The Role of Nitrous Oxide in Minor Pediatric Procedures in the Emergency Department: A Systematic Review

Background: Pediatric patients undergoing minor, but painful procedures in an Emergency Department (ED) need adequate relief of pain and distress to prevent long term negative effects and adversely impact procedures. Inhaled nitrous oxide (N2O) is a needle-free pain management option. We conducted a systematic review to determine whether N2O is as effective as local anesthesia in minor procedures. The purpose of this study was to evaluate available evidence regarding analgesic effectiveness of N2O in pediatric patients. Methods: We searched MEDLINE, Embase, Cochrane and Cinahl databases for controlled trials published in English with pediatric patients in an ED treated with N2O compared to local anesthesia and with pain as primary outcome. Adverse events was one of the secondary outcomes. The GRADE system was used to rate the overall quality of evidence. Results: We included seven studies with a total of 371 patients. Two studies showed N2O was equally effective in pain treatment as local anesthesia. Five studies showed N2O combined with local anesthesia is more effective in reducing pain than local anesthesia alone. None of the included studies reported major adverse effects. The quality of evidence is low. Conclusions: N2O can have an important contribution in pain management, but should be combined with local anesthesia for optimal pain management in pediatric patients undergoing minor, but painful procedures in an ED. Level of Evidence: IV.