Occupational Health Stewardship: Thoughts on Current and Future Use of Nitrous Oxide in Pediatric Sedation
Main Article Content
Abstract
Nitrous oxide is a well-tolerated, colorless, odorless gas with medical applications that facilitate procedural sedation and operative care. Like volatile inhalational agents used by anesthesia, nitrous oxide poses occupational health hazards to serially exposed clinicians and, as a greenhouse gas, has environmental consequences. While the anesthesia community has encouraged significant reduction or elimination of nitrous oxide, non-anesthesiologists supporting pediatric procedural sedation outside of the operating room continue to value the use of nitrous oxide, as it is safely applied without requirement for advanced airway devices and does not compound the patient’s recovery from subsequently administered sedatives. Responsible use of nitrous oxide entails optimization of those aspects of gas delivery practices that are modifiable, and sedation teams can benefit from collaboration with occupational and environmental health experts. Following a recent longitudinal process improvement project with Industrial Hygiene, we present an editorial discussion on three concepts that influence our perspective on current and future use of nitrous oxide for procedural sedation in the pediatric population. Specifically, we discuss the risk of leak inherent to all gas delivery systems, present options to mitigate nitrous oxide’s carbon footprint, and explore the growing demand for pediatric sedation services outside of the traditional operating room.
Article Details
How to Cite
KICKER, Jennifer S.; GARREN, Benjamin N..
Occupational Health Stewardship: Thoughts on Current and Future Use of Nitrous Oxide in Pediatric Sedation.
Medical Research Archives, [S.l.], v. 14, n. 1, jan. 2026.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/7205>. Date accessed: 03 feb. 2026.
doi: https://doi.org/10.18103/mra.v14i1.7205.
Section
Editorial
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
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doi:10.1111/pan.14695.
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doi:10.1111/anae.16407.
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21. Romano F, Brändle G, Abplanalp-Marti O, Gualtieri R, Sahyoun C. Procedural sedation and analgesia in Swiss Pediatric Emergency Departments: a national subgroup analysis of a European cross-sectional survey. Eur J Pediatr. 2024;183(10):4579-4583. doi:10.1007/s00431-024-05701-5.
22. Buhre W, Disma N, Hendrickx J, et al. European Society of Anaesthesiology Task Force on Nitrous Oxide: a narrative review of its role in clinical practice. Br J Anaesth. 2019;122(5):587-604. doi:10.1016/j.bja.2019.01.023.
23. Coté CJ, Wilson S, AMERICAN ACADEMY OF PEDIATRICS, AMERICAN ACADEMY OF PEDIATRIC DENTISTRY. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatrics. 2016;138(1):e20161212. doi:10.1542/peds.2016-1212.
24. Barbi E, Badina L, Marchetti F, et al. Attitudes of children with leukemia toward repeated deep sedations with propofol. J Pediatr Hematol Oncol. 2005;27(12):639-643. doi:10.1097/01.mph.0000193474.06870.9c.
25. Duffy EA, Adams T, Thornton CP, Fisher B, Misasi J, McCollum S. Evidence-Based Recommendations for the Appropriate Level of Sedation to Manage Pain in Pediatric Oncology Patients Requiring Procedures: A Systematic Review From the Children’s Oncology Group. J Pediatr Oncol Nurs. 2020;37(1):6-20. doi:10.1177/1043454219858610.
26. Veeravalli S, Michaud M, Colton J, et al. Adapting Perioperative Care for Neurodivergent Children - A Scoping Review. J Pediatr Surg. 2025;60(5):162224. doi:10.1016/j.jpedsurg.2025.162224.
27. Kamat PP, Bryan LN, McCracken CE, Simon HK, Berkenbosch JW, Grunwell JR. Procedural sedation in children with autism spectrum disorders: A survey of current practice patterns of the society for pediatric sedation members. Paediatr Anaesth. 2018;28(6):552-557. doi:10.1111/pan.13387.
