Lit Matters 3: Nitrous oxide for pediatric procedural sedation

Nitrous oxide provides rapid-on, rapid-off pediatric procedural sedation with a strong safety record in the ED. In children needing laceration repair or other brief procedures, adding intranasal fentanyl may deepen sedation but does not appear to improve overall success and does increase vomiting.

Nitrous Oxide Pediatric Sedation

• High procedural success: Nitrous oxide achieved successful pediatric procedural sedation in 97.4% of 831 ED cases, reinforcing it as a reliable option for short, painful procedures.
• Light to moderate sedation: The typical sedation depth was mild on the UMSS, and moderate sedation was reachable without IV access, a practical point we get into in the episode.
• Serious safety signal: No significant adverse events were reported across a decade of use, supporting nitrous oxide as a low-risk ED sedation strategy when patients are appropriately selected.
• Vomiting as main tradeoff: Vomiting was the dominant minor adverse event, and the odds rose with higher nitrous oxide concentrations, longer exposure, deeper sedation, and added intranasal fentanyl.
• Fentanyl add-on effect: Combining intranasal fentanyl with nitrous oxide was associated with deeper sedation but not better overall procedural success, making the analgesia-versus-emesis tradeoff the key decision.
• Mask tolerance limitation: Most failed sedations were not pharmacologic failures at all but inability to tolerate the facemask, a practical barrier that matters at the bedside and comes up in the chapter.