Nitrous Oxide in the ED

[Venko]

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Hi SDNers,

We recently had a grand rounds on the use of nitrous oxide as an anxiolytic in the ED for many of our noxious endeavors. I was wondering if anyone out there has used Nitrous or currently is using it and what their experiences with it are. Also, if there are infrastructural things you wished you had in place that would make the nitrous easier or safer to use, I'd love to hear that too as we are planning for the future and it would be great to take advantage of this widely varied and extensive SDN experience.

Cheers,
TL

 

[Groove]

Is there any data to indicate that it would be preferred over some of the more traditional IV/IM/PO anxiolytics that we typically use? That just seems so much faster and efficient vs N2O, especially if RT is going to need to be involved. I've never heard or anyone using N2O very much in the ED setting but am curious to see what the results are for you guys. If you have access to the presentation/article, etc.., I'd be interested in reading it.

 

[Venko]

Is there any data to indicate that it would be preferred over some of the more traditional IV/IM/PO anxiolytics that we typically use? That just seems so much faster and efficient vs N2O, especially if RT is going to need to be involved. I've never heard or anyone using N2O very much in the ED setting but am curious to see what the results are for you guys. If you have access to the presentation/article, etc.., I'd be interested in reading it.

THe data presented in the grand rounds had nursing administration and even patient self administration with very minimal side effects. The benefit is actually the very acute onset and the offset without the need for RT, and moderate sedation protocols...but it was a presentation and I have no real experience with it, but was extremely intrigued

 

[docB]

We used it in residency. We would have the patient hold their own mask. Consequently if they got too deep they would drop the mask. I had good experiences with it. Everyone I've ever talked to who uses it raves about it.

No one where I am now is interested in using it as we are slow to change or adopt new (if you can consider it "new," it's new to us) things. I do believe there is a lot of up front cost. I think there was some requirement put on years ago about using a system with scavenging capabilities which greatly limited access to it.

 

[B-Bone]

I recently had an interesting experience in our ED where I (the anesthesiologist) was called to evaluate a 10 year old girl for PDPH after LP (with an 18 gauge cutting needle... thanks ED😀). I was not aware of nitrous in our ED, but the EP suggested using it. I then had the surreal experience of performing a procedure (blood patch) in the ED while the emergency physician sedated the patient. It actually worked quite well and the girl got through it just fine and headache resolved immediately.

I think it has a niche for kids and perhaps insane needle phobes to allow you to place access and sedate for minor procedures. Not a real dangerous drug in my experience, other than that you replace O2 with nitrous and can't deliver high FiO2. People really can't get too deep with it, or even really lose consciousness and it wears off almost instantaneously. Kind of a headache to set up and has limited portability, but if it's in place, maybe not a bad option.

 

[WilcoWorld]

We use it where I work and we do not need nursing or RT in the room for it. As docB mentioned, we have the patient hold the mask on themself and this makes it self-titrating, because when they've had enough they stop holding on & the mask falls off. I like it a lot for short procedures like I&D's, especially in non-opiate naive patients (who tend to need a lot of I&D's).

 

[Cerberus]

Damn, wish we had this for peds. Such a hassle to do conscious sedation for a simple lac repair.

 

[gro2001]

Damn, wish we had this for peds. Such a hassle to do conscious sedation for a simple lac repair.

One of the places I did a sub-i has used it in peds for a while and were just introducing it for adults. Saw it used once on an adult. Advantages as stated above: easy to titrate (no need to play what's essentially a guessing game with dosage of benzos), pretty safe, fast off.

 

[NEATOMD]

I've used it. It works great for simple lac repairs in peds patients, etc. Essentially as mentioned above, we use patient controlled setup and let the patient self administer. When they fall asleep, they don't push the button anymore and don't get oversedated. I think there is more danger in using the continuous style or not lettting the patient administer it. It also seems to have less predictable results than other forms of sedation. On the plus side, it's very quick and painless.

 

[AvocadoLover]

I think there was some requirement put on years ago about using a system with scavenging capabilities which greatly limited access to it.

I was an ED pharmacist (now med student) and this was our main problem with access to N2O. There is a lot of good data to support the safe and effective use (including use by paramedics in Europe and I believe Canada a well) but it is actually quite difficult to procure. We ran into a lot of issued related to storage of a gas in the ED and having an appropriate scavenging system. Once you can get through these issues though, I think it is a great agent (esp for peds).

 

[Venko]

Those individuals who use nitrous, what methods have you developed for scavenging? I have heard some people use the wall suction?

 

[leviathan]

I saw a shoulder reduced in the ED with the patient on nitrous. This was a guy with a pretty extensive history of discloations + reductions so it's probably not a fair look at it, but the shoulder went in and he didn't even make a sound.

 

[KidDr]

I work in a dedicated pediatric ED and we use it all the time. I love it. The main issue is that we have to have a "nitrous certified" nurse in order to administer it, and there are times when someone who can administer it isn't available. Also, if the ED is really busy, it ties up a nurse for the whole time you're doing the procedure, so it's not always practical during those times. But when it works out, it's great. My favorite use is for LPs from around 2 years of age up to teenagers. I place a topical anesthetic (like LMX) over the LP site for about 45 minutes, give a dose of IV fentanyl (1-2 mcg/kg) then give nitrous. It works great in almost everyone (only the youngest kids sometimes still struggle) and the parents love it.