Consumer medicine information

Coregas Medical Nitrous Oxide

Nitrous oxide

BRAND INFORMATION

Brand name

Coregas Medical Nitrous Oxide

Active ingredient

Nitrous oxide

Schedule

S4

 

Consumer medicine information (CMI) leaflet

Please read this leaflet carefully before you start using Coregas Medical Nitrous Oxide.

SUMMARY CMI

COREGAS Pty Ltd MEDICAL NITROUS OXIDE
100% v/v gas in gas cylinder medicinal gas

Consumer Medicine Information (CMI) summary

The full CMI on the next page has more details. If you are worried about having Medical Nitrous Oxide, speak to your healthcare professional or emergency services officer.

1. Why am I having Coregas Pty Ltd Medical Nitrous Oxide?

Coregas Pty Ltd Medical Nitrous Oxide contains the active ingredient Nitrous Oxide. It is used in adults, children and babies mixed with other gases during operations, and it is used together with oxygen to relieve pain. It is also used for other types of procedures such as laparoscopy or, in liquid form, in cryotherapy.

For more information, see Section 1. in the full CMI.

2. What should I know before I have Coregas Pty Ltd Medical Nitrous Oxide?

You will not have Medical Nitrous Oxide if you:

  • Are hypersensitive to Nitrous Oxide.
  • Are having laser surgery in your airways.
  • Have had recent medical treatment (including certain types of eye, ear, brain or heart surgery) or are injured in any way, including face/jaw injury or head injury where you are not conscious.
  • Are feeling confused. drowsy or uncoordinated, have heart problems, swollen abdomen, breathing problems or emphysema, cysts, ear problems, have recently been scuba diving and/or have decompression sickness.
  • Have a Vitamin B12 or Folic acid deficiency, a genetic predisposition to these or you have a diet lacking in these vitamins.
  • Have an embolism (air bubbles) anywhere in your body or a blockage that may lead to an embolism.
  • Have had anaemia in the past.
  • Are intoxicated.

Talk to the person treating you if you have any other medical conditions including low blood pressure, vitamin B12 or folic acid deficiency or are pregnant or planning to become pregnant or are breastfeeding or planning to breastfeed.

You will only have this if your healthcare professional has said it is OK for you to use it.

For more information, see Section 2. in the full CMI.

3. What if I am taking other medicines?

Tell the person treating you if you are taking any other medicines.
See Section 3. in the full CMI.

4. How do I have Coregas Pty Ltd Medical Nitrous Oxide?

You will receive Medical Nitrous Oxide either via a mask or tube during an operation (gas) or via a thin tube directly onto the area being treated (liquid). It is normally given to you by a healthcare professional or emergency services officer. They will decide how much you can have

More information can be found in Section 4. in the full CMI.

5. What should I know while having Coregas Pty Ltd Medical Nitrous Oxide?

Things you should doTell the person treating you if you feel that you are not receiving enough Nitrous Oxide, or if you hear a hissing sound coming from the cylinder
Make sure your skin is clean and free from oils and grease
Be aware that you may have blood tests if you receive Medical Nitrous Oxide for a long time.
Things you must not do

Never smoke or stand near open flames, sparks or high heat.

Do not touch any part of the cylinder or equipment with oils or grease, and do not use oil-based moisturisers or creams on your face or nose).

For more information, see Section 5. in the full CMI.

6. Are there any side effects?

If you do experience any side effects, most of them are minor and temporary. The most important side effects that require immediate medical attention include problems breathing, problems thinking clearly, sudden headache, changed mood, feeling confused, euphoric, hyperactive or anxious, twitching, uncontrolled shaking (fits), slow or irregular heart rate, low blood pressure, cold burns if in contact with liquefied nitrous oxide, addiction, problems moving properly.

For information about these, and what to do if you get any side effects, see Section 6. in the full CMI.



FULL CMI

COREGAS Pty Ltd MEDICAL NITROUS OXIDE
100% v/v gas in gas cylinder medicinal gas

Active ingredient: Nitrous Oxide


Consumer Medicine Information (CMI)

This leaflet provides important information about having Coregas Pty Ltd Medical Nitrous Oxide.

Speak to your healthcare professional or emergency services officer if you want more information, if you are worried or if you have questions about using Medical Nitrous Oxide.

Where to find information in this leaflet:

1. Why am I having Coregas Pty Ltd Medical Nitrous Oxide?
2. What should I know before I have Coregas Pty Ltd Medical Nitrous Oxide?
3. What if I am taking other medicines?
4. How do I have Coregas Pty Ltd Medical Nitrous Oxide?
5. What should I know while having Coregas Pty Ltd Medical Nitrous Oxide?
6. Are there any side effects?
7. Product details

For the Healthcare Professional/Emergency Services Officer

1. Why am I having Coregas Pty Ltd Medical Nitrous Oxide?

Coregas Pty Ltd Medical Nitrous Oxide contains the active ingredient Nitrous Oxide. It is a medical gas. It is available only with a prescription.

It is used in adults, children and babies mixed with other gases during operations, and it is used together with oxygen to relieve pain.

It is also used for other types of procedures such as laparoscopy or, in liquid form, in cryotherapy.

