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We've been using nitrous oxide for inpatient,  ED, and outpatient procedures for 6 or 7 years.
1 - we use nitrous oxide down to 6 months of age
2 - we use 50-70% and went through the same anesthesia and sedation committee approval route.  Any concentration is classified as Anxiolysis/Minimal Sedation.
3 - We do not use nitrous if suspected increased ICP associated with medical or traumatic etiologies.
Good luck.  It has really decreased our use procedural sedation.
Kathey

Kathleen Goetz, M.D.
Medical Director, Swedish Pediatric Emergency Medicine
Seattle, WA




Sent from my Verizon, Samsung Galaxy smartphone

-------- Original message --------
From: "Jackson, Benjamin F" <[log in to unmask]>
Date: 6/8/17 12:49 PM (GMT-08:00)
To: [log in to unmask]
Subject: Nitrous Oxide in PED

Hello all:

We're soon to go live with Nitrous Oxide in our PED with a delivery system offering up to 70% N2O, and we're finalizing the policy, which must be reviewed by anesthesiology and the sedation committee outside of our department (no need or interest in taking us on journey into that tangential, potentially frustrating matter - it's simply the way it is and we have favorable collaboration in this project).

I have seen a few sample policies but am trying to get a broader sense of what others are doing:

1) Do you have a minimum age (2 or 3 years, for instance) below which you do not provide Nitrous Oxide for procedural facilitation?

2) Are you defining delivery of nitrous oxide  < 50% when not combined with an opioid, benzo, or other potentially sedating agent as MINIMAL sedation (anxiolysis) and >50 - 70% MODERATE sedation?

Or, are you defining the level of sedation based on intent as well as on patient effect?

I recognize the arbitrariness of 51 % vs 50 %.

I'm familiar with the 2008 Pediatrics paper by Babl et al in which the vast majority of patients receiving either 50% or 70% scored in the minimal sedation range according to the CH-Wisconsin Sedation Scale and that there was no significant difference in adverse events between the 50% group and the 70% group.

As such, I'm interested in how you are classifying it in terms of policy

3) I have seen where increased ICP is listed as a contraindication for some to the provision of nitrous oxide, but I also know that nitrous oxide is often provided for lumbar puncture in the outpatient non-ED procedural settings for oncology patients, who presumably have normal ICP. Is anyone in ED settings using nitrous oxide for LPs for meningitis or idiopathic intracranial hypertension or Guillain-Barre?

Happy to receive any feedback directly to my email address [log in to unmask]

Thanks so much.

Ben


Benjamin F. Jackson, MD, FAAP, FACEP
Associate Professor of Pediatrics
Pediatric Emergency Medicine
PEM Director of Procedural Sedation
Medical University of South Carolina
135 Rutledge Avenue, PO Box 250566
Charleston, SC 29425
Phone: 843-876-0795
Fax: 843-876-0962
Email: [log in to unmask]



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