nursing practice committee guidelines on use of entonox ......the drawing of an aerolised drug into...

Nursing Practice Committee Guidelines on

Use of Entonox® for Procedural pain

Authors: Gill O’ Callaghan, CNS Acute Pain Issue date: January 2013 Carol Hilliard, Nursing Practice Development Coordinator Review Date: January 2015 PURPOSE:

To provide a guideline for the management of the self- administration of entonox inhalation in children for procedural pain.

INTRODUCTION:

Entonox has been proven to be a useful analgesic and sedative agent that is fast, safe and easy to handle (Cleary et al, 2002; Burnweit et al. 2004; Glasper et al. 2010; BOC Healthcare, 2010). Use of Entonox is designated as 'minimal sedation' under the National Institute for Health and Clinical Excellence (NICE) guidance classification (NICE 2010). However, if used in combination with other sedatives or potent analgesia, there is an increased risk of sedation. Entonox is a powerful anaesthetic gas, misuse of this gas can lead to loss of consciousness, and therefore entonox should only be self–administered when used for procedural pain. Entonox is administered via flexible tubing with a one way demand valve, a filter and a mouthpiece. When Entonox® is self-administered the gas mix will only flow if there is enough negative pressure generated within the breathing circuit to open the demand valve. To generate this negative pressure the child must maintain a tight seal around the mouthpiece/mask of the breathing circuit, and must produce a good inspiritory effort. The demand valve is operated only when the child inhales and closes when the child stops breathing in. If a child becomes over-sedated while self-administering the Entonox®, he/she will be unable to maintain an effective seal around the mouthpiece, inhalation will stop, gas flow ceases, the child will inhale room air and gradually recover from the effects of the Entonox® . Once the child becomes more alert, he/she may start inhaling the Entonox® again (Bruce & Franck 2000, BOC 2010).

Staff should also be aware that Entonox is a habit-forming drug and has been subject to abuse. Documented cases of abuse are rare, but addiction may be a result of long-term use and lead to myeloneuropathy and serious neurological problems.

Due to the potential for problems related to repeated/long-term use, Entonox should only be used for painful procedures. Procedures that are primarily frightening in nature should be managed using psychological input and sedation/anxiolytics as appropriate.

DEFINITIONS: • Entonox is a gaseous analgesic agent composed of nitrous oxide and oxygen in equal

proportions of 50% Oxygen and 50% Nitrous Oxide (BOC Medical, 2010). When inhaled, it provides powerful, rapid onset analgesia within 20 seconds to 2 minutes. Offset is rapid, occurring after 2-5 minutes, as it is expired in an unchanged state as the child breathes out (Krauss 2001).

• Inhalation: the drawing of an aerolised drug into the lungs with the breath (Dorland’s Pocket Medical Dictionary 2004)

MECHANISM OF ACTION

The exact mechanism of action is unknown, Nitrous Oxide causes Central Nervous System (CNS) depression and appears to have properties that are similar to opioids and various neurotransmitters that inhibit pain transmission.

Nurse Practice Committee January 2013, 4th Edition 1

http://www.gosh.nhs.uk/health-professionals/clinical-guidelines/entonox-ward-administration-of/#References


ROLES AND RESPONSIBILITIES

Entonox should only be administered by staff who are: • Competent in the administration of Entonox and basic life support. • Familiar with the side effects of Entonox and its contra-indications. • Aware of the criteria for patient selection and exclusion. • The CNS acute pain can administer Entonox in clinical areas where staff have not been trained in

its use if she is available. The CNS should be contacted well in advance of the procedure.

The Registered nurse should have completed: • The BOC entonox training on line at ( http://www.entonox.co.uk/en/discover_enotonox/training-

support/online-training/entonox_online_training.shtml • Completed the competence assessment programme delivered by the CNS in acute pain. • The nurse performs this procedure under the Scope of Practice for Nursing and Midwifery

Framework An Bord Altranais (2000) and Our Lady’s Children’s Hospital medication, drug administration and related reference material , risk management, infection control policies and clinical care safety statement.

• The nurse will undertake Paediatric Intermediate Life Support training on a yearly basis.

INDICATIONS FOR USE Entonox uses are varied and may include but are not limited to:-

Reduction of fractures

Repair of laceration Sutures

Insertion PICC lines Venous cannulation

Application and removal of traction, Plaster of Paris(POP), and cleaning of pin sites

Bone Marrow Aspirate Lumbar puncture

Urinary catheterisation (urologic imaging, urodynamics

Aspiration of synovial fluid and/or intra-articular administration of steroids.

Painful Wound Dressing Nerve conduction studies

Botulinum (Botox) injection Drain Removal Gastrostomy change

CONTRAINDICATIONS

Nitrous Oxide diffuses into cavities so it is not used if: • pneumothorax or bowel obstruction is

suspected, • if there is abdominal distension, • suspected air embolism or decompression

sickness

Airway • Increased risk of airway loss, acute

respiratory infection (URTI) or exacerbation of asthma.

• Airway obstruction or history of difficult airway management.

Raised pulmonary vascular pressure e.g. Pulmonary Hypertension.

A patient with maxillofacial injuries as there is a need to grip the mouthpiece with teeth or firmly push the mask onto the face to get a good seal.

CNS • Head Injury with impaired consciousness as it

may cause an increase in Intra Cranial Pressure • Alcohol and drug intoxication as

consciousness levels are difficult to determine and compliance may be poor.

Possible middle ear infection. (It should be used with caution in children with “glue ear”. Discontinue use immediately if child complains of earache.) Nasal blockage –e.g. adenoid hypertrophy, common cold.

http://www.entonox.co.uk/en/discover_enotonox/training-support/online-training/entonox_online_training.shtml



RELATIVE CONTRAINDICATION: 1. Children who have already received sedation – In this situation, please discuss the child’s care with

Acute Pain Service or the Anaesthetic Consultant. (Note: the use of Opiates for analgesic effect does not out rule the use of Entonox®)

2. Entonox should be used with caution in patients at risk for nitrous oxide induced bone marrow suppression, neurotoxicity or increased homocyteine levels as exposure to nitrous oxide depletes the body’s stores of vitamin B12 and very rarely this can precipitate neurological complications.

• History of B12 or folate deficiency • Nutritionally compromised patients, vegetarians, patients on H2 blockers or proton pump

inhibitors • Concurrent underlying serious illness, severe infection or extensive tissue damage. • Patients with metabolic diseases associated with homocysteine metabolism (methionine

synthetase deficiency, homocystinuria and methylmalonic academia.

SIDE EFFECTS OF ENTONOX • These include: Dry mouth, disorientation, dizziness, euphoria, loss of inhibition, feeling floaty, blurred

vision and less commonly, nausea and vomiting, excessive sedation, tingling of fingertips, numbness of tongue

• Very rarely, with repeated uses, inactivation of B12 and folate metabolism. In this situation blood tests are carried out to detect red cell changes.

HEALTH AND SAFETY ISSUES • Entonox® is excreted unaltered via the patient’s breath. In the UK and Ireland, the maximum

exposure limits for nitrous oxide is set at 100ppm over an 8 hour period (BOC 2010).This level is significantly below the concentrations where any detrimental effect will be caused. Thorough ventilation or scavenging of waste gases should reduce treatment room levels of ambient nitrous oxide to a level below 100ppm.(BOC 2010)

• A risk assessment should be carried out by the practitioner to ensure ventilation is adequate and action should be taken to move the patient to a well ventilated area if necessary.

• As a health and safety measure, It is recommended that anyone who is in the first trimester of pregnancy should not remain in the room/immediate area while Entonox® is being use. Staff administering Entonox® have a duty of care to ensure that those in the immediate vicinity, including the child and family members where appropriate, are aware of this risk and have the opportunity to remove themselves from the immediate area discretely if they choose.

• To ensure the safe and effective functioning of the Entonox® regulator, the Clinical Engineering Department will oversee yearly maintenance and testing of the regulator.

STORAGE OF ENTONOX® • Entonox cylinders should have a blue and white collar and should be stored upright at a

temperature above minus 60 Celsius. If the cylinder has been stored at minus 60, the two gases will have separated, which could result in the child or young person receiving either oxygen only or high concentration nitrous oxide (BOC 2010).

• The Portable Entonox® cylinder is stored in the nitrous oxide gas room in PICU floor 1 (between the entrance of Operating Theatre and PICU floor 1 area). The mouthpieces are stored in the Acute Pain CNS office CNS office (bleep 8300). Only remove the cylinder and regulator from the storage area immediately prior to use.

• Entonox® supports combustion and must not be used near an ignition source (Bruce and Franck, 2000) Refer to BOC Medical Gases –Safe handling and storage of medical gas cylinders –Information leaflet.

• Details of where Entonox® is stored have been supplied to Technical Services and to the health and Safety Officer who have in turn informed the Fire Services.