2. What should I know before I have Coregas Pty Ltd Medical Nitrous Oxide?

You will not have Medical Nitrous Oxide if you:

  • Are hypersensitive to Nitrous Oxide
  • Are having laser surgery in your airways
  • Have had recent medical treatment (including certain types of eye, ear, brain or heart surgery)
  • Are injured in any way, including face/jaw injury or head injury where you are not conscious
  • Are feeling confused. drowsy or uncoordinated, have heart problems, swollen abdomen, breathing problems or emphysema, cysts, ear problems, have recently been scuba diving and/or have decompression sickness
  • Have a Vitamin B12 or folic acid deficiency, a genetic predisposition to these or you have a diet lacking in these vitamins.
  • Have an embolism (air bubbles) anywhere in your body or a blockage that may lead to an embolism.
  • Have had anaemia in the past.
  • Are intoxicated.

Check with the person treating you if you:

  • Have any other medical conditions, including low blood pressure or Vitamin B12 or folic acid deficiency.
  • Take any medicines for any other condition.

You will only have this if your healthcare professional or emergency services officer has said it is OK.

During treatment, you may be at risk of developing certain side effects. It is important that you understand these risks and how to watch for them. See additional information under Section 6 Are there any side effects?

Pregnancy and breastfeeding

Tell the person treating you if:

  • you are pregnant or planning to become pregnant
    or
  • you are breastfeeding or planning to breastfeed.

They will decide if the benefits of having nitrous oxide outweigh any risks to the unborn or newborn child. If necessary, you will be given the lowest amount of Medical Nitrous oxide for the shortest possible time.

Medical staff working in areas where Nitrous oxide is used should make sure the area is well ventilated and excess gas extracted (scavenged). There have been reports of reduced fertility in healthcare workers who are repeatedly exposed to Nitrous oxide although it is not known if Nitrous oxide is the cause of this.

Elderly people

Older people may need less Nitrous Oxide, and the amount they use will be increased very gradually.

Children and Babies

Children and newborns, especially premature babies, will be closely monitored by medical staff.

3. What if I am taking other medicines?

Tell the person treating you if you are taking any other medicines, including any medicines, vitamins or supplements that you buy without a prescription from your pharmacy, supermarket or health food shop.

Some medicines may interfere with Medical Nitrous Oxide and affect how it works.

4. How do I have Coregas Pty Ltd Medical Nitrous Oxide?

How much to have

Your healthcare professional or emergency services officer will decide how much to have.

Follow their instructions and use Medical Nitrous Oxide until you are told to stop. They will monitor you or your child's treatment and change the amount if needed.

How you will have Coregas Pty Ltd Medical Nitrous Oxide

  • You will receive Medical Nitrous Oxide as a gas via a mask or via a tube during an operation.
  • If Medical Nitrous Oxide is being given to you as a liquid it will be administered via a very thin tube directly on the area to be treated.
  • It is normally given to you by a healthcare professional or emergency services officer.
  • Avoid using oil-based moisturisers or creams on your face or nose when using Medical Nitrous Oxide

If you have had too much Medical Nitrous Oxide

If you are conscious, and you think that you have had too much Medical Nitrous oxide, you may need urgent medical attention and the amount of Nitrous oxide you are having will be reduced or stopped. This may be the case if you suddenly feel lightheaded, faint or intoxicated, your heart slows, or you have trouble breathing.

If you come into contact with liquefied Nitrous Oxide you may get a cold burn which will make your skin numb. You may need immediate medical attention. Bathe the area in warm (not hot) water and cover loosely with a sterile dry dressing. Do not smoke or drink alcohol.

You must immediately:

  • Tell the person treating you, or
  • Go to the Emergency Department at your nearest hospital, or
  • Phone the Poisons Information Centre
    (by calling 13 11 26).

5. What should I know while having Coregas Pty Ltd Medical Nitrous Oxide?

Things you should do

Tell your healthcare professional or emergency services officer straight away if you:

  • Feel that you are not getting enough Nitrous Oxide
  • Hear a hissing sound coming from the cylinder

Be aware that your blood may be tested for levels of blood components and vitamins, especially if you have to have Nitrous oxide for a few days or longer.

Things you must not do

  • You must drink alcohol or not be intoxicated when having this medicine.
  • Medical Nitrous Oxide in steel cylinders MUST NOT be used in the same area as MRIs under any circumstances.
  • Never smoke or stand near open flames, sparks or high heat while having Medical Nitrous Oxide.
  • Do not touch any part of the cylinder or equipment with oils or grease, and make sure your skin is clean and free from oils and grease (this includes not using oil-based moisturisers or creams on your face or nose.

Driving or using machines

Be careful before you drive or use any machines or tools until you know how Medical Nitrous Oxide has affected you.

Your doctor will assess you and decide whether you can drive or operate machines.

Drinking alcohol

Tell your healthcare professional or emergency services officer if you have recently drunk alcohol.

Looking after your medicine

Looking after Coregas Pty Ltd Medical Nitrous Oxide is the responsibility of the person or hospital treating you. There are separate instructions for them at the end of this leaflet.

It will be kept where children cannot see or reach it.

6. Are there any side effects?

All medicines can have side effects. If you do experience any side effects, most of them are minor and temporary. However, some side effects may need medical attention.

Read the following information and, if you need to, ask your doctor or pharmacist if you have any questions about side effects.

Less serious side effects

Less serious side effectsWhat to do
  • Feeling dizzy, light-headed or sleepy
  • Feeling bloated
  • Feeling or being sick
  • Problems hearing or pain in your ears
  • Headache
  • Numbness in your hands and legs; problems flexing hand muscles; muscle weakness
Speak to your healthcare professional or emergency services officer if you have any of these side effects and they worry you.

