Policies,Clinical,UWHC Clinical,Department Specific,Emergency Department

Provider Delivered Inhaled Nitrous Oxide in the Pediatric Emergency Department (ED) (44.4)

Provider Delivered Inhaled Nitrous Oxide in the Pediatric Emergency Department (ED) (44.4) - Policies, Clinical, UWHC Clinical, Department Specific, Emergency Department





The purpose of this proposal is to improve the culture of comfort, safety, and timely
service for Pediatric ED patients and their families utilizing inhaled nitrous oxide
during painful and anxiety provoking procedures.


A. UW Health strategic plan promotes a culture to provide a patient and family
experience of compassion and excellent clinical quality of care.
B. Patients and family members are partners in providing care in the Pediatric ED
and are given choices that promote comfort during painful and/or anxiety
provoking procedures.
C. Use of nitrous oxide will provide treatment for anxiety provoking and/or painful
procedures that are routinely performed, such as urinary straight catheterization,
incision and drainage, lumbar puncture, common laceration repair, foreign body
removal, minor fracture reduction, common splinting, arthrocentesis, and
challenging peripheral intravenous placement.
D. The use of nitrous oxide as a single agent is considered to be minimal sedation.
Nitrous oxide in combination with other agents regardless of the route given or
the level of sedation achieved is considered to be moderate sedation and will fall
under the Pediatric Sedation Policy (8.56).


A. Pediatric patient: Please refer to University of Wisconsin Children's Hospital
Admissions Administrative policy #7.44 for the definition of a pediatric patient.
B. Analgesic: Relieves pain by altering perception of nociceptive stimuli. (UWHC
Policy # 8.56)
C. Anxiolytic: Relieves apprehension and fear due to an anticipated act or illness.
(UWHC Policy # 8.56)
D. Minimal sedation: A drug induced state during which patients are quiet, drowsy
and respond normally to verbal commands. Although cognitive function and
coordination may be impaired, ventilatory and cardiovascular functions are
unaffected. Level of awareness for minimal sedation correlates with a Ramsey
sedation score of 1, 2 or 3 on the adult sedation scale or Pediatric sedation score
of 1, 2, 3. (UW Health Nursing Practice Guidelines approved 3/2016 by Sedation

Date: July
1, 2016

ED Policy Manual

Policy #: __44.4____
Emergency Department

X Original

Page _1_
of _5_

Provider delivered inhaled nitrous oxide in the
Pediatric Emergency Department (ED)


E. Qualified personnel (Physicians and Advanced Practitioners): Personnel
responsible for directing and/or administering sedative drugs will be:
1. Physicians and/or Advanced Practitioners who have successfully
completed hospital approved core competency education to monitor
and administer sedation.
2. Knowledgeable of the pharmacodynamics and pharmacokinetic
properties of nitrous oxide.
3. Skilled and knowledgeable in the assessment and management of
adverse effects of anxiolytic medications.
4. Knowledgeable of and capable of assembling additional resources as
5. Certified in, or demonstrate skills required for Healthcare Provider CPR.
6. Able to demonstrate skills in oxygen delivery, use of suction equipment,
and use of manual resuscitation equipment.
7. No personnel currently pregnant are allowed to administer nitrous oxide
or assist with the administration.


A. Assess patient eligibility for nitrous administration.
1. Pediatric patients that would benefit from mild sedation (anxiolysis) for
procedures in the Pediatric ED.
2. Education will be provided to the patient and/or family related to the
benefits and potential complications of nitrous administration.
3. Patients and/or family members are active participants in the care that
is delivered in the Pediatric ED.
4. Eligibility:
a. Age appropriate according to ability to cooperate with mask
b. NPO status should be considered when deciding whether to
proceed with nitrous oxide sedation
c. Some common procedures that may benefit from utilizing nitrous
oxide (not exclusive):
i. Urinary straight catheterization
ii. Incision and drainage
iii. Lumbar puncture
iv. Common laceration repair
v. Foreign body removal
vi. Minor fracture reduction
vii. Common splinting
viii. Arthrocentesis
ix. Challenging peripheral intravenous placement
x. Port access
5. Ineligibility:
a. Respiratory distress
b. Head trauma with altered level of consciousness
c. Abdominal trauma
d. Level of consciousness altered from baseline
e. Actual or suspected pneumothorax
f. Any signs of shock
g. Actively nauseated or vomiting
h. Facial injuries (when unable to create a seal with mask)


