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Pain Control II > Nitrous 2/20 > Flashcards

Nitrous 2/20 Flashcards

1
Q

local anesthesia

A

elimination of sensation of pan in one area of the body

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2
Q

analgesia

A

diminutio or elimination of pain

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3
Q

GA definition and stages

A

elimination of all sensation and loss of consciousness

  1. analgesia
  2. delerium
  3. surgical anesthesia
  4. respiraotry peralisis
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4
Q

GA staging is based on

A 
respiration status 
eyeball activity 
pupillary changes
eyelid reflex
swallowing 
response to surgical stimulation 
pharyngeal reflexes
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5
Q

stage that is undesirable

A

stage II – delirium

want this stage to last the least amount of time

ideally stage I to stage III

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6
Q

stage I

A

analgesia
pt is AWAKE
respiration, eye movements and protective reflexes are normal

amnesia (+/-) (loss of memory)

stage one is APPROPRIATE

WHERE WE WANT TO BE WITH NITROUS?

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7
Q

sedation is stage?

A

I

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8
Q

indications for sedation

A

anxious patient
- medical conditions
complex procedures

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9
Q

pain and axiety control

CNS depressants first affect? then?

A

first effect – depress the cerebral cortex (sensory and motor)

followed by basal ganglia, cerebellum, spinal cord and finll medulla

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10
Q

stage II

A

CNS depression is greater

paient looses consciousneess
- respiration is irregular

*Nystagmus (repetitive eye movements) is present
pupils react to light
skeletal muscle tone INCREASES
laryngeal and pharygngeal reflexes increases

UNDESRIABLE

want this to be as short as possible

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11
Q

stage III

A

surgical anesthesia

  • patient is unconcious

patient does not respond to surgical stimulus

  • respiration becomes irregular
  • muscular tone is lost
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12
Q

stage IV

A

medullary paralysis

onset of respiratory arrest

leads to loss of effective circulation

stage iv is reversible death

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13
Q

types of sedation

A

iatrosedation
- no medications - through doctor behavior like hypnosis -

pharmacosedation
- medications

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14
Q

iatrosedation

A

doc - patient communication
- bonds of trust and confidence

other

  • hypnosis
  • acupuncture
  • acupressure
  • audio analgesia
  • biofeedback
  • electro-analgesia
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15
Q

sedation def and stage?

A

stage I of anesthesia

  • altered state of consciousness in which the patient is in a relaxed stage
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16
Q

popularity of nitrous use

A

general 56
OMFS85
pediatric (most) 88

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17
Q

analgesia

A

diminuition or elimniation of pain

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18
Q

GA

A

elimination of all sensations and loss of consciounsess

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19
Q

CNS depressants first hit

A

first depress the cerebral cortex - sensory and motor

then the basal ganglia, cerebellu,, spinal cord and lastely medulla

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20
Q

hx of angina - use nitrous

A

yes

as long as keep oxygen at the level it needs

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21
Q

indications for sedation for adults

A

adult patients

  • anxious
  • complex procedures
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22
Q

indications for sedation for pediatric / younger

A

uncooperative child
extensive and complicated tx
acute pain or trauma
physically or mentally disabled

a very young child is best managed in hospital setting

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23
Q

indications for sedation for geritrics

A

same as adult

  • changes in pharmacokinestics and pharmacodynamics
  • increased risk of adverse drug rxns
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24
Q

minimal sedation vs moderate vs deep vs unconsciouss

A

minimla

  • first level
  • respond normally to verbal commands
  • ventilatory and cardio functinos are unaffected

moderate

  • minimally depressed level of consciousness
  • response to commanf, may need stimulus
  • protective reflexes intact, maintain airway

deep
- depressed consciousness and partial loss of protective reflexes

unconsciouss

  • not responding to commands
  • protective reflexes may not be intact
  • may not maintain airway
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25
Q

minimal sedation

A

SHOULD CARRY A MARGIN OF SAFETY WIDE ENOUGH TO NEVER RENDER UNINTENDED LOSS OF CONSCIOUSNESS.

not considered in minimal state if reflex withdrawl from repeated painful stimuli is only response

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26
Q

parenteral means

types?

A

bypass the GI

  1. inhalation
  2. intravenous
  3. intramuscular
  4. transmuscular
  5. transdermal

enteral - absorbed in GI tract -

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27
Q

initial dose of enteral drug?

A

NO more than the maximum recommended dose prescribed for unmonitored use at home

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28
Q

preoperative sedatives to children?