Serious side effects

Serious side effectsWhat to do
  • Problems when breathing
  • Problems thinking clearly, sudden headache, change in mood, feeling confused, euphoric, hyperactive or anxious
  • twitching, uncontrolled shaking (fits)
  • slow or irregular heart rate, low blood pressure,
  • cold burns if in contact with liquefied nitrous oxide
  • addiction to nitrous oxide
  • problems moving properly
  • low levels of red or white blood cells
Call the healthcare professional or emergency services officer straight away if you are already in hospital, otherwise go straight to the Emergency Department at your nearest hospital.

Tell the person treating you if you feel unwell in any way.

Other side effects not listed here may occur in some people.

Be aware that some people have abused nitrous oxide, and some people have become addicted to nitrous oxide.

Reporting side effects

After you have received medical advice for any side affects you may have had, you can report these side effects to the Therapeutic Goods Administration online at www.tga.gov.au/reporting-problems.

By reporting side effects, you can help provide more information on the safety of this medicine.

Always make sure you speak to your doctor or pharmacist before you decide to stop taking any of your medicines.

7. Product details

This medicine is normally supplied for use in hospitals, dental surgeries or in emergency situations.

What Coregas Pty Ltd Medical Nitrous Oxide contains

Active ingredient
(main ingredient)
Nitrous Oxide gas
Other ingredients
(inactive ingredients)
None
Potential allergensNone

What Coregas Pty Ltd Medical Nitrous Oxide looks like

Coregas Pty Ltd Medical Nitrous Oxide has a sweet smell and no colour.

The cylinders have a white body and ultramarine shoulder. They are made of either steel or aluminium and sealed with a Pin Index valve outlet.

Single cylinders that are used for administering liquid nitrous oxide have a different outlet and contain a dip tube.

They may be available in the following pack sizes:

Cylinder SizeWater Volume (litres)
C
D
E
G
6 Pack*
12 Pack**
2.8
9.5
23
50
300
600
* 6 Pack (bundles) of 6x 50 L Size G cylinders
** 12 Pack (bundles) of 12x50 L Size G cylinders

(Not all pack sizes or presentations may be available)

Who distributes Coregas Pty Ltd Medical Nitrous Oxide?

Coregas Pty Ltd
66 Loftus Road
Yennora NSW 2161
Australia

Email: [email protected]
Phone:1800807203
Website: www.coregas.com.au/healthcare
Aust R 27183.

This leaflet was revised in October 2023.

For the Healthcare Professional/Emergency Services Officer

Instructions for use/handling

Please refer to the Product Information for full safety information.

  • Coregas nitrous oxide is a simple asphyxiant in the absence of oxygen.
  • Care is needed in the handling and use of Medical Nitrous Oxide gas cylinders.
  • Refer to the respective S.D.S, the Product Information and the “caution” sections of the product label.
  • Check the following before use:
    - Sources of ignition (avoid contact with or close proximity with open flames or sparks, oils, greases, tarry substances, plastics)
    - Operability of oxygen mixing apparatus and availability of oxygen
    - Dispensing equipment matches cylinder valve outlet (there are different outlets for cylinders supplying gas and cylinders supplying liquid nitrous oxide)
    - Quantity in cylinder (measure contents by weight rather than rely on cylinder pressure).

Occupational Exposure

  • Nitrous oxide is classified as hazardous according to criteria of Worksafe Australia. Worksafe exposure standard TLV TWA is 25 ppm.
  • Professionals chronically exposed to nitrous oxide should have a regular full blood examination.
  • It is important that the nitrous oxide content in the ambient air is kept as low as possible and well below the nationally set limit value.
  • Scavenging of waste nitrous oxide gas should be used to reduce operating theatre and equivalent treatment room levels to a level below 25 ppm of nitrous oxide.
  • While a causal connection has not been established, reduced fertility in medical and paramedical personnel has been reported after repeated exposure to nitrous oxide in inadequately ventilated rooms.
  • Chronic exposure to nitrous oxide may lead to bone marrow or neurological impairment
  • Rescue personnel are advised to monitor nitrous oxide concentration before entering confined spaces and poorly ventilated areas which have been contaminated by a nitrous oxide leak.
  • Suitable manual handling equipment should be used to transport cylinders.
  • Accidental inhalation or cold burns should be treated immediately even if there Is no immediate effect on the person exposed. Accidental inhalation should be treated with fresh air and resuscitation if needed. Superficial cold burns may initially be treated by immersion in lukewarm water and use of dry sterile dressings; if extensive then hospital attention is required.

Use

  • Do not use this product if the cylinder is damaged or the tamper evident seal has been removed.
  • Nitrous oxide is stored in high pressure gas cylinders as a liquid under pressure at ambient temperature.
  • Check the cylinder label and valve outlet to distinguish between cylinders for administering gases and cylinders for administering liquid nitrous oxide.
  • In standard operation, the package is designed to deliver product in gaseous form, however rapid opening of the valve and sustained high flow rates can cause the discharged gas to re-liquefy. This liquid can cause cold burns if in contact with the eyes and skin.
  • Cylinders should be used in the vertical position with the valve uppermost. If not liquid may be discharged when the valve is opened.
  • When Medical Nitrous Oxide is intended for use in a room in which magnetic resonance imaging (MRI) is being performed, all steel medical Nitrous Oxide cylinders and associated equipment must be considered to potentially contain ferromagnetic materials. Steel cylinders do contain a substantial quantity of ferromagnetic material and MUST NOT be used in proximity to MRIs under any circumstances.
  • Electrical equipment capable of sparking or generating extreme heat should not be used in the vicinity of patients receiving Medical Nitrous Oxide.
  • Under no circumstances should oils or grease be used to lubricate any part of the medicinal Nitrous Oxide cylinder or the associated equipment used to deliver the gas to the patient. Always ensure hands are clean and free from any oils or grease.
  • Where moisturising preparations are required for use with a facemask., avoid using oil-based creams.
  • Where alcohol gels are used to control microbiological cross-contamination ensure that all alcohol has evaporated before handling
  • Use gas cylinders with suitable pressure reducing regulator.
  • Medical gases must only be used for medicinal purposes
  • Refer to manufacturer for cleaning guidelines.
  • All regulations concerning handling of pressure vessels must be followed.
  • Cylinders should be handled with care. They must not be allowed to fall or subjected to violent impact. If, after an accidental collision, a cylinder exhibits local deformation or a notch, even shallow, it should be considered as hazardous and removed from use. It must be returned to the supplier with notification of the damage.
  • Cylinders should only be moved with the appropriate size and type of cylinder trolley (pallet jack).
  • Smoking and naked lights must not be allowed within the vicinity of cylinders or pipeline outlets.
  • After use cylinder valves should be closed using moderate force only and the pressure in the regulator, manifold, etc released.
  • Immediately return used cylinders to the used cylinder store for return to Coregas.
  • Do not keep cylinders after their expiry date.

