Apply face mask ensuring adequate seal, aim for smallest fitting mask.Ensure line of sight monitoring of the child at all times.Plan options for sedation failure – consider alternate agent early if adequate sedation not achieved.Provide parent information for sedation procedures (See sedation for procedures).A minimum of two staff are required: proceduralist with experience in paediatric resuscitation including airway skills and an assistant trained to administer nitrous oxide and monitor child for side effects.In children outside of the ED, consider local ward guidelines and concomitant use of other agents.Consider fasting times (see local guidelines). Inform families of these effects as part of consent Procedure diffusion hypoxia (avoided with post-sedation with supplemental oxygen).More serious side effects are rare in short term usage, but include:.Monitoring Potential side effects and complications Entonox cylinder with appropriate mask/circuit.Nitrous and/or oxygen concentration control.Variable concentration nitrous oxide machine with:.Scents/essences for distraction and rapport building.Mask or mouthpiece (for older children).This usually restricts its use to school aged children If using Entonox (premixed 50:50 Nitrous and Oxygen) the child must cooperate and generate enough negative pressure on inspiration to open the valve.Increased risk of nitrous oxide induced bone marrow suppression: nutritionally compromised patients, current severe illness, severe infection or extensive tissue damage.Expansion of gas filled airspace: chest injury, abdominal distension, head injury with GCS 15 but ongoing symptoms.Increased risk of airway compromise: acute respiratory infection, history of difficult airway or airway obstruction.Increased risk of nitrous oxide induced bone marrow suppression, neurotoxicity or increased homocysteine level: methionine synthetase deficiency, homocystinuria and methylmalonic academia.Pulmonary hypertension associated with decreased exercise tolerance.Expansion of gas filled airspaces: pneumothorax, lung cyst, obstructive airways disease, recent craniectomy or trauma with pneuomocephalus, air embolus, decompression illness, bowel obstruction, middle ear disease or surgery with air trapping.Airway and/or breathing compromise: acute respiratory depression, current exacerbation of asthma.Nitrous can be considered for procedures that may cause pain, discomfort or anxiety and that require only short-term sedation Procedures for consideration of Nitrous Oxide
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