Launceston General Hospital Policy February 2010 SDMS ID: P2010/0436-001 LGH Nursing Policy 04/10N Title: Replaces:

Description: Target Audience: Key Words: Policy Supported: Administration of Nitrous Oxide to Paediatric Patients 12/06 Nitrous Oxide is an inhaled analgesic/ amnesic/ anxiolytic with a quick onset and offset of action Registered/Enrolled Nurses/Medical Staff Administration/Nitrous Oxide/Paediatric

DEFINITION Nitrous Oxide is an inhaled analgesic/ amnesic/ anxiolytic with a quick onset and offset of action. It can be used as either a premixed 50:50 combination of Nitrous Oxide and Oxygen or as a variable mixture controlled by flow mixer (up to a maximum concentration of 70% N2O: 30% O2). It has demonstrated success in paediatric use as an analgesic It has minimal side effects. INDICATION FOR USE May include but are not limited to: Fracture manipulation Lumbar puncture Abscess incision and drainage Injections Removal of foreign bodies from ear/ soft tissues Blood sampling Burns baths Wound debridement/ suturing Physiotherapy Insertion of intravenous cannula CONTRAINDICATIONS FOR USE There are no absolute contraindications for the use of Nitrous Oxide. However there are a number of relative contraindications requiring assessment and review by medical staff. Such review must be carried out prior to the ordering and use of Nitrous Oxide for any procedure. These contraindications include, but are not limited to, the following: Pneumothorax Abdominal distention Air embolism Head injury with loss of consciousness/ altered conscious state Alcohol or drug intoxication Difficult airway Children <1 year of age Tracheostomy
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Recent middle ear surgery/ Otitis media Women in early pregnancy Chest trauma Acute asthma Chronic lung disease OUTCOME: Effective rapid pain relief may be obtained without loss of consciousness, side effects and with the minimal time between onset of action and recovery following procedure. SPECIAL NOTES Children may benefit from the presence of parents or carers during any procedure. Staff must offer, where possible, the opportunity for such persons to be in attendance with the child during any procedure. Full explanation of the nature of the analgesic as well as the procedure to be performed must be discussed with parents/ carers prior to commencing the procedure. Adequate ventilation and appropriate scavenger equipment must be provided in all areas where Nitrous Oxide is to be delivered. Prolonged and repeated exposure to Nitrous Oxide can have adverse consequences for staff. Children should never be left alone during procedures. The child should hold the mask on their face. No other person should hold the mask for the child. REQUIREMENTS: STAFFING A minimum of two (2) staff are required to utilize Nitrous Oxide for procedural purposes, one to administer the Nitrous Oxide and one to perform the procedure. The staff member administering the Nitrous Oxide must be authorized to administer Nitrous Oxide (see below). A Medical Officer must also be present within the Paediatric Unit during the procedure. Who can administer Nitrous Oxide? Either Medical staff familiar with the procedure and technique and approved to do so by the Divisional Director of Paediatric Services or the Director of the Department of Emergency Medicine. Registered Nurses with at least 12 months paediatric experience and who have undergone appropriate training and are approved to do so by the Divisional Director of Paediatric Services or the Director of the Department of Emergency Medicine. Training of staff to administer Nitrous Oxide will be conducted by the Clinical Nurse Educators in the Department of Paediatrics and the Department of Emergency Medicine. EQUIPMENT Nitrous Oxide Machine Appropriate mask Scavenger equipment Pulse oximeter Yankauer sucker Resuscitation equipment
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PROCEDURE Pre procedure Physical assessment by medical officer for fitness for use of Nitrous Oxide Inform parents/ patient regarding procedure and use of Nitrous Oxide It is desirable that children should be fasted for 4 hours prior to planned procedures utilizing Nitrous Oxide. Ensure appropriate resuscitation equipment is available Medication order for use on Medication chart. Documentation in medical record. Ensure equipment is working and adequate gas levels are available to complete the procedure uninterrupted. Principle Ensures microbes are not transferred from one to another by removing soil and transient microorganisms Procedure Hand washing with soap and water prior to and after contact for at least 15 - 30 seconds

