Nitrous Oxide in the ED...

[miss81]

Hi All,

We are currently in the (very) preliminary stages of possibly creating a protocol for N.O. use by RN's in our ED for sedation during minor procedures. RN's use it daily in the L&D department. I know that this is not exactly the same use and the N.O. to O2 percentages are not the same in the blender. And from what I've seen with it's use in L&D it doesn't offer much "sedation" as such (which is a good thing in that setting), so I am looking specifically for ED use. Anyone use N.O. in their ED? Anyone know where I can read current policies specifically for this use? I'm just looking to read them to get some ideas on how other ED's use the gas, like I said we are still VERY early in this process.

P.S. This post could be appropriate for nurses who use N.O. in an ambulatory clinic, urgent care, or minor OR too...

Thanks!

[Porter_Instrument]

We already use nitrous oxide in our L&D dept, but I guess you would be the right person to ask about this considering where you work! Do you know where I can find any resources to use for creating a training module for RN's to use N20 for minor procedures in the ER? We do not titrate the percentage on L&D so our current training module does not discuss this. We would like to be able to titrate the percentage in the ER.

As for studies/articles r/t N2O and altitude, I found a few on pubmed but they were all very old (we're talking 80's). I did find one study that did discuss N2O and altitude, albeit only a little and I'm sure consider your job you already know this but I'll share anyway. This is not really significant to my practice as we are very close to sea level:

Nitrous oxide : The potency of anaesthetic gases is

proportional to their partial pressure and not the

percentage in mixture of oxygen is important. As

barometric pressure is reduced, fixed concentration

of inhaled anaesthetics will have less potency at

HA. So at HA above 3000 mtrs. There is significant

reduction of efficacy of 50% nitrous oxide in

reducing pain threshold9. Nitrous oxide has got

minimum alveolar concentration over 100% at sea

level. Since at HA, atleast 50% oxygen is to be

given in inspired gas as inhalation mixtures, so it is

of little use as an anaesthetic at 1500 mtrs and of no

value above 3000 mtrs due to its reduced

effectiveness.

http://medind.nic.in/iad/t02/i3/iadt02i3p175.pdf

Children's Hospital of MN has developed a tremendous nitrous oxide sedation program - the most organized that I have seen so far. They have put together a "Toolkit" that they share with others to help guide with setting up your own program. They have been very open to helping others learn from their mistakes - as well as avoiding "re-creating the wheel". Here is a link to their website:

http://www.childrensmn.org/forhealthprofessionals/nitrousoxidesedation.asp

Childrens of MN is also developing a training program that other hospitals can send people to - but I think this is down the road a bit. Unfortunately there are not a lot of sources for nitrous oxide education in the U.S. - with the exception of dental schools. I think with more hospitals getting interested in nitrous oxide this will increase the demand for education.

I think the ability to titrate is very important - and allows you to adjust the percentages to "get" your patients to a level of sedation that they (and you) are comfortable with. 50% fixed is good for some and potentially too much or to little for others. From what I have heard the most common procedures being done where N20 is being used include: catheter insertion, sutures, IV start, gastrostomy, joint injections, PICC lines, and CT scans.

I appreciate you sharing the article on altitude, and can imagine at extreme altitudes it is a challenge to sedate patients. The article references 3000 meters (9,000 feet). The previous post mentioned 4000 feet and I know there are many in Denver that use nitrous oxide effectively!

Sincerely,

Mike

[ZippyGBR, BSN, RN]

Nitrous Oxide for 'sedation' is probably not a good idea , although i can see why some might want it as quick and dirty conscious sedation especially if your anaesthetists are jumpy about propofol in the hands of non- Anaesthetists

50 + years of operational experience in the UK , 30 if not 40 years of experience with 'lay' person use in pre-hospital care ,

http://www.entonox.co.uk

http://www.emtcity.com/index.php/topic/20056-entonox-in-canada/

http://www.emtcity.com/index.php/topic/19129-is-pain-management-a-high-priority-in-your-approach-to-patient-care/