RDH 214_Week 2 Monitoring Nitrous Lecture.pptx

Chapter 15 Nitrous Oxide-Oxygen Analgesia A TSBDE Approved Course Objectives Discuss Discuss the Texas rules and regulations associated with nitrous oxide-oxygen analgesia monitoring for dental hygienists. Assess Assess the client’s medicodental history as it relates to the use of nitrous oxid...

Chapter 15 Nitrous Oxide-Oxygen Analgesia A TSBDE Approved Course Objectives Discuss Discuss the Texas rules and regulations associated with nitrous oxide-oxygen analgesia monitoring for dental hygienists. Assess Assess the client’s medicodental history as it relates to the use of nitrous oxide-oxygen analgesia. Describe Describe the dental anatomy and physiology as it relates to the use of nitrous oxide-oxygen analgesia. Describe Describe the pharmacological properties, actions, considerations, and contraindications to nitrous oxide-oxygen analgesia. Objectives Understand Understand the operation, safety features, and infection control of equipment used to administer and monitor nitrous oxide-oxygen analgesia. Determine Determine the appropriate titration level needed to ensure patient safety and comfort when monitoring nitrous oxide-oxygen analgesia. Determine Determine ways to prevent and manage potential emergency situations associated with nitrous oxide. Discuss Discuss the ethical and legal considerations and responsibilities associated with the use and monitoring of nitrous oxide-oxygen analgesia. History Discovery of N2O in ~ 1772 by Joseph Priestley Next several decades, however, it was used as a recreational drug History, cont. 1844 Dr. Horace Wells (dentist) attended a recreational gathering and noticed someone suffer a leg injury that went unnoticed Tested it by having his own teeth extracted with pure nitrous Eventually credited as the “Father of Anesthesia” as he was the first to successfully apply the use of vapors or gases for operations without pain. Important Point CURRENT SAFETY FEATURES DO NOT ALLOW DELIVERY OF 100% NITROUS OXIDE ALWAYS DELIVERS A MINIMUM OF 30% OXYGEN Characteristics of Nitrous Oxide Colorless Odorless Does not irritate the lungs Nonflammable gas Least potent of inhaled gases Nonallergenic Has the ability to produce depression of the CNS = conscious sedation Pain and Anxiety Management “Pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage. The experience includes the perception of an uncomfortable stimulus and the response to that perception.”* Pain is the leading public health problem in the US. 50 million days of work lost each year due to pain 35 million people avoid dental office due to fear Management of pain and anxiety major goal of the dental provider Assessing and Measuring Pain • Reactions vary • Variety of scales have been developed to objectify pain and enable clinicians to act appropriately and alleviate discomfort – Pictures, descriptors, and numbers have been used Understanding Fear and Anxiety • Anxiety-a nonspecific feeling of apprehension, worry, uneasiness, or dread, the source of which may be vague or unknown. • Fear-a feeling of fright or dread related to an identifiable source recognized by the individual. • Phobia-any persistent and irrational fear* of something specific, such as an object, activity, or situation, that results, in avoidance or desire to avoid the feared stimulus. Understanding Fear and Anxiety Fear and pain are so interrelated that they are often hard to separate. Both have physiologic and emotional components As pain increases, anxiety increases; as anxiety increases, pain becomes enhanced. When fear or pain is an issue, both must ultimately be managed. Assessing and Measuring Fear and Anxiety • Similar scales can be used and total score indicates level of anxiety – Modified Dental Anxiety Scale (MDAS) Sedation Continuum Minimal Modera te Deep Anxiolysis Analgesia Analgesia • Less than 50% N2O • Anxiety reduced • Relaxed • Respond normally • Vitals unaffected • Conscious sedation • Still able to respond • Greater depressed consciousness • Not airway intervention is • Response after repeated or painful stimulation • Airway intervention may be required General Anesthesia • Unarousable even with painful stimulation • Airway intervention required • Cardiovascular function Indications VS Contraindications Mild to moderate anxiety Anxiolytic