A

NOT taken before getting to the office b/c risk of unobserved respiratory obstruction during transport by untrained individuals

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29
Q

moderate sedation details

A

margin of safety wide enough to render unintended loss of consciousness (minimal was NEVER loss of consciousness)

  • respond purposefully to verbal commans either alonf or ACCOMPANIED BY LIGHT TACTILE STIMULATION

maintain airway and spontaneous ventilation is adeuate

cardio function is usually maintained

repeated dosing only after full drug effects are evident

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30
Q

deep sedation details

A

CANNOT be easily aroused but respond purposefully following repeated or painful stimulation

cardio usually maintained

may need respiratory assistance

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31
Q

patients are NOT arousbale during what

A

general anesthesia

32
Q

titration and what one must know

A

titration - asdministration of incremental doses of a drug until a desired effect is reached

must know

  1. time onset
  2. peak response and duration of action

MAKE SURE KNOW IF FULL EFFECT OF PREVIOUS DOSE WAS REACHED

33
Q

total volume to give is

A

7 L

so if add 1 L nitrous oxygen 6 L of oxygen

34
Q

if only breathe through mouth

A

nitrous prob not working

35
Q

baseline vital signs needed

A

blood pressure
pulse rate and rhythm
respiratory rate

36
Q

ASA I

A

normal - healthy

37
Q

ASA II

A 
mild systemic disease 
pregnant 
controlled HN
controlled NON insulin dependent Diabetes
controlled epilespy
38
Q

ASA III

A

severe disease that limits - but not incapacitating
well controlled insulin DEPENDENT DM
stable angina pectoris
controlled COPD
> 6 months post MI with no residual complications
mild CHF
moderatley / well controlled epilepsy

39
Q

ASA IV

A

incapacitating systemic disease that is a constant threat to life

  • unstable angina pectoris
  • MI or stroke in past 6 months
  • uncontrolled HTN
  • severe CHF or COPD
  • uncontrolled epilepsy
  • uncontrolled diabetes mellitus
40
Q

ASA V

A 
not expected to survive more than 24 hours with or without tx 
end stage malignancy
end stage cardio
end stage espiratory
end stage infectious
end stage hepatic
41
Q

ASA VI

A

declared brain dead patient whose organs are being removed for donor purposes

42
Q

mandatory monitoring during N2O-O2 sedation

A

BP – before during and after

pulse rate and rhythm
- values below 60 or above 110 / min = evaluate
regular or irregular

verbal response
anesthesia record

recommended
- pulse oximetry

43
Q

respiration monitored by

A

rate

rise and fall of chest

color of mucous membranes

44
Q

pulse oximetry

A

oxygen saturation of arterial blood

mandatory for IV sedation and GA

detects hypoxemia prior to EKG changes

monitors pulse rate

45
Q

physical properties of oxygen

A

non irritating
odorless
colorless
non flammable but supports combustion

green tanks - cylinders
100% oxygen
100% gas
2000psi at 70 degrees

avoid oil and grease close

46
Q

physical properties of nitrous oxide

A

non irritating
sweet smelling
colorless
boiling point of -885 degrees celcius

GAS AT ROOM TEMP

converts to liquid form at 28 degrees celcius and 50 atmospheric pressure

47
Q

supply of nitrous

A

BLUE cylinders
95 % LIQUID
5% VAPOR

fulll cylinder
- 750 psi at 70 degrees
575 psi at 50 degrees

48
Q

as liquid is vaporized…

A

the pressure gauge is not accurate – gauge may not decrease until levels are down 20%

so when half tank gone of nitrous - psi may show original 750

when half tank of oxygen – original 2000 psi will show half (1000 psi)

so wont know how much nitrous you have left really

49
Q

potency of nitrous? solubility?

A

LEAST POTENT
but 100 x more soluble than oxygen and 35 times more soluble than nitrogen in plasma

relatively insoluble
- blood gas solubility coefficient of .47 at 37 degrees

remains unchanged in the blood
- small quantities are needed to reach the required blood concentrations

50
Q

MAC of nitrous

A

minimum alveolar concentration

105%

concentration that prevents movement in 50% of subjects in response to a standard surgical incision

51
Q

nitrous oxide effect on the heart

A

NO CHANGE IN HR OR CARDIAC OUTPUT

blood pressure remains stable

CURRENTLY NO CONDITIONS INVOLVING THE CARDIOVASCULAR SYSTEM SHOULD INDICATE MEDICAL CONSULTATION OR POSTPONEMENT OF N2O/O2 USE

52
Q

contraindication to N2O/O2 sedation

A

patients having undergone recent pneumoencephalography or for patients who are abuser of nitrous oxide