INFECTION CONTROL ISSUES



• A bacterial filter protects the tubing from internal contamination. The outside is held by the patient • Each individual patient will have their own single patient use disposable mouthpiece and bacterial

filter. • The Entonox Delivery unit-Input hose must be decontaminated after each patient as per

manufacturers’ instructions/ hospital guidelines (i.e. cleaned with detergent and water and then disinfected with Actichlor solution (IPCT, Guideline on Cleaning and Disinfection 2012).

• The Carnet Valve is cleaned after each patient using detergent and water and then disinfected with Actichlor as per hospital guidelines/manufacturers instructions and Guideline on Cleaning and Disinfection 2012).

• Entonox cylinders being taken into an isolation cubicle should be covered in a protective plastic sheet (i.e. waste bag).

EQUIPMENT

• Entonox® cylinder (Blue with white cap) • Blood pressure monitor • Regulator • Pulse oximeter • Entonox Delivery unit-Input hose ( white

with blue line) • Oxygen and suction equipment available and in

working order in the room • Carnet Valve • Mouth piece with bacterial/viral filter

USE OF ENTONOX® EQUIPMENT Practitioners check that the equipment is in good working order before use. The following are checked:

• A suitable key to turn the cylinder on and off is attached to the equipment. • The regulator fits securely • Gas is blown through the system to check for leaks and to determine the gas is flowing correctly. • The equipment including the carnet valve and tubing is clean. • Entonox cylinders should be checked carefully before use to ensure that the correct cylinder is in

use, the cylinder is in date and there is sufficient gas in the cylinder for the procedure.

PREPARATION The child and family have the right to make an informed decision about care and so must be provided with adequate information of the potential risks and benefits of Entonox®, as well as alternative analgesia, and the opportunity to discuss these. Verbal consent/assent should be obtained prior to the procedure and documented in the child’s clinical record. The age at which a child is able to use nitrous oxide depends on a number of factors such as ability to co-operate and follow instructions. Children under 6 years are rarely able to self-administer nitrous oxide successfully.

INITIAL ASSESSMENT Assess the degree of pain likely for the procedure being performed. An initial assessment of the patient must be undertaken by a trained clinician and this should be documented in the child’s notes. This should include:

• Ensure that Entonox® is not contra-indicated for the patient. • Basic assessment of the child’s respiratory function including respiratory rate and comfort of

breathing pattern. • A baseline assessment of oxygen SaO2 should be made (>93% or appropriate to a child’s

known cardiac condition). If there is concern about a potential airway or breathing problem seek advice from the CNS Acute Pain/duty anaesthetist before administering Entonox®.

PRE-PROCEDURE


ACTION RATIONALE & REFERENCE

An appropriate risk assessment of the child will be made by his/her medical team or the Registered Nurse Prescriber prior to prescribing Entonox®.

To determine the suitability of the child for Entonox and to out rule contraindications to its use.

Entonox® will be prescribed To ensure effective, safe and ethical practice; and to comply with hospital medication policy.

If there are any concerns or contra-indications identified, the anaesthetic team can also be consulted. If Entonox® is considered inappropriate for the patient or the procedure alternative analgesia/ sedation should be prescribed.

To determine if another method of pain relief can be used.

Assess the child for ability to use Entonox® The child should be able to:

• Understand simple instructions • Hold the demand valve and inhale the gas

while breathing normally

The age at which children can use Entonox® will vary depending on the individual child and the procedure to be performed. The child must be able to co-operate and follow instructions. In addition, the child must be physically able to hold and use the mouthpiece (Glasper et al 2010).

The area where the procedure is to be performed should be well ventilated or scavenging equipment should be used

To prevent personnel being exposed to high levels of nitrous oxide and to maintain safe working environment. (Reynolds et al 1996) Thorough ventilation or scavenging of waste gases should reduce treatment room levels of ambient nitrous oxide to a level below 100ppm (BOC 2010).

PREPARING THE EQUIPMENT

1. Connect the regulator to the cylinder, with gauge side up.

2. Open the cylinder using the ratchet. 3. Check the gauge to identify the level of Entonox®

in the cylinder. 4. Connect exhalation valve and mouthpiece to

carnet demand valve. 5. Ensure all connections are intact, and that there

are no leaks.

6. Valve test: Press the purge/test button on the carnet demand valve.

To ensure there is sufficient Entonox® for the procedure. Patented exhalation valve prevents expired breath entering the handset (BOC 2010). Leaks will result in the child breathing air instead of Entonox® and analgesic effects will be inadequate.

To check that the equipment is functioning correctly and the gas is flowing. (BOC 2010)

Ensure oxygen saturation monitor is available To enable oxygen saturation level to be monitored if necessary during or after the procedure.

Ensure oxygen and suction is available and ready to use.

To ensure safety of patient should his or her condition deteriorate during the procedure.


PREPARING THE CHILD


Explain the procedure to be carried out and how Entonox® will be used, including information about any side effects. Reassure the child and parents or carer that if side effects occur they wear off quickly once they stop inhaling the gas.

To ensure child and parents understand the procedure and gain their trust and co-operation. (Glasper et al 2010)

The child should avoid eating a large meal for an hour before the procedure

To reduce the likelihood of nausea and vomiting

Ensure the child has also received other analgesia if appropriate: The child may continue to use their PCA if one is in progress A bolus of intravenous opioid may be given if a high degree of pain is anticipated.

To optimize pain management for the procedure

Perform and record baseline vital signs To use as a guide to detect any subsequent deviation from normal

Oxygen saturation level should be monitored throughout the procedure if a child’s has an underlying cardiac or respiratory condition

To observe for hypoxia and to treat side effects promptly

Allow the child to practice using the equipment. Involve the play specialist if possible

To ensure an effective technique is established.

If the patient is unable to inhale the gas effectively the use of Entonox® should be abandoned and alternative analgesia and/or sedation should be prescribed.

ADMINISTRATION

One nurse will specifically care for the child as he/she self-administers the Entonox.®

This nurse’s role will be to assess the child’s ability to self administer Entonox®, to observe for the effectiveness and side-effects of Entonox®, and the support and assist the child as necessary.

Explain the procedure to the child. Encourage the child to concentrate on their breathing.

Immediately pre treatment ask the child to report onset of any side effects they experience e.g. drowsy, light-headedness, dry mouth , tingling of fingers giddiness/tearfulness and explain that these will stop quickly when he/she stops inhaling the gas

Facilitates prompt recognition and treatment of side effects

Instruct the child to place the mouthpiece between their teeth and breathe through their mouth only. When used correctly a “hissing” sound will be heard.

If the chest expansion is too shallow, the patient may not inhale sufficient Entonox® to provide pain relief.

Inhalation should commence for at least 2minutes or more before the procedure commences

To ensure the patient obtains maximum benefit from Entonox® prior to the commencement of the procedure. (BOC 2010).

The child may need considerable encouragement to start inhaling the gas. It is worth persevering as any initial reluctance usually disappears once the child realises that the Entonox® is working.

The nurse/parent/carer should not hold the mask to the child’s mouth. However, some children may need assistance to support their mask/tubing

To prevent over-sedation ( Bruce and Franck 2000)



Once administration has commenced: • The child should continue to use Entonox® as

required throughout the procedure and should be encouraged to breathe slowly and deeply.

• If the child hyperventilates they should be encouraged to exhale slowly.

To provide effective analgesia

A level of sedation approximating a Sedation Score of 2-3 is the objective (aim for analgesia but not asleep). Administration should be temporarily discontinued if the patient becomes excessively drowsy.

To avoid unconsciousness

Observe the child throughout the procedure to determine; • Level of pain • Presence of side effects • Whether they are using Entonox® effectively

To ensure the patient is receiving adequate pain relief with minimal side effects.

Any change in the child’s observations should be immediately communicated with the physician responsible for the sedation and might require immediate intervention for airway compromise or cardiovascular depression

To ensure patient safety

If the child’s pain is not controlled sufficiently with Entonox® at any stage during the procedure it may be necessary to stop the procedure until alternative analgesia and/or sedation has been administered.

COMPLETING THE PROCEDURE

At the end of the procedure, ensure the child iscomfortable.

Take the mouthpiece or face-mask from the child andcontinue to monitor and remain with the child untileffects of Entonox® are no longer evident ( at least 10 minutes)

The effectiveness of the Entonox® and all side effectsor adverse events should be reported to the medical team and documented in the patient’s health Carenotes and the sedation record.

Facilitate prompt treatment and patient safety

Check the remaining level of Entonox® on the gauge and if less than ¼ left order a replacement cylinder from Technical Services (See Appendix).

To ensure there is sufficient Entonox® for the nextpatient.

Close the cylinder using the ratchet. Press the test button on the demand valve.

To remove residual gas from the tubing (BOC2010).

The outside of the regulator, the carnet demand valveand the tubing should be cleaned with detergent andwater and then disinfected with Actichlor.

To comply with infection control procedures

Remove the tubing and carnet valve and store inbasket on Entonox cylinder.