properties to relieve stress Increase tolerance for long appts Diminish gag Contraindications • COPD • Pregnancy • Cystic fibrosis • Recent ear surgery • Eye surgery • Upper respiratory problems • Deviated septum • claustrophobic Advantages Quick onset of action Controlled through titration Rapid recovery Quickly reversed Disadvantage s Low-potency drug Hypo responderes Ineffectiv severe anxiety or phobia Guedel’s Stages of Anesthesia* 1. Analgesia: the patient is conscious, comfortable and cooperative. Stage ends when loss of consciousness occurs 2. Delirium or excitement stage: Loss of consciousness begins here. 3. Surgical: the patient is unconscious and life support is required. Includes 4 planes 4. Respiratory or Medullary Paralysis: complete cessation of all respiration. Must be reversed or death occurs. Desirable Characteristics of N2O 1. Analgesia • 20% N2O & 80% O2 same analgesic equipotence (equivalent potency) as 15mg of morphine • Raises pain threshold when administrated BEFORE intraoral injections 2. Anxiolysis • Produces sedation (calm, relaxed, able to tolerate) or a sense of well-being • Facilitates positive behavior/patients more cooperative • Excellent choice for managing fear Desirable Characteristics of N2O 3. Amnestic Property • Postoperatively, decreases recall of severity of pain, anxiety, or its duration 4. Onset of Action • Rapid Onset; begins within 30 seconds with peak effect within 5 minutes • Parallels with onset of IV sedation Desirable Characteristics of N2O 5. Titration possible • Administer drug incrementally • Exact amount delivered to every patient at every appointment • Titration also available with IV sedation, but recovery differs. 6. Recovery/Eliminati on • Allows for COMPLETE recovery after a minimum of 5 minutes of 100% O2! • Rapidly eliminated from body after discontinuation of use. 7. Acceptancepatient acceptance is high Advantages of Nitrous Oxide Safe Technique No adverse affects on liver, kidneys, CNS,CVS Analgesic and Amnesic properties No biotransformation in body except by anaerobic bacteria in the bowel. Eliminated via the lungs. Disadvantages of Nitrous Oxide Initial investment high cost Continued high cost of gases Patient cooperation required Equipment occupies considerable space Staff training required N20 not a potent agent Possibility of chronic exposure to trace amounts of N20 Physical Properties, Pharmacokinetics, and Pharmacodynamics • Pharmacokinetics-is the activity or fate of drugs in the body over a period of time including ADME. – Review: • ADME depends on the solubility and potency of the drug • Insoluble drugs readily cross blood-brain barrier • Pharmacodynamics-the effects of drugs and the mechanism of their action Physical Properties, Pharmacokinetics, and Pharmacodynamics: N2O Dinitrogen monoxide Sweetsmelling, colorless gas Gas at room temperature; liquid when compressed into a cylinder Nonflammabl e; supports combustion Readily crosses alveolar membrane to enter bloodstream easily Remains N2O unchanged in Insoluble; readily blood-uptake by crosses bloodbody is limited, brain barrier therefore, equilibrium achieved quickly 99% eliminated through lungs without biotransformation Pharmacodynamic knowledge is limited: least potent of all inhalation drugs, Physical Properties, Pharmacokinetics, and Pharmacodynamics: O2 Dioxide In gaseous state, odorless, colorless, and tasteless In liquid state (183°C), pale blue liquid Nonflam mable; supports combusti on Highly reactive and combines with most elements Complications/Side Effects NAUSEA (most common) Its incidence increases with: • Prolonged administration (prevented by administering 100% oxygen every 45 minutes for longer appointments) • Rapid induction (not using the titration technique) • Following a heavy meal (suggest the patient eat lightly before a dental appointment) or fasting • In motion sickness sufferers or patients with a previous history of vomiting (avoid using it altogether). Complications/Side Effects Hypoxia: • lack of oxygen in the tissues. Always administer enough oxygen during and after the procedure. Psychologic Reactions: • Hallucinations or claustrophobia. Patients with a history of psychiatric disorders should not receive N2O without special consideration. Sometimes dreams and hallucinations may be sexually oriented, operator Fire: • N2O is combustible. Never allow grease/oil to contact the valves on the tanks or copper tubing. Anatomy Review: Respiratory System Terms to Review External respirati on Internal respirati on Eupnea Tachypn ea • Air from the environment into the lungs. The final exchange occurs in the alveolus. • exchange of gases from the lung into the blood stream and to the body’s cells. • normal breathing • rapid breathing Bradypn ea • slow breathing Hyperpn ea • over respiration Hypopne a • under respiration Anoxia • total lack of oxygen (cell death occurs) Hypoxia • decreased oxygen in the tissues. (N2O administration can cause this) Anatomy Review: Respiratory System Primary function: • Gas Exchange • Performed continuously and with minimal effort by the body • Medulla oblongata (Automacity) • cerebral cortex (voluntary) Includes: nose, pharynx, larynx, trachea, bronchi, bronchioles, alveolar ducts, alveolar sacs, and alveoli Nose Anatomy Review: Function: warm incoming air, humidify air, filter macro and microparticles N2O/O2 enters the respiratory tree at the nose; it is critical that the patient must be able Pharynx • 3 sections: nasopharynx, oropharynx, laryngopharynx • 12-14 cm tube leading to lower airway Larynx • Vocal cords and epiglottis • Digestive system or respiratory system path Trachea • 11 cm long tube that bifurcates and leads to left and right bronchi Bronchi • 2.5-5 cm long depends on side of body • Right diverges into smaller branches for the upper, middle, and lower lobes of the lungs • Left diverges into upper and lower lobes Bronchiol es, alveolar sacs, and alveoli • Each lobe contains bronchioles that lead to alveolar ducts, then to alveolar sacs, and then to the alveoli • Where the exchange between air and blood takes place Patient Assessment https://www.asahq.org/standards-and-practice-para meters/statement-on-asa-physical-status-classifica tion-system Patient Assessment Patient Assessment Patient Assessment ABSOLUTE Contraindications • Pneumothorax • Cystic Fibrosis • COPD • Recent pneumoencephalography • Suspected/known pernicious anemia or B12 deficiency • Significant bowel obstruction • 1st trimester of pregnancy* ABSOLUTE’s cont’d • Cancer therapy using bleomycin sulfate • Psychological impairment • Current psychotropic use • Current or recovering drug use/addiction • Patient in shock, semi-conscious, or with serious head/facial injuries • Inability to understand procedure • Not willing to consent Special Considerations • Cardiovascular disease – N2O reduces the level of stress thus reducing the risk of heart attack and angina pectoris. – Currently, there are no conditions that should indicate medical consult or postponement of N2O/O2 use • Hepatic disease – Liver diseases such as hepatitis or cirrhosis often contraindicate the administration of drugs due their to metabolism by the liver. – Nitrous, however, can be used as it is not metabolized, but eliminated in its original form from the lungs Patient Assessment • Pre-procedural patient evaluation: – Obtain vital signs (BP, pulse, resp., temp.) – Deliver verbal and written instructions before sedation – Patient should understand the following: • The intent of and indications for N2O/O2 use • What is expected during procedure • Description of S & S with instructions to inform operator if they become uncomfortable • Reminder to inform operator of all medications and illnesses • That 100% oxygen will be administered for 5 minutes post procedure and that dismissal will occur with full recovery criteria are met and patient feels normal. Patient Assessment • Pre-procedural patient evaluation (cont’d): – Not necessary to fast prior to procedure • Recommended not to eat fatty, greasy, fried foods just before procedure • Light meal with some carbohydrates 1-2 hours before is appropriate • (Vomiting should not occur if administered appropriately, but these measures give patient a level of control that makes them comfortable) Patient Assessment • Informed consent (MANDATORY): – Obtained after pre-operative information has been given – Elements of informed consent that must be met: • Understand purpose, how it will be accomplished, and what to expect • Benefits and risks of N2O/O2 must be made clear as well as the risks associated without using it. • Alternative options must also be offered • Opportunity