In today’s episode, we share the success of a nitrous sedation program and to help others consider nitrous as an option for their patients. 

So Mary Kay How did you first become interested in the use of nitrous oxide?

Actually, the first time I saw nitrous sedation used was in the emergency room. A patient with a dislocated shoulder was brought into our department with nitrous being used for pain control. The paramedic was delivering it with a mask and a small tank. The patient was calm and able to answer questions. When the nitrous was stopped, they were once again in severe pain. 

Not too long after that, I witnessed it when my niece broke her ankle playing ball, the drama queen that she was as a teen, very loudly suggested in reasonable pain. After the paramedics started the nitrous she was silent 

At that time, we were looking for something to repeat midazolam for our BCG patients during urinary catheterization, our radiology halls often sounded like a torture chamber with kids crying, we noticed that PO midazolam often did not calm down the kids and it didn't do much for the discomfort. 

After the exam, they were crabby and sleepy. Often the kids had hallucinations that were very scary. For example, one kid told us that his nurse had four eyes and that his mom looked like a green monster. This is all while there were several people holding the child down to place a catheter, so you can just imagine how scared those kids are inadequate or no sedation parents often reported that their child would not allow them even to change a diaper. 

After this type of traumatic experience, they had a horrible fear of health care providers or going to their doctor. 

Our sedation department was asked to take over sedation for this procedure. We wanted to try nitrous. We thought if paramedics and dental hygienists could be trained to do it. Why couldn't nurses that were trained in advanced sedation working under the direction of a doctor do what as well?

What led you to consider nitrous as a change in practice for urinary catheter placement needed for BCGs?

Our sedation team understood how pain and distress experienced by a child with painful and distressing procedures sets the tone for future medical interactions. 

This can have long term effects with their attitude and willingness to participate in health care now and in the future. We saw this even with parents who had gone through these types of procedures when they were a child, they didn't want to see their own children go through that. 

Nitrous is a gas used for pain and anxiety since the 1860s. It is useful in reducing pain and anxiety during minimally invasive procedures common to the pediatric population. Nitrous works fast. The effects start in just a few minutes with a quick recovery to baseline in about five minutes. It has a lengthy history for safety and efficacy efficiency so it's efficient and safe.

So what other procedural considerations could not just be used?

You can consider nitrous possibly with a topical anesthetic for PIVs, IM's, suturing, lumbar punctures, Botox injections, foreign body removal, imaging, subcutaneous implants, GYN exams and]]>Today's sedation podcast is dedicated to discussing how to start a nitrous oxide service. I am delighted to be joined by Mary Kay Ferrell and Laura Mitchell. Mary Kay, a clinical sedation and procedural nurse at the Children's Hospitals and Clinics of Minnesota, who also has over 20 years of experience as a clinical educator for sedation and procedural services. She is a top national expert on the use of nitrous oxide in pediatric sedation, and how to start a nitrous oxide service. She is joined by Laura Mitchell, a child life specialist with the sedation team at Nemours Children's Hospital in Delaware. Laura is also on the executive board of the SPS.

In today’s episode, we share the success of a nitrous sedation program and to help others consider nitrous as an option for their patients. 

So Mary Kay How did you first become interested in the use of nitrous oxide?

Actually, the first time I saw nitrous sedation used was in the emergency room. A patient with a dislocated shoulder was brought into our department with nitrous being used for pain control. The paramedic was delivering it with a mask and a small tank. The patient was calm and able to answer questions. When the nitrous was stopped, they were once again in severe pain. 

Not too long after that, I witnessed it when my niece broke her ankle playing ball, the drama queen that she was as a teen, very loudly suggested in reasonable pain. After the paramedics started the nitrous she was silent 

At that time, we were looking for something to repeat midazolam for our BCG patients during urinary catheterization, our radiology halls often sounded like a torture chamber with kids crying, we noticed that PO midazolam often did not calm down the kids and it didn't do much for the discomfort. 

After the exam, they were crabby and sleepy. Often the kids had hallucinations that were very scary. For example, one kid told us that his nurse had four eyes and that his mom looked like a green monster. This is all while there were several people holding the child down to place a catheter, so you can just imagine how scared those kids are inadequate or no sedation parents often reported that their child would not allow them even to change a diaper. 

After this type of traumatic experience, they had a horrible fear of health care providers or going to their doctor. 

Our sedation department was asked to take over sedation for this procedure. We wanted to try nitrous. We thought if paramedics and dental hygienists could be trained to do it. Why couldn't nurses that were trained in advanced sedation working under the direction of a doctor do what as well?

