Maurine Clark, RN, MN, CRNI Seattle Children s Hospital maurine.clarkseattlechildrens April 21, 2012 Society of Pediatr

2. Objectives Understand the properties, use, advantages, limitations and contraindications of nitrous oxide/oxygen sedation Explore the necessary steps to initiate and implement a nurse administered nitrous oxide program in a health care facility Apply research, clinical evidence and national guidelines in the design of a safe and effective nurse administered nitrous oxide program

3. Nitrous oxide. 1840�s

4. Properties of N2O/O2 Anxiolytic Analgesic Amnestic Minimal sedation Patient remains awake and able to respond Rapid onset, rapid recovery Not metabolized Delivered with oxygen (reversal agent) Fail safe equipment Phenomenal safety record

5. Documents sent by the DOH to determine nursing scope of practice

6. Clinical Trials

8. Findings Nurse administration of nitrous oxide is safe with adequate training. Nitrous oxide in concentrations of 50-70%, is safe and effective in reducing the pain and anxiety of children undergoing minor hospital procedures. Nitrous oxide sedation is safe for children over 11 months of age. Nitrous oxide as a single-agent may not be adequate for very painful procedures (such as fracture reduction). Nitrous oxide is equally as effective as EMLA cream to reduce pain before venous cannulation, but when used together, a synergistic effect occurs to significantly reduce pain and anxiety of venous cannulation. 70% nitrous oxide administration has no greater adverse events than 50% nitrous oxide administration.

9. Timeline for Nurse-Administered Nitrous Oxide Program Month 1 � learning, writing proposal. Read, study, research. Proposal for State Nursing Commission Month 2 � endorsements Appointments. Medical Directors, Nursing Executives. Time on Sedation Committee agenda Month 3 � stakeholders Physician champion. Multidisciplinary planning team. Month 4 � training Funding for training, equipment Instructors, plan for 6-8 hour training course Month 5 � equipment Choose equipment, mask design. Inventory health care facility for scavenging, storage. Safety Officer for code requirements. Month 6 � policy & procedure Write policy Policy approval: Sedation Committee, Peds P & T Committee, Best Practice Committee, Standards Committee, Safety & Environmental Services Month 7 � forms & documentation Forms: Parent Info. Guide. Equipment Set-up Checklist. Order Set. Flowsheet. QA Plan. Supply Order form. E-competency chart. Month 8 � begin administration Competency training Learning module for in-house training & refresher Month 9 � nurse administration Transition to RN administration. Hospitalist training Month 10 � team building Team meeting. Training at Ed. Day. Expand to ED, radiology, outpatient

10. Indications

11. Procedures Consider nitrous oxide/oxygen for procedures which would likely cause mild to moderate pain and/or produce anxiety or distress, including but limited to: Bladder catheterization (VCUG) Peripheral IV start (PIV) Peripherally inserted central catheter (PICC) placement Nasogastric (NG) tube insertion Gastrostomy/GJ tube change Blood draws Lead placement for EEG Incision and drainage (I & D) Lumbar puncture (LP) Joint injection Barium enema Suturing Wound debridement Dressing changes Fracture reduction, reduction dislocation Joint injection Foreign body removal Removal of plaster/suture

12. Contraindications Contraindications including any condition where air may be trapped in the body: Unresolved pneumothorax Bowel obstruction Air embolism Severe bullous emphysema Maxillofacial injuries with potential for trapped gas Intraocular surgery (involving injected gas in last 10 weeks) Penetrating injury to the globe of the eye Craniotomy in past 3 weeks unless imaging shows no free air Decompression sickness (consider exclusion if diving in last 24 hrs) Other Contraindications: Increased intracranial pressure Impaired level of consciousness Pregnancy Vitamin B12 deficiency Treatment with bleomycin sulfate Intoxication with drugs or alcohol

13. Adverse Events

14. Signs of adequate sedation Signs of adequate sedation (anxiolysis); Comfortable and relaxed but aware of surroundings Able to respond to directions Tingling sensation of hands and feet and/or near the mouth Heaviness in legs and arms Warmth over chest, cheeks or face Feeling of floating Signs of over-sedation: Sudden agitation, excessive movement Diaphoresis Nausea, vomiting Asleep, unable to respond to verbal commands Signs of under-sedation: Crying, combative, tense FLACC score greater than 5

15. Anxiolytic sedation with nitrous oxide

16. Issues of Sedation Intent of minimal sedation Continual assessment of the child Dose is titrated based on the response of the child Safety measures of minimal and moderate sedation are clearly defined in policies and procedures A sedation scale that clearly distinguishes between minimal and moderate sedation Mechanisms of rescue are in place Outcome data on sedation depth and adverse events

17. Tiered level of training

18. Disposable mask and circuit

19. N2O/O2 Flowmeter

20. Documentation

21. Forms Nitrous Oxide/Oxygen Sedation for Children A Parent�s Information Guide Nitrous Equipment Checklist Contraindications Checklist Nitrous Oxide Administration Flowsheet Nitrous Oxide Administration Order Set Policy and Procedure NITROUS OXIDE/OXYGEN SEDATION 

22. Lessons learned Inexperience led to higher rate of vomiting Environment is key Younger children require a greater concentration of nitrous, especially between 2 to 4 years of age Doesn�t work for everyone Persistence, passion, and scientific inquiry can start a program