to ask questions and be satisfied with all question/answers • Consent to be obtained for EACH administration • Written Informed consent required in Texas Patient Assessment • Patient Monitoring: – Patient must be CONTINUALLY monitored while on N2O/O2 – When monitoring you are evaluating: • Level of consciousness-response to verbal stimulation • Pulmonary ventilation-observation or auscultation of the frequency and depth of respirations • Oxygenation-pulse oximetry use should be considered during N2O/O2 analgesia Emergenc Patient Assessment y Preparedn Personnel preparedness ess • CURRENT knowledge and training • Emergency kit/equipment • AED • Medications • Oxygen • Access to emergency services • 911 protocol/EMS services Armamentarium Two main types of supply systems: 1. Central Storage System: – A “built-in” system for highuse offices; gases are stored in tanks away from the operatories. – Typically, there is a tank room with manifold and regulators, a zone valve for remote control, operatory outlets, and central location for alarms. Armamentarium 2. Portable Gas Delivery System: • Often used when N2O/O2 is used less frequently • Smaller tanks on unit so it is easily moved to different locations within the facility – Yoke stand • is the backbone/support structure of the unit • May hold 2-4 tanks Armamentarium – Color-coded hoses (green and blue) – Regulator • Reduce gas pressure to appropriate levels~50psi • Full Tank PSI –N2O: 750 –O2: 2000 • Pin-index safety feature Pin Index Armamentarium – Flowmeter • Further reduces gas pressure to local atmospheric pressure • Indicates the amount of gas being delivered to patient Armamentarium • Reservoir Bag, conduction tubing, breathing apparatus Safety Features Oxygen fail-safe system- Most important safety feature! designed so that the N2O will automatically turn off when oxygen is depleted before the N2O tank is empty. The fail-safe alarm will sound. Pin and diameter index- make it impossible to connect N2O tanks to O2 yokes and vice versa. Minimum oxygen liter flow- assures that a minimum of 2.5 L/min of O2 is administered and that a maximum of 75% N2O can be administered. Safety Features O2 flush button• located on the machine below the flow meter. • This mechanism allow for 100% O2 to be administered through the reservoir bag in the event of an emergency. • However, a full-face mask is required for forced oxygen. Color coding• all parts (knobs, tanks, and occasionally tubing) are colored • blue for N2O • green for O2 Tidal Volume and Minute Volume Tidal Volume • Quantity of air that is inhaled and exhaled during normal respiration • Adult between 6 L to 8 L per minute • Children between 4 L to 6 L per minute • Watch reservoir bag to determine Minute Volume • Based on respiration rate per minute Titration of Gases Titration is a method of administering a drug in incremental amounts until a desired endpoint is reached. • For N2O/O2 sedation, N2O is given in incremental doses until the patient reaches a comfortable, relaxed state of sedation. • The ability to titrate N2O is significant because it allows the specific amount of the drug that is required by the patient to be delivered. • If done properly, the patient does not receive more Titration of Gases Another advantage of titration is the ability to adjust levels of sedation. • The clinical effects of N2O is rapid. • Signs and symptoms must be monitored closely! Allows for prolonged procedures to be accomplished effectively. • As intensity of treatment increases, N2O/O2 may be increased, as intensity decreases, N2O may be decreased. • 100% O2 flow for a minimum of 5 minutes is delivered as procedure nears completion-enabling full recovery. Signs and Symptoms of N20 Sedation Signs and Symptoms of N2O/O2 Sedation Signs and symptoms for APPROPRIATE N2O/O2 sedation: Patient is: • Comfortable and relaxed • Acknowledges reduced fear and anxiety • Aware of surroundings • Responds to directions and conversation Eyes become less active and glazed look appears Patient may experience: • Tingling in extremities and/or near mouth • Heaviness in extremities • Body warmth • Vasodilation in head and neck Signs and Symptoms of Sedation Ideal Sedation (Table 15.3) • Able to respond to commands • Slower eye movement • Relaxed posture and facial features • Lightheadedness or heavy