Nitrous oxide RDA

Indications for Nitrous Oxide

1. Anxious patient 2. Increased gag reflex 3. Traumatic dental procedures 4. Sickle cell trait-anemia 5. Bleeding disorders 6. Physical handicap 7. Epilepsy 8. Pregnancy (not first trimester) 9. Cardiac disorders 10. Mentally handicapped

Contraindications for Nitrous Oxide

1. Common cold 2. Tonsillar/adenoidal hyperplasia 3. Serious pulmonary disease 4. Psychiatrically treated patient 5. Multiple sclerosis 6. Myasthenia gravis

Three general factors that may produce dyspnea:

1.The patient's state of mind .2.Increased work of respiration .3.Abnormalities in the oxygen and carbon saturation

Normal blood pressure

120 mm Hg - Systolic Pressure 80 mm Hg - Diastolic Pressure

rule of thumb for reading nitrous gauge

2.5 units of oxygen are utilized to every 1 unit of nitrous oxide unit

Stages of Anesthesia: Stage 4

Death

Oversedation - - Management

Decrease the concentration of nitrous oxide in increments of 10-20*

Bradycardia

Decreased Heart Rate or slowness of a heart beat Less than 60/min

Rule 108.31108.3

Delegation of the monitoring of the nitrous oxide/oxygen monitoring inhalation conscious sedation procedure to a dental auxiliary who has been certified to monitor the been certified

Most Common Cause of Hypoxia

During inhalation conscious sedation is inadequate oxygenation - ventilation

Larynx

Epiglottis and Vocal cords

Alteration of Psychological and Physical State

Euphoria and Excitation Floating and Delusions Numbness and Tingling Review other in text

Minor Complications:

Excessive perspiration Increased expectoration Shivering Paresthesia Numbness Tingling in extremities "Light-headed" Fear Hyperventilation

Stages of Anesthesia: Stage 2

Excitement Loss of consciousness, disappearance of Eyelid reflex, irregular respiration, irregular respiration, agitation, dilated pupils

Advantages of Inhalation Conscious Sedation

Few Side Effects Rapid Onset Peak Clinical Effect Quick Increase Decrease effect Variable Duration Rapid Recovery Analgesia Agent Non-invasive Procedure Administered In-Office

Diffusion Hypoxia

Hypoxia is an inadequate oxygen concentration necessary for cellular respiration and function.

Signs of Patient Over sedation

Inability to Keep Mouth Open Agitation Failure to Respond to Verbal Commands or Stimulation Slurred / Incoherent Speech Uncooperative Increased Excitability Uncoordinated Muscular Movement Nausea

Tachycardia

Increased Cardiac Output or rapid beating of the heart Greater than 110/min

YOU SHALL NOT

Induce or start nitrous oxide-oxygen on any patient Increase the concentration of nitrous oxide for any reason

Oxygen Flush

It is activated by pressing a button which opens the oxygen flow directly from the line bypassing the flowmeter utilized to get a large volume of oxygen to the reservoir bag or patient quickly.

Precautions for tank storage

Keep oil or grease from coming in contact with the high pressure gas When gas flows from the tank at high pressure, a rapid increase in temperature may result. not flammable but they will support combustion vertical position restrained against a wall

Direct Supervision

Level of supervision in which the dentist is physically present when the dental auxiliary performs delegated functions

ONLY the Dentist

May induce and administer the sedation medication (nitrous sedation medication (nitrous oxide-oxygen).oxide-oxygen

Plane 1

Moderate Analgesia Utilization of N2O of between 5-25%

Patient monitoring-Post treatment

Monitor for hypoxia/respiratory status

Nitrous Oxide Concentrations

Most dental analgesia obtained 25-50% O2 concentration never below 30%

Certification for Monitoring

Must be currently certified in basic cardiac life support Must pass a written certification examination pass a written certification examination prepared and administered by a TSBDE

Major Complications:

Nausea Vomiting Regurgitation Pulmonary Aspiration Tachycardia Tachypnea Cyanosis Hypoxia Bradycardia

Basic Pharmacology Facts

Nitrous oxide diffused readily to and from the blood and body tissues. It does not change its form the majority of the gas is exhaled from the body within 3 - 5 minutes after its termination.

Physical Properties Nitrous oxide

Nitrous oxideis a colorless, odorless , tasteless, non-irritating gas with central nervous system depressant ability

Respiratory Rate

Normal 12-20 beats/min Exceed 35/min - hypoxia

Pulse

Normal adult 60-72

Diastolic Pressure

Pressure is controlled by the compliance or resistance of the vascular system

Systolic Pressure

Pressure that is created by the left ventricular contraction and may be influenced by vascular factors

Anesthesia

Preventing the brain from receiving painful stimuli

Reservoir Bag

Rubber or sillicone range from sizes 1-8 3 liter size is commonly used with adults while a pediatric bag of 1 liter used for child

Nasal Hood or Mask

The most commonly used apparatus in the dental office .The hood only covers the nose

Pharynx

The pharynx is divided anatomically into three areas: areas: nasopharynx ,oropharynx and laryngopharynx

Correct Cuff Size

The size of the pressure cuff utilized must be appropriate for the patient's arm. A cuff smaller than indicated will produce a high aberration (deviation from the normal) in the blood pressure while a larger cuff will do the opposite.