Storage

  • Medical Nitrous Oxide cylinders should be kept out of the reach of children.
  • They should not be near heavy traffic or emergency exits
  • Cylinders should not be stored near stocks of flammable or combustible materials, poisons or sources of ignition. It is highly dangerous when nitrous oxide comes into contact with oils, greases, tarry substances and many plastics due to the risk of spontaneous combustion.
  • The cylinders will be stored so they are upright, secure and on a firm, level floor, where the temperature does not go above 45°C.
  • Warning notices prohibiting smoking and naked lights must be posted clearly.
  • The normal precautions required in the storage of medical gas cylinders as described below are applicable.

Standard storage Instructions for Medical Nitrous Oxide Cylinders

  • Emergency services should be advised of the location of the cylinder store.
  • Cylinders should be stored under cover, preferably inside, kept dry and clean and not subjected to extremes of heat or cold.
  • Medical cylinders should be segregated by medical gas type and identified as such within the store.
  • Full and empty cylinders should be stored separately. Full cylinders should be used on a “first in / first out” basis.
  • Cylinders must not be re-painted. Cylinder markings must not be obscured. Product labels must not be removed. Foreign objects and attachments must not be affixed when returning cylinders. All gas cylinders should be stored vertically.
  • Precautions should be taken to protect cylinders from theft and / or interference.
  • Cylinders must be stored in storage area specially provided for the purpose. The storage area must be ventilated.
  • If they are placed along a personnel passageway, they must be prevented from falling by means of chains.
  • Whether empty or full, all cylinders in the storage area must be equipped with their valve protection caps and valve closed.

This leaflet was revised in October 2023

Published by MIMS January 2024

BRAND INFORMATION

Brand name

Coregas Medical Nitrous Oxide

Active ingredient

Nitrous oxide

Schedule

S4

 

1 Name of Medicine

Nitrous oxide.

2 Qualitative and Quantitative Composition

Nitrous oxide 100% v/v.

3 Pharmaceutical Form

Compressed medical gas (for medicinal use only).

4 Clinical Particulars

4.1 Therapeutic Indications

Nitrous oxide is used:
1. General anaesthesia: when an inhalation anaesthetic is required, the administration is usually accompanied by simultaneous administration of a volatile agent such as halothane, ethrane, etc.
2. Analgesia with oxygen:
relief from severe pain, usually in emergency situations, by inhalation with oxygen;
useful also in short-term procedures which inevitably involve pain, such as wound and burn dressing, wound debridement and suturing. Administration with oxygen;
in dental work to provide short-term analgesia for tooth extraction and other brief procedures. Administration with oxygen.
3. Others:
occasionally as an insufflating agent in laparoscopy;
in cryosurgery as a refrigerant.

4.2 Dose and Method of Administration

Where the clinical indication is the production of general anaesthesia it should be noted that:
In the average adult, nitrous oxide is administered by inhalation through a suitable anaesthetic apparatus in concentrations up to 80% with oxygen as the balance.
As people age, there is a steady reduction in the indices of cardiac and respiratory function evidenced by a lowering of cardiac output and in lung ventilation and perfusion. In addition, there is an increase in dead space in the lung which increases minute ventilation. Cerebral blood flow is reduced by up to 30%. The result of these changes mean that susceptibility to anaesthesia is increased. Nitrous oxide is, therefore, more useful in the elderly and the depressant effects of added agents are reduced.
There are no essential differences in clinical indications between the adult and child.
Nitrous oxide is strongly recommended in the anaesthesia of neonates.
In obstetrical anaesthesia, the nitrous oxide level is kept below 70% to allow a substantial oxygen level to be provided. Nitrous oxide plays a major role because injected agents depress the breathing of the infant and volatile agents depress uterine contraction.
As a general rule, the more ill the patient, the more susceptible is the patient to other anaesthetic agents and the more nitrous oxide is relied upon.

Routes of administration.

Use as a gas.

Nitrous oxide administered through a face mask or tracheal tube by means of an anaesthetic apparatus. The gas is breathed in by the patient and absorbed through the lungs.
Nitrous oxide should only be administered by medical personnel trained in the appropriate techniques.
Cylinders should only be used in conjunction with medical nitrous oxide gas pressure regulators.

Use as a liquid refrigerant in cryosurgery.

Aluminium cylinders with dip tubes are used for extracting liquid nitrous oxide. A hose is attached to the cylinder, and the liquid applied topically.

