5. Nitrous Oxide/Oxygen Analgesia Flashcards by J L

Potential Candidates

\_\_\_\_ or fearful 
Young children 
\_\_\_\_ challenged 
Hyperactive gag reflex
Those undergoing an \_\_\_\_ or extensive procedure

anxious
behaviourally
invasive

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Anxiety is a stress response to an ill anticipated situation, feelings of ____ or anticipation of possible danger.

Fear is a physiological process that occurs when the person is threatened by more ____ identifiable danger.

Phobia is a persistent or ____ fear that results in a compulsion to avoid a specific object, activity or situation; it can impede daily ____.

threat
immediate
irrational
function

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Phobias

usually originate in ____
persist throughout ____
lead to avoidance of ____ therapy contribute to diminished dental ____

childhood
life
dental
health

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____% of Americans are very nervous or terrified of having dental treatment.

7-15

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Assessing the need for anesthesia and sedation in the general population

18 percent of adults would visit the dentist more frequently if they were given a ____ to make them less nervous

____ discrepancy between the number of patients who would prefer to receive sedation and the availability of these services

drug

threefold

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Patient Assessment:
History

Medical History 
\_\_\_\_ disease 
Cardiovascular disease 
\_\_\_\_
Psychiatric condition
Previous experience with \_\_\_\_

Medication
Prescribed \_\_\_\_ 
Alternative remedies 
\_\_\_\_ drugs
Allergy

respiratory
pregnany
sedation
medication
recreational

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Patient Assessment:

Physical Examination
   ■ ■ ■ ■
\_\_\_\_ exam 
Neurologic exam 
\_\_\_\_ exam 
Cardiovascular exam

airway

pulmonary

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American Society of Anesthesiology Classification of Physical Status (ASA)

I - normal, ____ patient
II - a paitnet with ____ systemic disease
III - a patient with ____ systemic disease limiting activity but not incapacitating
IV - a patient w ____ disease that is a constant threat to life
V - moribund patient not expected to live more than ____ hours with or without treatment

healthy
mild
severe
incapicitating
24

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Stages of Anesthesia
Stage I
begins with ____ and ends with the patient’s loss of ____ analgesia/sedation

Stage II, or REM stage
____ and sometimes dangerous responses to stimuli
____ and uncontrolled movement

Stage III, or surgical anesthesia
____ muscles relax
breathing becomes regular
eye ____ stop

Stage IV, or overdose
____ paralysis
death

induction
consciousness
uninhibited
vomiting
skeletal
movements
medullary

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ADA guidelines
■
“ a minimally depressed level of consciousness that retains the patient’s ability to independently and continuously maintain an ____ and respond appropriately to ____ stimulation or verbal command . . .”

airway

physical

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Guidelines for the Elective Use of Conscious Sedation, Deep Sedation and General Anesthesia in Pediatric Dental Patients

(1) Facilitate the provision of quality ____
(2) Minimize the extremes of disruptive behavior
(3) Promote a ____ psychologic response to treatment
(4) Promote patient welfare and safety
(5) Return the patient to a physiologic state in which ____ discharge, as determined by recognized criteria, is possible

care
positive
safe

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Assessment by Observation

\_\_\_\_
Calm
Responsive to \_\_\_\_
Response to tactile stimulation Response to \_\_\_\_
No response

agitation
voice
pain

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Sedation:
Routes of Administration

\_\_\_\_ 
Oral 
\_\_\_\_ 
Intramuscular 
\_\_\_\_ 
Submucosal 
\_\_\_\_

inhalation
intravenous
rectal
intranasal

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Assessment of Technique
  ■ ■ ■
\_\_\_\_ effective 
\_\_\_\_ effective 
\_\_\_\_

clinically
cost
safe

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Inhalation
A technique of administration in which a gaseous or volatile agent is introduced into the ____ tree and whose primary effect is due to ____ through the pulmonary bed.

pulmonary

absorption

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Airway Physiology
Airways become ____ as you move toward
the periphery but the ____
increases.

smaller

cross-sectional area

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Airway Physiology

Central and peripheral respiratory sensory receptors
The central chemoreceptors respond to ____ and the peripheral chemoreceptors respond to ____

