The Highs & Lows of Nitrous Oxide A Multidisciplinary Reflection Shannon Rivers, BS, CCLS II Leslie Mellin, RN, BSN

Understand the history and best use practices for Nitrous Oxide Review the process of starting a new Nitrous Oxide program Discuss different Child Life techniques to use during Nitrous Oxide sedation Open discussion

Discovered in the late 1700’s and used for recreation purposes and side show exhibitions. In 1844, Dr. Gardner Colton hosted an exhibition to demonstrate the “exhilarating” effects of inhaling N2O2. Horace Wells, a dentist, witnessed a participant receive this gas. The volunteer started euphorically jumping around and in the process injured his leg by creating a deep bloody laceration. The volunteer displayed no evidence of pain. This resulted in Horace Wells experimenting with the properties of N2O2 in his dental practice for tooth extractions. And so the start of Nitrous Oxide analgesic and sedation properties start.

N2O2 is a sweet smelling, colorless gas. At room temperature it is a gas; however, when compressed into a cylinder, it becomes a liquid. Frost may be seen on the tank surface during prolonged and continuous use. N2O2 is quickly eliminated in the lungs. Monitor with minimum of pulse oximeter and increase as provider deems necessary.

Analgesic properties (pain control) It has been reported that a mixture of 20% N2O2/80% O2 is equivalent to 15mg of morphine. Anxiolytic properties (sedative effects) N2O2/O2 sedation has been shown to facilitate positive behavior and lowered anxiety levels on sequential visits in pediatric patients. Amnesic properties Diminishes recall of severity of pain or duration of procedure. Onset of Action Clinical effects begin within 30 seconds, peak effects within 5 minutes.

Titration Allows the exact amount of the drug to be administered to each individual patient. Recovery After breathing approximately 2 minutes of pure oxygen at the completion of N2O2 administration, the effects of the gas will be dissipated Elimination Approximately 99% is excreted unchanged via the lungs. It is 99% eliminated from the body within 5-10 minutes after discontinuation. Approx. 1% is excreted over 24hrs via the skin and lungs.

Nitrous OxideOral/IV Sedation Rapid Onset in less than 30 secondsOnset is from 1-10 minutes Ability to titrate to desired effectInability to easily titrate Minimal side effectsRisk of aspiration, respiratory depression, hypoxia, hypotension Able to provide analgesic propertiesNo analgesic properties Painless administrationIV administration requires painful injection Not metabolizedMetabolized by the liver Rapid recovery in 5-10 minutesRecovery time in minutes

N2O2 diffuses rapidly into air-filled cavities causing expansion of those spaces. Therefore, N2O2/O2 should not be used in patients with pneumothorax, intestinal obstruction, middle ear occlusion, maxillofacial injuries, post intraocular surgery(w/in 10wks), craniotomy(w/in 3wks), increased ICP, and CF. N2O2 should also not be used on patients with B12 deficiency, COPD, bleomyocin therapy, impaired level of consciousness, and first trimester of pregnancy. Health care workers who are pregnant should not be in room during administration.

IV start, PICC insertions, lab draw (promotes vasodilation) Botox injections VCUG Echocardiogram EEG, LTM hook-up I&D, dressing change and wound debridement Eye exams NG tube placement, pH probe placement US Injections-IM,SQ or port access Sutures Closed reductions (with pain meds, i.e. Fentanyl) Foreign body removal (ears, nose) Minor surgical procedures

The American society of Anesthesiologists (ASA) and the American Academy of Pediatric Associates consider Nitrous Oxide sedation <50% minimal sedation (can be RN administered) Anything over 50% must be MD admisitered Titration is key to maintain a relaxed and therapeutic level Patient may experience: Tingling in extremities and/or near mouth, heaviness in legs and arms, body warmth, light feeling, flushed in face and neck, circumoral numbness, relaxed happy feelings and giddiness.

Always combine nitrous oxide with some type of distraction. Nitrous oxide increases imaginative suggestibility and imaginative ability. Guided imagery, videos, I-Pad apps, story telling and singing can direct the child's focus away from the procedure. Avoid too much distraction by several people, the child may lose focus and become agitated Include a qualified child life specialist. If the procedure is expected to be modestly painful use topical or local anesthesia.

Plan for success! Start with school age cooperative patients who are to undergo only a mildly painful procedure. Don’t be discouraged by failure. Some children simply do not relax with nitrous oxide administration. Parents must be informed that their child will not be deeply asleep during the sedation and may respond to pain with a flinch or vocalization. Parents may be reassured that many children do not recall the painful portion of the procedure.

Anesthesia Sedation credentialed Physicians (procedural and ED) Nursing Administration (Director and Manager) Education Specialist Members of SJCH Pain Committee Nursing (specifically from procedural areas) Child Life Specialists BioMedical/engineering

Porter MXR E Stand Package N2O2 Administration Policy N2O2 gas Scavenging system Safety, Anesthesia Gas Scavenging Policy Monitoring equipment Suction and Emergency Resuscitation Equipment Safety Checks

Similar to pre-op surgery mask prep Child can pick a flavor to paint their mask Developmentally appropriate mask play and explanation for “special/sleepy air” Patient with still be awake, just very relaxed Prepare highly sensitive/anxious patients about the air tank noise (vacuum cleaner) Promote control by encouraging patient to hold the mask on their face

Parental presence during N2O2 administration Hospital policies may vary Prepare parents and use them to help assess patient’s level of sedation One Voice Minimal sensory stimulation TV/movie, music, low-stim I-pad game, VECTA Guided Imagery, story telling

CCLS can help assess when patient is feeling the full effects of nitrous Parent assessment is especially helpful for delayed and non- verbal patients Ask pt “Do you feel any changes?”, “Are you comfortable?” Common signs of “full effect”: Loses tone and grip in hand/arm May close eyes May have non-focused gaze; looking “off in space” Less responsive to verbal command Laughs easily

Must be observed for 15 minutes Engage in recovery play & distraction Offer food and drink Follow up with patient and family regarding their experience Used primarily for our Botox patients Only 1 family preferred Versed only VCUG patients still struggle with imaging after catheter placement

Anesthesia accustomed to pt’s being fully sedated No parents allowed back or at bedside Anesthesia schedule was very limited Minor equipment malfunctions Need more credentialed RNs Expensive, 2-day training Equipment cost and storage

More sedation credentialed physicians and nurses Expand to the Pediatric Emergency Department Ideal for fracture reductions, sutures, abscess I&D, and foreign body removals Expand Nitrous schedule Offered on more days and for a wider range of procedures Full time radiology/Day Hospital Child Life Specialist NPO changes Floor/bedside procedures

Malamed, S: Sedation A Guide to Patient Management. Mosby, 4 th ed Clark & Brunick: Handbook of Nitrous Oxide & Oxygen Sedation. Mosby, 3 rd ed. Luhmann, Kennedy, Porter, Miller, and Jaffe, Annal of Emergency Medicine, 37:1, January 2001 Zier, Tarrago and Liu, Anesthesia & Analgesia, May 2010 vol.110 no Babl, Oakley, Seaman, Barnett and Sharwood, Pediatrics Digest, Vol. 121, No. 3, March 1, 2008, p e528-e532