feeling • Tingling/numbness of perioral area • Tingling of fingers and toes • Warm feeling Heavy or Oversedation (Table 15.4) • Sweating • Nausea • Uncontrollable • Vomiting emotions • Loss of – Laughter consciousness – Crying – Agitation/ irritation • Sleepiness Signs and Symptoms of N2O/O2 Sedation Signs and symptoms for N2O/O2 OVERSEDATION: Detachment/dissociation from environment Dreaming, hallucinating, fantasizing Out-of-body experiences Floating/flying Inability to move, communicate, keep mouth open Humming or vibrating sounds that progressively worsen Patient may experience: • • • • • • • Drowsiness Dizziness Diaphoresis Nausea Light-headedness Fixed eyes Uncomfortable body warmth May progress to: • • • • • Sluggish, delayed responses Slurred words or no verbal sense Agitated or combative behavior Vomiting Unconsciousness Potential Biohazard for Health Personnel Guidelines for monitoring exposure for health personnel provided by NIOSH and OSHA. Nitrous system should be checked daily and when tanks are changed. Replace rubber ring when changing tanks, listen for leaks. Potential Biohazard for Health Personnel Nitrous Oxide and Spontaneous Abortion in Dental Assistants, American Journal of Epidemiology, March 15, 1995 Elevated risk of lost pregnancy in dental assistants working with nitrous more than three hours a week in an office not using scavenging equipment. No difference in offices with properly maintained scavenging equipment Potential Biohazard for Health Personnel Hand-Held monitoring device Portable gas monitor gives a continuous measure of N20 in the ambient air Sources of Leaks No talking! Gas can leak at any connection Only O2 flush in emergency Ill-fitting mask Conducting tubing and reservoir bag- soap and water method to detect leaks Maintenanc e of systems Appropriate tidal volume Vacuum system, optimal flow 45L/min. Nitrous Oxide Abuse Issues Feeling of euphoria = potential for abuse Tank theft from hospitals, dental offices Whipping cream charger, “whippets” Abuse in office, who’s supervising? Purchasing is not well regulated N20 tanks for auto racing N20 rarely detected in routine urine tests Titration Technique or Incremental Flow Technique Turn on main tanks slowly and make sure both tanks are full. Turn on the nitrous oxide regulator. Place the colored hoses into the corresponding hook ups. Place the high-speed suction into the scavenging hose and turn the suction on. Patient is seated, vital signs and medical history checked The machine should be positioned behind the patient, easily accessible to the operator Inform the patient of the sensations they may be feeling and ask them to not talk too much as they breath through the nosepiece. Obtain informed consent. Lay the patient back into a supine position. Set the oxygen level at 6 liters flow. Fill the reservoir bag with oxygen. Fit the nosepiece, tightening the hoses under the back of the chair. As the patient breathes check to see that the reservoir bag is moving and maintaining air. If the patient uses all the air in the bag quickly, adjust the oxygen flow to a higher setting. If the bag is not moving, check for blockages in the hoses or turn the flow down slightly. Begin Nitrous Oxide administration by raising the nitrous oxide bubble to 1L and moving the Oxygen bubble down 1L. Let the patient breathe the new air for about 1 minute before readjusting each level by 5% until analgesia occurs. Pt. should feel the sensations of Plane II analgesia. Do not exceed 50% nitrous oxide administration. Following the dental procedures, turn the nitrous oxide to the off position (0liter flow) and replace the oxygen to 6 L flow for 3-5 minutes or until the Documentation • • • • • • • Medical history review Record vitals pre and postop Indications for N20/02 use. Physical examination Confirmation of patient consent Confirmation of delivery of pre/post procedure instructions Equipment readiness confirmation Maximum levels of nitrous oxide and oxygen stated in terms of % of each gas administered • Length of administration • Length of oxygenation and patient’s report of feeling normal prior to dismissal • Any side effects/complications incurred, or the fact that none occurred Ethical and Legal Considerations Ethical and Legal Considerations • Appropriate education for N2O/O2 administration • Informed