4.3 Contraindications

All these effects are well documented, extremely rare and may follow prolonged exposure to levels of nitrous oxide over 5,000 ppm or to frequent (more than once every two days) exposure to analgesic concentrations. Vitamin B12 inactivations have been reviewed by Nunn.
Hypersensitivity to nitrous oxide or any other component in the gas is a contraindication.
Nitrous oxide should not be administered without the required level of oxygen (see Section 4.4 Special Warnings and Precautions for Use, Use with caution in the following circumstances).
Nitrous oxide should not be used with any condition where air is entrapped within a body and where its expansion might be dangerous, such as:
the presence of intracranial air;
severe head trauma;
head injuries with impairment of consciousness;
pneumopericardium;
artificial, traumatic or spontaneous pneumothorax;
air embolism;
gas embolus;
decompression sickness;
following a recent dive;
following cardiopulmonary bypass or air encephalography;
severe bullous emphysema;
during myringoplasty;
occluded middle ear;
cysts;
gross abdominal distension;
intoxication;
maxillofacial injuries;
after intraocular gas injection in ophthalmic surgery, for example with sulphur hexafluoride (SF6) or perfluoropropane (C3F8), until the intraocular gas had been completely absorbed, due to the risk of further expansion of the gas bubble possibly leading to blindness.
Nitrous oxide should not be used on intoxicated patients.
Medicinal nitrous oxide is also contraindicated:
In patients with cardiac failure or severely impaired cardiac function (e.g. after cardiac surgery), since the mild myocardio-depressive effect may cause further deterioration in cardiac function.
In patients presenting persistent signs of confusion, changed cognitive function or other signs that could be related to increased intra-cranial pressure, as nitrous oxide may further increase the intra-cranial pressure.
In patients presenting decreased consciousness and/or co-operability, when used in analgesia, because of the risk for loss of protecting reflexes.
In patients presenting with a vitamin B12 or folic acid deficiency or genetic perturbation in this system.
Nitrous oxide should not be used as an analgesic or anaesthetic agent for more than 24 hours without monitoring of peripheral blood for features of megaloblastic anaemia and leukopenia. (See Section 4.4 Special Warnings and Precautions for Use; Section 4.8 Adverse Effects (Undesirable Effects)).

4.4 Special Warnings and Precautions for Use

General.

Coregas nitrous oxide is a simple asphyxiant in the absence of oxygen.

Occupational exposure to nitrous oxide.

Nitrous oxide is classified as hazardous according to criteria of Worksafe Australia. Worksafe exposure standard TLV TWA is 25 ppm.
Reduced fertility in medical and paramedical personnel has been reported after repeated exposure to nitrous oxide in inadequately ventilated rooms. It is not currently possible to confirm or exclude the existence of any causal connection between these cases and nitrous oxide exposure. It is important that the nitrous oxide content in the ambient air is kept as low as possible and well below the nationally set limit value (see Section 4.6 Fertility, Pregnancy and Lactation, Effects on fertility).
Scavenging of waste nitrous oxide gas should be used to reduce operating theatre and equivalent treatment room levels to a level below 25 ppm of nitrous oxide gas.
Rescue personnel are advised to monitor nitrous oxide concentration before entering confined spaces and poorly ventilated areas which have been contaminated by a nitrous oxide gas leak.
Chronic occupational exposure to nitrous oxide may lead to bone marrow or neurological impairment (see also below Interference with vitamin B12 metabolism leading to neurological and bone marrow toxicity).
Suitable manual handling equipment should be used to transport cylinders.

Interference with vitamin B12 metabolism leading to neurological and bone marrow toxicity.

Nitrous oxide causes inactivation of Vitamin B12 (a co-factor of methionine synthesis), which interferes with folic acid metabolism. Nitrous oxide inhibits methionine synthetase which contributes to the conversion of homocysteine to methionine. The inhibition of this enzyme affects/reduces the formation of thymidine, which is an important part of DNA formation. Thus, DNA synthesis is impaired following prolonged nitrous oxide administration. These disturbances can result in megaloblastic bone marrow changes and possibly polyneuropathy and/or subacute combined degeneration of the spinal cord (see Section 4.8 Adverse Effects (Undesirable Effects)). The effect on DNA synthesis is one of the probable reasons for the influence of nitrous oxide on blood formation and the foetal damage seen in animal studies.
Nitrous oxide should be used with caution in patients at risk of vitamin B12 or folic acid deficiency. See Section 4.3 Contraindications.
Risk factors include the elderly, those with poor or vegetarian diet, and previous history of anaemia. Nitrous oxide should therefore not be used for prolonged periods of time.
See also Chronic exposure below.
In patients with undiagnosed subclinical deficiency of vitamin B12, neurological toxicity has occurred after single exposures to Nitrous Oxide gas during general anaesthesia. Other analgesic therapies should be considered in patients showing signs of vitamin B12/folate deficiency (see Section 4.3 Contraindications).

Chronic exposure.

Care should be taken with long term usage of nitrous oxide. Chronic exposure to nitrous oxide, such as in abuse, can inactivate vitamin B12 with resulting neurological and haematological side effects such as polyneuropathy, megaloblastic anaemia, bone marrow depression and reproductive side effects (see Section 4.8 Adverse Effects (Undesirable Effects)).
A polyneuritic type of neuropathy and spinal cord sclerosis can appear during chronic administration of high concentrations of nitrous oxide gas.
Administration of nitrous oxide more frequently than every four days should be accompanied by routine blood cell counts for evidence of megaloblastic change in red blood cells and hypersegmentation of neutrophils.
A full blood examination should also be performed in abusers and professionals chronically exposed for evidence of megaloblastic change in red blood cells and hypersegmentation of neutrophils.

