Nitrous Oxide in the ED...

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!

[miss81, BSN, RN]

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...

[dthfytr, ADN, LPN, RN, EMT-B, EMT-I]

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.

[miss81, BSN, RN]

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

[miss81, BSN, RN]

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...

[GilaRRT]

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.

[miss81, BSN, RN]

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.

[GilaRRT]

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, ADN, LPN, RN, EMT-B, EMT-I]

Honestly, I think it's a combination of altitude and lawyers scaring the docs of.

[ObtundedRN, BSN, RN]

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.

[Porter_Instrument]

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

[miss81, BSN, RN]

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