consent for N2O/O2 sedation • Ethical principles: – Nonmaleficence – Beneficence – Autonomy – Veracity • Ethical responsibility: – Do not abuse N2O/O2 yourself – Titrate using recommended technique – Use updated, maintained equipment with scavenging systems Ethical and Legal Considerations Sexual phenomena associated with N20 Reports of hallucinations, visualizations, and auditory illusions- turn N20 down! Specific legal cases against male practitioners by female patients following N20 at 50% or higher. Charges dismissed. CYA- 3rd party present. Texas State Board (tsbde.state.tx.us) License must be display ed Additional certification required following graduation to monitor N2O/O2 Auxiliary staff must be CPR certified Good resuscitative equipment, oxygen and drugs necessary to treat adverse reactions Texas State Board N2O Certification in Texas • www.tsbde.state.tx.us • Lists of CE course locations available • Download certificate application on state board website • Additional fee required • Self query, two forms, unopened, notarized Texas State Board Section 110.3 pages 110-6 to 110-10 Monitoring • “The dentist must induce the nitrous oxide/oxygen inhalation sedation and must remain in the room with the patient during the maintenance of the sedation until pharmacologic and physiologic vital sign stability is established.” • “After pharmacologic and physiologic vital sign stability has been established, the dentist may delegate the monitoring of the nitrous oxide/oxygen inhalation sedation to a dental auxiliary who has been certified to monitor the Texas State Board Pre-Procedure Preparation and Informed Consent • “The patient, parent, guardian, or care-giver must be advised regarding the procedure associated with the delivery of any sedative agents and must provide written, informed consent for the proposed sedation.” • “Baseline vital signs must be obtained in accordance with Rule 108.7 and Rule 108.8 of this title.” • “Pre-procedure verbal and written instructions must be given to the patient, parent, escort, guardian, or care-giver.” Texas State Board • Direct supervision of dentist required for use by dental hygienist or dental assistant. • Completion of certification course • CPR required • Dentist induces patient and staff member may make adjustments (decreasing the N2O) only and may turn the machine off. Texas State Regulations on N2O/O2 Monitoring for the RDH • In addition to the duties that a dentist may delegate pursuant to the Dental Practice Act and Board Rules, a Texas-licensed dental hygienist (hygienist) may perform the following services and procedures in the dental office of his/her supervising Texas-licensed dentist (dentist) or dentists who are legally engaged in the practice of dentistry in this state or under the supervision of a supervising dentist in an alternate setting: – monitor patients receiving nitrous oxide/oxygen inhalation conscious sedation only after obtaining certification issued by the State Board of Dental Examiners and only under the direct supervision of a Texas licensed dentist. Certification may be obtained by successful completion of a board-approved course, that includes examination, on the monitoring of the administration of nitrous oxide. Pediatric Considerations Pediatric Considerations 1993 Study of Pediatric Dentists, 89% use N20 in their practice. Delivery of 40% N20/ 60% 02 significantly improved patient behavior without affecting hemoglobin saturation or type of breath sound. Goals of Pediatric Sedation Guarding child’s safety and welfare Suppressing gag reflex Minimizing physical discomfort and pain Controlling anxiety, maximizing amnestic potential ***Controlling behavior and movement*** Returning patient to a safe state to discharge Patient Selection is Key! Pediatric Considerations Remember, “misbehavior” in the dental chair is an expression of fear. TLC, behavior management still required when sedating a child Reduced time in chair, number of appts No crying! Not appropriate for hours long appts Pediatric Challenges Cooperation with nasal hood required Mildly to moderately anxious, cooperative child Nitrous weak, further sedation needed? Access to maxillary anterior teeth Upper respiratory infections Age threshold around age 3-4 Pediatric Considerations Additional Considerations Preventio n of sickle