28. Havidich JE, Cravero JP. The current status of procedural sedation for pediatric patients in out-of-operating room locations. Curr Opin Anaesthesiol. 2012;25(4):453-460. doi:10.1097/ACO.0b013e32835562d8.
29. Ciavola L, Sogni F, Mucci B, et al. Analgosedation in Pediatric Emergency Care: A Comprehensive Scoping Review. Pharmaceuticals (Basel). 2024;17(11):1506.
doi:10.3390/ph17111506.
30. Kamat PP, McCracken CE, Simon HK, et al. Trends in Outpatient Procedural Sedation: 2007-2018. Pediatrics. 2020;145(5):e20193559. doi:10.1542/peds.2019-3559.
31. Srinivasan M, Bhaskar S, Carlson DW. Variation in Procedural Sedation Practices Among Children’s Hospitals. Hosp Pediatr. 2015;5(3):148-153. doi:10.1542/hpeds.2014-0090.
32. Sahyoun C, Cantais A, Gervaix A, et al. Pediatric procedural sedation and analgesia in the emergency department: surveying the current European practice. Eur J Pediatr. 2021;180(6):1799-1813. doi:10.1007/s00431-021-03930-6.
33. Obara S. Involvement of anesthesiologists in pediatric sedation and analgesia outside the operating room in Japan: is it too late, or is there still time? J Anesth. 2025;39(2):311-317. doi:10.1007/s00540-024-03431-4.
34. Langhan ML, Mallory M, Hertzog J, Lowrie L, Cravero J, Pediatric Sedation Research Consortium. Physiologic monitoring practices during pediatric procedural sedation: a report from the Pediatric Sedation Research Consortium. Arch Pediatr Adolesc Med. 2012;166(11):990-998.
doi:10.1001/archpediatrics.2012.1023.
35. Khurmi N, Patel P, Kraus M, Trentman T. Pharmacologic Considerations for Pediatric Sedation and Anesthesia Outside the Operating Room: A Review for Anesthesia and Non-Anesthesia Providers. Paediatr Drugs. 2017;19(5):435-446.
doi:10.1007/s40272-017-0241-5.
36. Croughan S, Barrett M, O’Sullivan R, Beegan A, Blackburn C. Safety and efficacy of a nitrous oxide procedural sedation programme in a paediatric emergency department: a decade of outcomes. Emerg Med J. 2024;41(2):76-82. doi:10.1136/emermed-2022-212931.
https://www.who.int/health-topics/occupational-health. Accessed October 20, 2005.
2. Duplechan L. How Health Care Organizations Can Be Stewardship Leaders. AMA J Ethics. 2022;24(10):E1013-E1021. Published 2022 Oct 1. doi:10.1001/amajethics.2022.1013.
3. Occupational Safety and Health Administration. OSHA Occupational Chemical Database: Nitrous Oxide.
https://www.osha.gov/chemicaldata/4. Accessed October 20, 2025.
4. Kicker JS, Timbie CY, Kline SL. Dosimetry as a Lagging Indicator of Occupational Exposure to Nitrous Oxide in Pediatric Sedation: A Collaborative Process Improvement Project With Industrial Hygiene. Mil Med. 2025;190(7-8):e1765-e1771. doi:10.1093/milmed/usae523.
5. Wilson S, Gosnell ES. Survey of American Academy of Pediatric Dentistry on Nitrous Oxide and Sedation: 20 Years Later. Pediatr Dent. 2016;38(5):385-392.
6. Tsze DS, Mallory MD, Cravero JP. Practice Patterns and Adverse Events of Nitrous Oxide Sedation and Analgesia: A Report from the Pediatric Sedation Research Consortium. J Pediatr. 2016;169:260-5.e2. doi:10.1016/j.jpeds.2015.10.019.
7. U.S. Department of Health and Human Services, Food and Drug Administration (2017). Deemed Granted: Medical Gas Certification Request, Nitrous Oxide.
https://www.accessdata.fda.gov/drugsatfda_docs/appletter/2017/209989MG_ltr.pdf. Accessed October 31, 2025.
