Nitrous Oxide in the ED...

  1. 0 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!
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  3. Visit  miss81 profile page

    About miss81

    miss81 has '8' year(s) of experience and specializes in 'Surgery, Tele, OB, Peds,ED-True Float RN'. Joined Jun '08; Posts: 346; Likes: 432.

    13 Comments so far...

  4. Visit  miss81 profile page
    0
    Oh, and I did look through the previous posts and found that most of the links in the posts no longer work and many of the posts are 5-10 yrs old! Thanks...
  5. Visit  dthfytr profile page
    0
    Used it for awhile with good results, but the docs decided it was too great a risk becuase we're 4000 ft above sea level. Never did get a good explantaionof that, but no hospitals or EMS here use it.
  6. Visit  miss81 profile page
    0
    I guess I'll have to check out how altitude affects nitrous oxide! Thanks! We are at sea level here!

    BTW... I should not have used N.O. for short... that my make ppl think I was referring to Nitric oxide... not nitrous oxide AKA N2O

    Thanks
  7. Visit  miss81 profile page
    0
    Quote from dthfytr
    Used it for awhile with good results, but the docs decided it was too great a risk becuase we're 4000 ft above sea level. Never did get a good explantaionof that, but no hospitals or EMS here use it.
    dthfytr, did you complete a course or module re: administration of N2O? Can't seem to find any online...
  8. Visit  GilaRRT profile page
    2
    Quote from dthfytr
    Used it for awhile with good results, but the docs decided it was too great a risk becuase we're 4000 ft above sea level. Never did get a good explantaionof that, but no hospitals or EMS here use it.
    Nitrous readily penetrates lipid membranes and can easy offgas in air filled cavities. Ears, stomach, intestines and even eyes can be effected. Clearly, changes in barometric pressure can be met with consequences in patients with bowel obstruction, retinal detachment and so on. Another potential concern is B12 deficiency with prolonged use and potential concern about teratogenic effects and pregnancy.
    Anna Flaxis and dthfytr like this.
  9. Visit  miss81 profile page
    0
    Quote from gilarrt
    nitrous readily penetrates lipid membranes and can easy offgas in air filled cavities. ears, stomach, intestines and even eyes can be effected. clearly, changes in barometric pressure can be met with consequences in patients with bowel obstruction, retinal detachment and so on. another potential concern is b12 deficiency with prolonged use and potential concern about teratogenic effects and pregnancy.
    yes, i know about the side effects and contraindications for the gas (we use it daily for our l&d pt's) but i guess i have never really paid attention to the altitude aspect of possible consequences as it hasn't really been an issue here.
  10. Visit  GilaRRT profile page
    1
    I can see problems primarily with the gas laws and ascent/descent. Is it a real, well founded risk at 3,000 feet msl? I'm not so sure, but the United States is a bit fickle in some areas regarding treatments and interventions.
    dthfytr likes this.
  11. Visit  dthfytr profile page
    0
    Honestly, I think it's a combination of altitude and lawyers scaring the docs of.
  12. Visit  ObtundedRN profile page
    0
    Our EMS agency uses it. It is patient controlled with a hand held mouth piece. They figure if the patient gets too much, they won't be able to get it in their mouth to inhale more.
  13. Visit  Porter_Instrument profile page
    0
    Quote from dthfytr
    Used it for awhile with good results, but the docs decided it was too great a risk becuase we're 4000 ft above sea level. Never did get a good explantaionof that, but no hospitals or EMS here use it.
    Hello - I would be curious to learn more about this. Our nitrous oxide equipment is used all over the world at varying altitudes and I have not heard of any adverse events.

    Is there documentation or a study somewhere that I can read? We are seeing more and more interest from hospitals that are looking to implement nitrous oxide sedation programs - and I am trying to do my homework!

    Sincerely,
    Mike Civitello
    Porter Instrument
  14. Visit  miss81 profile page
    0
    Quote from Porter_Instrument
    Hello - I would be curious to learn more about this. Our nitrous oxide equipment is used all over the world at varying altitudes and I have not heard of any adverse events.

    Is there documentation or a study somewhere that I can read? We are seeing more and more interest from hospitals that are looking to implement nitrous oxide sedation programs - and I am trying to do my homework!

    Sincerely,
    Mike Civitello
    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
  15. Visit  Porter_Instrument profile page
    0
    Quote from miss81
    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/forhealth...desedation.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


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