Nitrous oxide

Background

Policy for the use of Inhaled Nitrous Oxide utilizing the Sedara Unit in the Adult and Pediatric Emergency Departments at Harbor-UCLA Medical Center Nitrous oxide sedation is expected to produce moderate sedation. As with all sedation agents, the possibility of reaching a deeper level of sedation than expected exists. Therefore, the current hospital policy regarding Procedural Sedation, policy number 355, will apply in its entirety to the use of this agent.

Indications

Nitrous oxide is indicated for brief painful procedures in patients older than 4 years and/or weighing greater than 15 kg who are ASA Class 1 or 2 with the goal of minimal sedation or anxiolysis. It may be used as an adjunct with local anesthetics for more painful procedures. Examples may include:

• Peripheral or Central IV placement
• Nasogastric tube 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

For overtly painful procedures or when additional moderate sedation is needed other agents such as narcotics or benzodiazepines may be added but smaller dosages should be used initially and titrated as needed to effect. Examples may include:

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

Contraindications

Nitrous oxide should NOT be coadministered with ketamine, etomidate or propofol and extreme caution should be used when combined with benzodiazepines or opioids in light of possible synergistic effects.

• 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

• An authorized physician provider with procedural sedation privileges may order nitrous oxide use utilizing the Sedera unit in the adult or pediatric emergency departments.
• An authorized patient monitor for moderate procedural sedation must be present at all times in addition to the provider.
• Informed consent for the procedure and sedation with nitrous oxide are required.
• A pre-sedation assessment must be performed.
• 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