cell crisis due to stress Epilepsy and stress reductio n Asthma, stress reductio n Chronic lung diseases, reduce dosage due to compromised air exchange, consult physician Additional Considerations Nitrous can be successfully used in patients with Down Syndrome Acceptance depends on individual patient Additional Considerations Nitrous oxide has been shown to reduce orofacial muscle tonus in patients with Cerebral Palsy during dental treatment. Careful monitoring of O2 exchange Additional Considerations N20 alone or in combination with oral sedation used with varying rates of success Unclear passage of time helps with short attention span Additional Considerations Nitrous use in Autism Spectrum Disorder is controversial Abnormalities in folic acid metabolism, Vit. B-12 deficiency, MTHFR dyfunction. Report of death during lengthy general anesthesia Dentistry- low dose and duration Possibility of negative behavior reaction Pediatric Considerations Ultimate goal, create a cooperative patient who no longer requires sedation through positive dental Questions • Patient contraindications for N2O can include? – A. language barrier – B. asthma patient – C. overactive gagger – D. cardiac patient Questions • Which of the following should be done when introducing the patient to the nitrous oxide procedure? – A. Ask the patient to refrain from mouth breathing. – B. Allow only the patient to choose mask fit – C. Liken the feeling to use of alcohol – D. Have the patient sit upright with legs crossed. Questions • A scavenging system is designed to – A. Collect exhaled nitrous oxide and return it to the tank. – B. Collect exhaled nitrous oxide and vent it out through the suction system. – C. Control the source of infection in the mask from the patient. – D. Control costs of the nitrous oxide gas. Questions • Is it okay to eat before receiving N20 and 02? • Does the conduction tubing need to be sterilized after each patient? • How does N20 affect the lactating (nursing) mother? Questions • Can a person with asthma use N20/02 sedation? • How about a person with sickle cell anemia? • How about a person with cancer? • How about a person with dental phobia? Questions • Do I need to titrate the level of N20 back down in steps? • How long should 100% O2 be administered before removing nasal hood? • Can the N20 tank accidentally get attached to the 02 side of a portable sedation unit? Questions • Can the patient return to work/school immediately following N20/02? • What is the youngest age in which N20/02 sedation can be used? • Does insurance pay for N20/02 sedation? Questions • What is the number one potential side effect? • Is it necessary to document the N20/02 procedure in the chart? Remember, Documentation! • • • • Record vitals pre and postop Indications for N20/02 use Patient/Parent informed written and verbal consent Maximum levels of nitrous oxide and oxygen stated in terms of % of each gas administered • Length of administration and exact time started and stopped • Length of oxygenation and patient’s report of feeling normal prior to dismissal • Any side effects/complications incurred, or the fact that none occurred Calculations • Determine the percentage concentration of both gases. • Take liters of gas and divide by total volume of gases. • Multiply by 100 to get the percentage. • Example: 3 L N2O and 5 L O2 = 8 L Tidal Volume – 3/8 = 0.375 – 0.375 x 100 = 37.5% Nitrous – 5/8 = 0.625 – 0.625 x 100 = 62.5% Oxygen Case #1 • Patient presents for his dental cleaning and exam. You are aware of his medical history and know he is taking Gabapentin. After 10 minutes of being on 30% N2O: 70% O2 your patient begins to shake and loses consciousness. – What is your patient experiencing? – What should you do? Case #2 • Patient presents in your operatory at 9:00 am for 2 quadrants of Scaling and Root Planing. She tells you she is healthy and is taking Metformin. You take her blood glucose and it is 300 mg/dl. – What questions should you ask her? – What should you do next? References • www.Porterinstruments.com • www.cdc.gov/niosh/nitoxide.html • Malamed, S: Sedation A Guide to Patient Management. Mosby, 4th ed • Clark & Brunick: Handbook of Nitrous Oxide & Oxygen Sedation. Mosby 4th ed • https://www.yumpu.com/en/document/view/47619937/aiding-in-theadministration-of-nitrous-oxide-oxygen-idaho-