Maurine Clark, RN, MN, CRNI maurineclark@msn.com www.ouchlesshealthcare.org April 21, 2012

1. The Ouchless Hospital Developing a Nurse Administered Nitrous Oxide Program Using research, current guidelines and the voices of children Maurine Clark, RN, MN, CRNI maurineclark@msn.com www.ouchlesshealthcare.org April 21, 2012 Society of Pediatric Nurse 22nd Annual Convention Houston, Texas

2. Properties of N2O/O2 • Anxiolytic • Analgesic • Amnestic • Minimal sedation • Patient remains awake and able to respond • Rapid onset, rapid recovery • Not metabolized • Delivered with oxygen (reversal agent) • Fail safe equipment • Phenomenal safety record

3. Determining nursing scope of practice • Documents provided by the WA State Nursing Commission:

4. Clinical Trials Zier et al. (2007). Case-series of nurse-administered nitrous oxide for urinary catheterization in children. Anesthesia & Analgesia, 109(4), 876-879. Minnesota, USA Frampton et al. (2003). Nurse administered relative analgesia using high concentration nitrous oxide to facilitate minor procedures in an emergency department. Emergency Medicine Journal, 20(5), 410-413. Sydney, Australia Babl et al, (2007). High-concentration nitrous oxide for procedural sedation in children: Adverse events and depth of sedation. Pediatrics, 121(3), e528-32. Melbourne, Australia Babl et al. (2008). Limited analgesic efficacy of nitrous oxide for painful procedures in children. Emerg Med J, 25, 717-721. Melbourne, Australia

5. Faroux et al. (2004). The efficacy of premixed nitrous oxide and oxygen for fiberopticbronchoscopy in pediatric patients: A randomized, double-blind, controlled study. Chest, 125(1), 315-321. Paris, France Paut et al. (2001). EMLA versus nitrous oxide for venous cannulation in children. AnesthAnalg, 93, 590-593. Marseilles, France Hee, Goy & Ng. (2003). Effective reduction of anxiety and pain during venous cannulation in children: a comparison of analgesic efficacy conferred by nitrous oxide, EMLA and combination. PaediatricAnasthesia, 13, 210-216. Singapore Tunsia, North Africa Abdelkefi et al., (2004). Effectiveness of fixed 50% nitrous oxide oxygen mixture and EMLA cream for insertion of central venous catheters in children. Pediatr Blood Cancer, 43, 777-779. Williams, et al. (2006). Inhaled nitrous oxide during painful procedures: a satisfaction survey. Paediatric Nursing, 18(8), 31-33. Wolverhampton, UK

6. Indications No NPO requirements

7. Procedures • Consider nitrous oxide/oxygen for procedures which would likely cause mild to moderate pain and/or produce anxiety or distress, including but limited to: • Bladder catheterization (VCUG) • Peripheral IV start (PIV) • Blood draws • Peripherally inserted central catheter (PICC) placement • Nasogastric (NG) tube insertion • Gastrostomy/GJ tube change • Lead placement for EEG • CT scans • Incision and drainage (I & D) • Lumbar puncture (LP) • Joint injection • Barium enema • Suturing • Wound debridement • Dressing changes • Fracture reduction, reduction dislocation • Joint injection • Foreign body removal • Removal of plaster/suture

8. Contraindications Contraindications including any condition where air may be trapped in the body: • Unresolved pneumothorax • Bowel obstruction • Air embolism • Severe bullous emphysema • Maxillofacial injuries with potential for trapped gas • Intraocular surgery (involving injected gas in last 10 weeks) • Penetrating injury to the globe of the eye • Craniotomy in past 3 weeks unless imaging shows no free air • Decompression sickness (consider exclusion if diving in last 24 hrs) Other Contraindications: • Increased intracranial pressure • Impaired level of consciousness • Pregnancy • Vitamin B12 deficiency • Treatment with bleomycin sulfate • Intoxication with drugs or alcohol

9. Tiered level of training

10. Maurine Clark maurineclark@msn.com www.ouchlesshealthcare.org