8. Olfert SM. Reproductive outcomes among dental personnel: a review of selected exposures. J Can Dent Assoc. 2006;72(9):821-825.
9. Isserman RS, Yuan I, Elliott EM, et al. Reducing the environmental impact of mask inductions in children: A quality improvement report. Paediatr Anaesth. 2023;33(9):728-735.
doi:10.1111/pan.14695.
10. Southall P, Shelton C, Chakera A. Consensus on decommissioning piped nitrous oxide from UK and Ireland operating theatre suites: a rational approach to an increasingly ignoble gas. Anaesthesia. 2024;79(12):1274-1279.
doi:10.1111/anae.16407.
11. Seglenieks R, Wong A, Pearson F, McGain F. Discrepancy between procurement and clinical use of nitrous oxide: waste not, want not. Br J Anaesth. 2022;128(1):e32-e34. doi:10.1016/j.bja.2021.10.021.
12. Royal College of Anaesthetists, Association of Anaesthetists, College of Anaesthesiologists of Ireland, Association of Paediatric Anaesthetists of Great Britain and Ireland, Obstetric Anaesthetists’ Association. Consensus Statement on the Removal of Pipeline Nitrous Oxide in the United Kingdom and Republic of Ireland. 2024.
https://rcoa.ac.uk/media/43071. Accessed October 22, 2025.
13. American Society of Anesthesiologists, Committee on Environmental Health. Greening the Operating Room.
https://www.asahq.org/about-asa/governance-and-committees/asa-committees/environmental-sustainability/greening-the-operating-room. Accessed October 23, 2025.
14. Gordon DW. Environmental impact of anesthetic drugs. Curr Opin Anaesthesiol. 2024;37(4):379-383. doi:10.1097/ACO.0000000000001395.
15. U.S. Environmental Protection Agency. Climate Change Indicators: Atmospheric Concentrations of Greenhouse Gases, Figure 3.
https://www.epa.gov/climate-indicators/climate-change-indicators-atmospheric-concentrations-greenhouse-gases. Accessed October 23, 2025.
16. Schulte PA, McKernan LT, Heidel DS, et al. Occupational safety and health, green chemistry, and sustainability: a review of areas of convergence. Environ Health. 2013;12:31. Published 2013 Apr 15.
doi:10.1186/1476-069X-12-31.
17. Varughese S, Ahmed R. Environmental and Occupational Considerations of Anesthesia: A Narrative Review and Update. Anesth Analg. 2021;133(4):826-835. doi:10.1213/ANE.0000000000005504.
18. Boiano JM, Steege AL. Precautionary practices for administering anesthetic gases: A survey of physician anesthesiologists, nurse anesthetists and anesthesiologist assistants. J Occup Environ Hyg. 2016;13(10):782-793. doi:10.1080/15459624.2016.1177650.
19. Gaines M, Pinder A, MacCarrick T, Khan-Perez J, Fang L, Shelton C. Bench experiments to investigate the effect of nitrous oxide cracking technology in ideal circumstances. Anaesthesia. 2022 Feb;77(2):225-226. doi: 10.1111/anae.15632.
20. Pinder A, Fang L, Fieldhouse A, et al. Implementing nitrous oxide cracking technology in the labour ward to reduce occupational exposure and environmental emissions: a quality improvement study. Anaesthesia. 2022;77(11):1228-1236. doi:10.1111/anae.15838.
21. Romano F, Brändle G, Abplanalp-Marti O, Gualtieri R, Sahyoun C. Procedural sedation and analgesia in Swiss Pediatric Emergency Departments: a national subgroup analysis of a European cross-sectional survey. Eur J Pediatr. 2024;183(10):4579-4583. doi:10.1007/s00431-024-05701-5.
22. Buhre W, Disma N, Hendrickx J, et al. European Society of Anaesthesiology Task Force on Nitrous Oxide: a narrative review of its role in clinical practice. Br J Anaesth. 2019;122(5):587-604. doi:10.1016/j.bja.2019.01.023.
