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

In this episode, we will be welcoming Dr. Maala Bhatt, the Associate Professor of Pediatrics at the University of Ottawa. She is the Research Director for the Division of Emergency Medicine and a pediatric emergency medicine physician at the Children’s Hospital of Eastern Ontario (CHEO). She is a member of the Society for Pediatric Sedation. She led the development of the first standardized definitions for procedural sedation and has published the largest emergency department procedural sedation cohort, establishing practices associated with the safest sedation outcomes. 

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

In this episode, we will be welcoming Dr. Kevin Couloures, a clinical associate professor of pediatrics at Stanford University and a pediatric critical care physician at the Lucile Packard Children’s Hospital and the California Pacific Medical Center in California. He has been with the Society for Pediatric Sedation for maNy years and is currently the vice-chair for the research committee and the Pediatric Sedation Research Consortium, the research arm of the Society for Pediatric Sedation.

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