DEN 155 1 - Nitrous Oxide and Oxygen Sedation- FINAL EXAM

What is the primary design of the respiratory system?

To perform the exchange of gases across pulmonary capillary membranes.

What controls the automatic process of breathing?

The medullary center in the brainstem.

Name the three sections of the pharynx.

Nasopharynx, oropharynx, laryngopharynx.

What is the function of the larynx?

To produce vocal sounds and is where the reflex for vomiting is located.

What is the role of bronchi in the respiratory system?

To bifurcate into right and left bronchi and conduct air to the lungs.

At which generation of bronchioles does gas exchange begin?

In generation 17-23, which is considered the respiratory zone.

What is tidal volume?

The amount of gas inspired into the lungs, dependent on physical characteristics.

How is minute ventilation calculated?

By multiplying tidal volume by the rate of respiration.

What is diffusion hypoxia?

A condition when nitrous in the air doesn't replace the N2O in the bloodstream.

What is a normal O2 saturation level measured by pulse oximetry?

96% to 100%.

What is the universal sign for choking?

The Heimlich maneuver.

Name a contraindication for using N2O in respiratory patients.

Patients with a cold or sinus infection.

What is one interaction with the body for the hematopoietic system?

Watch for pernicious anemia, which prevents absorption of vitamin B12.

What should be avoided in patients with cognitive disabilities when using N2O?

If patients cannot understand what to expect and distinguish discomfort.

In which trimester is N2O contraindicated during pregnancy?

In the first trimester.

What are the physical properties of Nitrous Oxide (N2O)?

Dinitrogen monoxide, slightly sweet-smelling colorless gas, gas at room temperature, becomes liquid when compressed, found in minimal concentrations in the atmosphere, used in food processing, auto racing, and dentistry.

What is the significance of the blood-gas partition coefficient?

It measures the solubility of inhaled anesthetics in blood and indicates how quickly the anesthetic can diffuse into the bloodstream.

Describe the pharmacokinetics of Nitrous Oxide.

Nitrous oxide is relatively insoluble, does not disassociate in the body, is quickly eliminated, metabolized through the lungs, and may require increased dosage at higher altitudes.

What does the term 'potency' refer to in pharmacodynamics?

Potency refers to the strength of a drug; for Nitrous Oxide, it is the weakest (least potent) inhalant used for anesthesia.

What is MAC in pharmacodynamics?

MAC stands for Minimum Alveolar Concentration, which is the amount of drug necessary to prevent movement in 50% of subjects responding to surgical incision.

List some manufacturers of Nitrous Oxide delivery systems.

Porter Instruments located in Hatfield, PA; Accutron located in Phoenix, AZ.

What safety features are included in Nitrous Oxide delivery systems?

O2 failsafe to prevent 100% N2O delivery, index safety system, DISS for safe connections, and an oxygen flush button for emergencies.

What are some uses of oxygen (O2)?

Oxygen is used in the steel industry, medical field, and is available at oxygen bars.

Describe the role of the reservoir bag in Nitrous Oxide delivery.

The reservoir bag holds extra gas for the patient, monitors respiration through expansion and contraction, and can be used to provide emergency oxygen.

What is a significant characteristic of scavenging nasal hoods?

Scavenging nasal hoods provide fresh gas to the patient while evacuating exhaled gas through a separate set of hoses.

What is pain defined as?

An unpleasant sensory and emotional experience associated with actual or potential tissue damage.

What are the factors that affect pain?

Mental, social, cultural, emotional, and physiological factors.

How does managing pain benefit patients?

It relaxes them and increases compliance.

What is anxiety?

A feeling of apprehension caused by anticipation of danger, characterized by discomfort and an autonomic response.

What are some signs of fear?

Sweating, crying, refusal to cooperate, obsessive talking, and white-knuckle syndrome.

What is sedation in a dental context?

An individual response that can be difficult to predict, requiring knowledge of how to rescue a patient if sedation deepens.

What are some methods of pain and anxiety management?

Noninvasive methods, hypnosis, acupuncture, systematic desensitization, distraction, TENS, and local anesthesia.

What are some desirable characteristics of nitrous oxide/oxygen sedation?

Analgesic effects, anxiolytic effects, amnestic properties, rapid onset, titration, and favorable elimination and recovery.

