6- Nitrous Oxide Analgesia Technique(1) (1).pdf

NITROUS OXIDE ANALGESIA TECHNIQUE RUBEN FIGUEROA DMD, MS ORAL AND MAXILLOFACIAL SURGEON Minimal Sedation Preoperative Preparation informed consent adequate oxygen supply equipment necessary to deliver oxygen under positive pressure baseline vital signs focused physical evaluation pre-operative dieta...

NITROUS OXIDE ANALGESIA TECHNIQUE RUBEN FIGUEROA DMD, MS ORAL AND MAXILLOFACIAL SURGEON Minimal Sedation Preoperative Preparation informed consent adequate oxygen supply equipment necessary to deliver oxygen under positive pressure baseline vital signs focused physical evaluation pre-operative dietary restrictions pre-operative verbal and written instructions Minimal or Moderate Sedation Personnel and Equipment Requirements Personnel: one additional person trained in Basic Life Support for Healthcare Providers Equipment: A positive-pressure oxygen delivery system Inhalation equipment must have: a fail-safe system functioning device that prohibits the delivery of less than 30% oxygen scavenging system Minimal Sedation Monitoring & Documentation Monitoring: A dentist or trained individual, must remain in the operatory Monitoring must include: Oxygenation: Color of mucosa, skin or blood must be evaluated continually Oxygen saturation Ventilation: observe chest excursions continually verify respirations Circulation: Blood pressure and heart rate, pre-operatively, post-operatively, intra-operatively Documentation: record must be maintained Moderate Sedation Monitoring & Documentation Monitoring: A qualify dentist administering moderate sedation must remain in the operatory When patient recovers to a minimally sedated level a qualified auxiliary may be directed by the dentist to remain with the patient The dentist must not leave the facility until the patient meets the criteria for discharge and is discharged from the facility Monitoring must include: Level of consciousness Oxygenation: Color of mucosa, skin or blood must be evaluated continually Oxygen saturation Moderate Sedation Monitoring & Documentation Ventilation: observe chest excursions ventilation (This can be accomplished by auscultation of breath sounds, monitoring end-tidal CO2 or by verbal communication) Circulation: blood pressure and heart ECG monitoring of patients with significant cardiovascular disease should be considered. Documentation: time-oriented anesthetic record, including the names of all drugs administered, including local anesthetics, dosages and monitored physiological parameters Pulse oximetry, heart rate, respiratory rate and blood pressure Minimal Sedation Recovery and Discharge Oxygen and suction equipment must be immediately available if a separate recovery area is utilized. Dentist or appropriately trained clinical staff must monitor the patient during recovery until the patient is ready for discharge by the dentist. Dentist must determine and document that level of consciousness, oxygenation, ventilation and circulation are satisfactory prior to discharge. Post-operative verbal and written instructions must be given to the patient, parent, escort, guardian or care giver. Moderate Sedation Recovery and Discharge Oxygen and suction equipment must be available dentist or appropriately trained clinical staff must continually monitor the patient’s blood pressure, heart rate, oxygenation and level of consciousness. dentist must determine and document that level of consciousness; oxygenation, ventilation and circulation are satisfactory for discharge. Post-operative verbal and written instructions must be given to the patient, parent, escort, guardian or care giver. If a reversal agent is administered before discharge criteria have been met, the patient must be monitored until recovery is assured. Minimal and Moderate Sedation Emergency Management If a patient enters a deeper level of sedation than the dentist is qualified to provide, the dentist must stop the dental procedure until the patient returns to the intended level of sedation. The qualified dentist is responsible for the sedative management, adequacy of the facility and staff, diagnosis and treatment of emergencies related to the administration of minimal sedation and providing the equipment and protocols for patient rescue. Minimal and Moderate Sedation Management of Children For children 12 years of age and under, the American Dental Association supports the use of the American Academy of Pediatrics/American Academy of Pediatric Dentists Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures. American Academy of Pediatric Dentists (AAPD). Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures: An Update. Developed through a collaborative effort between the American Academy of Pediatrics and the AAPD. Available at http://www.aapd.org/media/policies.asp PUTTING IT ALL TOGETHER NITROUS OXIDE CASE N20-02 ANALGESIA TECHNIQUE Preoperative considerations Assess armamentarium Infection control Accurate flow meter, scavenging mask, vacuum system able to ventilate gases at a rate of > 45 L/min No leaks at connections Soap water bubbles Ensure vacuum & ventilation are vented out Assess room area ventilation Noncirculating ventilation system is best TECHNIQUE Obtain baseline vital signs Select appropriate mask/nasal hood Initiate and adjust oxygen flow Most adults: begin at 6-7 liters/min Most children: begin at 4-5 liters/min PREPARATION OF PATIENT Preparation of the Patient Request that the patient visit the restroom and void if necessary before the start of the sedative procedure Review the medical history Record preoperative vital signs Contact lenses should be removed Informed consent The procedure begins and ends with 100% Oxygen The patient should not be left alone TECHNIQUE Position patient in comfortable, reclined position in dental chair. TECHNIQUE Position the inhalation sedation unit TECHNIQUE Start the flow of O2 at 6 L/min, place the nasal hood over the patient's nose, and remind the patient to breathe through the nose. TECHNIQUE Secure the nasal hood TECHNIQUE Instruct patient breathe through nose & keep lips sealed Decide optimal flow volume Subjective patient comfort TECHNIQUE Start O2 administration Always pre-oxygenate for 3-5 minutes Start N20 Administration Constant O2 level technique Oxygen remains constant and N20 is titrated to effect Variable O2 level technique O2 decreases as N20 is added Observe the reservoir bag. TECHNIQUE Observe the reservoir bag. TECHNIQUE N20 administration Slow titration is key to success and safety Start with 10 % N20 Wait 60 seconds for clinical effects Titrate to ideal sedation level Add N20 in increments of 5 % with at least a 60 second pause in between increments SIGNS & SYMPTOMS OF N2O-O2 SEDATION Psychological Patient is relaxed and comfortable Patient’s mood is happy, pleasant, or satisfied Body Movement Relaxation Shoulders dropping, arms laying looser on arm rests Deeper respirations, deep sigh Eyes Not as active, patient no longer focused on activities of others Eyes may appear “glazed” or “glassy” SIGNS & SYMPTOMS OF N2O-O2 SEDATION Facial Expression More of a “flat” expression Patients smile easily Awareness Patients are conscious Patients respond rationally and coherently to operators’ directions Cough and gag reflexes remain intact OBSERVE THE PATIENT. SIGNS & SYMPTOMS OF N2O-O2 SEDATION Patient May Also Experience Numbness or tingling in extremities and around the mouth Heaviness in legs and arms Body warmth Light feeling Vasodilatation in the face and neck RECOVERY Turn off N2O (Can start before procedure complete) Post procedure administer 100% O2 at 6-7 liters/min for a minimum of 5 minutes Assess Recovery Continue There should be NO signs of: Lethargy Dizziness Light-headedness Headache Obtain Postoperative Vital Signs TECHNIQUE REVIEW SUMMARY OF NITROUS OXIDE/OXYGEN ADMINISTRATION TECHNIQUE Titrate to desired level Perform operative procedure Terminate nitrous oxide, and give 100% oxygen for 5 minutes after procedure Assess recovery Continue postoperative oxygen if necessary Ensure recovery and dismiss patient Complete sedation record Disinfect and/or sterilize sedation equipment OVERSEDATION WITH NITROUS OXIDE Detachment Hallucinating Out-of-body experiences Floating Inability to move, communicate Humming or vibrating sounds that progressively worsen OVERSEDATION WITH NITROUS OXIDE Patient may experience: Drowsiness Dizziness Diaphoresis Nausea Light-headedness Fixed eyes Uncomfortable body warmth Agitation vomiting Oversedation Signs & Symptoms Turn Off Nitrous Oxide: Deliver 100% O2 Nausea or Vomiting Suction, Turn Patient’s Head to side Oversedation Unconscious with Snoring Turn Off Nitrous Oxide Place on 100% O2 Reposition Airway: Chin Lift ANY QUESTIONS?