Use with caution in the following circumstances.

Nitrous oxide gas should never be given with less than 21% oxygen but a maximum of 30% oxygen should be used during anaesthesia and more at altitude and in the presence of disorders affecting oxygenation.
Nitrous Oxide gas passes into gas containing spaces in the body faster than nitrogen passes out.
Prolonged anaesthesia may result in bowel distension, middle ear damage, rupture of ear drums and expansion of other non-vented gas containing cavities. Nitrous oxide gas administration may increase the pressure in catheter balloons e.g. in tracheal intubation.
Addiction to and abuse of nitrous oxide has been reported. Delirium has been reported upon withdrawal.
Due to the potential for myocardial depression, nitrous oxide should be used with caution in patients with mild to moderate cardiac dysfunction and is contraindicated in patients with severe cardiac dysfunction or pronounced cardiac failure (see Section 4.3 Contraindications).
In patients taking other centrally acting medicinal products, such as morphine derivatives and/or benzodiazepines, concomitant administration of nitrous oxide may result in increased sedation, and consequently have effects on respiration, circulation and protective reflexes. (See Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).
Nitrous oxide gas in high concentration can lead to the loss of laryngeal reflexes and reduce consciousness. In higher concentrations it often causes unconsciousness and the risk for impairment of the laryngeal reflexes increases.
When nitrous oxide gas is used in conjunction with other volatile or intravenous anaesthetic agents, the MAC of those agents may be reduced.
Nitrous oxide should not be used during laser surgery in the airways due to the relative risk for explosive fire.
At the end of nitrous oxide/oxygen anaesthesia, withdrawal of the mask leads to an outpouring of nitrous oxide from the lungs and consequent dilution of oxygen in the incoming air. This results in diffusion hypoxia and is counteracted by giving 100% oxygen for a few minutes when the flow of nitrous oxide is stopped.
Nitrous oxide should be used with caution in patients with severe hypotension.

Check the following before use.

Nitrous oxide is non-flammable but strongly supports combustion (including some materials which do not normally burn in air) and should not be used near sources of ignition. It is highly dangerous when nitrous oxide comes into contact with oils, greases, tarry substances and many plastics due to the risk of spontaneous combustion.
Operability of oxygen mixing apparatus and availability of oxygen.
Dispensing equipment connection matches cylinder valve outlet.
Cylinder pressure is not a true indicator of quantity remaining in cylinder until all liquid has vapourised. Measure contents by weight.

Use of gas cylinders.

Cylinder should be kept out of the reach of children.
Smoking should be prohibited when using nitrous oxide.
Under no circumstances should oils or grease be used to lubricate any part of the Nitrous Oxide cylinder or the associated equipment used to deliver the gas to the patient.
Where moisturising preparations are required for use with a facemask, oil based creams should not be used.
Check that hands are clean and free from any oils or grease.
Where alcohol gels are used to control microbiological cross-contamination ensure that all alcohol has evaporated before handling.
Care is needed in the handling and use of medical nitrous oxide gas cylinders. Nitrous oxide is stored in high pressure gas cylinders as a liquid under pressure at ambient temperature.
Most containers are designed to deliver product in gaseous form, however, rapid opening of the valve and sustained high flow rates can cause the discharged gas to re-liquefy. Special cylinders with dip tube are designed to deliver liquid nitrous oxide for cryosurgery. This liquid can cause cold burns if in contact with the eyes and skin.
Gas cylinders should be used in the vertical position with the valve uppermost. If not, liquid may be discharged when the valve is opened. Cylinders with dip tube are designed to administer liquid nitrous oxide and must not be used for gas administration.
Additional information is contained in the Material Safety Data Sheet for Medical nitrous oxide.

Cold burns.

Burns should not occur if the product is administered correctly (see Section 4.9 Overdose, Accidental contact with liquid nitrous oxide (cold burns) - symptoms and signs).

Use in hepatic impairment.

No data available.

Use in renal impairment.

No data available.

Use in the elderly.

Elderly patients are more susceptible to the effects of nitrous oxide.

Paediatric use.

Paediatric neurotoxicity.

Some published studies in children have observed cognitive deficits after repeated or prolonged exposures to anaesthetic agents early in life. These studies have substantial limitations, and it is not clear if the observed effects are due to the anaesthetic/analgesic/sedation drug administration or other factors such as the surgery or underlying illness.
Published animal studies of some anaesthetic/analgesic/sedation drugs have reported adverse effects on brain development in early life and late pregnancy. The clinical significance of these nonclinical findings is yet to be determined.
With inhalation or infusion of such drugs, exposure is longer than the period of inhalation or infusion. Depending on the drug and patient characteristics, as well as dosage, the elimination phase may be prolonged relative to the period of administration.

Effects on laboratory tests.

No data available.

4.5 Interactions with Other Medicines and Other Forms of Interactions

Nitrous oxide inactivates vitamin B12. There are no major incompatibilities with nitrous oxide.
Nitrous oxide reduces the amount of volatile anaesthetics required for anaesthesia when administered concomitantly.
Nitrous oxide and CNS depressants may lead to increased CNS depression, increased respiratory depression and increased hypotensive effects.
Nitrous oxide and opioids together may lead to further circulatory depression. High dose fentanyl with nitrous oxide may decrease heart rate and cardiac output.
The uptake of an inhalational anaesthetic from the lungs is accelerated by the uptake of nitrous oxide when administered concomitantly. This is known as the second gas effect.

Methotrexate.