What is titration in the context of sedation?

The process of administering a drug incrementally to achieve a specific level of sedation and prevent unintentional overdose.

How quickly does nitrous oxide take effect?

It has a rapid onset of action, beginning within 30 seconds.

What is the elimination process of nitrous oxide?

Nitrous oxide is eliminated through the lungs, allowing for faster recovery.

What are patients' perceptions of nitrous oxide?

Patients and parents generally like the use of nitrous oxide.

What is a primary safety consideration for using N2O in medical settings?

N2O is safe to use and does not pose health risks if managed properly.

What health risk was suggested by early research regarding N2O exposure?

Anesthesiologists experienced more reproductive problems, but no definitive link has been established since then.

How does N2O affect vitamin B12?

N2O oxidizes cobalt in vit B12, preventing it from functioning as a coenzyme for methionine synthase.

Why is scavenging important in the context of N2O use?

Scavenging minimizes trace amounts of gas exposure before, during, and after use.

What is one method used to detect N2O in the atmosphere?

Infrared spectrophotometry detects N2O levels lower than 1 ppm.

What are the symptoms of N2O abuse?

Fatigue, fainting, nausea, and potential cardiac arrest are symptoms of N2O abuse.

What are common sources of leakage of N2O?

Leakage can occur from ill-fitting masks, equipment connections, and poor ventilation systems.

What are the general categories of inhalants?

Inhalants are generalized into solvents, nitrites, aerosols, and gases.

What are the negative side effects of chronic N2O exposure?

Chronic exposure can lead to neurologic side effects, including peripheral neuropathy.

What legislation exists regarding the regulation of N2O?

Few regulations exist, but some states have laws against the sale or possession of N2O.

What is autotolerance in the context of N2O use?

Autotolerance is the body's adaptation leading to reduced effects of the drug with continued use.

What does individual bio variability refer to in the context of nitrous oxide sedation?

It refers to the varying signs and symptoms of sedation that can differ from person to person and from day to day in the same individual.

What are psychological signs of appropriate sedation?

Patients are relaxed, comfortable, acknowledge a reduced sense of fear and anxiety, and generally have a happy and pleasant mood.

What body movements indicate relaxation in a sedated patient?

Shoulders dropping, legs uncrossing, arms positioned looser on arm rests, and taking deeper breaths.

What is indicated by the activity level of a patient's eyes during sedation?

Initially, eyes are active and alert; as sedation deepens, eye activity slows, and they may appear glossy or glazed.

What facial expressions are common in a sedated and comfortable patient?

Patients will appear content, have a flat expression with no signs of tension, and can smile easily.

What signs indicate inappropriate minimal sedation?

Signs include discomfort, annoying tingling, sudden discomfort, dreaming or hallucinating, and may not be visually obvious.

What physiologic signs can indicate over-sedation?

Drowsiness, slurred speech, dizziness, and a sensation of spinning.

What action should be taken if over-sedation is not corrected quickly?

Uncontrolled over-sedation can lead to vomiting, unconsciousness, and potential aspiration of vomit into the lungs.

What is the purpose of monitoring during nitrous oxide administration?

To watch the patient's behavior and responses, monitor the reservoir bag, ensure patient comfort, and adjust sedation levels as needed.

What should be done at the termination of nitrous oxide sedation?

Deliver 100% O2 for a minimum of 5 minutes, assess recovery, and obtain vital signs.

What key information should be recorded in patient charts after administering nitrous oxide?

Patient name, ASA classification, indications for use, preoperative, intraoperative, and postoperative vitals, and any adverse reactions.

What are the guidelines for nitrous sedation according to the American Academy of Pediatrics?

Guarding patient safety, minimizing physical discomfort, controlling anxiety, modifying behavior, and using the lowest effective dose.

What considerations should be taken into account for pediatric patients during sedation?

Creating a quiet environment, the personnel's attitude, the child's ability to follow directions, and building trust.

What should not be done when using nitrous oxide with children to prevent over-sedation?

Avoid using it in combination with other drugs and being mindful of any self-medication or missed medications.

What should be documented during and after nitrous treatment?

All aspects of patient monitoring, recovery time, and consent documentation.

Preprocedural Patient Evaluation

A formal interview process to gather a patient's health history, typically conducted by the DDS or assistant.