Plane 2

The utilization of nitrous oxide concentration of between 25-55%

Induction Phase

This phase begins as the dentist first turns the dials of the nitrous oxide oxygen machine and places the nasal mask on the patient

Maintenance Phase

This phase begins when the desired level of sedation is obtained, continues for the indicated duration of the procedure

Recovery Phase

This phase begins when the nitrous oxide is turned to the "off" position continues during the oxygen administration, and ends when the patient is in total control of their well being

Plane 3

Total Analgesia The utilization of a nitrous oxide concentration of between 55-70% Patients may experience amnesia and even lose consciousness

Patient Monitoring-Pre-Treatment

Visual and auditory observation most important aspect vital signs checked every every 15 minutes A current history and limited physical evaluation on all dental patients should be performed.

Monitoring Objective Symptoms

What Can be observed Consciousness Relaxation Normal Vital Signs Decreased eye lid blink Reflexes Intact Responds to Verbal Command Decreased Response to Painful Decreased Movement

Monitoring Subjective Symptoms

What the patient is feeling Paresthesia or tingling Mental and Physical Relaxation Psychic and Somatic Sedation Altered Pain Threshold Lethargy Euphoria Dreaming Feeling of Warmth Sense of Detachment

continuous flow types

a continuous, constant flow of gases is delivered to the patient gases is delivered to the patient even on exhalation

Nitrous oxide is stored

as a gas and about 30% liquid As the gas is used, the liquid is converted to more gas

nasopharynx

begins at the posterior opening of the nose, and extends to the superior opening of the nose, and extends to the superior portion of the soft palate.

oropharynx

begins at the soft palate and extends to the level of hyoid bone in the neck. contains the tonsillar lymphatic tissue bilaterally

complete face mask

best use of the face mask is in the event of an emergency

Nitrous oxide

blue

Sir Humphrey Davy

described the analgesic-euphoric properties of the analgesic-euphoric properties of nitrous oxidenitrous oxide and later named it and later named it "laughing gas.1978

Joseph Priestley

discovered nitrous oxide in 1773

Purpose of the reservoir bag

even gas flow which prevents wide swings in gas concentrations helpful as a respiratory monitoring device may also be used as a means to assist or control respiration in the event of an emergency.

laryngopharynx

extends from the hyoid bone to the beginning of the esophagus

Horace Wells

first to recognize the medical application of recognize the medical application of nitrous oxidenitrous oxide. 1842

Portable System

gas cylinders combined into one single unit ,movable from one operatory to another

Oxygen is stored

gas under pressure between 2000 - 2200 psi

Oxygen

green

Weak / Thready Pulse

indicative of a decrease in the stroke volume as seen in hypo tension, syncope, cardiac failure, or shock

Central Storage System

larger gas cylinders (G or H cylinders) are stored in a dedicated area away from the operatory, the cylinders are connected to the operatory by copper tubing

Gas Flow Measured in

liters /minute

Direct hypoxia

may occur due to the dilution of oxygen. subsequent hypoventilation and indirect hypoxia will occur

Flowmeter

measures the quantity of the gas delivered

Oxygen Fail Safe

mechanism which shuts off or prevents the initiation of nitrous oxide delivery without oxygen flowing

Patient monitoring- Treatment phase

mental status cardiovascular status respiratory status skin color

Personal Supervision

physically present in the physically present in the room with the patient at all times room with the patient at all times during the induction and during the induction and maintenance of the procedure

Internal Nose

posterior openings into the nasal pharynx are called the choanae. Any blockage would potentially alter the amount of sedation agent getting to the patient

Transport or Conduction system

provides for the transport of air (oxygen and other gases) from outside of the body to the respiratory area of the lungs and transport of waste gases (carbon dioxide)to the outside.

Cyanosis

the bluish color noted in the skin as a result of excessive unoxygenated hemoglobin in the blood. a late symptom of tissue hypoxia. tissue Treat the problem with 100% oxygen

Prevention:

Administer 100% oxygen for 3-5 minutes after termination of N2O

Staff Safety

Air mixing utilized by placing a fan in the operatory levels drop to 14 ppm (parts per million).

What activates vomiting?

Cortical (Brain) Stimulus stress, fear, depression, smell, taste, visual, pain, fear, depression,pain, migraine headaches, increased intracranial pressure, and hypoxia

Dyspnea "short of breath."

An awareness of increased difficulty breathing due to a disproportion between the perceived demand for disproportion ventilation and that achieved

Hypoxia

An inadequate oxygen concentration necessary n necessary for cellular respiration and function.

Stages of Anesthesia: Stage 1

Analgesia begins at the induction of the sedation or general anesthesia procedure and ends with the loss of consciousness

Heart Rate

Average adult rate: 60-80/min

Rule 109.171

Chapter 108, , Subchapter C, in February 2001 allow delegation of patient monitoring during the inhalation sedation procedure under certain conditions.

Nitrous Oxide Safety Considerations

Scavenging Hood Air Mixing Disposable Nasal Hood Testing of N2O Equipment Proper Venting of Gases Monitoring of N2O concentrations

Cortical Stimulation

Secondary to hypoxia and the leading cause of nausea and vomiting during nitrous oxide conscious sedation procedures

Stages of Anesthesia: Stage 3

Surgical

Combined System

Systems that unite the central gas cylinder storage and the portability of cylinder storage and the portability of machine movement among the operatories wall outlets are referred to as a combined system

Hypertensive Readings

Systolic> 160 mm Diastolic> 115 mm Pulse> 90-104 bpm

Pulmonary Aspiration

The aspiration of gastric contents or other fluids or solids into the pulmonary bronchial system

Analgesia

The diminution elimination of pain.pain

Analgesia

The diminution or production of increased tolerance to pain in the conscious patient.