What led you to consider nitrous as a change in practice for urinary catheter placement needed for BCGs?

Our sedation team understood how pain and distress experienced by a child with painful and distressing procedures sets the tone for future medical interactions. 

This can have long term effects with their attitude and willingness to participate in health care now and in the future. We saw this even with parents who had gone through these types of procedures when they were a child, they didn't want to see their own children go through that. 

Nitrous is a gas used for pain and anxiety since the 1860s. It is useful in reducing pain and anxiety during minimally invasive procedures common to the pediatric population. Nitrous works fast. The effects start in just a few minutes with a quick recovery to baseline in about five minutes. It has a lengthy history for safety and efficacy efficiency so it's efficient and safe.

So what other procedural considerations could not just be used?

You can consider nitrous possibly with a topical anesthetic for PIVs, IM's, suturing, lumbar punctures, Botox injections, foreign body removal, imaging, subcutaneous implants, GYN exams and procedures the list really goes on the more people that find it for their own uses, the more things that they consider it for. 

You can consider nitrous combined with opioids benzos and topical or local anesthetic for fracture reduction, intra articular injections, joint aspiration, extensive suturing drill Tomic procedures, my ring anatomies organ biopsies such as for thyroid and liver, so you clearly outline that the expectations must match the capabilities of nitrous and really should be considered part of the Sedation Procedure Plan.

What are the clinical effects of nitrous oxide?

The clinical effects includes sedation, analgesia, amnesia with a rapid onset from one to five minutes and a rapid recovery to baseline with 100% 

Oxygen about three to five minutes and you get all of this from one medication. Nitrous administered at less than or equal to 50% without other sedating agents is classified as minimal sedation by the American Academy of Pediatrics. 

When nitrous is greater than 50%, it may produce moderate sedation. Nitrous alone, even at 70% is incapable of producing general anesthesia. Many patients will remain awake, interactive, even to play games at 70%. 

The big trick of nitrous is the art of titration to a patient's need. The level of sedation is the key to success along with distraction, and child life. And what we notice is that older kids often need less than younger ones. Nitrous juice with other medications such as benzynes or opioids is more likely to produce moderate or deep sedation.

Can you explain for our audience the pharmacokinetics for nitrous?

Nitrous is a colorless gas heavier than air with a faint sweet sweet smell. Because it is relatively insoluble in blood, alveolar uptake is rapid and equilibrium is reached quickly and vascular beds such as the brain, sedative effects may be apparent within the first 30 seconds with full effects and five minutes. 

Nitrous is not metabolized in the liver or kidneys are stored in tissue. It's just eliminated on change through exultation from the lungs. When inhalation is discontinued, and the patient receives a few minutes of oxygen, the sedative backs abate within minutes. 

There are clinical effects beyond sedation, it can cause expansion of trap gas. So an example would be nitrous replacing the same nitrogen and any closed gas space. Since nitrogen diffuses faster and nitrogen diffuses slower, it can trap gas and it will expand a pneumothorax that can double its size in 10 minutes. 

Nitrous can increase cerebral blood flow and may increase ICP intracranial pressure. Consider your contraindications before use. On the good side it increases venous tone which makes things easier to appear which helps and IV starts.

What types of side effects should we be looking out for? 

A common side effect that we see is nausea and vomiting. It could occur in two to 3% of the cases. So it's not a lot but it's something to be aware of. And we know that if you administer it longer than 15 minutes are higher than 50% 

The chances increase. And one point that I want to make is the most common procedures that we use it for our IV starts in urinary catheters, and many times the whole thing is done in less than 10 minutes to fusion hypoxia is a theoretical risk of alveolar oxygen dilution, as nitrous leaves the bloodstream more quickly than the nitrogen is absorbed. 

For this reason 100% Oxygen is delivered after nitrous is discontinued with a scavenging system to reduce residual exhaled nitrous and eliminate the risk of diffusion hypoxia. Also hallucinations occur, but it is difficult to differentiate the actual hallucinations from dreams that are encouraged with the aid of guided imagery. In higher concentrations of nitrous sexually stimulated hallucinations have been described. Hence the need to have a parent or caregiver at the bedside with a patient during nitrous administration.

What are some of the contraindications to nitrous administration?

All patients should be screened for contraindications as part of the pre-screening, any condition where there is air that could be trapped in the body, including a pneumothorax intestinal obstruction, a craniotomy within three weeks, or an attempted panna plasti. Within two weeks, I just want to make it clear that PE to observe diving within 24 hours, intraocular surgery within 10 weeks, severe boletus emphysema, and we like to use caution with cystic fibrosis. 