Decontaminate hands in accordance with hand hygiene policy

To prevent hospital acquired infection

Return Entonox® cylinder to store room in PICU floor 1, or store room in St Annes ward

To maintain a safe environment. Entonox® cylinders must be stored in a secure environmenton a trolley and away from children when not inuse


The mouthpiece and filter (and corrugated tubing used


for scavenging system) are single patient use only andare changed weekly. Store in a labelled plastic bag in child’s room. Visibly contaminated corrugated tubing (St Annes) ischanged immediately. Dispose of this in Healthcare Non-Risk Waste (i.e. Household Waste).

Document all care given; evaluate the effectiveness of Entonox® and record any adverse reaction.

Record the time of commencement and completion ofEntonox® administration in the child’s prescription chart.

To facilitate communication, to provide evidence ofdelivery of quality care, and to ensure evaluation of this care To ensure safe practice and maintain accountability (An Bord Altranais 2002).

Patients may be discharged from hospital once theymeet the following discharge criteria:

− Return to normal (presedation) level of consciousness

− Resumption of purposeful neuromuscular activity − Ability to ambulate (if appropriate) or able to sit

without support - Ability to verbalize appropriate for age

NOTE If Entonox is to be administered more frequently than every 4 days routine blood counts must be performed

To observe for:• Evidence of megaloblastic change in red

cells.• Reduced production of leucocytes• Hypersegmentation of neutrophils

(Amos et al 1984, Nunn 1987)

ORDERING DETAILS FOR ENTONOX ® When one cylinder is less than ¼ full please order a replacement cylinder.

Product Remarks Order from Order details Replacement cylinders Replace when ¼ full Engineering Officer, Technical

Services ( 6608) 2000litre Size Entonox® cylinder

Carnet valve Multi-patient use BOC Gases Ireland 4094827

Supplies

Exhalation valve/ mouthpiece (attaches to carnet valve)

Single patient use

BOC Gases Ireland 4094827

Contact Clinical Engineering

Corrugated tubing ( Scavenging system St Annes ward)

Single patient use – change weekly or more frequently if contaminated

Materials Management Flexicare 22mm Corrugated Tubing 50meter roll Ref: 038-01-225

Green connector (for corrugated tubing, St Annes)

Single patient use Materials Management 22M-30F, Ref

Facemask (if required) Single patient use Materials management

5INS2490 - size 2 5INS2543 - size 3 5INS2489 - size 4

Green connector for use with a facemask

Single use only Materials Management

Ref. 1969

Troubleshooting Guide Problem Possible reason & action


The child’s pain is not relieved

• The child should also receive other analgesia, e.g. Paracetamol and/or NSAIDs and/or opiates.

• To be effective, the child should take several breaths of the Entonox® (at least 2-3 minutes) prior to commencing the dressing change.

• There may be a leak - if so, the child will breathe air instead of Entonox®. • Check that the mouthpiece and filter, and the apparatus and tubing are

securely connected. Is the cylinder empty or valve closed? • If a leak from the cylinder is suspected. Close the cylinder with the ratchet

valve and reconnect the regulator. If there are still problems contact Clinical Engineering on ext. 6639/6171, Bleep 8465.

• Child may not inhale deeply enough – explain the procedure again. Ensure the child has practised using the apparatus. Entonox® is not always effective. Allow longer use of Entonox®, or consider the need for alternative analgesia.

Nausea/vomiting • Discontinue administration of Entonox®- the nausea will rapidly disappear. Administer anti-emetic if necessary

• The child does not need to fast prior to receiving Entonox®. However, it is advisable to avoid a large meal for an hour prior to administering Entonox® OLCHC 2010)

The child is afraid to use Entonox®

The child may be fearful or may associate the use of gas with an unpleasant experience in the past. Give reassurance and explanations but don’t insist on use.

Dizzy or disorientation

This is a common but not usually distressing side effect. Stop inhalation until sensation starts to wear off and the sensation of pain starts to return, then continue inhalation

Earache

May occur if Nitrous Oxide accumulates in the middle ear • If occurs, stop inhalation of Entonox® to prevent perforation of tympanic

membrane. Administer alternative analgesia.

Dry Mouth A dry mouth is a common complaint but not usually distressing. Provide water/juice/ice chips and encourage the child to continue inhaling.

Vitamin B12 depletion

Prolonged exposure to Entonox® can deplete the body’s stores of Vitamin B12, which can cause megaloblastic changes to the red blood cells.

o Prior to first administration of Entonox® – perform a full blood count (FBC), a Vitamin B12 level and Red Cell Folate.

o Perform an FBC on a weekly basis for the duration of Entonox® administration – monitoring the MCV.

• If MCV is increasing, Folinic Acid supplements can be prescribed. • If child is receiving Entonox® for >3 hours daily, consider a methionine

enriched diet. Consult with Haematology team and dietician (OLCHC 2006).


Audit of Entonox®

Please complete the audit form following each use of Entonox®.

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REFERENCES


An Bord Altranais (2002) Recording Clinical Practice Guidance to Nurses and Midwives. An Bord Altranais,

Dublin.

An Bord Altranais (2007) Guidance to Nurses and Midwives on the Administration of Medical Preparations. An

Bord Altranais, Dublin.

BOC Medical (2010) Entonox® controlled pain relief. Reference guide. BOC Limited, Manchester.

Bruce E. and Franck L. (2000) Self-administered nitrous oxide (Entonox) for the management of procedural

pain, Paediatric Nursing. 12(7), 15-19.

Bruce E, Franck L, Howard R. (2006) the Efficacy of morphine and Entonox analgesia during chest drain

removal n children. Pediatric Anesthesia; 16:302-308

Burnweit C., Diana-Zerpa J.A. Nahmad M.H., Lankau C.A., Weinberger M., Alvezzi L., Smith L., Shapiro T.,

Thayer K. (2004) Nitrous oxide analgesia for minor pediatric procedures: An effective alternative to

conscious sedation? Journal of Pediatric Surgery, 39 (3):495-499

Cleary A.G., Ramanan A.V., Baidam E., Birch A., Sills J.A., Davidson J.E. (2002) Nitrous oxide analgesia

during intra-articular injection for juvenile idiopathic arthritis. Archive Disease in Children; 86:416-418

Department of Health and Children (2004) Segregation Packaging and Storage Guidelines for Healthcare Risk

Waste 3rd edn. Department of Health and Children, Dublin.

Ekbom. K , Jakobsson., J. and Marcus., C. (2005). Nitrous Oxide inhalation is a safe and effective way to

facilitate procedures in paediatric outpatients departments. Archives of Disease of Children 90: 1073-

1076

Ekbom K., Kalman S., Jakobsson J., Marcus C. (2011) Efficient intravenous access without distress: a double-

blind randomized study of Midazolam and nitrous oxide in children and adolescents. Archive Pediatric

and Adolescent Medicine; 165 (9):785-91

Farrell M.K., Drake G.J., Rucker D., Finkelstein M., Zier J.L. (2008) Creation of a Registered Nurse

Administered Nitrous Oxide Sedation Program for radiology and beyond. Pediatric Nursing; 34(1)29-36

Glasper A., Aylott M. and Battrick C. (2010) Developing Practical Skills for Nursing Children and Young

People, Hodder Arnold, London.

Krauss B. (2001) Continuous-flow Nitrous Oxide: searching for the ideal procedural anxiolytic for toddlers.

Annals of Emergency Medicine 31(1), 61-62.

Kanagasundarum. S. A., Lane., L.J, Cavalletto., B.P. et al. (2001). Efficacy and safety of nitrous oxide in

alleviating pain and anxiety during painful procedures Archives of Disease of Children: 492-495

National Institute for Health and Clinical Excellence (NICE) (2010) Sedation in child or young person and

young people NICE clinical guideline 112. Viewed on: 1/8/2012.

Nunn JF(1987)Clinical aspects of the interaction between nitrous oxide and vitamin B12. British Journal of

Anaesthesia ; 59:3-13.

Our Lady’s Children’s Hospital (2007) Prevention of abuse of children by a staff member while in the care of

the hospital: Guidelines for good practice. Our Lady’s Children’s Hospital, Dublin.

Our Lady’s Hospital for Sick Children (2001) Medication Policy. Our Lady’s Hospital for Sick Children, Dublin.

http://www.nice.org.uk/nicemedia/live/13296/52130/52130.pdf



Our Lady’s Childrens Hospital (2012) Guidelines on cleaning and disinfection. Our Lady’s Children’s Hospital,

Crumlin Dublin

Our Lady’s Childrens Hospital (2012) Guidelines on hand hygiene. Our Lady’s Children’s Hospital, Crumlin

Dublin

Our Lady’s Childrens Hospital (2010) Analgesia Guidelines. Our Lady’s Children’s Hospital, Crumlin Dublin

Our Lady’s Childrens Hospital (2010) Sedation Guideline. Our Lady’s Children’s Hospital, Crumlin Dublin

Reinoso-Barbero F., Pascual-Pascual S.I., de Lucas R., Garcia S., Billoet C., Dequenne V., Onody P.(2011)

Equimolar nitrous oxide/oxygen versus placebo for procedural pain in children: a randomized trial.

