Nitrous oxide: Difference between revisions
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==Background==
==Background==
For moderate sedation
*For minimal sedation or anxiolysis
*It may be used as an adjunct with local anesthetics for more painful procedures


==Indications==
==Indications==
*Older than 4 years and/or weighing greater than 15 kg  
*Older than 4 years and/or weighing greater than 15 kg  
*ASA Class 1 or 2 with the goal of minimal sedation or anxiolysis. It may be
*ASA Class 1 or 2
used as an adjunct with local anesthetics for more painful procedures. Examples may include:
*Sole Nitrous Oxide use examples include:
*Peripheral or Central IV placement
**Peripheral or Central IV placement
*Nasogastric tube placement
**Urinary catheter insertion
*Urinary catheter insertion
**Intramuscular injections
*Intramuscular injections
**Joint aspiration or injection
*Joint aspiration or injection
**Lumbar puncture
*Lumbar puncture
**Laceration repair
*Laceration repair
**Abscess incision and drainage
*Abscess incision and drainage
**Nail removal
*Nail removal
**Wound packing or dressing change
*Wound packing or dressing change
**Foreign body removal
*Foreign body removal
*Nitrous Oxide + narcotic or benzodiazepine examples include (smaller dosages should be used initially and titrated as  
 
needed)
For overtly painful procedures or when additional moderate sedation is needed other agents such as
**Lumbar puncture
narcotics or benzodiazepines may be added but smaller dosages should be used initially and titrated as  
**Laceration repair
needed to effect. Examples may include:
**Abscess incision and drainage
*Lumbar puncture
**Foreign body removal
*Laceration repair
**Simple or minimally displaced fracture reduction
*Abscess incision and drainage
*Foreign body removal
*Simple or minimally displaced fracture reduction


==Contraindications==
==Contraindications==
Nitrous oxide should NOT be coadministered with ketamine, etomidate or propofol and extreme caution  
*Should NOT be coadministered with
should be used when combined with benzodiazepines or opioids in light of possible synergistic effects.
**ketamine
 
**etomidate
**propofol
**extreme caution should be used when combined with benzodiazepines or opioids  
*Age greater than 4 years and/or weight greater than 15 kg
*Age greater than 4 years and/or weight greater than 15 kg
*ASA Class 3 or above
*ASA Class 3 or above
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==Procedure==
==Procedure==
*An authorized physician provider with procedural sedation privileges may order nitrous oxide use utilizing the Sedera unit in the adult or pediatric emergency departments.
*Pre-sedation establishment of an IV is not required
*An authorized patient monitor for moderate procedural sedation must be present at all times in addition to the provider.
*General monitoring procedures shall be followed
*Informed consent for the procedure and sedation with nitrous oxide are required.
*Nitrous oxide administration should be limited to 30 minutes
*A pre-sedation assessment must be performed.
*Administer 100% oxygen for 2-5 minutes after discontinuing nitrous oxide or if nitrous oxide / oxygen administration is interrupted for > 30 seconds
*The procedural sedation documentation record must be utilized
*All resuscitation and monitoring equipment shall be readied and checked prior to sedation
*A new disposable facemask or mouthpiece is to be used for each administration.
*Pre-sedation establishment of an IV is not required.
*General monitoring procedures shall be followed.
*Nitrous oxide administration should be limited to 30 minutes.
*Administer 100 % oxygen for 2-5 minutes after discontinuing nitrous oxide or if nitrous oxide / oxygen administration is interrupted for > 30 seconds
*Recovery and discharge procedures shall be followed

Revision as of 23:54, 2 October 2013

Background

  • For minimal sedation or anxiolysis
  • It may be used as an adjunct with local anesthetics for more painful procedures

Indications

  • Older than 4 years and/or weighing greater than 15 kg
  • ASA Class 1 or 2
  • Sole Nitrous Oxide use examples include:
    • Peripheral or Central IV placement
    • Urinary catheter insertion
    • Intramuscular injections
    • Joint aspiration or injection
    • Lumbar puncture
    • Laceration repair
    • Abscess incision and drainage
    • Nail removal
    • Wound packing or dressing change
    • Foreign body removal
  • Nitrous Oxide + narcotic or benzodiazepine examples include (smaller dosages should be used initially and titrated as

needed)

    • Lumbar puncture
    • Laceration repair
    • Abscess incision and drainage
    • Foreign body removal
    • Simple or minimally displaced fracture reduction

Contraindications

  • Should NOT be coadministered with
    • ketamine
    • etomidate
    • propofol
    • extreme caution should be used when combined with benzodiazepines or opioids
  • Age greater than 4 years and/or weight greater than 15 kg
  • ASA Class 3 or above
  • Closed head injury, recent craniotomy, altered level of consciousness or suspicion of elevated intracranial pressure
  • Penetrating globe injury or recent eye surgery
  • Complex upper respiratory infection (obstructive sinusitis, bullous otitis media)
  • Maxillofacial injuries
  • Acute asthma, bullous emphysema or pneumonia
  • Pneumothorax or chest trauma
  • Pulmonary hypertension
  • Congenital heart disease
  • Bowel obstruction or ileus
  • Recent SCUBA diving, barotrauma or decompression illness
  • Pregnancy

Procedure

  • Pre-sedation establishment of an IV is not required
  • General monitoring procedures shall be followed
  • Nitrous oxide administration should be limited to 30 minutes
  • Administer 100% oxygen for 2-5 minutes after discontinuing nitrous oxide or if nitrous oxide / oxygen administration is interrupted for > 30 seconds
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