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Entonox (nitrous oxide)

Discussion in 'General Issues and Discussion Forum' started by twirly, Jun 12, 2008.

  1. twirly

    twirly Well-Known Member

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    Hi all,

    I was uncertain in which forum this thread should be placed or indeed if it has been covered before.

    My question is, do any of us use entonox for sedation?

    From the material I have read online (my lovely Google) ;) there seems to be no reason why we do not utilise this gas mixture to alleviate pain & anxiety in certain situations eg. nail surgery & painful injections.

    It has been noted in the following article that it is recommended that individuals do not drive for 12 hours post use but even if that is the case then children or needle phobic patients would be ideal clients if given the choice.

    It is identified as very safe (barring certain exclusions eg. head injury or risk of pneumothorax, air embolism etc.).

    I am interested to hear anyones views either for or against.

    Attached following article:

  2. DAVOhorn

    DAVOhorn Well-Known Member

    Re: Entonox

    Dear All,

    Appropriate Safety Precautions.

    Nitrous Oxide Gas ask your local car hoon and watch his face light up . This is used in Dragsters to supplement fuel to get outrageous power.

    It is highly flammable.:butcher:

    Now add Oxygen which is an oxidising agent and you have an even more flammable gas.:deadhorse:

    I used nitrous oxide gas years ago as a freezing agent for the tt of VP.

    Not many people in the building realised the risks of using such a gas and used to ask why we hada pipe to vent the spent gas to the outside of the building. Worying as it meant many had no idea that myself and the dental clinic used such a flammable gas. :boohoo:

    So please make sure you understand the fire risks associated with this gas mixture.:sinking:

    regards David
  3. twirly

    twirly Well-Known Member

    Re: Entonox

    Hi Dave,

    I appreciate that risk factors should always be given consideration but if the appropriate protocols were in place would you consider the use of entonox as a sedative?

  4. posalafin

    posalafin Active Member

    Re: Entonox

    Entonox is a very effective drug, simple to use and vrtually no persistent side effects or contraindications (at least not in the podiatric office seting). It has been used widely in medical and dental practice for decades. The explosive dangers are no more than those that apply to having an oxygen cylinder in your practice. However there should be a scavenging system in place wherever etonox is used to prevent exposure to the gas by others in the room.

    Would be fanastic option for brief painful procedures, and especially for those podiatrists who manage acute injuries such as fractures that may need closed reduction & casting it would be an excellent drug to have available. Not really sure what the legalities are regarding its use by podiatrists in Australia but I do know that it has / still is used widely in Australian ambulance services and I understand that even some first aid organisations / occupational health first aiders / surf lifesavers are using it.
  5. twirly

    twirly Well-Known Member

    Re: Entonox

    I cannot understand why this drug (given the benefits) is not more widely used in Podiatric practice.

    I understand Dave is concerned RE: explosive/flammable potential but as posalafin identified, if oxygen is available in a clinic environment then surely health & safety issues including appropiate storage & disposal would already be in place.

    Still my question is, are any pods actually using entonox?

    If yes, is there access to appropriate training in its use?

    I'm sure I have mentioned previously that my daughter is needle phobic. Not shy, scared or a little worried. The sort of see a needle on a syringe, passing out & throwing up kinda scared witless.

    She required a very minor op. (partial nail avulsion) Would not permit me, colleagues or lord God almighty to inject L/A into her toe.

    She was booked privately into local hospital for general anaesthetic.
    Problem 1) G/A requires siting of needle usually into dorsum of hand to administer.
    Problem 2) Screaming 16 year old in hysterics while pod. surgery team & aneathetist look on.

    Solution 1) Aneasthetist in a moment of inspiration offers gas & air to calm her. Two whiffs of mask & tada..... shunt in place & child asleep.

    In truth I feel the g/a was unecessary as a l/a could easily be administered once she was calmed by the gas mix.

    Surely we all see patients who become so distressed at the thought of a relatively routine procedure that could be made so much less of a trial given the choice of such a simple solution.

    Any thoughts?
  6. Sez Osborne

    Sez Osborne Member

    Re: Entonox


    I know this thread hasn't been active for a while, but entonox use in Podiatry is a topic i have recently become very interested in.

    I'm a 3rd year student, and when i was on placement the NHS Pod department i was working in had a training day for their Podiatrists on the use of entonox in nail surgery.