Pediatrics; 127(6):e1464-e1470

Weiss J.E., Uribe A.G., Malleson P.N., Kimura Y.(2010) Anesthesia for intra-articular corticosteroid injections in

juvenile idiopathic arthritis: A survey of pediatric rheumatologists. Rheumatology Online Journal; 8:3

http://www.ped-rheum.com/content/pdf/1546-0096-8-3.pdf. Accessed 12/8/2012

ADDITIONAL RESOURCES Online learning resource - http://www.entonox.co.uk/en/index.shtml

Document Number: Approved By: Nurse Practice Committee (NPC)

Edition Number: Date of Approval:

Number of Copies: Ratified By: Geraldine Regan, Director of Nursing.

Signature:

Responsibility for this Document: NPC Date of Ratification:

© 2012, Our Lady’s Children’s Hospital Crumlin, Dublin 12. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means without the prior written permission of the copyright holder. Our Lady’s Children’s Hospital makes no representation, express or implied, with regard to the accuracy of the information contained in this publication and cannot accept any legal responsibility for any errors or omissions that may be made.

http://www.ped-rheum.com/content/pdf/1546-0096-8-3.pdf

http://www.entonox.co.uk/en/index.shtml

Appendix 1: Entonox portable set up


Appendix 2: Entonox Checklist


Nursing Practice Committee Guidelines on

Use of Entonox® for rheumatology patients undergoing Joint Injections

Author: Gill O’ Callaghan, CNS Acute Pain Issue Date: January 2013 Carol Hilliard, Nursing Practice Development Coordinator Review Date: January 2015 Purpose:

To provide a guideline for the management of the self- administration of nitrous oxide inhalation in rheumatology patients attending Our Lady’s Children’s Hospital ,Crumlin

Introduction: Entonox has been proven to be a useful analgesic and sedative agent that is fast, safe and easy to handle (Cleary et al, 2002; Burnweit et al. 2004; Glasper et al. 2010; BOC Healthcare, 2010). Use of Entonox is designated as 'minimal sedation' under the National Institute for Health and Clinical Excellence (NICE) guidance classification (NICE 2010). However, if used in combination with other sedatives or potent analgesia, there is an increased risk of sedation. Entonox is a powerful anaesthetic gas, misuse of this gas can lead to loss of consciousness, and therefore entonox should only be self–administered when used for procedural pain. Entonox is administered via flexible tubing with a one way demand valve, a filter and a mouthpiece. When Entonox® is self-administered the gas mix will only flow if there is enough negative pressure generated within the breathing circuit to open the demand valve. To generate this negative pressure the child must maintain a tight seal around the mouthpiece/mask of the breathing circuit, and must produce a good inspiritory effort. The demand valve is operated only when the child inhales and closes when the child stops breathing in. If a child becomes over-sedated while self-administering the Entonox®, he/she will be unable to maintain an effective seal around the mouthpiece, inhalation will stop, gas flow ceases, the child will inhale room air and gradually recover from the effects of the Entonox® . Once the child becomes more alert, he/she may start inhaling the Entonox® again (Bruce & Franck 2000, BOC 2010).

Staff should also be aware that Entonox is a habit-forming drug and has been subject to abuse. Documented cases of abuse are rare, but addiction may be a result of long-term use and lead to myeloneuropathy and serious neurological problems.

Due to the potential for problems related to repeated/long-term use, Entonox should only be used for painful procedures. Procedures that are primarily frightening in nature should be managed using psychological input and sedation/anxiolytics as appropriate.

Definitions: • Entonox is a gaseous analgesic agent composed of nitrous oxide and oxygen in equal

proportions of 50% Oxygen and 50% Nitrous Oxide (BOC Medical, 2010). When inhaled, it provides powerful, rapid onset analgesia within 20 seconds to 2 minutes. Offset is rapid, occurring after 2-5 minutes, as it is expired in an unchanged state as the child breathes out (Krauss 2001).

• Inhalation: the drawing of an aerolised drug into the lungs with the breath (Dorland’s Pocket Medical Dictionary, 2004)

Mechanism of action

The exact mechanism of action is unknown, Nitrous Oxide causes Central Nervous System (CNS) depression and appears to have properties that are similar to opioids and various neurotransmitters that inhibit pain transmission.

Nurse Practice Committee January 2013 Edition

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Roles and Responsibilities

Entonox should only be administered by staff who are: • Competent in the administration of Entonox and basic life support. • Familiar with the side effects of Entonox and its contra-indications. • Aware of the criteria for patient selection and exclusion.

The Registered nurse should have completed: • The BOC entonox training on line at ( http://www.entonox.co.uk/en/discover_enotonox/training-

support/online-training/entonox_online_training.shtml • Completed the competence assessment programme delivered by the CNS in acute pain. • The nurse performs this procedure under the Scope of Practice for Nursing and Midwifery

Framework An Bord Altranais 2000 and Our Lady’s Children’s Hospital medication, drug administration and related reference material , risk management, infection control policies and clinical care safety statement.

• The nurse will undertake Paediatric Intermediate Life Support training on a yearly basis. • The CNS acute pain can administer Entonox in clinical areas where staff have not been trained in

its use if she is available. The CNS should be contacted well in advance of the procedure.

Indications for use To relieve procedural pain during aspiration of synovial fluid and/ or intra-articular administration of steroids in children with arthritis.

Contraindications

Nitrous Oxide diffuses into cavities so it is not used if: • pneumothorax or bowel obstruction is suspected, • if there is abdominal distension, • suspected air embolism or decompression

sickness

Airway • Increased risk of airway loss, acute

respiratory infection (URTI) or exacerbation of asthma.

• Airway obstruction or history of difficult airway management.

Raised pulmonary vascular pressure e.g. Pulmonary Hypertension.

Patients with maxillofacial injuries as there is a need to grip the mouthpiece with teeth or firmly push the mask onto the face to get a good seal.

CNS • Head Injury with impaired consciousness as it

may cause an increase in Intra Cranial Pressure • Alcohol and drug intoxication as consciousness

levels are difficult to determine and compliance may be poor

Possible middle ear infection. (It should be used with caution in children with “glue ear”. Discontinue use immediately if child complains of earache.) Nasal blockage –e.g. adenoid hypertrophy, common cold

Relative Contraindication:

1. Entonox should be used with caution in patients at risk for nitrous oxide induced bone marrow suppression, neurotoxicity or increased homocyteine levels as exposure to nitrous oxide depletes the body’s stores of vitamin B12 and very rarely this can precipitate neurological complications. History of B12 or folate deficiency Nutritionally compromised patients, vegetarians, patients on H2 blockers or proton pump

inhibitors Concurrent underlying serious illness, severe infection or extensive tissue damage. • Patients with metabolic diseases associated with homocysteine metabolism (methionine

synthetase deficiency, homocystinuria and methylmalonic academia.

2. Children who have already received sedation – In this situation, please discuss the child’s care with Acute Pain Service or the Anaesthetic Consultant. (Note: the use of Opiates for analgesic effect does not outrule the use of Entonox®)




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Side effects of Entonox • These include: Dry mouth, disorientation, dizziness, euphoria, loss of inhibition, feeling floaty, blurred

vision and less commonly, nausea and vomiting, excessive sedation, tingling of fingertips, numbness of tongue

• Very Rarely, with repeated uses, inactivation of B12 and folate metabolism. In this situation blood tests are carried out to detect red cell changes.

Health and Safety Issues • Entonox® is excreted unaltered via the patient’s breath. In the UK and Ireland, the maximum

exposure limits for nitrous oxide is set at 100ppm over an 8 hour period ( BOC 2010).This level is significantly below the concentrations where any detrimental effect will be caused. Thorough ventilation or scavenging of waste gases should reduce treatment room levels of ambient nitrous oxide to a level below 100ppm.( BOC, 2010)

• A risk assessment should be carried out by the practitioner to ensure ventilation is adequate and action should be taken to move the patient to a well ventilated area if necessary.

• As a health and safety measure, It is recommended that anyone who is in the first trimester of pregnancy should not remain in the room/immediate area while Entonox® is being use. Staff administering Entonox® have a duty of care to ensure that those in the immediate vicinity, including the child and family members where appropriate, are aware of this risk and have the opportunity to remove themselves from the immediate area discretely if they choose.

• To ensure the safe and effective functioning of the Entonox® regulator, the Clinical Engineering Department will oversee yearly maintenance and testing of the regulator.

Storage of Entonox® • Entonox cylinders should have a blue and white collar and should be stored upright at a

temperature above minus 60 Celsius. If the cylinder has been stored at minus 60, the two gases will have separated, which could result in the child or young person receiving either oxygen only or high concentration nitrous oxide (BOC 2010).

• The Portable Entonox® cylinder is stored in the nitrous oxide gas room in PICU floor 1 (between the entrance of Operating Theatre and PICU floor 1 area). The mouthpieces are stored in the Acute Pain CNS office CNS office (bleep 8300). Only remove the cylinder and regulator from the storage area immediately prior to use.

• Entonox® supports combustion and must not be used near an ignition source (Bruce and Franck, 2000) Refer to BOC Medical Gases –Safe handling and storage of medical gas cylinders –Information leaflet.