The normal respiratory rate (RR) is ____ breaths per minute

carbon dioxide (CO2)
oxygen (O2)

14-16

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Composition of respiratory gases

O2
% in inspired air: ____%

CO2
% in inspired air: ____%

N2
% in inspired air: ____%

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1976 - ____ devices for O2

safe

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Training Requirements Pennsylvania

At least ____ hours of undergraduate or postgraduate didactic instruction and clinical experience
Must provide ____ and address of training facility
____ seal
Completed by course director

14
name
hospital/facility

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Office/ Equipment Certification

Make, model and serial number
Is the equipment in proper working order? Is the equipment properly ____?
Does the equipment contain a fail
Do you have written office ____ for administering nitrous oxide/oxygen analgesia and handling emergencies related to the administration of nitrous oxide/oxygen analgesia

calibrated

procedures

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Regulation
■ ____ Administration
■ U.S. ____

food and drug

department of transportation

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Preparation (N2O)

____ > (heat - 240o) > ____ + ____

NH4NO3
N2O
2H2O

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Properties of nitrous oxide

Properties
\_\_\_\_
\_\_\_\_ smelling
Colorless
\_\_\_\_ form in cylinder
Not \_\_\_\_ or explosive 
Supports combustion of other agents 
Undergoes little \_\_\_\_
Non allergenic
Present in the \_\_\_\_

nonirritating
sweet
liquid
flammable
biotransformation
atmosphere

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Solubility (Partition Coefficients) Determines the time necessary for equilibration between two ____ to occur Blood gas solubility coefficient N2O= ____ ____ solubility = ____ onset and recovery ____ min onset and offset

``` phases 0.47 low rapid 3-5 ```

low blood gas coefficient > ____ solubility > ____ onset of action and ____ elimination

low fast rapid

COmparison of blood: gas partition You don't have to remember these numbers!! But realize with the lower partition coefficient is going to be ____ solubility, ____ onset, and ____ offset. ____ > Desflurane > Sevoflurane > Isoflurane > Enflurane > ____

low fast fast N2O halothane

Concentration Effect Occurs when ____ concentrations of a gas are administered The higher the ____ more rapidly the ____ tension of the gas increases

high inspired partial pressure arterial

Second Gas Effect Administration of high concentrations of N2O ____ the rate of concomitantly inhaled gases Uptake is more ____ than predicted

accelerates | uptake

Potency of Anesthetic Gases MAC = the minimal ____ concentration of anesthetic that prevents movement in ____% of subjects in response to a surgical stimulus Dose at which an anesthetic gas produces its ____ ____ effect

alveolar 50 effect additive

MAC for inhaled anesthetics • Nitrous oxide is going to be much less potent than isoflurane so you need more and more of that drug. So MAC is ____ proportional to potency. ____ > desflurane > sevoflurane > isoflurane > enflurane > ____

inversely N2O halothane

A MAC of ____ prevents movement in at least 95% of patients.

1.2-1.3

Factors that decrease MAC ``` Increasing ____ ____ Other CNS ____ ____ ____ ```

``` age antihypertensives depressants hypothermia pregnancy ```

``` Factors that increase MAC ■ ■ ■ ____ Chronic ____ abuse ____ ```

hyperthermia ETOH MAOI's

Diffusion Hypoxia Causes ____, headache, and lethargy Reverse of ____ effect Rapid diffusion of large volumes of N2O into the alveoli produces a ____ of O2 ____

nausea concentration dilution prevention

Effects on Systems ``` NS ____, hearing, touch and pain are depressed Ability to ____ is decreased Primarily effects the ____ ____ ``` CV Slight depression of myocardial ____ No ____ in HR, BP or CO Cutaneous ____

sight concentrate cerebral cortex neuropathy contraction change vasodilation

Effects on Systems Respiratory No risk of ____ No ____ affect on RR or TV GI/GU No ____ effect

bronchospasm direct significant

Mechanism of Action ____ Analgesic effect is mediated through interaction with ____ receptors Anxiolytic effect is mediated through interaction with ____ receptors ____ properties

unknown opioid GABA amnestic

The analgesia produced by ____ N2O is equal to that by morphine 10 to 15.

20%

Clinical effects of nitrous oxide conscious sedation in children 59 healthy children (ages 4 to 13) ____ treatment behavior and clinical effects were assessed before and ____ minutes after 50% ____ sedation 95% liked the ____, and 86% reported feeling different

dental restorative nitrous oxide 5 ntirous oxide

Nitrous oxide ``` Advantages ____ onset of action Rapid recovery time ____ No ____ required Safe High ____ Can be combined with other ____ ```