    It was really interesting to see how easy entonox was to use and the positive effect it had on the patients, who as a result of the gas felt very little discomfort from the LA injections. There was one very nervous patient in particular who i am sure would not have gone through with the proceedure if he hadn't had entonox

    I have been researching entonox a bit and cant see that it is being used in Podiatry very much. As part of my 3rd year i have to produce a research proposal, and i was wondering about about seeing how useful/viable entonox is as pain releif for LA administration during nail surgery. if anyone has any thoughts or opinions or has used entonox in their practise i would be really interested to hear from you!

  7. G Flanagan

    G Flanagan Active Member

    Re: Entonox

    I work in a pod surg unit and we frequently give entonox to nervous patients before LA is given. DAVOHORN, watch that 15 blade, one slip your finger could be gone! seriously don't be so over protective! :boxing:
  8. twirly

    twirly Well-Known Member

    Re: Entonox

    Hello G Flanagan,

    Thank you for your post RE: Entonox use in Podiatry.

    I understand from your post that your team use entonox for procedures.

    If possible could you post your protocols for its use.

    I am very interested in the use of entonox in certain situations & appreciate its potential value in otherwise anxiety producing situations for patients.

    Kind regards,

    Mandy Brooks

    PS. Sez, I would also be very interested in your findings.

    Thank you.

    Mandy Brooks
  9. W J Liggins

    W J Liggins Well-Known Member

    Re: Entonox

    Hi Twirly

    Entonox was quite widely used in the early days of the Podiatry Association in the U.K. The reasons that most podiatric surgeons stopped using it were i) improved technique with L.A. and ii) patients requiring sedation were transferred to hospitals and sedated by Anaesthetists who tend to prefer G.A. or i/v sedation. I certainly did not hear of any adverse reactions from podiatric use of Entonox at the time , nor since.

    All the best

  10. twirly

    twirly Well-Known Member

    Re: Entonox

    Thank you Bill,

    May I also ask?

    Considering the needle phobic patient, would you consider the use of Entonox to be a viable consideration prior to injecting?

    Given that the syringe even in the most experienced hand would still evoke fear.

    Thank you once again.

  11. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Re: Entonox

    Its my understanding that podiatrists in Western Australia are allowed to use methoxyflurane for sedation in minor procedures etc.

    They had a short training course, and apparently it is very popular.

  12. twirly

    twirly Well-Known Member

    Re: Entonox

    Thank you LL,

    I have been trying to locate more information RE: The use of inhalation sedation.

    Google search led to Wikipedia:http://en.wikipedia.org/wiki/Methoxyflurane
    This was very helpful although it highlighted the use of Methoxyflurane is no longer permitted.

    Are you aware if Australian medical teams have access? As the article also mentioned:
    The links provided by Wikipedia would have been helpful but each one shows as 'Not available.'

    Determined to find more information I managed to locate another site:

    The articles available are very interesting although usually pertaining to Obstetrics.


    Should keep me occupied for hours. ;)

    Kind regards,

  13. W J Liggins

    W J Liggins Well-Known Member

    Re: Entonox

    Hi Twirly

    It happens that I don't use it because my practice does not require it. However, given that there are no known adverse reactions recorded (that I have been able to find), that the patient effectively self administers, that it is avantageous to the (nervous) patient, then why not?

    My comment pre-supposes that all consents are appropriate and signed, that insurance is checked and that Health and Safety measures are as required.

    All the best

  14. R.E.G

    R.E.G Active Member

    Re: Entonox

    I have recently used entonox to perform a PNA, without phenolisation, and No LA on the son of a community midwife, hence the Entonox.

    It was done without pain of fuss.

    On questioning the 12 year old afterwards his memories were vague, could not decide whether that was the Entonox or because he was a 12 year old lad.:confused:

    Big disadvantage, the equipment is abut £500, so how often in PP would I use it?
  15. posalafin

    posalafin Active Member

    Re: Entonox

    Hi Mandy

    Methoxyflurane is used extensively by all ambulance services in Australa for inhalational pain relief. It has been demonstrated in this setting to be an effective & safe analgesic.

    It was withdrawn from anaesthetic practice due to it nephrotoxic effects and the introduction of better inhalational anaesthetics such as sevoflurane. The kidney toxicity isn't such an issue in the short term use of methoxyflurane as the doses and duration of use are typically much less than in the anaesthetic setting.

    In having said that it is contraindicated in patients with established renal disease and in patients currently taking tetracycline antibiotics.


  16. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Re: Entonox

    ...as well as surf lifesavers, ski patrollers and mine operators in certain jurisdictions.

    If it is safe enough for non-health professionals to use - then there should be little argument from drug regulators for us to use it.

