patients for side effects and outcomes. The study revealed mild side effects that were well tolerated. Just over five percent of children experienced nausea or vomiting, which resolved quickly when the nitrous was discontinued.