53
Q

CNS effects of nitrous

A

mild depression of all sensations

vomitting center NOT affected - unless hypoxia develops

54
Q

renal system with nitrous

A

no effects and no contraindications

55
Q

nitrous with respiratory system

A

effects are sedation and anxiety relief - no irritant to pulmonary epithelium

should be AVOIDED in patients with pneumothorax or cystic fibrosis

should be postponed for patients experiencing acute sinusitis or upper respiratory tract infections

medical consult for patients with COPD

56
Q

postpone nitrous in

A

patients with upper resp tract infection or sinusitis

or signigicant bowel obstruction (otherwise no clinically significant effects on the GI system)

57
Q

pernicious anemia or other vit b 12 deficiency

A

avoid or consult before use of nitrous

58
Q

nittrous with hematopoetic system

A

long term
- bone marrow supression

repeated short term

  • increased spontaneous abortions
  • decrease in fertility
  • vitamin b12 metabolism – pernicious anemia – neuropathy could ensue
59
Q

pregnancy with nitrous

A

AVOID IN FIRST TRIMESTER
- then medical consult in others

  • passes through placenta into fetus
  • use at least 20% oxygen
60
Q

cancer with nitrous?

A

IF RECEIVING BLEOMYCIN SULFATE THERAPY – should be avoided or postponed

most serious toxic effect of bleomycin is interstitial pneumonitis which occuurs in approx 10-20%

61
Q

cognitive disorders with nitrous

A

if the level of understanding is NOT present or the practioner is unable to determine its presence - Nitrous SHOULD NOT be used

62
Q

mind altering conditions with nitrous

A

contraindications for patients

  • current / recovering alcoholic
  • drug addiction
  • antidepressant or psych drug therapy
63
Q

middle ear disturbances, eye surgeries, other

A

CONTRAINDICATED FOR

  • tympanic membrane graft
  • with recent eye surgey using perfluoropropane ot sulfur hexafluoride gas
  • in shock or semiconscious state
  • serious head or facial injuries
  • taking medications to induce sleep
  • unwilling to consent
64
Q

peak?
analgesia?
optimal concentration?

A

peak within 3-5 minutes

analgesia
20% concentration = 10-15 mg morphine

optimal concentration - variably but approx 35%

65
Q

concentration effect of nitrous

A

vacuum type effect
higher the concentration of gas inhaled - more rapid is the increase in the arterial tension of the gas
- significant at higher concentrations (over 70% )
- not significant at lower concentrations

66
Q

second gas effect

A

occurs when other inhalation agents are COMBINED with n2o2

INCREASES CONCENTRATION OF SECOND GAS
- ADVANTAGES during GA as it minimizes the required concentration of other agent

67
Q

diffusion hypoxia

A

occurs at termination of sedation

prevent with 100% o2 for 3-5 minutes

the hangover effect

  • headache
  • nausea
  • dixxiness
  • lethargy
68
Q

advantages of nitrous

A 
practice builder
rapid onset
rapid recovery 
depth of sedation controlled
no injected required
excellent safety record
patient acceptance
69
Q

disadvantages of nitrous

A 
cost of equipment
low potency
required patient cooperation 
chronic exposure (has some health side effects?
staff training required
70
Q

medically compromised who can use nitrous

A

cardio
cerebrovascular
asthma

71
Q

abosulte contraindications for nitrous

A 
pneumothorax
cystic fibrosis
COPD
recent pneumoencephalography 
suspected or known pernicious anemia or B12 deficiency 
significant bowel obstruction
first trimester 
cancer therapy using bleomycin sulfate 
psychological impairment
current psychotropic drug use 
recovering or user of drugs 
patient in shock / semi sconsciouss or with serious head facial injury 
inaibility to understand procedure or unwilling to consent
72
Q

relative contraindication to nitrous

A

current URT infection
middle ear disturbance / surgery
recent eye surgery using perfluropropane or sulfur hexafluoride

73
Q

safety on delivery + % gas delivery mechanism

A

pin index - prevents accidental attachment of n2o cylinder to o2 portal with portable machines

diameter index safety system - prevents accidental attachment of n20 hose to o2 portal

flowmeter - minimum oxygen delivery - fail sage mechanism – will shut off if oxygen stops

02 - minimum 30%
N2O maximum is 70%

74
Q

written record must have

A

all patient biographical date

record all medications / fluids

  • dose
  • route of administration
  • time of administration

vital signs

  • preoperative
  • intraoperative q 15 mins
  • postoperative
75
Q

good for gag reflex?

A

yes

Pain Control II (15 decks)

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