N2O in ANAESTHETICS

Lina Quteineh MD, PhD

N2O Commonly Used (and

misused)
88% of Pediatric Dentists use N2O, and
about 58% of general dentists use N2O.

Purpose of Nitrous Oxide Sedation:

• Reduce fear, apprehension, or anxiety
• Raise pain reaction threshold
• Reduce fatigue

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 Fear Reduction and N2O

Four Stages of Anesthesia

• Analgesia
– patient is conscious
– reflexes are intact
The patient is unconscious in
• Delerium Stages 2, 3, and 4.
• Surgical Anesthesia
• Respiratory Paralysis

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 Analgesia
• In analgesia stage, the patient is
conscious, has all vital reflexes intact, can
communicate and cooperate with the
dentist, and quickly returns to a normal
state following a few minutes of
oxygenation.

Four Plateaus of Analgesia

• Paresthesia - tingling of hands, feet
• Vasomotor - warm sensations
• Drift - euphoria, pupils centrally fixed,
sensation of floating
• Dream - eyes closed but will open in
response to questions, difficulty in
speaking, jaw sags open

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 N2O Should Be Used To:
• Ease fears and anxieties
• Aid in the treatment of special patients
• Increase tolerance for longer appointments
• Raise the pain reaction threshold

N2O Should Not Be Used To:

• Control defiant or uncontrolled behavior
• Control pain by replacing local anesthesia
• Replace poor techniques of behavior
management

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 Signs of Saturation
• Reminding child continuously to hold
mouth open
• No response to questions
• Agitation
Monitor
• Sweating Frequently

• Nausea
• Unconsciousness

Elimination of N2O
• Rapid
• Primarily through the lungs
• Small amount through skin, sweat glands,
urine, and intestinal gas

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 Administration of N2O
• Medical history & vital signs
• 5 - 6 liters O2
• Increase N2O gradually; watch for
stages of analgesia
• Maintenance about 20 - 40%
• Reduce N2O with long procedures
• Record N2O levels in the chart
• 3 - 5 minute O2 flush
• Rapid induction (surge) technique

Technique
• An RA (relative analgesia) machine will not deliver less
than 30% O2 .
• Start by delivering 100% O2 via a nasal mask and set
flow control to match their tidal volume
• Then give 10% N2O for 1 min, then (if needed) to 20%
for 1 min, then to 30% (if needed) for 1 min, and so on.
• Most patients achieve adequate levels of sedation at 20
to 30%; some may require less, a few rather more.
• To discontinue, turn flow to 100% O2 and oxygenate
patient for 2 min.
• Then remove mask and get the patient to sit in a
recovery room for 10 min, by which time 90% of N20 will
have been blown off and they will be safe to leave the
surgery.

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 Complications/Precautions
• Vomiting - due to:
– overdosage
– prolonged administration
– pre-existing GI infection, influenza
– history of motion sickness or vomiting (use anti-
emetic)
– impurities in the delivery system (rare)
• Prevent vomiting by close observation of
patient

Hallucinations
• Complications/Precautions

Always have an assistant

present!

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 Complications/Precautions
• Mild rhinitis or colds are not absolute
contraindications
• Contraindicated in patients with a
depressed respiratory system
– chronic emphysema
– tuberculosis
– multiple sclerosis
– remember, N2O will potentiate drugs that
depress the respiratory system

Complications/Precautions

• Contraindicated in patients with blocked

eustachian tube, pneumothorax,
pneumoperitoneum, and
pneumopericardium
• Contraindicated in the first trimester of
pregnancy

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 Complications/Precautions
• Other possible contraindications:
– severe cardiac disease
– hyperthyroidism
– uncontrolled diabetes
– sickle cell anemia
– severe asthmatic conditions