ASA Physical Status Classification System

A system used to classify patients' fitness for sedation based on their health status.

ASA I

A normal healthy patient with no smoking or minimal drinking.

ASA II

A patient with mild systemic disease, such as a smoker with well-controlled diabetes.

ASA III

A patient with severe systemic disease, but not incapacitating.

Vital Signs

Measurements of the body's most basic functions, including height, weight, body temperature, blood pressure, pulse, and respiration.

Informed Consent

A legal process to obtain permission from a patient after they understand the procedure, risks, and benefits.

Sedation Monitoring

Continuous observation of a patient's vital signs and level of consciousness during sedation.

Titration

The method of gradually administering a drug in increments until the desired effect is achieved.

Rapid Induction Technique

A sedation technique primarily used in pediatric patients that involves a quick delivery of nitrous oxide.

Discovery of Nitrous oxide (N2o) and oxygen(o2)

-Discovery happened 1771-1777

-nitrous oxide was discovered

-"good air" was also discovered now known as oxygen

Who inhaled pure N2O?

Who noted that pain was Diminished while using N2O?

When was N2O pursued to diminish pain?

What was the first clinical procedure when using N2O?

-Humphrey Davy inhaled pure N2O despite people thinking it would contribute to many diseases and deadly conditions.

-Davy noted diminished pain from using N2O while having inflammation of the gum.

-this diminished pain wasn't pursued for some time until the early 19th century

-The first clinical procedure using nitrous as an anesthetic agent was tooth extraction

who is the father of anesthesia

Horace Wells

Attempted to extract a tooth in front of peers to show that nitrous oxide worked, after completing several successful extractions

anesthesia

Defined as insensitivity to pain, especially as artificially induced by the administration of gases or the injection of drugs before surgical operations

Anesthesia was at first unpredictable

Nitrous oxide now produces a very predictable outcome for anesthesia

where there early forms of anesthesia, if so what were they?

Early forms of anesthesia include the following

 -chloroform

 -ether

 -alcohol

 -cocaine

when was lidocaine introduced?

Lidocaine was introduced in 1940

 minimal allergies

 diminished Nitrous oxide use

Resurgence of nitrous oxide

Gardner Colton encouraged dentists to use pure N20 - he had 193,000 documented cases with no fatalities

Dr. Edmund Andrews suggested that the blood isn't appropriately oxygenated with 100% nitrous oxide

Now the ADA standard is ensured that 30% of oxygen is delivered at all times

Not just used for pain control but also to reduce anxiety

Guidelines for best practice

The dental profession was the first to adopt the use of nitrous oxide sedation.

The safety of the use of nitrous is well tested and it has withstood the test of time.

It's effects are quickly reversed.

Few side effects as long as operator is using updated equipment and appropriate technique

1. It is difficult to predict how a patient will react to sedation.

2. There are several levels of sedation

Minimal sedation

Moderate sedation

Deep sedation

General anesthesia

The intent of nitrous oxide is to:

control pain and anxiety

be quickly and easily reversed

make the patient comfortable

Levels of sedation

Minimal Sedation (anxiolysis)

• Drug induced state during which patients respond normally to verbal commands

• Airway reflexes, breathing and cardiovascular function are unaffected

• Nitrous less than 50% concentration

Moderate Sedation

• Drug induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation

• Airway requires no intervention, and cardiovascular function is maintained

• Nitrous more than 50% concentration, or given less than 50% but with another sedative

Deep Sedation

• Drug induced depression of consciousness during which patients cannot be easily aroused but respond after painful stimulation

• May require assistance in maintaining an airway, and cardiovascular function is maintained

• Think IV sedation at a dental office or oral surgeon

General anesthesia

• Drug induced loss of consciousness during which patients are not arousable even by painful stimulation

• Often require assistance in maintaining an airway, and cardiovascular may be impaired.

• Not typical to reach this with nitrous oxide

• (Think joint replacement)

Current Practice Guidelines

Created in 2002 for those delivering N2O but not specialists in anesthesiology

 ie: dentists, podiatrists, physicians

Most current information was published in 2018

Separate guidelines for pediatric patients was written in 2016 with input from the following agencies

 ASA (American Society of Anesthesiologists)

 AAP (American Academy of Pediatrics)

 AAPD (American Academy of Pediatric Dentistry)