Nitrous Oxide and Intranasal Fentanyl for Sedation

I'm not sure about this.
Clay Smith
Intranasal (IN) fentanyl plus nitrous oxide (N2O) for sedation has two advantages: rapid recovery time and no IV access.  This was a prospective study, with the patient as his/her own control, comparing pain and anxiety before and during fracture reduction, using the above drugs for sedation.  Faces pediatric pain score was unchanged, but another was markedly worse during the procedure (FLACC score, recorded by observers).  Patients were asked to rate pain during the procedure using the Faces scale, but most were amnestic, which likely led to the null effect of this score. This was a small study.  Twelve percent had vomiting.  More kids seemed agitated and in pain, yet remarkably patient and provider satisfaction scores were high.  I'm definitely not sold on this approach, and I totally disagree with the authors' conclusion that, "IN fentanyl and N2O is effective and safe."

Spoon Feed
Intranasal fentanyl and N2O was a rapid way to perform pediatric sedation with no IV, but more patients cried, grimaced, and kicked during the procedure and 12% vomited.

Source
Intranasal fentanyl and inhaled nitrous oxide for fracture reduction: The FAN observational study  Am J Emerg Med. 2017 May;35(5):710-715. doi: 10.1016/j.ajem.2017.01.004. Epub 2017 Jan 5.

Peer Review and Commentary
Thomas Davis
I wonder how many children cry, grimace, and kick while obtaining IV access. Nitrous likely has a role in procedural sedation. Unfortunately, when and how to use it remains unclear. Maybe digital or hematoma blocks would have been a better pain adjunct than IN fentanyl.