1. Title - xxx Speaker’s name etc Implementing paediatric procedural sedation in emergency departments- 2013 Nitrous oxide Gerry Silk Paediatric Nurse Consultant

2. Nitrous oxide

3. 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

4. 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

5. 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

6. Pre-procedure: use of risk assessment and record form

7. Pre-procedure: child suitable for sedation Positive feature(s) on risk assessment or exclusion criteria Procedural sedation in ED not appropriate for this patient!!!

8. Pre-procedure: fasting Somewhat controversial Nitrous oxide 2 hours solids and liquids

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. Depth of sedation score 0Awake and alert 1Minimally sedated: may appear tired/sleepy, response to verbal stimulus 2Moderately sedated: somnolent/sleeping, roused with light tactile stimulation 3Deep sedation: deep sleep, rousable only with deep physical stimulation 4Unrousable

17. 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

18. 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

19. Questions