Nitrous oxide potentiates the effect of methotrexate on folate metabolism, yielding increased toxicity such as severe, unpredictable myelosuppression, stomatitis and neurotoxicity with intrathecal administration. Avoid concomitant use of nitrous oxide in patients receiving methotrexate.

4.6 Fertility, Pregnancy and Lactation

Effects on fertility.

See Section 4.4 Special Warnings and Precautions for Use, Occupational exposure to nitrous oxide.
(Category A)
Medicinal nitrous oxide interferes with vitamin B12/folic acid metabolism (see Section 4.4 Special Warnings and Precautions for Use).
Inhibition of the methionine synthase may cause adverse effects during early stages of pregnancy.
Pregnant females may experience spontaneous abortion and low birth weight babies.
Epidemiological studies suggest an increased risk of spontaneous abortion and low birth weight in off-spring in female workers employed in operating theatres and dental surgeries. These findings are controversial.
Published animal studies of some anaesthetic/analgesic/sedation drugs have reported adverse effects on brain development in early life and late pregnancy.
Animal studies have demonstrated that high concentration or prolonged exposure during particular stages of pregnancy can induce teratogenic effects. The potential risk for humans is unknown.
All general anaesthetics carry the potential to produce central nervous system and respiratory depression in the newborn infant. However, in the compromised foetus, careful consideration should be given to this potential depression and to the selection of particular anaesthetic drugs, doses and techniques.
Inhalation anaesthetics cross the placenta.
Published studies in pregnant and juvenile animals demonstrate that the use of anaesthetic/analgesic/sedation drugs that block NMDA receptors and/or potentiate GABA activity during the period of rapid brain growth or synaptogenesis may result in neuronal and oligodendrocyte cell loss in the developing brain and alterations in synaptic morphology and neurogenesis when used for longer than 3 hours. These studies included anaesthetic agents from a variety of drug classes.
Mild skeletal teratogenic changes have been observed on pregnant rat embryos when the dam has been exposed to high concentrations of nitrous oxide during the period of organogenesis.
There is no published material which shows that nitrous oxide is toxic to the human foetus, however, no increased incidence of foetal malformation has been discovered in 8 epidemiological studies and case reports in human beings.
See Section 4.4 Special Warnings and Precautions for Use, Occupational exposure to nitrous oxide.
It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when nitrous oxide is administered to a nursing woman.

4.7 Effects on Ability to Drive and Use Machines

Nitrous oxide is rapidly eliminated but it is recommended that driving, use of machinery and other psycho-motor activities should not be undertaken until 12 hours have elapsed after nitrous oxide anaesthesia and until the patients have returned to their initial mental status as judged by attending healthcare professional.
General anaesthetics may cause a slight decrease in intellectual function following anaesthesia.

4.8 Adverse Effects (Undesirable Effects)

Nitrous oxide is an asphyxiant in the absence of oxygen.

Other adverse effects (frequency and seriousness).

The adverse effects listed are derived from public domain scientific medical literature and post marketing safety surveillance.

Cardiovascular.

Cardiovascular depression, hypotension, arrhythmia, increased pulmonary vascular resistance.

Gastrointestinal.

Bowel distension following prolonged anaesthesia.

General.

Cold burns (see Section 4.9 Overdose, Accidental contact with liquid nitrous oxide (cold burns) - symptoms and signs).
Addiction to and abuse of nitrous oxide have been reported.

Haematological.

The use of nitrous oxide causes inactivation of vitamin B12 which is a co-factor of methionine synthase. Folate metabolism is consequently interfered with and DNA synthesis is impaired following prolonged nitrous oxide administration. This results in symptoms similar to vitamin B12 deficiency and megaloblastic bone marrow changes. Bone marrow depression with resultant leukopenia, thrombocytopenia and severe megaloblastic anaemia, including fatal cases, have been noted.
Exceptionally heavy occupational exposure and addiction have resulted in myeloneuropathy and subacute combined degeneration.
These effects include rarely: drowsiness, confusion, paraesthesia in the legs, hyper-reflexia and weakness of the intrinsic hand muscles.
If these effects occur, usage of nitrous oxide should be stopped and daily vitamin B12 replacement administered. Effects should then be expected to be reversed gradually.
All these effects are well documented, extremely rare and may follow prolonged exposure to levels of nitrous oxide over 5,000 ppm or to frequent (more than once every two days) exposure to analgesic concentrations.

Neurological.

CNS excitation and depression, raised intracranial pressure, anxiolytic effects, neuropathy, seizures, convulsions, drowsiness. Exceptionally heavy or frequent use, including occupational exposure and addiction, have resulted in myeloneuropathy (including polyneuropathy) and subacute combined degeneration of the cord.

Fertility, pregnancy and lactation.

See Section 4.4 Special Warnings and Precautions for Use; Section 4.6 Fertility, Pregnancy and Lactation. It has been suggested that prolonged occupational exposure to high levels of nitrous oxide may affect a woman's ability to become pregnant.

Respiratory.

Hypoxia, diffusion hypoxia, asphyxia.
Nitrous oxide gas passes into all gas containing spaces in the body faster than nitrogen passes out. The main contraindications which follow from this are listed in Section 4.3 Contraindications, but in addition prolonged anaesthesia may result in bowel distension, middle ear damage and rupture of ear drums. See Table 1.

Reporting suspected adverse effects.

Reporting suspected adverse reactions after registration of the medicinal product is important. It allows continued monitoring of the benefit-risk balance of the medicinal product.
Healthcare professionals are asked to report any suspected adverse reactions at www.tga.gov.au/reporting-problems.

4.9 Overdose

Inhalation - symptoms and signs.