    If you're not in WA, write to your local Board.

  17. twirly

    twirly Well-Known Member

    Re: Entonox

    Thank you Bob,

    I appreciate that the costs are high (also including abiding by COSH standards & regulations for carrying potentially explosive gas etc) although if a clinic also kept O2 then safety & a supplier should already be in place to negotiate a reasonable fee.

    The cost (I imagine, I have not enquired as yet) should be 100% tax deductable.


  18. davidh

    davidh Podiatry Arena Veteran

    Re: Entonox

    Hi Mandy,

    I used Entonox in a surgery setting in the late 70s/early 80s. I stopped using it only because I moved away from general practice.

    Mostly we found it useful for those patients who were nervous about having an LA.

    As you rightly say, costs (of equipment and anything ese required) are tax deductable.

  19. R.E.G

    R.E.G Active Member

    Re: Entonox

    David and Mandy,

    Slightly off the subject but Mandy raised the issue of Tax.

    IMO this is often misunderstood by 'business' people.

    True you can set the cost of equipment against expenses therefore such costs will reduce your tax bill at the end of the year.

    However how much you 'benefit' by this depends on what level you pay tax at, basic or higher rate.

    But you still bear a large proportion of the cost of the equipment which should in a well run business show a return on investment over a reasonable period of time.

    !00% tax relief does not mean you get all your money back from the Tax man.

    I'm sure you all understand this, but just for those that may be confused?

  20. Steve Jackson

    Steve Jackson Member

    Re: Entonox

    I practice in Perth WA and we had a short day course in the use of Methoxyflurane approxiamtely 18 months ago. I have since used it a few times on patients who are needle phobic.... mainly children and big burly men!!

    It has been very successful and easy to use. We buy it in a single use disposable pack which includes a vial of the drug and the inhaler. The whole thing cost approx $30, which is passed on as an extra fee, to the patient.
  21. twirly

    twirly Well-Known Member

    Re: Entonox

    Thank you Steve,

    Unfortunately Methoxyflurane is not available (unless there have been any recent changes) in the UK.

    Single use packs sound a great idea. Unsure if this could be applied to Entonox though. I have only seen it in large pressurised cylinders.


  22. davidh

    davidh Podiatry Arena Veteran

    Re: Entonox

    Hi Twirly,

    You pay for the demand valve and pipe. You pay BOC a rental for whichever size cylinder of Entonox you need (from memory you can have quite a small cylinder). The Entonox istelf is not expensive.

    Check with BOC (Medical) for info.


  23. twirly

    twirly Well-Known Member

  24. admin

    admin Administrator Staff Member

  25. R.E.G

    R.E.G Active Member


    Very interesting.

    It does however not mention the 'fire hazard' referred to by another poster!

    I'm not convinced there is one.

    Anyone have evidence to the contrary?

    As far as 'course' go I when I did my degree I was trained in the use of Entonox so see no reason why I should not use it.

    Equally as the Wiki bit says it is actually 'self administered'.

    Google Entanox and there is loads of info.

    Still reckon you are looking at an initial investment of about £500 and yes David the 'little' cylinder a 'D' cylinder is what in general is now used, all the equipment is very similar to emergency Oxygen. which of course does need specialist training to administer!

    Hey I was a 'bent diver' terrified of Entanox.:craig:

  26. posalafin

    posalafin Active Member

    The fire hazard of entonox is no more so than the fire hazard of an oxygen cylinder. Same precautions apply avoid getting oil/grease near outlet and avoid naked flame when using it. You also need to have a warning plate indicating there is oxidising gas in place for fire services (at least in australia).

    Safety is alwas important but I think the poster who brought up the fire risk of entonox was overstating it just a little.
  27. twirly

    twirly Well-Known Member

  28. R.E.G

    R.E.G Active Member

    Well done on finding this course Mandy, and very well done on resurrecting the South Yorkshire branch of the SCP, and becoming it's Chair.

    Just a couple of questions.

    Is this course just for ST Johns Ambulance members or is it open to the 'general public'?

    If you undertook this course, which does not state any 'qualification' would the Society recognise it for insurance purposes if you were using Entonox in your day to day practise?

    My fear is that those recently trained FHPs may see this course and think that once done they could join the St Johns Ambulance Brigade then merrily go around treating IGTN under Entonox.

    And why not?

  29. betafeet

    betafeet Active Member

    Hi just want to throw in a little diversion clubbers and festival goes use this on a regular basis I have seen the empty canisters thrown on the floor and people filling up balloons from the back of their cars from larger bottles. Not sure what the effects of long term users on there lungs will be.

