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Implementing paediatric procedural sedation in emergency departments- 2013

Nitrous oxide

Gerry SilkPaediatric Nurse Consultant

Nitrous oxide

What is it?

• Anaesthetic gas with analgesic/sedative properties

• Rapid onset/offset

• Delivered in variable concentrations with oxygen

• Requires some degree of cooperation

• 2 forms: • Continuous flow

• 0-70% N20: 100%-30% 02• Demand flow

• Entonox (50% N20: 50% 02)

• Piped or cylinder

Nitrous oxide – indication and contra indication

INDICATION:

• Short painful procedures in cooperative children

• Useful for suturing, IV insertion, foreign body removal, minor fracture

CONTRAINDICATIONS:

• Child < 1 year

• Acute respiratory infection (URTI) or exacerbation of asthma

• Risk of expansion of air-filled closed space

– Pneumothorax, lung cyst, bowel obstruction, middle ear disease

• Increased risk of neuro-toxicity or bone marrow depression

Nitrous oxide – adverse effects

• Vomiting and aspiration

• Dizziness, light-headedness

• Excessive drowsiness with loss of airway

• Expansion of air-filled closed space: • pneumothorax, bowel, middle ear

• Increased intracranial pressure

• Risk to staff

Pre-procedure: use of risk assessment and record form

Pre-procedure: child suitable for sedation

Positive feature(s) on risk assessment or

exclusion criteria

Procedural sedation in ED not

appropriate for this patient!!!

Pre-procedure: fasting

• Somewhat controversial

• Nitrous oxide• 2 hours solids and liquids

Pre-procedure: parent information and consent

• Local context/policy needs to include

• explain the procedure to the child and parent

• gain parent/family consent

• consent must be informed

• consent should be documented

Staff

• Trained in paediatric life support• Staff trained and credentialed in use of sedation• Correct mix of staff to carry out the procedure

and sedation• Team approach

A clinician (doctor or nurse) credentialed in nitrous oxide use to perform the sedation and monitor the child

A clinician (doctor or nurse) to perform the procedure

Prepare child and parent for the procedure with sedation

• Build trust and rapport with the parent and child

• Explain the procedure and sedation to the parent and child

• Useful for the child to play with the nitrous tubing and mask

• Use age appropriate language and other distraction techniques

• Appropriate positioning of the child

• The procedure and sedation needs to be undertaken in an appropriate location eg procedure room

• Location needs to have monitoring equipment, oxygen, suction and airway support equipment and access to paediatric resuscitation equipment and drugs

• Scavenging unit

Location

Equipment: general

• Bag–mask-valve setup appropriate for child age and size attached to separate oxygen source

• Operating suction with a yankauer sucker attached

• Pulse oximeter operative

• Equipment must be checked and available prior to commencing sedation episode

Equipment: nitrous oxide specific

• Nitrous oxide equipment is checked and working

• Bacterial filter filters for use in N2O circuit

• Apply scented essence to mask NOT filters

• Scavenging unit is set up

• Specific details of nitrous set will be covered in practical demonstration

During the procedure

• All medication used in sedation episode (including nitrous) require written orders and documented once administered

• Adjust flow of oxygen/N2O to achieve the desired concentration and sedation level

• Monitor the child’s level of sedation

• Monitor the child’s respiration, O2 saturation, heart rate and level of sedation

• Document every 5 minutes

• Identify and manage of any adverse events

Depth of sedation score

0 Awake and alert

1 Minimally sedated: may appear tired/sleepy, response to verbal stimulus

2 Moderately sedated: somnolent/sleeping, roused with light tactile stimulation

3 Deep sedation: deep sleep, rousable only with deep physical stimulation

4 Unrousable

Post procedure

• Administer 100% O2 for 2 minutes post procedure

• Monitor the child until their conscious state returns to baseline, 5 minutely observations documented until awake

• Once awake, monitor the child 15 minutely until fully recovered

• Nil orally until fully alert

• Document procedure and sedation on risk assessment and record form

• Manage and document any side effects or adverse events

Discharge

• Procedure completed successfully

• Child meets discharge criteria

• Discharge instructions discussed and provided to parent

• GP letter to parent (if required)

• Follow-up arrangements (e.g. GP, fracture clinic, etc)

• Ensure all documentation is complete included the risk assessment and record form

Questions