Inappropriate, unwitting or deliberate inhalation of nitrous oxide will ultimately result in unconsciousness, passing through stages of increasing lightheadedness and intoxication, and, if the victim were to be within a confined space, death from anoxia could result.
Other signs may include: bradycardia, respiratory depression, cardiovascular depression and severe hypotension.

Inhalation - treatment.

The treatment is fresh air, mouth-to-mouth resuscitation and, if necessary, the use of an oxygen resuscitator.

Accidental contact with liquid nitrous oxide (cold burns) - symptoms and signs.

Local pain usually warns of freezing, but sometimes no pain is felt or is short lived. Frozen tissues are painless and appear waxy, with a pale yellowish colour. Thawing of the frozen tissue can cause intense pain.
Shock may occur if the area is large.

Accidental contact- treatment.

Skin.

Loosen any clothing that may restrict circulation and seek immediate hospital attention for all but the most superficial injuries. Do not apply direct heat to the affected parts, but if possible, place the affected part in lukewarm water. Sterile dry dressings should be used to protect damaged tissues from infection or further injury, but they should not restrict circulation. Alcohol and cigarettes should not be given.
For information on the management of overdose, contact the Poisons Information Centre on 131126 (Australia).

5 Pharmacological Properties

5.1 Pharmacodynamic Properties

Mechanism of action.

Nitrous oxide is not very soluble in water but is fifteen times more soluble than oxygen. Water dissolves nitrous oxide, taking 100 volume % and blood plasma 45 volume %.
Nitrous oxide is an inhalational anaesthetic.
Nitrous oxide is an analgesic and a weak anaesthetic. Pain reduction is achieved at a concentration of around 25%. Induction with nitrous oxide is relatively rapid, but a concentration of about 70% is needed to produce unconsciousness. Endorphins are probably involved in the analgesic effect; a concentration of 25% nitrous oxide is usually adequate to provide a marked reduction in pain.
Nitrous oxide alone may increase pulse rate and have depressant effects on respiration.

Clinical trials.

No data available.

5.2 Pharmacokinetic Properties

Absorption.

No data available.

Distribution.

Nitrous oxide is a low potency inhalation anaesthetic and only slightly soluble. The advantage of this is that concentrations not greater than 70% are used and induction of anaesthesia and recovery occur quickly.
At a constant inspired concentration, the rise time of alveolar concentrations is faster than that of any other anaesthetic agent.
The blood/gas partition coefficient of nitrous oxide at 37°C is 0.46 compared with that of nitrogen of 0.015, causing nitrous oxide to expand into internal gas spaces.
Under normal anaesthesia, the adult body contains 25 litres of gaseous nitrous oxide (this gives some notion of its essential safety and lack of acute toxicity).

Metabolism.

Not applicable.

Excretion.

The elimination of nitrous oxide is faster than that of any other anaesthetic.
Nitrous oxide is eliminated unchanged from the body mostly by the lungs.
The flow of nitrous oxide out from the tissues through the lungs at the end of anaesthesia may lead to a degree of transient hypoxia.

5.3 Preclinical Safety Data

Genotoxicity.

No data available.

Carcinogenicity.

No data available.

6 Pharmaceutical Particulars

6.1 List of Excipients

No excipients present.

6.2 Incompatibilities

There are no major incompatibilities with nitrous oxide.

6.3 Shelf Life

Not applicable.

6.4 Special Precautions for Storage

Nitrous oxide will decompose at temperatures above 400°C and the speed of decomposition increases with increasing temperature. Explosive decomposition can occur at 650°C at atmospheric pressure.
The normal precautions required in the storage of medical gas cylinders as described below are applicable.
Cylinders should be stored away from sources of ignition, poisons, flammable or combustible materials. They should be secured upright, in a secure area, below 45°C, on a dry well ventilated area constructed of non-combustible material with a firm, level floor (preferably concrete) away from heavy traffic and emergency exits.
Cylinders should be kept out of the reach of children.

6.5 Nature and Contents of Container

Gas cylinders are supplied in steel or aluminium cylinders and fitted with pin index, valve outlet.
The cylinder colour code is: white body with ultramarine shoulder as per AS4484.
Cylinder size (nominal water capacity, Litres): C (2.8 L), D (9.5 L), E (23 L), G (50 L), 6 pack (300 L); 12 pack (600 L).
For cryoablation liquid withdrawal the cylinders composed of aluminium (sizes C, D, E, G), contain a dip tube and the valve outlet is different to that of the gas valves, to avoid operator error.
All cylinders and outlets comply with the relevant Australian Standards.
AUST R: 27183.

6.6 Special Precautions for Disposal

The cylinder pack should not be disposed of but must be returned to the supplier.

6.7 Physicochemical Properties

Nitrous oxide is a sweet smelling colourless gas. Nitrous oxide is not very soluble in water but is fifteen times more soluble than oxygen. Water dissolves nitrous oxide, taking 100 volume % and blood plasma 45 volume %. Boiling point: -88.6°C (at 1 bar). Specific gravity at 15°C and 101.3 kPa is 1.53. Density at 115°C and 101.3 kPa is 1.875 kg/m3. Nitrous oxide is an oxidising substance which will support combustion of materials which may not normally burn in air. The molecule is stable and comparatively unreactive at ordinary temperatures. At elevated temperatures it decomposes to nitrogen and oxygen.

Chemical structure.

A linear but unsymmetrical molecule of the form N-N-O.
Molecular Formula: N2O.
MW: 44.01.

CAS number.

10024-97-2.

7 Medicine Schedule (Poisons Standard)

S4 - Prescription only medicine.

Summary Table of Changes