23. Coté CJ, Wilson S, AMERICAN ACADEMY OF PEDIATRICS, AMERICAN ACADEMY OF PEDIATRIC DENTISTRY. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatrics. 2016;138(1):e20161212. doi:10.1542/peds.2016-1212.
24. Barbi E, Badina L, Marchetti F, et al. Attitudes of children with leukemia toward repeated deep sedations with propofol. J Pediatr Hematol Oncol. 2005;27(12):639-643. doi:10.1097/01.mph.0000193474.06870.9c.
25. Duffy EA, Adams T, Thornton CP, Fisher B, Misasi J, McCollum S. Evidence-Based Recommendations for the Appropriate Level of Sedation to Manage Pain in Pediatric Oncology Patients Requiring Procedures: A Systematic Review From the Children’s Oncology Group. J Pediatr Oncol Nurs. 2020;37(1):6-20. doi:10.1177/1043454219858610.
26. Veeravalli S, Michaud M, Colton J, et al. Adapting Perioperative Care for Neurodivergent Children - A Scoping Review. J Pediatr Surg. 2025;60(5):162224. doi:10.1016/j.jpedsurg.2025.162224.
27. Kamat PP, Bryan LN, McCracken CE, Simon HK, Berkenbosch JW, Grunwell JR. Procedural sedation in children with autism spectrum disorders: A survey of current practice patterns of the society for pediatric sedation members. Paediatr Anaesth. 2018;28(6):552-557. doi:10.1111/pan.13387.
28. Havidich JE, Cravero JP. The current status of procedural sedation for pediatric patients in out-of-operating room locations. Curr Opin Anaesthesiol. 2012;25(4):453-460. doi:10.1097/ACO.0b013e32835562d8.
29. Ciavola L, Sogni F, Mucci B, et al. Analgosedation in Pediatric Emergency Care: A Comprehensive Scoping Review. Pharmaceuticals (Basel). 2024;17(11):1506.
doi:10.3390/ph17111506.
30. Kamat PP, McCracken CE, Simon HK, et al. Trends in Outpatient Procedural Sedation: 2007-2018. Pediatrics. 2020;145(5):e20193559. doi:10.1542/peds.2019-3559.
31. Srinivasan M, Bhaskar S, Carlson DW. Variation in Procedural Sedation Practices Among Children’s Hospitals. Hosp Pediatr. 2015;5(3):148-153. doi:10.1542/hpeds.2014-0090.
32. Sahyoun C, Cantais A, Gervaix A, et al. Pediatric procedural sedation and analgesia in the emergency department: surveying the current European practice. Eur J Pediatr. 2021;180(6):1799-1813. doi:10.1007/s00431-021-03930-6.
33. Obara S. Involvement of anesthesiologists in pediatric sedation and analgesia outside the operating room in Japan: is it too late, or is there still time? J Anesth. 2025;39(2):311-317. doi:10.1007/s00540-024-03431-4.
34. Langhan ML, Mallory M, Hertzog J, Lowrie L, Cravero J, Pediatric Sedation Research Consortium. Physiologic monitoring practices during pediatric procedural sedation: a report from the Pediatric Sedation Research Consortium. Arch Pediatr Adolesc Med. 2012;166(11):990-998.
doi:10.1001/archpediatrics.2012.1023.
35. Khurmi N, Patel P, Kraus M, Trentman T. Pharmacologic Considerations for Pediatric Sedation and Anesthesia Outside the Operating Room: A Review for Anesthesia and Non-Anesthesia Providers. Paediatr Drugs. 2017;19(5):435-446.
doi:10.1007/s40272-017-0241-5.
36. Croughan S, Barrett M, O’Sullivan R, Beegan A, Blackburn C. Safety and efficacy of a nitrous oxide procedural sedation programme in a paediatric emergency department: a decade of outcomes. Emerg Med J. 2024;41(2):76-82. doi:10.1136/emermed-2022-212931.