• Details of where Entonox® is stored have been supplied to Technical Services and to the health and Safety Officer who have in turn informed the Fire Services.

Infection control Issues

• A bacterial filter protects the tubing from internal contamination. The outside is held by the patient • Each patient will have their own single patient use disposable mouthpiece and bacterial filter. • The Entonox Delivery unit-Input hose is cleaned after each patient use using Actichlor • The Carnet Valve is cleaned after each patient use, using Actichlor. • Entonox cylinders being taken into an infectious risk cubicle should be covered in a protective

plastic sheet (i.e. waste bag). Equipment

• Entonox® cylinder • Regulator • Entonox Delivery unit-Input hose • Carnet Valve • Mouth piece with bacterial/viral filter (disposable) • Dinamap • Pulse oximeter • Oxygen and suction equipment available in the room

Use of Equipment



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Practitioners check that the equipment is in good working order before use. The following are checked: • A suitable key to turn the cylinder on and off is attached to the equipment. • The regulator fits securely • Gas is blown through the system to check for leaks and to determine the gas is flowing correctly. • The equipment including the carnet valve and tubing is clean. • Entonox cylinders should be checked carefully before use to ensure that the correct cylinder is in

use, the cylinder is in date and there is sufficient gas in the cylinder for the procedure.

Preparation The child and family have the right to make an informed decision about care and so must be provided with adequate information of the potential risks and benefits of Entonox®, as well as alternative analgesia, and the opportunity to discuss these. Verbal consent/assent should be obtained prior to the procedure and documented in the child’s clinical record. The age at which a child is able to use nitrous oxide depends on a number of factors such as ability to co-operate and follow instructions. Children under 6 years are rarely able to self-administer Entonox® successfully.

Initial assessment Assess the degree of pain likely for the procedure being performed. An initial assessment of the patient must be undertaken by a trained clinician and this should be documented in the child’s notes. This should include:

• Ensure that Entonox® is not contra-indicated for the patient. • Basic assessment of the child’s respiratory function including respiratory rate and comfort of

breathing pattern. • A baseline assessment of oxygen SaO2 should be made (>93% or appropriate to a child’s known

cardiac condition). If there is concern about a potential airway or breathing problem seek advice from the CNS Acute Pain/duty anaesthetist before administering Entonox®.

PRE-PROCEDURE


An appropriate risk assessment of the child will be made by his/her medical team or the Registered Nurse Prescriber prior to prescribing Entonox®.

To determine the suitability of the child for Entonox® and to out rule contraindications to its use.

Entonox® will be prescribed To ensure effective, safe and ethical practice; and to comply with hospital medication policy.

If there are any concerns or contra-indications identified, the CNS acute pain or anaesthetist can also be consulted. If Entonox® is considered inappropriate for the patient or the procedure alternative analgesia/ sedation should be prescribed.

To determine if another method of pain relief can be used.

Assess the child for ability to use Entonox® The child should be able to:

• Understand simple instructions • Hold the demand valve and inhale the gas

while breathing normally

The age at which a child can us Entonox® will vary depending on the individual child. The child must have be able to co-operate and follow instructions. In addition, the child must be physically able to hold and use the mouthpiece (Glasper et al. 2010).

The area where the procedure is to be performed should be well ventilated.

To prevent personnel being exposed to high levels of nitrous oxide and to maintain safe working environment. (Reynolds et al, 1996) Thorough ventilation of waste gases should reduce treatment room levels of ambient nitrous oxide to a level below 100ppm.( BOC, 2010).


Staff who are in the first trimester of pregnancy or There have been concerns that exposure to high


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planning to conceive may wish to avoid the area whilst entonox is being administered.

levels of Nitrous Oxide can reduce fertility (Rowland et al, 1993) , or may be harmful to the foetus. However, there is little reported evidence to conclusively support these concerns (Dougherty and Lister, 2004)

Ensure oxygen saturation monitor is available To enable oxygen saturation level to be monitored if necessary during or after the procedure.

Ensure oxygen and suction is available and ready to use.

To ensure safety of patient should his or her condition deteriorate during the procedure.

Preparing the equipment 1. Connect the regulator to the cylinder, with gauge

side up. 2. Open the cylinder using the ratchet. 3. Check the gauge to identify the level of Entonox®

in the cylinder. 4. Connect exhalation valve and mouthpiece to

carnet demand valve. 5. Ensure all connections are intact, and that there

are no leaks.

6. Valve test: Press the purge/test button on the carnet demand valve.

To ensure there is sufficient Entonox® for the procedure. Patented exhalation valve prevents expired breath entering the handset, BOC 2010. Leaks will result in the child breathing air instead of Entonox® and analgesic effects will be inadequate. To check that the equipment is functioning correctly and the gas is flowing. ( BOC, 2010)

Preparing the child

Explain the procedure to be carried out and how Entonox® will be used, including information about any side effects. Reassure the child and parents or carer that if side effects occur they wear off quickly once they stop inhaling the gas.

To ensure child and parents understand the procedure and gain their trust and co-operation. (Glasper et al. 2010)

The child should avoid eating a large meal for an hour before the procedure

To reduce the likelihood of nausea and vomiting

Ensure the child has also received other analgesia if appropriate.

To optimize pain management for the procedure

Perform and record baseline vital signs To use as a guide to detect any subsequent deviation from normal

Allow the child to practice using the equipment. Involve the play specialist if possible

To ensure an effective technique is established.

If the patient is unable to inhale the gas effectively the use of Entonox® should be abandoned and alternative analgesia and/or sedation should be prescribed.

Oxygen saturation level should be monitored throughout the procedure if a child’s has an underlying cardiac or respiratory condition

To observe for hypoxia and to treat side effects promptly

ADMINISTRATION



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One nurse will specifically care for the child as he/she self-administers the Entonox.®

This nurse’s role will be to assess the child’s ability to self administer Entonox®, to observe for the effectiveness and side-effects of Entonox®, and the support and assist the child as necessary.

Explain the procedure to the child. Encourage the child to concentrate on their breathing.

Immediately pre treatment ask the child to report onset of any side effects they experience e.g. drowsy, light-headedness, dry mouth , tingling of fingers giddiness/tearfulness and explain that these will stop quickly when he/she stops inhaling the gas.

Facilitates prompt recognition and treatment of side effects

Instruct the child to place the mouthpiece between their teeth and breathe through their mouth only. When used correctly a “hissing” sound will be heard.

If the chest expansion is too shallow, the patient may not inhale sufficient Entonox® to provide pain relief.

Inhalation should commence for at least 2minutes or more before the procedure commences.

To ensure the patient obtains maximum benefit from Entonox® prior to the commencement of the procedure. (BOC, 2010).

The child may need considerable encouragement to start inhaling the gas. It is worth persevering as any initial reluctance usually disappears once the child realises that the Entonox® is working.

The nurse/parent/carer should not hold the mask to the child’s mouth. However, some children may need assistance to support their mask/tubing

To prevent over-sedation ( Bruce and Franck, 2000)

Once administration has commenced: • The child should continue to use Entonox® as

required throughout the procedure and should be encouraged to breathe slowly and deeply.

• If the child hyperventilates they should be encouraged to exhale slowly.

To provide effective analgesia

A level of sedation approximating a Sedation Score of 2 is the objective (aim for analgesia but not asleep). Administration should be temporarily discontinued if the patient becomes excessively drowsy.

To avoid unconsciousness

Observe the child throughout the procedure to determine; • Level of pain • Presence of side effects • Whether they are using Entonox® effectively

To ensure the patient is receiving adequate pain relief with minimal side effects.

Any change in the child’s observations should be immediately communicated with the physician responsible for the sedation and might require immediate intervention for airway compromise or cardiovascular depression

To ensure patient safety

If the child’s pain is not controlled sufficiently with Entonox® at any stage during the procedure it may be necessary to stop the procedure until alternative analgesia and/or sedations has been administered.


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Completing the procedure

At the end of the procedure, ensure the child is comfortable.

Take the mouthpiece or face-mask from the child and continue to monitor and remain with the child until effects are no longer evident ( at least 10 minutes)

The effectiveness of the Entonox® and all side effects or adverse events should be reported to the medical team and documented in the patient’s Health Care Record and the sedation record.

Facilitate prompt treatment and patient safety

Check the remaining level of Entonox® on the gauge and if less than ¼ left order a replacement cylinder from Technical Services (See Appendix).

To ensure there is sufficient Entonox® for the next patient.

Close the cylinder using the ratchet. Press the test button on the demand valve.

To remove residual gas from the tubing. BOC 2010

The outside of the regulator, the carnet demand valve and the tubing should be cleaned using Actichlor.

To comply with infection control procedures

Remove the tubing and carnet valve and store in basket on Entonox® cylinder.

Decontaminate hands in accordance with hand hygiene policy

To prevent hospital acquired infection

Return Entonox® cylinder to store room in PICU floor 1 To maintain a safe environment. Entonox® cylinders must be stored in a secure environment on a trolley and away from children when not in use

The mouthpiece and filter are single patient use only. Dispose of this in Healthcare Non-Risk Waste (i.e. Household Waste).

