Many children and adolescents undergo painful or distressing interventions as part of their care. Effective procedural sedation can assist in facilitating successful interventions. Nitrous oxide is an anaesthetic gas with significant analgesic, some amnesic and anxiolytic properties. It has a rapid and predictable onset and offset of action and can safely be titrated to produce a state of conscious sedation.

• To optimize conditions for performing a procedure
• To improve patient and family experiences when undergoing procedures
• To minimise anxiety and distress
• To minimise pain by providing analgesia as a complement to sedation
• To safely administer sedation to appropriately identified patients

• Intravenous cannulation/venepuncture

• Intramuscular injection

• Wound/dressing care

• Urinary catheterisation

• Removal of wound drains and catheters

• Removal of foreign body

• Fractures and plaster care

• Other minor procedures with duration less than 45 minutes

Nitrous oxide will diffuse into closed spaces causing increased volume and increased pressure within the confined cavity. Therefore nitrous oxide is NOT to be used in patients where there is a risk of trapped gas e.g.:

• Pneumothorax or suspicion of pneumothorax

• Pulmonary hypertension

• Impairment of consciousness prior to procedure

• Any airway obstruction or history of difficult airway maintenance

• Acute asthma

• Lung cyst

• Closed head injury/raised ICP

• Bowel obstruction

Other exclusion criteria

• Children under the age of 2 years

Pregnancy and nitrous oxide. Exposure to nitrous oxide should be avoided during pregnancy. It is recommended that exposure to nitrous oxide not occur in the first trimester of pregnancy. Occasional brief exposure later in pregnancy is considered 'low risk'. Repeated exposure should be avoided in the 2nd and 3rd trimesters.

• Accutron continuous nitrous oxide system with disposable circuit and appropriate size mask

• Monitoring equipment - Sa02 and HR

• Separate oxygen and suction source must be checked and available prior to commencing procedure

• Access to the resuscitation trolley

• Distraction aids

Nitrous Oxide should only be administered by Nursing Staff who have

• Read this CPG including the attached Nitrous Oxide Administration and Care videos attached in the Appendices

• Successfully completed four (4) supervised episodes of administering nitrous oxide. To be supervised by staff who are experienced in administering nitrous (delivered nitrous oxide more than 20 times) and signed off by the supervising staff member on the attached Nitrous Oxide Administration Training Record.

• Current Resus4Kids

Pre Procedure

1. Complete the Prior to Sedation section of the Paediatric Sedation Record (MR367.0), including obtaining consent from parent/carer

2. If staff performing the sedation has any concerns regarding the risk assessment or patient assessment please consult with the paediatric medical staff.

3. Run test check on Accutron Digital Ultra Flowmeter

4. Connect nitrous oxide disposable circuit and age appropriate mask

5. Turn on scavenger unit

6. Check separate source of oxygen and suctioning available and working

7. Turn on vital sign monitoring equipment

Procedure

1. Patient must remain in the line of sight of nitrous oxide trained staff member. Continually assess UMSS, HR, RR and Sa02.

2. Staff responsible for the delivery of nitrous oxide MUST NOT be utilised for any other task during the procedure.

3. Start with 100% oxygen and have the patient breath regularly through the mask. Adjust the amount of flow to maintain the bag as being full but not overinflated. Bag should empty with patients breath.

4. Titrate nitrous oxide to achieve desired sedation. Maximum concentration is 70% nitrous oxide:30% oxygen. The lowest concentration of nitrous oxide should be used to maintain the desired level of sedation. Signs of sedation are glassy eyes, dilated pupils, the body relaxing and flushing of the face.

   Ensure the patient is able to respond to directions and conversation and has a protective cough/gag reflex. Monitor for signs of over sedation such as increasing nausea and vomiting, increasing dizziness and sweating, laughing excessively, visual disturbances such as hallucinations or room spinning.
   
   Over sedation Management
   
   Cease nitrous oxide immediately and place patient on their side. Press the 02 flush button and apply 100% oxygen or administer high flow oxygen via separate mask. Closely monitor airway and vital signs. Monitor for a reduction in symptoms. If symptoms persist after 5minutes seek further medical support

Post Procedure

1. Administer 100% oxygen for 3-5 minutes to prevent diffusion hypoxemia.

2. Discuss with parent/carer post sedation care.

3. Patient may be discharged when patient has:

• Returned to baseline sedation score and vital signs,

• A responsible adult is present to accompany patient home,

• Can sit up unaided/walk (developmentally appropriate).

Complete remaining sections of Paediatric Sedation Record (MR367.0)