Other contraindications include a history of bleomycin administration, vitamin B 12 deficiencies, impaired level of consciousness intoxication with drugs or alcohol MTHFR, shunt dependent cardiac defects, and pregnancy within the first and second trimester, we advise the contraindications to be discussed with a Physician since some of the contra-indications are absolute and some may be considered safe in some situations.

What equipment would be needed to deliver nitrous sedation?

Today, there's choices to meet the medical needs of patients. All equipment must be equipped with a scavenging system to minimize the risk of occupational exposure. Choices include continuous flow and demand systems. Continuous flow systems have a nitrous blender and allow the continuous delivery of a variable percent of nitrous with oxygen as the remaining gas. 

This allows titration of nitrous percentage to be matched to the individual patient's need. Due to continuous flow there is an increased risk of environmental contamination if the mass seal is not maintained. Where the demand system is designed to be set at a fixed concentration, the demand bell provides gas only when the patient inhales and the gases are mixed automatically the same as the continuous equipment. 

This is simple to use, and the demand bill may decrease environmental contamination. But young children have difficulty overcoming the demand bill to initiate gas flow. There are new demand equipment setups now that are starting to show up that have the potential to be able to titrate or be fixed as well as the ability for younger patients to be able to initiate as well.

Why should an institution bother about offering nitrous as part of their sedation program?

Because it's the right thing to do. We know that there's a growing recognition for even minor procedures, such as needle sticks that can affect a child's long term emotional well being. 

Nitrous is a sample of it's simple, it's safe, it's effective means can help pain and anxiety, patient parents and staff satisfaction is greatly improved when we take the time to meet the needs of the patients experiencing the pain and anxiety.

What are some of the first steps to starting a nitrous program in your institution?

You can divide it into three parts:

1) the institutional issues

2) the regulatory issues

3) equipment issues

The first thing you want to do is identify the problem you want to solve. Are there patients who can benefit from nitrous? Determine the patient and the procedure you want to improve? Do you have a patient not well served in your current practice? Are patients undergoing distressful and painful procedures without sedation or adequate analgesia, you also want to think about short procedures with sedation, that you might have your patients too deep or lasting longer than necessary.

 And then you want to create a plan. Who is going to deliver the nitrous? And are there sedation providers at the bedside in case the patient becomes moderately or deeply sedated? Who can administer nitrous? What is appropriate monitoring? What policies and procedures are guided by your patients that you want to serve? In some states, RNs can administer nitrous sedation as minimal sedation, and it was in their scope of practice that they can do this.

Since it's a delegated order from a bartering provider, you want to include the stakeholders and there's a lot of departments involved. A nitrous program involves the whole medical facility, including physicians, advanced practice nurses, RNs administration, biomed facilities, purchasing, occupational health, and most important your patients.

You want to assess your facility to make sure you have the capability to remove exhaled nitrous via an active nitrous backup system. In most cases, it's just your wall section. That area chosen for nitrous administration must have the capability to remove exhaled nitrous via active vacuum systems and facilities can help you. 

determine that as well as the exchanges of air in your department. rooms need to be equipped with safety monitoring and rescue equipment for any sedated patient.

What are some of the equipment issues that you may face along the way?

Regarding the equipment you chose, you will be able to include an oxygen and nitrous source so you can either have plumbed in or tanks, flow meters with a blender, circuit mask and scavenging systems. The advantage of a tank is that it's portable. It's a system that you can move around pretty easily, the system can be set up to travel. The disadvantages are that you can run out of nitrous.

The gauges on a nitrous tank are not as reliable as compared to an oxygen tank so you can run out of nitrous with very short or no notice. You need to always make sure that you have a full tank. If you have one that empties, there are also more security issues with tanks and nitrous tanks need to be locked up at all times when not used. 

The advantages of a wall system are that it's cheaper after the initial construction, you'd have an unlimited supply and you never run out during a procedure. The wall system is easier to use and seems to have less weeks. The disadvantages are that you cannot be as mobile. So you want to consider this with any new construction and the wall systems are really good for a procedure room or sedation room.

Tell us more about how Child Life Specialists contribute to the nitrous oxide program at your institution?

The Child Life Specialist really plays a key role here. It all starts with our assessment process where we collaborate with the state agency and the proceduralist to identify which patients have the capacity to be the most successful incorporating nitrous oxide into their sedation plan.