Document all care given; evaluate the effectiveness of Entonox® and record any adverse reaction. Record the time of commencement and completion of Entonox® administration in the child’s prescription chart.

To facilitate communication, to provide evidence of delivery of quality care, and to ensure evaluation of this care To ensure safe practice and maintain accountability. An Bord Altranais 2002.

Patients may be discharged from hospital once they meet the following discharge criteria: − Return to normal (presedation) level of

consciousness − Resumption of purposeful neuromuscular activity − Ability to ambulate (if appropriate) or able to sit

without support - Ability to verbalize appropriate for age

NOTE If Entonox is to be administered more frequently than every 4 days routine blood counts must be performed

To observe for:• Evidence of megaloblastic change in red

cells.• Reduced production of leucocytes• Hypersegmentation of neutrophils

(Amos et al 1984, Nunn, 1987)

Ordering details for Entonox ®


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When one cylinder is less than ¼ full please order a replacement cylinder.

Product Remarks Order from Order details

Replacement cylinders Replace when ¼ full

Engineering Officer, Technical Services ( 6608)

2000litre Size Entonox® cylinder

Carnet valve Multi-patient use BOC Gases Ireland 4094827

Supplies

Exhalation valve/ mouthpiece (attaches to carnet valve)

Single patient use

BOC Gases Ireland 4094827

Contact Clinical Engineering

Facemask (if required) Single patient use Materials management

5INS2490 - size 2 5INS2543 - size 3 5INS2489 - size 4

Green connector for use with a facemask

Single use only Materials Management

Ref. 1969


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Troubleshooting Guide Problem Possible reason & action The child’s pain is not relieved

• The child should also receive other analgesia, e.g. Paracetamol and/or NSAIDs.

• To be effective, the child should take several breaths of the Entonox® (at least 2-3 minutes) prior to commencing the joint injection.

• There may be a leak - if so, the child will breathe air instead of Entonox®. • Check that the mouthpiece and filter, and the apparatus and tubing are

securely connected. Is the cylinder empty or valve closed? • If a leak from the cylinder is suspected. Close the cylinder with the ratchet

valve and reconnect the regulator. If there are still problems contact Clinical Engineering on ext. 6639/6171, Bleep 8465.

• Child may not inhale deeply enough – explain the procedure again. Ensure the child has practised using the apparatus. Entonox® is not always effective. Allow longer use of Entonox®, or consider the need for alternative analgesia.

Nausea/vomiting • Discontinue administration of Entonox®- the nausea will rapidly disappear. Administer anti-emetic if necessary

• The child does not need to fast prior to receiving Entonox®. However, it is advisable to avoid a large meal for an hour prior to administering Entonox®. (Dr J Mc Ginley Anaesthetic Department, OLHSC 2010)

The child is afraid to use Entonox®

The child may be fearful or may associate the use of gas with an unpleasant experience in the past. Give reassurance and explanations but do not insist on use.

Dizzy or disorientation

This is a common but not usually distressing side effect. Stop inhalation until sensation starts to wear off, then continue inhalation

Earache

May occur if Nitrous Oxide accumulates in the middle ear • If occurs, stop inhalation of Entonox® to prevent perforation of tympanic

membrane. Administer alternative analgesia.

Dry Mouth A dry mouth is a common complaint but not usually distressing. Provide water/juice/ice chips and encourage the child to continue inhaling.

Vitamin B12 depletion

Prolonged exposure to Entonox® can deplete the body’s stores of Vitamin B12, which can cause megaloblastic changes to the red blood cells.

o Prior to first administration of Entonox® – perform a full blood count (FBC), a Vitamin B12 level and Red Cell Folate.

o Perform an FBC on a weekly basis for the duration of Entonox® administration – monitoring the MCV.

• If MCV is increasing, Folinic Acid supplements can be prescribed. • If child is receiving Entonox® for >3 hours daily, consider a methionine

enriched diet. Consult with Haematology team and dietician. (Dr. C. McMahon, Consultant Haematologist, OLCHC, 2006)

Nurse Practice Committee January 2013 Edition 10

Audit of Entonox®

Please complete the audit form following each use of Entonox®.

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REFERENCES Amos RJ, Amess AL, Nancekievill DG & Rees GM. (1984) Prevention of nitrous oxide induced megaloblastic changes in bone marrow using folinic acid. British Journal of Anaesthesia ; 56:103-7 An Bord Altranais (2002) Recording Clinical Practice Guidance to Nurses and Midwives. An Bord Altranais, Dublin. An Bord Altranais (2007) Guidance to Nurses and Midwives on the Administration of Medical Preparations. An Bord Altranais, Dublin. BOC Medical (2010) Entonox® controlled pain relief. Reference guide. BOC Limited, Manchester. Bruce E and Franck L (2000) Self-administered nitrous oxide (Entonox) for the management of procedural pain, Paediatric Nursing. 12(7), 15-19. Burnweit C et al. (2004) Nitrous oxide analgesia for minor pediatric procedures: An effective alternative to conscious sedation? Journal of Pediatric Surgery, 39:495-499 Cleary AG, Ramanan AV, Baidam E, Birch A, Sills JA, Davidson JE. (2002) Nitrous oxide analgesia during intra-articular injection for juvenile idiopathic arthritis. Archive Disease in Children; 86:416-418 Department of Health and Children (2004) Segregation Packaging and Storage Guidelines for Healthcare Risk Waste 3rd edn. Department of Health and Children, Dublin. Dougherty. L. and Lister., S. (2004). The Royal Marsden Hospital Manual of Clinical Nursing Procedures , 6th Edition, Blackwell Science, Oxford. Farrell MK, Drake GJ, Rucker D, Finkelstein M, Zier JL. (2008) Creation of a Registered Nurse Administered Nitrous Oxide Sedation Program for radiology and beyond. Pediatric Nursing; 34(1)29-36 Glasper A, Aylott M and Battrick C (2010) Developing Practical Skills for Nursing Children and Young People, Hodder Arnold, London. Krauss B (2001) Continuous-flow Nitrous Oxide: searching for the ideal procedural anxiolytic for toddlers. Annals of Emergency Medicine 31(1), 61-62. Kanagasundarum. S. A., Lane., L.J, Cavalletto., B.P. et al. (2001). Efficacy and safety of nitrous oxide in alleviating pain and anxiety during painful procedures Archives of Disease of Children: 492-495 National Institute for Health and Clinical Excellence (NICE) (2010) Sedation in child or young person and young people NICE clinical guideline 112. Viewed on: 1/8/2012. Nunn JF(1987)Clinical aspects of the interaction between nitrous oxide and vitamin B12. British Journal of Anaesthesia ; 59:3-13. Our Lady’s Children’s Hospital (2007) Prevention of abuse of children by a staff member while in the care of the hospital: Guidelines for good practice. Our Lady’s Children’s Hospital, Dublin. Our Lady’s Hospital for Sick Children (2001) Medication Policy. Our Lady’s Hospital for Sick Children, Dublin. Weiss JE. Uribe AG, Malleson PN, Kimura Y.(2010) Anesthesia for intra-articular corticosteroid injections in juvenile idiopathic arthritis: A survey of pediatric rheumatologists. Rheumatology Online Journal; 8:3 http://www.ped-rheum.com/content/pdf/1546-0096-8-3.pdf. accessed 12/8/2012

ADDITIONAL RESOURCES Online learning resource - http://www.entonox.co.uk/en/index.shtml

Document Number: Approved By: Nurse Practice Committee (NPC)

Edition Number: Date of Approval:

Number of Copies: Ratified By: Geraldine Regan, Director of Nursing.

Signature:

Responsibility for this Document: NPC Date of Ratification:

© 2012, Our Lady’s Children’s Hospital Crumlin, Dublin 12. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means without the prior written permission of the copyright holder. Our Lady’s Children’s Hospital makes no representation, express or implied, with regard to the accuracy of the information contained in this publication and cannot accept any legal responsibility for any errors or omissions that may be made.



http://www.ped-rheum.com/content/pdf/1546-0096-8-3.pdf

http://www.entonox.co.uk/en/index.shtml


Audit Standards Each practitioner supervising the use of Entonox will be knowledgeable, skilled and safe to instruct its administration

100% Nil Evidenced in personal portfolio

Each practitioner will have attended training in the use of Entonox as per hospital policy. 100% Nil List of attendees kept in the Department of

Practice Development. All patients fulfill the criteria for the administration of Entonox 100% Nil No contraindications are present

All patients will have the use of Entonox documented in the appropriate documentation 100% Nil Prescription chart & relevant professional notes

Level of sedationscore

No sedation anxious, agitated or in pain

Minimal

Moderate Arouses to consciousness with moderate tactile or loud verbal stimulus

Deep Arouses slowly to consciousness with sustained painful stimulus

Anaesthesia Unresponsive to painful stimulus

Our Lady’s Children’s Hospital Crumlin, Dublin 12

Entonox competency assessment-OLCHC 2012 - 1 -

Assessment of Competence in the supervision of the self-administration of Entonox® by children

Introduction

To ensure the safe and effective use of Entonox, nurses will be assessed in both the theory and practice of supervising the self-administration of Entonox® by children. The time frame for completing the competency assessment is expected to be 1-6 months. Criteria for nursing staff who may supervise children during self-administration of Entonox® • Must be a registered nurse who is employed by Our Lady’s Children’s Hospital Crumlin. • Must have received practical and theoretical instruction in relation to the use of Entonox®. • Must have acquired the necessary knowledge and skill prior to supervising the administration of Entonox®. • Must then assess if the skill is within her/his scope of practice. • Will undertake PILS training on a yearly basis.

