Wholeheartedly, yes. Please exempt nitrous oxide from further regulation in office settings and consider it minimal sedation. It is invaluable, both the use of dentistry and other painful in-office procedures such as plasma rich protein therapy injections. I have personally used both, and have never had an adverse experience in the slightest. I believe it is efficient, budget-friendly, and very safe. As a chronic pain patient, I have used many methods of pain relief and sedation. Using a benzodiazepine and/or opioid before similar procedures has a much longer recovery period and does not even work as well for immediate pain relief. I have been questioning for many years why it is not used more frequently and in more locations, considering its safety record and ease of use. Thank you for reading, Kate Burton

Easing the restrictions on nitrous oxide seems very reasonable to allow more patients to safely have comfort during low risk surgical procedures that can cause anxiety such as minor excision performed in the office under local anesthesia. I support this change. thank you

The following comment is submitted on behalf of the Washington Association of Nurse Anesthetists (WANA). Nitrous oxide as a solo inhaled agent in concentrations of 50% or less has a plethora of support in the literature as a safe and effective minimal sedative. When used in combination with any other agent, the effects can be synergistic and not simply additive. As a result, WANA recommends the WMC limit nitrous oxide to be combined only with oxygen. In concentrations up to 50%, nitrous oxide is an effective substitute for other minimal sedation methods providing pain and anxiety alleviation while protecting crucial airway protective reflexes. There is, however, very limited data on the use of nitrous oxide in neonates or infants (children less than 1 year of age) outside of the anesthesia space. WANA recommends that this policy only apply to children 1 year or older. An apparatus that limits concentration of nitrous oxide should be utilized and inspected periodically for accurate delivery concentration; WANA recommends utilization and periodic inspection of the apparatus, and that patients are monitored according to institutional policy, and that waste gas scavengers are be used.

I am delighted to see further conversation about the safety and efficacy of nitrous oxide for minimal sedation. Was the decision intentional to use the language of "physician" rather than "health care practitioner" as is used elsewhere in the WAC? I'm concerned that this rule will be used to exclude ARNPs from providing minimal sedation with nitrous oxide. For our reproductive health setting, our ARNPs are looking forward to having nitrous as an option for minor gynecologic procedures such as IUD insertion or colposcopy.

I agree with other commenters that ARNPs should be able to use nitrous oxide, not just physicians. Also, why are rules for physicians so different from dentists? My son had nitrous at the dentist with no other provider monitoring and my dentist does not have ACLS meds in her office, nor is she ACLS certified. And at the dentist it is put on the patient's face. In our office, the nitrous gas would be self-administered by the patient. The patient needs to be able to hold it only their face to use it. It is very mild sedation per your definition and ACLS provider and equipment should not be needed. This is a great option for many procedures that women's health professionals perform, including IUD insertion, treatment of miscarriage, first trimester abortion, uterine biopsy, or even just a speculum exam in a patient with a trauma history for whom exams are very difficult. These are all easily done in the office but some patients desire or need more analgesia than others. I recommend removing the need for ACLS certification, changing the working from physician to "provider" or maybe "appropriately credential provider", and not requiring another provider for monitoring. There should always be a nurse or medical assistant in the room to monitor the patient and assist the provider. We want to help patients get care they need. not make so many rules that it is impossible. And again, the dentists have been using nitrous for many, many years with little issue. Why do medical office rules need to be more stringent? Sincerely, Dina J Levin, MD Medical Director Women's Care, WhidbeyHealth Coupeville, WA

Many of my friends have abused nitrous, some have completely lost themselves in addiction to the drug that is readily available at any smoke shop, and some gas stations across the state. They can be a fun quick sedative, dissociative high, but those with addictive tendencies suffer far more. The common result of nitrous abuse is depression, anxiety, isolation, loss of cognitive function, memory, psychosis, loss of feeling, beginning in the lower extremities. The product is expensive, abuse is financially devastating. Nitrous is sold in large colorful tanks, with mouth pieces for consumptions, along with a big warning label on the back advising against consumption. The UK and Louisiana have already banned the sale of nitrous oxide for regular consumption, I ask that Washington follow suit.