We want to know will they be accepting of the mask? Will the sensory experience of nitrous oxide be overwhelming for them? Will they be responsive to the cues for rhythmic breathing that will be provided? We consider these questions through the lens of the patient's psychosocial and emotional development. 

In our discussions with the team, we also consider which procedures would be the most appropriate for this medication. Just like Mary Kay said, we actually also use it for IV placement, urinary catheter placements, we also use nitrous for suture removal, and both classic Botox injections just to name a few.

How can we help kids have the most positive experience with nitrous oxide?

We recommend incorporating the one voice methodology and maintaining it throughout their procedural experience. One voice, which is an acronym, was conceptualized by the child life specialist Deb Wakers. to help healthcare professionals incorporate the elements of childhood interventions into their everyday practice.

So generally speaking, this acronym incorporates the concepts of pre procedural preparation, family centered care, comfort, positioning, multidisciplinary collaboration, etc. All the things that we know are incredibly important, and it really combines them into a clear and concise approach. 

So when we are using nitrous, the most critical element of this overarching approach is the actual one or singular voice that will be interacting with the patient to avoid an overstimulating experience. 

Think of your voice as a tool just like any other in your bag of tricks. When you're using your procedure voice or at my hospital, you may also need to incorporate some sensory elements of the procedure into your scripting. Whether it's promoting that rhythmic breathing, reminding a patient that those warm floaty feelings are normal or preparing them for the sensory experience of the procedure itself. 

The feelings of cold or wet or pushing or pressure that might be associated with what their procedure is actually incorporating. Guided imagery is also incredibly valuable. And when we're utilizing that we want to think about specific scripting that will create an immersive experience so that the elements of the procedure can be incorporated into your script. We also want to be thoughtful as our patients are kind of reemerging from the nature of experience. reframe any of those dreams that they might remember so that they can emerge in a safe space and remind them that they were successful.

Resources:

Society of Pediatric Sedation 

Her primary research interest is in the safety of emergencies department procedural sedation. She has published multiple articles and peer review journals on sedation related topics including on fasting before procedural sedation. The first patient case scenario is of an eighteen month old girl scheduled for a brain MRI for a focal seizure which occurred three days ago, and her parents are asking if they have to keep their NPO for so long and whether there is any science behind this practice of fasting before sedation. 

The second case is one of a seven year old boy with a forearm fracture which requires redaction and casting under procedural sedation. The patient had eaten a peanut butter sandwich an hour before the fall. Join us as we dive into this insightful discussion with Dr. Bhatt on fasting before procedural sedation and how previous fasting guidelines came about, and what is changing about that. Enjoy!

Show Highlights

• Our understanding of aspiration and its risk factors with respect to the history of fasting guidelines (02:16)
• The risk for aspiration during procedural sedation (04:52)
• The aspiration risk for children prior to sedation when drinking clear liquids (05:38)
• Advantages and disadvantages of prolonged fasting in children with respect to clear liquids (06:51)
• Current guidelines being followed today in procedural sedation (08:31)
• The association between pre-procedural fasting duration and the incidence of sedation related adverse outcomes during emergency department sedation of children (10:43)
• Dr. Bhatt’s thoughts on the 2016 study reporting on the association between aspiration and patient and procedure factors (12:26)
• Changes in practice that may come about from different publications stating that fasting is not a risk factor for aspiration (15:46)
• Understanding that NPO time on its own is not a predictor for aspiration (17:45)

Additional Resources

• Association of Preprocedural Fasting With Outcomes of Emergency Department Sedation in Children

The first patient case today is that of a four year old boy who needs a brain MRI for a focal seizure he had two days ago. The patient has no allergies and is previously healthy. He was sedated using a propofol bolus and is maintained on a propofol infusion in the MRI. It’s going to be a very insightful episode so don’t miss out. 

Show Highlights

• Why the monitoring of a patient undergoing procedural sedation is so important (01:32)
• How to classify intended levels of sedation (03:08)
• The monitoring tools used in pediatric procedural sedation (05:00)
• Monitoring a child who is receiving mild, moderate or deep sedation (05:24)
• The ideal monitoring for a patient who just went through a procedure and is waiting for discharge (07:37)
• Role of pulse oximetry and capnography in procedural sedation (08:43)
• Bispectral (Bispectral index monitor) analysis during pediatric procedural sedation outside the operating room and its role (12:12)
• Recommended monitoring for short hematology oncology procedures such as lumbar punctures (13:24)
• Information available from the pediatric sedation research consortium about monitoring (14:40)
• Dr. Couloures’ personal clinical pearls regarding physiologic monitoring of patients undergoing procedural sedation (16:00)