Hand washing

Procedure Switch on Regulators Switch on Scavenging system Instruct child how to use the mask or mouthpiece Ensure child maintains satisfactory seal around edge of mask Adjust flow meters to 50:50 mix initially o Rate 3 litres/ minute if child < 20 kg o Rate 4 litres/ minute if child > 20 kg Instruct the child to breath deeply at a normal rate via the mask. Child should commence using the mask at least 2-3 minutes prior to commencing the procedure Administrator should constantly observe the child during the procedure to: o Ensure child is having effective analgesia o Is not asleep o Monitor (see monitoring below) o Oxygen and nitrous oxide flow may be adjusted by 1 litre/minute at a time. Child should continue breathing Nitrous Oxide/ Oxygen until 1 minute following the completion of the procedure At this time the child should breathe 100% Oxygen for 2-3 minutes before returning to their room. All children should remain attended by staff during this period. At completion of the procedure ensure all equipment (Nitrous Oxide, Oxygen and scavenging equipment) is switched off.

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Monitoring The staff member administering the Nitrous Oxide is responsible for monitoring the child during the procedure. They must have no other role during the procedure. Monitoring consists of constant attention to the airway, state of consciousness and respiratory level. Drowsiness, hearing abnormalities, visual disturbances, laughing, sweating or nausea may indicate oversedation Verbal communication should be maintained with the child at all times. Continuous pulse oximetry should be used throughout all procedures involving Nitrous Oxide except where the patient is in a burns bath. Any concern regarding the childs airway, respiratory status or level of consciousness should be reviewed by a medical officer. Ensure the child returns safely to bed following the procedure. Some childrens gait may be affected for a short period after administration. Parents and carers should be made aware of this. Minor side effects have been reported including light headedness, dry mouth, nausea, tingling in the fingers related to hyperventilation, euphoria, hearing and visual changes. Discharge Following Procedure Children may be discharged following a procedure utilising Nitrous Oxide when they have returned to pre procedure level of consciousness. Discharge assessment criteria are as described in the Paediatric Sedation Guidelines 1009. Disposal of Equipment Research indicates that anaesthetic equipment presents a significant cross infection risk for patients in hospital. All masks should have a microbiological filter fitted during administration of Nitrous Oxide. These come attached to the prepackaged mouthpieces and tubing. Mouthpieces and tubing are disposable and obtained from the hospitals stores department. After hours they are available from Labour ward (4B) or DEM. All masks are single patient use only and are to be disposed of following usage in yellow hazardous waste disposal bags. If a child is having repeated procedures on consecutive days then the same tubing mouthpiece set maybe used providing the filter remains dry. The mouthpiece should be cleaned between usages by wiping with 70% alcohol and 30% distilled water. Documentation Vital signs before and during administration should be recorded. Following the procedure it should be appropriately documented in the childs medical record. This record should have the date and time of the procedure, the rationale for using Nitrous Oxide and the procedure performed, the concentration of Nitrous Oxide used, the length of time the procedure took, the efficacy of Nitrous Oxide use and the name of the person who administered the Nitrous Oxide. The record of administration should be signed on the drug chart next to the appropriate order. Staff should record the administration on their personal record of administration for annual re-accreditation.

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References: Anesthesia Patient Safety Foundation. Recommendations for Safe Administration of Sedation and Analgesia (Conscious Sedation), Adapted from the American Society of Anesthesiologists Guidelines for Sedation and Analgesia by Non-Anesthesiologists. http://gasnet.med.yale.edu/apsf/clinical/sedation, 4/7/2003. Australian and New Zealand College of Anaesthetists (2001) Guidelines on Conscious Sedation for Diagnostic, Interventional Medical and Surgical Procedures, www.medeserv.com.au/anzca/publications/profdocs/profstandards/PS99_2001.htm, 19/2/2002. Babl F, Oakley E, Seaman C, Barnett P and Sharwood LN, (2008) High concentration Nitrous Oxide for procedural sedation in children: adverse events and depth of sedation. Pediatrics, e528 e532. Babl F, McGowan V, Priestley S, Krieser D, Miller J, Spicer M, Tully M, McKenzie A (2005) Sedation of Children in the Emergency Department at Sunshine Hospital and Royal Childrens Hospital. BOC Medical (2002) Nitrous Oxide the balanced solution, BOC Medical, North Ryde. Brown, TB, Lovato, LM and Parker, D (2005) Procedural Sedation in the Acute Care Setting, American Family Physician, 71(1), 85-90. Bruce, E and Franck, L (2000) Self administered nitrous oxide (Entonox) for the management of procedural pain, Paediatric Nursing, 12(7), 1519. Bruce L (2003) Adminsistration of Entonox Clinical Practice Guidelines Greater Ormond Street Hospital For Children Trust Clinical Practice Committee, London Chilvers R and Weisz, M (2000) Entonox equipment as a potential source of cross infection, Anaesthesia, 2000, 155, 176-179. Clark, M, Renehan, BW and Jeffers, BW (1997) Clinical use and potential biohazards of nitrous oxide/ oxygen, General Dentistry, September- October, 486-491. Clinical Affairs Committee (2003) Policy on minimizing Occupational Health Hazards Associated with Nitrous Oxide, Reference Manual 2005 2006, 49-50. Department of Health and Human Services (2003) Guidelines and Procedure Administration of Nitrous Oxide to Paediatric Patients, Launceston General Hospital, Launceston. Dowling, S (2006) Email correspondence, Mayo Healthcare Pty. sdowling@mayohealthcare.com.au General Medicine and Emergency Department (2001) Nitrous Oxide/ Oxygen Mix Clinical Practice Guidelines, Parkville; Royal Childrens Hospital. Division of Nursing (2001) No: 02.46a Policy for the administration of nitrous oxide Relative Analgesia, Westmead, Childrens Hospital at Westmead.
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Frampton A, Browne GJ, Lam LT, Cooper MG and Lane LG (2003) Nurse administered relative analgesia using high concentration Nitrous Oxide to facilitate minor procedures in children in an emergency department, Emergency Medicine Journal, 20, 410-413.