    Must say did not like it myself when I gave birth made me feel sick and then there was a the rubber mask uhhh

    Last edited: Sep 24, 2008
  30. Sez Osborne

    Sez Osborne Member


    I have been told anecdotally (by the entonox trainer and the Pods who were undertaking the training) that as Podiatrists are registered with the Health Professions Council we are permitted to use Entonox as long as local PCT policy permits and practitioners have undergone appropriate training.

    I have contacted the HPC to try and veryfy this bit of information, but as there are pods training and using entonox i am guessing it is correct!

    Sez x
  31. Sez Osborne

    Sez Osborne Member

    Hi Me again!

    I have also contacted the Society of Chiropodists and Podiatrists to hear where they stand on this!

    sez x
  32. twirly

    twirly Well-Known Member

    Hi Bob,

    Thank you Bob. My colleague ( & branch secretary) Brian Tansey was actually the one who provided the impetus to reforming the branch.

    I am unsure of this Bob. I have looked once again on their web site & the courses are divided into sections, one of which is directed at the general public (I noticed no mention of administering gases in that particular link).

    The individual at the suppliers requested my HPC registration details No. which was encouraging.

    Again, the supplier of the medical gases requested details on my HPC reg. (also they wished to know was I currently registered to use L/A) & are forwarding details to me in the post. I of course would take no further action until I can guarantee approval/insurances from the Society.

    I would suggest that this would be inadvisable (to say the least). If this was to happen then the HPC may indeed be powerless to act against the non registrant but I would certainly expect a solicitor would.

    Kind regards,

  33. jacksen

    jacksen Welcome New Poster

    Nitrous oxide gas, mixed with oxygen, is an effective and safe analgesic which, although widely used in many areas of clinical practice, has not been fully recognized in the community setting for painful procedures. The reasons why it has not been implemented and used to the patient's advantage have been suggested as apathy, lack of confidence, lack of knowledge and lack of resources.In midwifery it replaced the use of gas and air and has become a widely used form of analgesia.More and more research is being carried out looking at new applications for this very useful and safe product.

    Internet marketing
  34. hmb1v07

    hmb1v07 Member

    I remembered reading this thread some time ago but I just visited the British Pain Society website and thought this was relevant -
    They mention that 'Linde' also manufacture 50/50 nitrous oxide & oxygen. Also the Anaesthesia UK site gives a clear run of everything from the history of this drug through to its storage and effects.

    Was a reply ever received from the HPC about whether podiatrists are permitted to use this gas mix?
  35. twirly

    twirly Well-Known Member

    Hi hmb1v07,

    I could be wrong (not the frst time) I believe it would be your insurers eg. Society & not the Health Professions Council that will be the deciding factor on use of gases in clinical practice.

    Sez has contacted the Society of Chiropodist & Podiatrists for information.

    Any news yet Sez?

  36. Sez Osborne

    Sez Osborne Member


    Two e-mails and a phone call later not answer as yet, but I now have a direct e-mail contact so will try that and let you know the answer!

    sez x
  37. eiregal

    eiregal Member

    If any thing should the use of nitrous oxide not reduce our insurance costs as we'd be removing 2 of the greatest risks in podiatry - needle stick injury and Toxic shock / alergic reaction.
  38. twirly

    twirly Well-Known Member

    Hi eiregal,

    I can appreciate your thoughts on the use of sedative gas reducing the risk of needle stick injuries, pt. calm = pt. doesn't pull foot away or kick out.
    However could you explain your 2nd observation please: toxic shock/allergic reaction? :confused:

    Many thanks,

  39. G Flanagan

    G Flanagan Active Member


    Sorry for the very late reply, as far as i'm aware we have no departmental procedures within my pod surg unit for entonox. the larger hospital of which we are a sister hospital has everyone but the porter allowed to use entonox.

    I recently went on an update entonox administration course, it lasted about half an hour, as it is very easy to use and dare i say it has no adverse complications. as a side note, the course provider noted it was available OTC!!!
  40. twirly

    twirly Well-Known Member

    Thank you G Flanagan,

    Much appreciated. A recent patient is a paramedic in the local ambulance team & he is going to contact his training team RE: available courses in the area & if it would be possible for external candidates to attend.

    The ones advertised by St. Johns were a little too far afield for me at present.

    I will hope to follow this up in more detail in 2009 (after the dreaded tax bill!!) :rolleyes:

    Thanks everyone for your replies.

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