Additional Resources

• www.Capnography.com
• Bispectral analysis during procedural sedation in the pediatric emergency department

Dr. Landrigan comes on to help us gather insight on how sedation practitioners should approach procedural sedation in high risk patients outside of the operating room where they focus on pre-screening prior to procedural sedation. Join us to learn more

Show Highlights

• Why it’s so important to assess a child’s risk profile prior to procedural sedation (01:29)
• Patient risk factors associated with sedation related adverse events (03:02)
• Concerns regarding the sedation of infants where the infants are under 3 months of age (04:50)
• How prematurity poses a risk for sedation related adverse events (06:24)
• The relation between obesity and increased risk for adverse events in procedural sedation (07:58)
• Risks posed to procedural sedation by children that have upper respiratory tract infections (09:11)
• Scenario where a child snores like an adult while sleeping or has noisy breathing during sleep (11:07)
• Dealing with children who have heart disease when they are presented for procedural sedation (13:34)
• Different instances where sedation practitioners should be very cautious and consult an anesthesiologist (17:53)
• Clinical pearls in sedating high risk patients and the necessary careful pre-screening required for such patients (20:08)

Resources:

Society of Pediatric Sedation Website

He is the Director of Pediatric Sedation Programs at Arkansas Children’s Hospital. One of the hypothetical cases is where the patient is a three year old boy who needs an MRI with contrast for a prolonged focal seizure which occurred four days ago. He is previously healthy, has no significant past medical history and has not been exposed to anesthesia or procedural sedation in the past. He has no known drug allergies and on examination, his physical exam is unremarkable with normative vital signs for his age. He is also appropriately NPO. Stay tuned to learn more from Dr. Peters and Dr. Dalabih!

Show Highlights

• Factors to consider when creating a sedation regimen for a child who will undergo procedural sedation (01:18)
• Examples of painful, non-painful and distressing procedures (02:45)
• How to go about choosing a sedation regimen for patients in line with the guidelines of the American Academy of Pediatrics (05:22)
• Sedation for a child who has proven allergies such as anaphylaxis (06:55)
• Second hypothetical case: 5 year old girl with symptoms consistent with acute lymphocytic Leukemia and requires procedural sedation for a diagnostic bone marrow aspiration and biopsy with a lumbar puncture (10:09)
• Procedural sedation for a 6 year old girl who has autism spectrum disorder and requires procedural sedation in order to undergo venipuncture, ECD, and Echo (13:36)
• 9 year old with a distal radius and ulna fracture from a recent fall on his right arm requiring reduction and casting of the fracture (16:12)
• The importance of using a multidisciplinary team approach to sedation for (18:05)

Additional Resources

• Is Orally Administered Pentobarbital a Safe and Effective Alternative to Chloral Hydrate for Pediatric Procedural Sedation?

In our case today, we have a five months old infant who requires an MRI of his brain. The patient is an ex-32 week premature infant with a history of difficult IV access. There’s no history of upper respiratory tract infection, no snoring, heart disease, or any medication allergy in this infant. The MRI is needed for a focal seizure that occured two weeks ago and the patient doesn’t require an IV since this is not a contrasted MRI. Dr. Sulton will generously share with us why intranasal medications are needed in procedural sedation and so much more, so don’t miss out if this is a topic of interest for you.

Meet your hosts:

Pradip Kamat, MD, MBA - Associate Professor of Pediatrics and Critical Care Physician at Emory University School of Medicine and Children’s Healthcare of Atlanta/Egleston.

Anne Stormorken, MD - Professor of Pediatrics and Critical Care Physician at UH Rainbow Babies and Children’s Hospital and Case Western Reserve School of Medicine of Cleveland, OH.

Show Highlights

• Diving into how intranasal medications work (01:58)
• Circumstances where intranasal medications must not be used for procedural sedation (04:35)
• How she uses Dexmedetomidine and Midazolam (06:28)
• Research findings on the success rate with the use of intranasal medications (09:14)
• Other medications that can be used intranasally for procedural sedation (11:42)
• Optimizing the efficacy of intranasal medications when delivering them (12:09)
• Giving IV sedation where there is intranasal medication failure (13:23)
• Large dataset studies that support the successful use of intranasal medications in procedural sedation (14:23)

Additional Resources

The Use of Intranasal Dexmedetomidine and Midazolam for Sedated Magnetic Resonance Imaging in Children