Learning Outcomes Following completion of the competency assessment in Entonox® administration, the nurse will demonstrate knowledge and competence of the:

Use of Entonox®, including it’s contraindications, Risk assessment and safety implications Complications of Entonox® and how these may be both detected and managed Role of the nurse during the self-administration of Entonox® by children

Use of the Entonox® equipment and supervision of children who are self-administering Entonox®

Competency assessment To demonstrate practical competence and a sound knowledge base, the registered nurse is required to complete this competency assessment package within 6 months. In addition you must complete the package if you:

Have returned to practice after a break in practice of >1 year (at discretion of CNS Acute Pain. Any other updating at the discretion of the Clinical Nurse Specialist Acute Pain.

Advice on demonstrating your competence and knowledge may be obtained from: Clinical Nurse Specialist Acute Pain

Competence Assessment Strategy

There are three parts to the assessment of competence in relation to the administration of Entonox®. Part 1 The nurse will complete the BOC on-line learning resource and receive theoretical and practical instruction relating to the use of Entonox® for the relief of procedural pain. http://discover.entonox.co.uk/ Part 2 The nurse will complete the Entonox® workbook contained in this document, which the Clinical Nurse Specialist Acute Pain will correct. Part 3 On at least three occasions the nurse will undergo assessment of competence (including practical & theoretical assessment) in the administration of Entonox® under the supervision of CNS Acute Pain or a nurse who has already been deemed competent in the administration of Entonox®. The assessment grading system is outlined below. On successful completion of the competence assessment and workbook, forward summary sheet to Clinical Nurse specialist Pain or Clinical Nurse Facilitator in your clinical area. If the candidate is unsuccessful on 1st assessment of competence, two further attempts at reassessment may be undertaken. An action plan will be developed and recorded by the assessor. Action Plan The action plan must be documented and should detail the following:

The area(s) of practice which require development as agreed by the nurse and the assessor Specific details of how these area(s) of practice will be addressed in the clinical area An agreed period of time for further supervised practice

Part 1: ENTONOX® On-Line Training Package

PART 1 Completed BOC training package _______________________________ ______ / ______ / 20 __ Signed : CNS Acute Pain □, CNF□ Date The nurse can now proceed to completing the workbook.

http://discover.entonox.co.uk/



Part 2: ENTONOX® WORKBOOK

Please locate the following documents, be familiar with the contents and tick when read:- OLCHC Guidelines for the supervision of the self-administration of Entonox® by children An Bord Altranais (2000) The Code of Professional Conduct for each Nurse and Midwife An Bord Altranais (2000) Scope of Nursing and Midwifery Practice Framework OLCHC (2007) Guidelines for Good Practice An Bord Altranais (2007) Guidance to Nurses and Midwives on Medication Management OLCHC Current Hospital Formulary Royal Pharmaceutical Society of Great Britain, Current BNF for Children OLCHC Hospital Medication Policy OLCHC Infection Control/Waste Policy OLCHC Guidelines on Hand Hygiene OLCHC Sedation guideline

I confirm that I have located the above documents and have a comprehensive up to date understanding of their contents relevant to the skill of supervising the self-administration of Entonox®. Signed: ______________________________________ Date: _______________________ Name of nurse undertaking assessment

Part 2: Workbook Policy CNS/CNF

1. What criteria must a nurse meet before supervising the administration of Entonox® by children?

…………………………………………………………………………………………………………… ……………………………………………………………………………………………………………

2.

How long before procedure should the child begin to use Entonox®, provide rationale for answer?

……………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………

3. Does the child need to fast before using Entonox®?…………………………………………………………

4. Why should the nurse/parent not hold the mouthpiece for the child?

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5. List four things which the nurse should be monitoring during the self-administration of Entonox®?

1) ………………………………………………… 2) …………………………………………………

3) ………………………………………………… 4) …………………………………………………

6.

What blood tests might you need to monitor if a child is receiving Entonox®, more than 3 times a week, please provide rationale?.................................................................................................................................................. …………………………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………………………….. ………………………………………………………………………………………………………………………………….

7. How often should the FBC be monitored? ……………………………………………………………

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8.

What should you do if the child experiences the following when using Entonox®?

1) Nausea ………………………………………………………………………………………………………

2) Earache …………………………………………………………………………………………………..…

3) Respiratory depression ……………………………………………………………………………………

Part 2: Workbook completed satisfactorily ______________________________ _______ / ______ / 20 __ CNS Acute Pain CNF Date The nurse can now proceed to administering Entonox® to children under supervision.



Part 3 – COMPETENCY ASSESSMENT Guide for Assessors An assessor must be a registered nurse who is deemed competent in the administration of Entonox®. When undertaking supervision of nurses administering Entonox®and for the final assessment of competence, it is recommended that the learning outcomes and domains of competence as outlined in the workbook are used as a guide.

ASSESSMENT GRADING SYSTEM GRADE Learning experience not available 0 Limited knowledge, observed demonstration of the skill but doubt ability to perform skill safely without guidance/direction 1 Could perform the skill safely under supervision 2 Can utilise knowledge and perform the skill safely independently 3 Confident and competent of the knowledge required and ability to perform the skill safely and efficiently 4

Domains of Competence Domain 1 Competencies in relation to Professional / Ethical Practice Domain 2 Competencies in relation to the Holistic approaches to Care and the Integration of Knowledge Domain 3 Competencies in relation to Interpersonal Relationships Domain 4 Competencies in relation to the Organisation and Management of Care Domain 5 Competencies in relation to Personal and Professional Development

Domain Section 3.1 Complete on at least 3 occasions Date Assessor Demonstrate pre-procedural inspection and proper set up of Entonox Cylinder and equipment.

1, 2, 3. Demonstrate knowledge of correct storage of Entonox® cylinder.

2, 4 Demonstrate ability to assemble and disassemble the regulator, tubing and mouth piece.

2, 4 Demonstrate how to open, and close the Entonox® cylinder.

2,4 Demonstrate how to check the contents of the Entonox® cylinder.

2, 4 Demonstrate the preparation of clinical area.

Preparing the child

2 Perform a thorough patient assessment prior to administering Entonox® using risk assessment checklist.

3 Check Nitrous oxide 50/50 (Entonox®) prescription.

3 Provide information/teaching/ demonstration to child & family about Entonox®

2 Assess child’s pain & administer appropriate analgesia if needed before procedure

Care of the child during the procedure

1, 2, 3 Safely supervises the self-administration of Entonox® by a child

2, 4 Monitor effectiveness of Entonox®.

2 Identify and manage possible side-effects or hazards of Entonox® and take appropriate actions.

2 Delivers nursing care that is accurate, safe and ensures child’s comfort. After the procedure

4 Demonstrate how to: Close the cylinder, decompress and disconnect tubing from the cylinder. Clean equipment. Disposal or storage of patient equipment (mouth-piece/mask +/-tubing). Storage of cylinder and regulator.

2 Continues to assess and monitor the child for a minimum of 15 minutes following completion of the procedure.

3 Completes accurate records of procedure and care received by the child.



Competency Assessment cont.

Domain Section 3.2 Complete this section during final assessment Date Assessor

1 Demonstrates knowledge and understanding of legal and professional responsibilities in relation to administration of Entonox.®

1 Practices within the limits of own competence and takes measures to develop own competence.

1 Implements the policies and guidelines relating to the administration of Entonox®

1 Discusses the research and evidence related to administration of Entonox®.

4 Discuss the principles of the safe administration of Entonox.®

4 Discuss the Indications/contra-indications for using Entonox.®

5 Demonstrates commitment to Continuing Professional Development by completing the competency assessment in relation to Entonox® administration.

