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Original article

Vol. 149 No. 0910 (2019)

Ketamine procedural analgosedation before and after introducing nitrous oxide 70% in a paediatric emergency department

  • Michelle Seiler
  • Georg Staubli
Cite this as:
Swiss Med Wkly. 2019;149:w20027



The spectrum of agents available for procedural analgosedation (PAS) in paediatric emergency departments (EDs) has increased over the last few decades, yet the pharmacological agents most used in our ED are ketamine and nitrous oxide (N2O). The aim of this study was to assess which patient characteristics in an ambulatory setting were associated with physicians selecting N2O 70% or ketamine as the sedating agent in our paediatric ED, after N2O 70% was introduced.


Patients aged 0 to 16 years who received PAS in a tertiary children’s hospital ED in 2007 (before N2O 70% implementation) and 2016 (after N2O implementation) were included in this retrospective, single-centre cohort study. Data were collected by querying the outpatient ED database for N2O 70% and ketamine. Obtained data included patient characteristics, procedure type and sedation medication.


1168 patients were included; 59.8% (699) were male. The overall mean age was 6.3 (± 4.0) years; in the ketamine subgroup, 4.6 (± 4.0) years and in the N2O subgroup, 7.8 (± 3.4) years. In 2016, N2O was chosen in 86.7% of cases involving children aged 4 to 16 years, compared to 28.5% of cases involving children three years and younger. The most apparent shift from ketamine to N2O occurred in patients with displaced upper extremity fractures, with an increase of N2O 70% from 0% in 2007 to 90.8% in 2016.


The use of ketamine PAS shifted to N2O PAS, especially in children older than three years and for the reduction of displaced upper extremity fractures.


  1. Pearce JI, Brousseau DC, Yan K, Hainsworth KR, Hoffmann RG, Drendel AL. Behavioral Changes in Children After Emergency Department Procedural Sedation. Acad Emerg Med. 2018;25(3):267–74. doi:.
  2. Bennett J, DePiero A, Kost S. Tailoring Pediatric Procedural Sedation and Analgesia in the Emergency Department: Choosing a Regimen to Fit the Situation. Clin Pediatr Emerg Med. 2010;11(4):274–81. doi:.
  3. Innes G, Murphy M, Nijssen-Jordan C, Ducharme J, Drummond A. Procedural sedation and analgesia in the emergency department. Canadian Consensus Guidelines. J Emerg Med. 1999;17(1):145–56. doi:.
  4. Coté CJ, Wilson S ; American Academy of Pediatrics; American Academy of Pediatric Dentistry; Work Group on Sedation. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update. Pediatrics. 2006;118(6):2587–602. doi:.
  5. Hartling L, Milne A, Foisy M, Lang ES, Sinclair D, Klassen TP, et al. What Works and What’s Safe in Pediatric Emergency Procedural Sedation: An Overview of Reviews. Acad Emerg Med. 2016;23(5):519–30. doi:.
  6. Miller AF, Monuteaux MC, Bourgeois FT, Fleegler EW. Variation in Pediatric Procedural Sedations Across Children’s Hospital Emergency Departments. Hosp Pediatr. 2018;8(1):36–43. doi:.
  7. Mace SE, Barata IA, Cravero JP, Dalsey WC, Godwin SA, Kennedy RM, et al., Emergency Nurses Association. Clinical policy: evidence-based approach to pharmacologic agents used in pediatric sedation and analgesia in the emergency department. J Pediatr Surg. 2004;39(10):1472–84. doi:.
  8. Krauss B, Green SM. Procedural sedation and analgesia in children. Lancet. 2006;367(9512):766–80. doi:.
  9. Kost S, Roy A. Procedural Sedation and Analgesia in the Pediatric Emergency Department: A Review of Sedative Pharmacology. Clin Pediatr Emerg Med. 2010;11(4):233–43. doi:.
  10. Bergman SA. Ketamine: review of its pharmacology and its use in pediatric anesthesia. Anesth Prog. 1999;46(1):10–20.
  11. Martin HA, Noble M, Wodo N. The Benefits of Introducing the Use of Nitrous Oxide in the Pediatric Emergency Department for Painful Procedures. J Emerg Nurs. 2018;44(4):331–5. doi:.
  12. Duchicela SI, Meltzer JA, Cunningham SJ. A randomized controlled study in reducing procedural pain and anxiety using high concentration nitrous oxide. Am J Emerg Med. 2017;35(11):1612–6. doi:.
  13. Seiler M, Landolt MA, Staubli G. Nitrous Oxide 70% for Procedural Analgosedation in a Pediatric Emergency Department With or Without Intranasal Fentanyl?: Analgesic Efficacy and Adverse Events if Combined With Intranasal Fentanyl. Pediatr Emerg Care. 2017;0000000000001213:1. doi:.
  14. Babl FE, Belousoff J, Deasy C, Hopper S, Theophilos T. Paediatric procedural sedation based on nitrous oxide and ketamine: sedation registry data from Australia. Emerg Med J. 2010;27(8):607–12. doi:.
  15. Sacchetti A, Stander E, Ferguson N, Maniar G, Valko P. Pediatric Procedural Sedation in the Community Emergency Department: results from the ProSCED registry. Pediatr Emerg Care. 2007;23(4):218–22. doi:.
  16. Cravero JP, Blike GT, Beach M, Gallagher SM, Hertzog JH, Havidich JE, et al.; Pediatric Sedation Research Consortium. Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the Pediatric Sedation Research Consortium. Pediatrics. 2006;118(3):1087–96. doi:.
  17. Staubli G, Baumgartner M, Sass JO, Hersberger M. Laughing Gas in a Pediatric Emergency Department-Fun for All Participants: Vitamin B12 Status Among Medical Staff Working With Nitrous Oxide. Pediatr Emerg Care. 2016;32(12):827–9. doi:.
  18. Merritt C. Fear and loathing in the ER: managing procedural pain and anxiety in the Pediatric Emergency Department. R I Med J (2013). 2014;97(1):31–4.
  19. Poonai N, Canton K, Ali S, Hendrikx S, Shah A, Miller M, et al. Intranasal ketamine for procedural sedation and analgesia in children: A systematic review. PLoS One. 2017;12(3):e0173253. doi:.

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