• Nitrous has been in use for over 200 years in various settings labor and delivery, emergency medicine, dentistry, and ambulatory setting. On labor and delivery, it’s self administered without continuous observation or monitoring by nursing staff and is set up by the capable RN team. In the dental setting, where it is set up in a continuous flow fashion, it’s administered by dental assistants in a setting where only 2 BLS providers need to be available. In the discussed ambulatory setting it would provide patients a self-administered, low-risk and quickly reversible anxiolytic and anesthetic option. The use in the clinic would be intermittent for less 15 minutes each patient. 3-5 minutes of continuous O2 reverses the effects of nitrous and patient can return to normal activity. Throughout the entirety of my time evaluating the use of Nitrous in these settings I saw no indication for physician only administration. ARNPs are fully qualified to order the administration on L&D. Literature: • University of Minnesota children focused on IUD placement of adolescents 12-22 offered IUD in clinic or placement with nitrous under sedation. They were asked to record their pain on 100 point scale 2 minutes after placement. Of the patients electing for nitrous ppp was 24.7, compared to 54 in clinic group. • Minnesota children’s hospital showcased the creation of an RN administered nitrous oxide sedation for urological imaging, mostly catheterization. 3 years and over 3,100 sedations adverse effects included 2% nausea, 3% emesis. No episodes of apnea. 4 episodes of o2 desaturation (mentally delayed patients with hx of breath holding spells without sedation). No airway interventions and all patients responded to cessation of nitrous and administration of 100% oxygen. Conclusion: provides another option for reducing distress. • A study published last year in an international journal (medicine), compared the use of nitrous oxide use for D&Cs, office hysteroscopy, and polypectomies. Found similar levels of effectiveness, patient satisfaction, significantly faster recovery options. The conclusion that inhaled nitrous oxide could be an alternative analgesic technique for minor gynecologic operative procedures, which would improve patients comfort and tolerance to the procedures and health care quality without serious side effects. • In the literature, accidental N2O-related deaths are rare. They are mostly related to inhalation of this substance for recreational and autoerotic purposes; For general anesthesia, nitrous oxide (50 to 70%) is used and the delivery system allows for further titration. Nitrous Oxide is Inefficient as an independent method of induction; it’s required to be paired with another inhaled anesthetic such as sevofluorine https://www.ncbi.nlm.nih.gov/books/NBK532922/ In the ambulatory setting: Nitrous oxide is widely used in dental settings. Dental hygienists and assistants are authorized to administer nitrous oxide in most states. Our Washington State guidelines are as follows: WAC 246-817-740 A licensed dentist who administers minimal sedation with nitrous oxide must hold a current and valid BLS certification. A second individual is in the office and able to immediately respond to any request from the licensed dentist or anesthesia provider. Ambulatory care = BLS https://app.leg.wa.gov/wac/default.aspx?cite=246-817-740#:~:text=(6)%20A%20licensed%20dentist%20who,%5BStatutory%20Authority%3A%20RCW%2018.32 ACOG practice bullion 209: self-administered using a mouthpiece or facemask, with a 50% mix of nitrous oxide in 50% oxygen, either blended from two separate gas cylinders or the hospital's piped gas supply through a small regulator or from a single premixed cylinder The apparatus must use a demand valve so that doses are given only when the patient inhales using the mask and must have scavenging equipment to limit others' environmental exposure. Nitrous oxide use does not preclude mobility for the patient, does not require additional monitoring, and allows the laboring woman to control the effect. Another advantage is its quick termination of effect once the parturient removes the mask. https://www.acog.org/-/media/project/acog/acogorg/clinical/files/practice-bulletin/articles/2019/03/obstetric-analgesia-and-anesthesia-labor-causes.pdf Modern anesthetic machines have fail-safe mechanisms to prevent overdose (nitrous oxide-oxygen proportioning systems). The device is preset to deliver nitrous oxide and oxygen at a 1:1 mixture–neither the patient nor providers can adjust the ratio, eliminating the risk of delivering a hypoxic mixture. An oxygen failsafe mechanism is built in to avoid the administration of pure nitrous oxide. Should the oxygen line depressurize for any reason, the device can’t deliver nitrous oxide. https://www.sedationsystems.com/https://www.ncbi.nlm.nih.gov/books/NBK532922/ - Prior to administration, provider will need to review contraindications for use of N2O and patient will complete a screening form. Contraindications of use including any condition where air may be trapped in the body, including pneumothorax, intestinal obstruction, middle ear occlusions, cystic fibrosis, intraocular surgery within last 10 weeks, increased intracranial pressure, known B12 deficiency, impaired LOC, intoxication, recovering drug addiction. - To monitor staff exposure, some organizations choose dosimetry. The dosimetry unit is most consistently placed on the unit itself and sent annually to an independent lab. Our Community hospital’s L&D RN team safely implemented and maintained nitrous oxide for labor analgesia, by following ACOG guidance, for over 5 years with initial peer training and sign-off. - Most manufacturers provide onsite training and competencies with implementation. Cost varies by distributor but the initial investment of a unit with a waste gas suction is about $9,500. Each cylinder of nitrous gas is less than $50. The duration of use would be highly dependent on patient volume. At our clinic we estimate each cannister would last 3-6 months. The cost per patient of disposable supplies is approximately $45. These fees are generally not reimbursable by insurance. While these fees may not transfer directly to reimbursement, the marketing of offering pain reducing options for uncomfortable, and often traumatic experiences will be attractive to women who understand the pain associated with these procedures. And would likely increase our patient volume. Allowing nitrous oxide in the ambulatory setting without excessive barriers would allow us to provide greater access to women’s healthcare.