5 Contributes to the learning of colleagues/ children/parents.

ACTION PLAN

Action Plan No. 1 (if unsuccessful at 1st Assessment)

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……………… Re-assessment of Competence (Please circle as appropriate)

Demonstrates Competence: Yes □ No □ Signature of Assessor: ____________________________ Date: ______________________

Signature of Candidate: ____________________________ Date: ______________________ If candidate is unsuccessful refer to Action Plan No. 2 Action Plan No. 2 (if unsuccessful at 2nd Assessment) ………………………………………………………………………………………………………………………………………

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…………………………………………………………………………………………………………………………………… Re-assessment of Competence (Please circle as appropriate)

Demonstrates Competence Yes □ No □ Signature of Assessor: _____________________________ Date: ______________________

Signature of Candidate: ____________________________ Date: ______________________



Our Lady’s Children’s Hospital

Crumlin, Dublin 12

Completion of Competence Assessment in the supervision of the

self-administration of Entonox® by children Summary Sheet

Full Name: _______________________________ Date: __________________________________ ABA Number: ________________ Clinical Area/Unit: ____________________________________

Date

Signature of Assessor

Received theoretical instruction relating to Entonox® (BOC on line learning), and has observed the skill prior to undertaking supervised practice

Entonox ® Workbook Completed and Signed

The nurses’ practice has been supervised on three occasions and he/she has completed the competence assessment in Entonox®

Outcome of Assessment: (Please tick as appropriate)

Demonstrates Competence: Yes □ No □ Signature of Assessor: ______________________________ Date: ___________________

Signature of Candidate: _____________________________ Date: ____________________

If candidate is unsuccessful refer to Action Plan. Appendix 1 Please forward summary sheet only to Clinical Nurse Specialist Acute Pain, or CNF of the appropriate ward. It is advisable to keep a copy of summary sheet for one’s own personal records/portfolio.

If you have any questions about the use of Entonox® please talk to your child’s nurse or doctor

Additional Information …………………………………………………………………………

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Our Lady’s Children’s Hospital Crumlin

Dublin 12. Phone: 01-4096100 (main switch)

Our Lady’s Children’s Hospital,

Crumlin, Dublin 12.

Entonox® Information for Parents and

Guardians

Pain Service - (01) 4096100

Our Lady’s Children’s Hospital, Crumlin

© 2012, Our Lady’s Children’s Hospital, Crumlin, Dublin 12. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means without the prior written permission of the copyright holder. Our Lady’s Children’s Hospital makes no representation, express or implied, with regard to the accuracy of the information contained in this publication and cannot accept any legal responsibility for any errors or omissions that may be made.

Entonox® is a gas that may be offered to help your child manage

his/her pain during some procedures that can be painful (e.g.

changing a dressing, joint injection for arthritis, putting on a

plaster cast, etc).

Entonox® is a colourless, sweet-smelling gas. It is a mixture of

50% Oxygen and 50% Nitrous Oxide. It provides powerful pain

relief within a short time of being inhaled.

Entonox® can be used by children over the age of about 6 years.

They must be able to understand how to breathe in (Inhale) and

they must be able to hold the mouthpiece or mask without help.

There is minimal risk involved with the administration of Entonox®

the main concern is that the gas may become trapped in the

body- this only a problem if your child has specific medical

conditions. Your child will be assessed to decide if is appropriate

to use Entonox®.

Entonox® is sometimes called `gas and air` and is administered

using a demand-valve system. Your child will be shown the

Entonox® equipment, and allowed to practice using it before the

procedure starts.

Children do not have to fast to use Entonox® for painful

procedures. Your child will be monitored throughout the

procedure by the nursing staff. In most cases, a parent or

guardian can be present for the procedure.

To get the best effects your child will be encouraged to start

using Entonox® at least 2 minutes before the procedure starts,

to allow time for it to work. To get the best effect your child will be

encouraged to take slow deep breaths.

After breathing in the Entonox® your child might become slightly

sleepy. This is OK. When your child is sleepy, he or she will not

be able to hold the mouthpiece in his/her mouth and therefore will

not breathe in Entonox®. This prevents your child from breathing

in too much Entonox®. Once your child becomes more alert,

he/she will be able to start inhaling the Entonox® again.

To ensure that your child does not breathe in too much Entonox®,

only your child should hold the mouthpiece.

Some children experience side-effects when using Entonox®.

These include:

Drowsiness or light-headedness, Giddiness and changes to the voice, Dry mouth, Nausea, all these

sensations will wear off quickly once your child stops

breathing in the Entonox®.

Earache - if this occurs, Entonox® will be stopped and

nurses will give your child other painkillers.

An Effect on the body’s stores of Vitamin B12 – if a

child receives Entonox® more frequently than every 4

days, we will monitor your child’s blood count.

After using Entonox® the effects will wear off quickly. However,

we advise that your child should remain in bed or on a trolley for

at least 15 minutes. This is because Entonox® can sometimes

make their legs feel wobbly.

Your child will also receive other painkillers before or during the

procedure if this is appropriate. This is to make sure his/her pain

is also controlled after the procedure.

Entonox® Patient Assessment Form

Entonox Patient assessment form. GO’ Callaghan/ August 2012 1

Date:______________ Weight:___________ Name Procedure_________________________________ HCR No Entonox® Prescribed YES No ( Do not proceed unless prescribed) Contraindications (if any Yes responses check with medical practitioner / CNS Acute Pain)

Airway obstruction or history of difficult airway management. Yes No Sleep apnoea Yes No Increased risk of airway loss, acute respiratory infection (URTI) or exacerbation of asthma Yes No Large / artificial / traumatic / spontaneous pneumothorax Yes No Intestinal obstruction Yes No Maxillofacial injuries Yes No Increase in pulmonary vascular pressure e.g. Pulmonary Hypertension. Yes No Middle ear occlusion / pathology Yes No Any depressed conscious level Yes No Any recent head injury or raised ICP Yes No Any recent underwater dive Yes No

Relative Contraindication: Children who have already received sedation – In this situation, please discuss the child’s care with Acute Pain Service or the Anaesthetic Consultant. (Note: the use of Opiates for analgesic effect does not out rule the use of Entonox®)

Special precautions 1. Exposure to nitrous oxide depletes the body's stores of vitamin B12 and very rarely this can precipitate neurological complications. Careful thought should be given to those: who use Entonox frequently, those with poor intake or with malabsorption syndrome, those on synthetic diets (eg. phenylketonuria, maple syrup urine disease). Staff or parent in the first trimester of pregnancy may wish to avoid the area while Entonox is in use

USE OBSERVATION SHEET OVERLEAF FOR PATIENTS WHO HAVE RECENTLY RECEIVED OR ARE CURRENTLY RECEIVING IV OPIATES OR SEDATIVE DRUGS

Pre Eentonox® Risk Assessment ( see above) Yes No Comments Allergies Yes No Baseline set of observations HR,RR, SaO2 prior to procedure Yes No Check ID Band against prescription Yes No Pulse oximeter required (if cardiac /respiratory condition) Yes No Analgesic administered prior to procedure if appropriate Yes No Venue Yes No Adequate staff available Yes No Room well ventilated Yes No Equipment in working order Yes No Oxygen and suction and monitoring available at bedside Yes No During Procedure Child using entonox well Yes No Side effects ( list) or adverse events Yes No Observations and Sedation level monitored ( see over) Yes No Safe environment maintained (e.g. airway) Yes No Post Procedure Patient returned to baseline level of sedation Yes No Observations within normal limits Yes No Would child use entonox again? Yes No Documentation in Health care Record Yes No Clean handset and tubing Yes No Blood test required ( repeated Entonox administration) Yes No Entonox cylinder needs replacing ( contact fitter) Yes No Entonox cylinder returned to storage area Yes No Name of person carrying out procedure

Name of Entonox® administrator

Entonox® Patient Assessment Form

Entonox Patient assessment form. GO’ Callaghan/ August 2012 2

Signature of trained Entonox Administrator______________________________________ Date ___________________________ Time__________________ If pain score ≥7/10 STOP procedure, encourage child to use Entonox

If sedation score of ≥3 STOP Entonox and administer Oxygen

Start Time 00 05 10 15 20 25 30 35 40 45 50 55

SpO2

Sedation

Awake and Alert =0

Minimally sedated = 1

Moderately Sedated = 2

Deep sedation = 3

Unrousable = 4

Pain score 0-10

Nausea

Respiratory Rate

SEDATION SCORE

Awake and Alert - Sedation Score 0 (University of Michigan Sedation Score UMSS)

Minimal sedation ("anxiolysis") — Sedation Score 1

o A drug-induced state during which patients may respond normally to verbal commands o Cognitive function and coordination may be impaired o Respiratory and cardiovascular functions are minimally affected

Moderately sedated ("conscious sedation") — Sedation Score 2

o A drug-induced state of depressed consciousness with preserved airway protective reflexes

o Patients may be somnolent/sleeping but easily aroused with light tactile stimulation or simple verbal command

NOTE: It is possible for patients to progress from a state of moderate sedation into a state of deep sedation/obtundation

Deep sedation — Sedation Score 3 -This is essentially near anaesthesia o A drug-induced state of depressed consciousness from which the patient is not easily aroused o Deep sedation may be accompanied by partial or complete loss of protective airway reflexes o Patients are usually unable to respond purposefully to physical stimulation or verbal commands

Unrousable - Sedation Score 4

Nausea score Pain score

O= none 0 = No Pain

1= nausea only 1 - 3 = Mild Pain

2 = vomit x 1 4 - 6 = Mild Pain

3 = vomit more than one vomit 7 -10 = Severe Pain

nursing practice committee guidelines on use of entonox ......the drawing of an aerolised drug into...

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