``` quick titratable injection acceptance modalities ```

Disadvantages ``` Cost ____ requirements Not ____ Requires cooperation ____ required ```

space potent training

Relative Contraindications ``` ____ Compulsive personality ____ care Severe behavioral problems ____ use Upper respiratory tract infections Chronic ____ COPD ____ Cystic fibrosis ____ ```

``` claustrophobia psychiatric drug nasal obstruction pneumothroax pregnancy ```

Indications ____ and anxiety Gagging Medically ____ patients

fear | compromised

Armamentarium Supply of ____ Apparatus for ____ to the patient

gases | delivery

Portable System Compressed gases are attached to the ____ unit Constant ____ of gas cylinders required

sedation | replacement

Central Storage System Supply of gases is ____ from the treatment area Delivered through ____ pipes

distant | copper

Nitrous Oxide Sedation Unit ____ ____ flow Administers ____ gases Accuracy to within ____%

compact continuous compressed 2

Nitrous Oxide Sedation Unit: Components ``` ____ gas cylinders Reducing valves (regulators) ____ gauges Flowmeters ____ bag Conducting tubing ____ hood ```

compressed pressure reservoir nasal

Compressed gas cylinders Stored in ____ position Avoid ____ or oil ____ coding ◦Nitrous oxide = ____ ◦Oxygen = ____ (for the US!)

vertical grease color blue green

Compressed gas cylinders: Oxygen ``` ____ Present in ____ state only Filled ____% Gas pressure “E” cylinder = ____ psig Produces ____ L of O2 ```

``` green gaseous 100 1900 660 ```

Compressed gas cylinders: Nitrous Oxide ``` ____ Present in both ____ and gaseous state Filled ____% with liquid Gas pressure “E” cylinder = ____ psig Produces ____ L of N2O ```

``` blue liquid 90 to 95 750 1600 ```

Look at bottom: OXYGEN • When the tank is 100% full, the pressure gauge reads ~1900psig • When the tank reaches 50%, the gauge will also reduce to about ____ • When tank is empty, the gauge will read 0 Look at top: NITROUS OXIDE • When the tank is completely full, the pressure gauge read ~750psig • When the tank is half full, the gauge will STILL READ ~____psig • You won’t see a drop in the pressure until the tank is almost ____ ◦But this is whatever. We are more so concerned about oxygen pressure levels bc that’s more important/essential for life

1900 750 empty

____ O2 cylinders are used for every N2O • This is bc there is 660L of oxygen compared to 1600L of nitrous ◦Thus, 2.5 oxygen cylinders needed per 1 nitrous oxide cylinder

2.5

``` Nitrous Oxide Sedation Unit: Components ■ ■ ■ ■ ■ ■ ■ Compressed gas cylinders ____ valves (regulators) Pressure gauges Flowmeters Reservoir bag Conducting tubing Nasal hood ```

reducing

Regulators Located between the compressed gas cylinder and the ____ Reduces high pressure gas to a constant ____ gas pressure Delivery pressure = ____ psig

flow meter low 45 to 55

Pressure Gauges: already talked about this but... • Will be able to tell how much is left for ____ • Will NOT be able to tell how much is left for ____

oxygen | nitrous

Flowmeters Permit delivery of ____ volumes of gases Measured using a ____ (____) Gases combine in the ____

precise float L/min mixing chamber

Reservoir Bag ____ or silicone Ranges in sizes from ____ L A ____ of the gas(es) is diverted to it Inflates slightly with ____ and deflates slightly with ____

``` rubber 1 to 8 portion exhalation inspiration ```

Reservoir Bag Provides a source of ____ gas Mechanism for ____ patient Provides ____ pressure ventilation

additional monitoring positive

Conducting Tubing ____ diameter Corrugated and ____ Anatomic length is related to ____ space ____ free

large noncorrugated dead latex

Nasal Hood ``` ____ or silicone ____ seal Variety of ____ ____ use Variety of ____ ____ type ```