Graber, M (2002) Reference Materials: Paediatric Sedation, in University of Iowa Family Practice Handbook (4th Edition), www.vh.org/Providers/ClinRef/FPHandbook/Chapter23/01-23.html; downloaded 21/12002. Green, S (1996) Nitrous Oxide a potential hazard, British Journal of Theatre Nursing, 6(6), 27, 30-33. Haas, DA (1999) Oral and inhalational conscious sedation, Anesthesia in Dentistry, 43(2), 341-359. Kanagasundaram, SA, Lane, LJ, Cavaletto, BP, Keneally, JP and Cooper, MG (2001) Efficacy and safety of Nitrous Oxide in alleviating pain and anxiety during painful procedures, Archives of Diseases in Childhood, 84, 492-495. Kennedy, RM, Luhmann JD, Luhmann SJ (2004) Emergency Department Management of Pain and Anxiety of Pain Related to Orthopaedic Fracture Care A Guide to Analgesic Techniques and Procedural sedation in Children. Pediatric Drugs 6(1), 11-31. Paris, PM (1996) Treating the patient in pain, Emergency Medicine, September, 66-90. Pershad, J and Gilmore, B (2006) Succesful Implementation of Radiology Sedation Service Staffed Exclusively by Pediatric Emergency Physicians, Pediatrics 117, 413-422. Pickup, S and Pagdin, J (2000/2001) Procedural Pain; Entonox can help, Paediatric Nursing, 12(10), 33-36. Schumann, D (1990) Nitrous Oxide Anaesthesia: risks to health personnel, International Nursing Review, 37(1), 214-217.

Scottish Intercollegiate Guidelines Network, (2004) Safe Sedation of Children Undergoing Diagnostic and Therapeutic Procedures, A National Clinical Guideline, Royla College of Physiscians, Edinburgh. Smith, DA (1998) Hazards of Nitrous oxide exposure in healthcare personnel, Journal of the American Association of Nurse Anesthetists, 66(4), 390-393. Street, D (2000) A practical guide to giving Entonox, Nursing Times, 96(34), 47-48. Wertz, EM (1994) Pediatric Conscious Sedation, Emergency, August, 18-23. Wong, DL (1999) Whaley and Wongs Nursing Care of Infants and Children (6th Edition), Mosby, Philadelphia.
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All Staff Positions accountable for a) compliance with the policy: Registered/Enrolled Nurses/Medical Staff b) monitoring and evaluation of the policy: Post Graduate Clinical Development Coordinator and Paediatric Course Facilitator, Paediatric Unit c) development and revision of the policy: enter applicable staff here Post Graduate Clinical Development Coordinator and Paediatric Course Facilitator, Paediatric Unit

Review Date: Developed By: Stakeholders:

Annually verified for currency or as changes occur, and reviewed every 3 years. Post Graduate Clinical Development Coordinator and Paediatric Course Facilitator, Paediatric Unit Registered/Enrolled Nurse/Medical Staff

AUTHORISED BY DIRECTOR OF NURSING ..28 February 2010 Helen Bryan Date

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