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