``` rubber airtight sizes single scents scavenging ```

Safety features - ____-coded cylinders - pin-index safety system - ____ safety system - reservoir bag - ____

color diameter index lock

Safety Features continued: • There should be a minimum oxygen percentage (which relates to oxygen flow) ◦We need at least ____% oxygen given to the patient AT ALL TIMES ◦This is built into the machine to prevent any hypoxic event • Oxygen fail-safe system and ____ button — ensure that whenever nitrous oxide is being delivered, so is oxygen. You will NEVER give nitrous without ____!!! • Already talked about the ____ bag

20 oxygen flush oxygen reservoir

Technique of administration: titration vs fixed % ■ ■ ■ Allows delivery of required ____ amount ____ adverse responses ____ success rates

indiviudal less higher

Basic Principles 1. Always begin and end with 100% ____ 2. ____ is titrated

O2 | N2O

``` Inadequate Sedation: Potential Causes ■ ■ ■ Nasal ____ Mouth ____ Not ____ enough ```

obstruction breathing potent

``` Pretreatment Visit ■ ■ ■ ■ Discuss the ____ of the procedure, risks and benefits and ____ Describe the ____ ____ meds ____ ```

``` intent alternatives technique preoperative diet ```

``` Appointment Day ■ ■ ■ ■ Preparation of ____ Informed consent ____ of patient Monitoring ____ vitals ```

equipment preparation pre-op

Technique of Administration 1. Establish ____ flow of O2 2. Position and secure the ____ hood 3. Adjust ____ rate for patients 4. 100% O2 for ____ min 5. titration of ____ every to desired effect 6. 100% O2 for ____ min 7. assess recovery

``` 6L/min nasal hood flor 3 to 5 N2O 3 to 5 ```

Signs and symptoms - ____-headedness - relaxed and comfortable - responds to ____ and conversation - ____ reflexes remain intact - paresthesia - ____ - diaphoresis - "floating" or "heavy" feeling

light directions protective flushing

Titration schedule N2O (%) 0 Time (min): ____ 20 Time (min): ____ 30 Time (min): ____ 40 Time (min): ____ 50 Time (min): ____ - you will go up to ____% NO at times. that is the most you cna titrate up to.

``` 3-5 1-1.5 1-1.5 1-1.5 1-1.5 ``` 70

% of N 2 > 5,000 N2O-O2 sedations at the USC Majority were at ____ %N2O!

20-40

``` Signs and Symptoms of Oversedation ■ ■ ■ ■ ■ Difficulty keeping mouth ____ Spontaneous mouth ____ N/V Failure to respond to ____ command Uncooperative or ____ ```

open breathing verbal agitated

``` Discharge Post-op ____ Assess recovery (lethargy, headache, dizziness, confusion, nausea) Gradually resume ____ position No ____ required ```

vitals upright escort

Anesthesia record Consent ____ ASA classification Pre-op vitals Pre-op: 100% O2 at ____ L/min for ___ min -- ___% N2O: ____%O2 at ____ L/min for ____ min Post-op: 100% O2 at ____ L/min for ____ min Post-op vitals Adverse reactions or comments

obtained wtf???

Equipment Sterilization | ____ versus ____ patient use nasal hoods

autoclavable | single

``` Safety of Staff ■ ■ ■ ____ exposure Recreational ____ ____ assaults ```

chronic abuse sexual

Work in surgical theatres and its influence on the health of anesthesiologists Demonstrated ____ rates of fatigue, irritability, nausea, pruritis, spontaneous abortion and fetal malformation

higher

``` Chronic Toxicity ■ ■ ■ ■ ____ Spontaneous abortion ____ suppression Neurologic deficits ```

infertility | bone marrow

Methods to minimize N2O levels Test equipment for ____ Venting of waste gases Scavenging ____ Minimize talking ____ devices

leaks nasal hoods monitoring