i. Pregnancy
j. Inability to comply with instructions for use
k. Pre-existing pockets of air (i.e. bowel obstructions,
pneumotympanum, otitis media)
l. Chronic respiratory disorders (BPD, chronic lung disease)
m. Vitamin B-12 deficiencies (genetic or environmental)
n. Folic acid deficiencies (caution in patients receiving high-dose
intrathecal methotrexate)
o. Patients that have recently been diving
p. Patients with recent cardiac surgery or severe cardiac condition
q. Patients who have received nitrous oxide within the preceding
r. Procedures that are anticipated to require more than 30 minutes
of minimal sedation.
B. Physician and/or Advanced Practitioner will place an order for nitrous oxide.
C. Prepare nitrous delivery equipment:
1. Scavenger system
2. Mask
3. Breathing circuit
4. Suction
5. Supplemental source for delivery of oxygen only if nausea develops
(non-rebreather mask)
6. Airway and resuscitation equipment will be available
D. Contact Child Life Services to assist with coping and therapeutic modalities.
E. Staff members who are pregnant are not allowed to participate in the care of the
pediatric patient receiving nitrous oxide.
F. Obtain full set of vital signs prior to administering nitrous oxide.
1. Obtain and document weight, heart rate, respiratory rate, temperature,
and blood pressure.
2. Assess level of consciousness and document.
3. Assess pain level and document.
4. Assess anxiety level and document.
G. Educate patient and/or family on use of nitrous and practice.
1. Patient to choose “flavor” of mask and smell the mask prior to
procedure begins.
2. How to provide tight seal with the mask and take slow, deep breaths.
3. To exhale into the mask.
4. Avoid unnecessary conversation – use hand signals (thumbs up/thumbs
5. Discontinue, or reduce percentage of nitrous oxide if nausea develops
or any other complication.
H. Begin visual imagery, soft music, or other distraction techniques.
I. Allow patient to inhale gas for 3-4 minutes (possibly up to 6 minutes) before
beginning any procedure.
J. Monitor for side effects during procedure:
1. Most patient have no side effects
2. Nausea and vomiting are the most common side effects, and the risk
increases with higher levels of nitrous oxide (Zier, 2010).
K. After procedure, apply supplemental oxygen (100%) after procedure for 3-5
minutes to wash out residual nitrous oxide.
L. Obtain full set of vital signs following procedure:


1. Obtain and document weight, heart rate, respiratory rate, temperature,
and blood pressure.
2. Assess level of consciousness and document.
3. Assess pain level and document.
4. Assess anxiety level and document
M. Document length of nitrous oxide inhalation therapy and response to procedure
within medical record according to identified procedure for documentation.
N. Follow standard discharge criteria and assessment prior to discharge home.


A. UWHC Hospital Administrative Policy 7.44, American Family Children’s Hospital
(AFCH) Admissions
B. UWHC Hospital Administrative Policy 8.56, Pediatric Sedation Policy
C. Nursing Practice Guidelines – Patient and Family Centered Care
D. UWHC Ambulatory Service Standards

Fein, J., Zempsky, W., Cravero, J., & Committee on Pediatric Emergency
Medicine…(2012). Relief of pain and anxiety in pediatric patients in
Emergency Medical Systems. Pediatrics, 130(5): e1391-e1405.
German, M, Pavo, M., Palacios, A., & Ordonoz, O. (2011). Use of fixed 50% nitrous
oxide-oxygen mixture for lumbar punctures in pediatric patients. Pediatric
Emergency Care, 27(3): 244-245.
Luhmann, J. & Kennedy, R. (2000). Nitrous oxide in the pediatric emergency
department. Clinical Pediatric Emergency Medicine, 1(4): 285-289.
Luhmann, J., Kennedy, R., Jaffe, D., & McAllister, J. (1999). Continuous-flow
delivery of nitrous oxide and oxygen: A safe and cost-effective technique for
inhalation analgesia and sedation of pediatric patients. Pediatric Emergency
Care, 15(6): 388-392.
UW Health. (2014, September). UW Health strategic plan: Refocus and Renew
2013-2015. Retrieved from
Zier, J., Tarrago, & Liu, M. (2010). Level of sedation with nitrous oxide for pediatric
medical procedures. International Anesthesia Research Society Anesthesia
and Analgesia, 110 (5).


Emergency Department Clinical Operations Committee
UW Health Sedation Steering Committee
Pediatric Champion Team, Emergency Department
Emergency Department Nursing Council

Associate Vice Chair Pediatrics, Department of Emergency Medicine