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

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. 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. Babl et al, (2007). High-concentration nitrous oxide for procedural sedation in children: Adverse events and depth of sedation. Pediatrics, 121(3), e528-32. Babl et al. (2008). Limited analgesic efficacy of nitrous oxide for painful procedures in children. Emerg Med J, 25, 717-721. Minnesota, USA Sydney, Australia Melbourne, Australia

5. Faroux et al. (2004). The efficacy of premixed nitrous oxide and oxygen for fiberoptic bronchoscopy in pediatric patients: A randomized, double-blind, controlled study. Chest, 125(1), 315-321. Paut et al. (2001). EMLA versus nitrous oxide for venous cannulation in children. Anesth Analg, 93, 590-593. 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. Paediatric Anasthesia, 13, 210-216. 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. Paris, France Marseilles, France Singapore Tunsia, North Africa 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: o Bladder catheterization (VCUG) o Peripheral IV start (PIV) o Blood draws o Peripherally inserted central catheter (PICC) placement o Nasogastric (NG) tube insertion o Gastrostomy/GJ tube change o Lead placement for EEG o CT scans o Incision and drainage (I & D) o Lumbar puncture (LP) o Joint injection o Barium enema o Suturing o Wound debridement o Dressing changes o Fracture reduction, reduction dislocation o Joint injection o Foreign body removal o Removal of plaster/suture

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

9. Tiered level of training

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