The following is submitted on behalf of the Washington Association of Nurse Anesthesiology (WANA). In the United States, nitrous oxide can be administered by current and licensed physicians, dentists, APRNs, PAs, and paramedics. WANA recommends that the language of WAC 246-919-603 be modified to an inclusive list. Sedation is a continuum which may produce a deeper level of sedation than initially intended (i.e. anesthesia). WANA recommends the language be clear that the provider administering and monitoring the nitrous oxide be a separate provider than the proceduralist. WANA cautions that the use of illicit or prescriptive substances is prevalent and acute or chronic use could result in additive or synergistic effects when used with nitrous oxide. A consideration would be to obtain a targeted history or testing for substances known to act in synergy prior to nitrous oxide administration. WANA recommends that any administering or monitoring providers obtain education in administration and in identifying the different levels of sedation to record the level of sedation as part of the record. WANA recommends that the provider administering and monitoring nitrous oxide receives appropriate training/certification to allow rescue should a patient enter a state deeper than initially intended similar to WAC 246-817-720. Both the American Society of Anesthesiology (ASA) and American Academy of Pediatrics (AAP) classify nitrous at less than 50% as minimal sedation. The current proposed language includes a pre-anesthesia evaluation, continuous monitoring, and advanced resuscitative technique training. WANA recommends that nitrous used at less than 50% be under the same monitoring requirements as other minimal sedation methods and the include the definition of minimal sedation. This would include a pre-sedation assessment including vital signs to determine appropriateness and contraindication to sedation and/or nitrous. This would not require a pre-anesthesia evaluation. Should the commission choose to continue with nitrous oxide as minimal sedation, WANA recommends that the commission mirror the language from WAC 246-817-720 through 246-817-745 including the details of healthcare BLS training, emergency medications, minimal sedation, and record keeping. Should the commission determine that pre-anesthesia evaluation, continuous monitoring, and advanced resuscitative technique training be required, WANA would recommend that nitrous oxide in less than 50% continue to be categorized as an anesthetic and be subject to the same requirements of moderate and deep sedation with certified physician or nurse anesthesiology provider oversight. As written, the monitoring and requirements of this “minimal sedation” aligns with deeper levels of anesthesia and not the definition of minimal sedation. WANA recommends congruence of definition and scope of training to fully align with current minimal sedation rules to avoid ambiguity and potential unsafe practice.