Nitrous oxide-oxygen

Analgesia
• Sedation & General anaesthesia are a part of
the pharmacological techniques for
management of children.

• Definition:

Conscious sedation is a controlled,

pharmacologically induced, minimally
depressed level of consciousness that retains
patient’s ability to maintain a patent airway
independently and respond appropriately to
physical stimulation.
 Nitrous oxide
The only agent used with inhalation technique
that meet the requirement of sedation is
nitrous oxide.
Properties of nitrous oxide:
Sweet smelling, colourless, inert gas
Heavier than air.
Nonflammable but supports combustion.
Always coupled with more then 40% O2.
Rapidly absorbed from lung alveoli with rapid
excretion when concentration gradient is
reversed.
 Equipment used for delivering
nitrous oxide-oxygen

The machine is of continuous flow

design type with flow meters capable of
accurate regulation.
A fail-safe mechanism that provides
automatic shutdown if oxygen falls below
20% with audible and visual alarms is an
important design feature.
There should be a flush-lever for easy
immediate flushing of the system with
100% oxygen.
Induction Slow – 0.5-1 lit/min
Rapid – 2–4 lit/min
40% nitrous oxide
60% oxygen
Maintenance 20-30% nitrous oxide
Reversal 100% oxygen
Effects of various systems of body:
CNS depressant action, though there is limited
analgesia. Amnesia is possible only at higher
concentration.
Reduces CO2 stimulated respiratory drive
therefore problems may result if used in combination
with narcotics.
Decreases cardiac output and increases peripheral
vascular resistance. This is significant in patients
suffering from cardiac problems.
Vomiting may be induced depending on the length
of exposure and concentration of the drugs.
For the patient- It should be pleasant, non
irritating, should not cause nausea or vomiting.
Induction and recovery should be fast with no after
effect.

For the surgeon- It should provide adequate

analgesia, immobility and muscle relaxant.
It should be noninflammable and nonexplosive so
that cautery may be used.
Anaesthetic Nitrous oxide
Boiling point (ºc) Gas
Inflammability Noninflammable
Irritancy (odour) -
Oil: Gas Partition
coefficient 1.4
Blood: Gas Partition
coefficient 0.47
MAC (%) 105
Induction Fast
Muscle relaxation Poor
Stage of analgesia
Stage of delirium
Surgical anaesthesia:
-Plane 1: Roving eye balls. This plane ends
when eyes become fixed.
-Plane 2: Loss of corneal and laryngeal
reflexes.
-Plane 3: Pupil starts dilating and light reflex
is lost.
-Plane 4: Intercostal paralysis, shallow
abdominal respiration, dilated pupil.
Medullary paralysis
Indication and benefits:
- can be used for mild to moderate levels
of anxiety
- Analgesia for brief, comfortable
procedures
- Rapid onset and early elimination and
recovery
- The duration of action can be easily
controlled
Limitation and risks
- Agent has week potency.
- It can be used to decrease the anxiety
level, but not in children with severe
behaviour problems.
- Also cannot be used in claustrophobic
patients, respiratory tract infection.
Three elements of importance stated were:
1. The administration of low to moderate
concentrations of nitrous-oxide, carefully
titrated to the patients need.
2. The patient is simultaneously subjected to a
steady flow of reassuring & semi-hypnotic
suggestion.
3. The use of equipment, such that it is not
possible to administer 100% nitrous oxide
accidentally or deliberately.
The patient at rest has tidal volume of 6-8 litres. with
anxiety this increases. Thus it is necessary to establish
flow rate as per the patients tidal volume.

Rate/minute Tidal Volume Average tidal

Volume/minute
Adult 12-16/m 500cc 7 Liters
Child 20-24/m 200-250cc 5 Liters
Infant 25-30/m 100-175cc 3 Liters
Nitrous oxide is carried in a simple solution in
the body and does not enter any chemical
combination i.e. its solubility in blood is
extremely low. thus free state is high and a
rapid equilibrium between alveolar and arterial
tension takes place & the onset as well as
elimination occurs in a few minutes.
It is a weak GA gas and cannot produce full
general anaesthesia on its own. but it is an
excellent analgesic.
• Plane I- moderate sedation & analgesia
- Achieved with concentrations of 5-25% N20
- As the patient inhales, reassure that the
symptoms may not be felt. when the symptoms
are felt, specially in children the instructions
have to be adapted to the terminology
understood. simultaneously, it is also
important to connote a floating, light feeling.
 - Patient may sense dizziness.
- Patient may feel tingling in the fingers,
toes, cheeks, tongue, back head or chest.
- Marked sense of relaxation, the pain threshold
is raised.
- Diminution of fear and anxiety occurs.
- Hearing, vision also impaired but pupils are
normal & contract when a light is shown.
- Perioral musculature is also relaxed.
Plane II: dissociation sedation & analgesia
- Concentrations of 25-45%
- May or may not experience symptoms.
- psychological symptoms such as dissociation or
detachment are felt. a cuphoric state, similar to
alcoholic intoxication (the laughing gas parties).
- the patient is suffused by a warm wave and may
experience a slight humming or buzzing in the ear,
with a ‘floaty’ feeling.
- Patient has pleasant dreams and has a level of
psychosedation with a leg, hand sliding off the
chair.
- Patient is conscious and responds to question,
with however a considerable mental effort
involved in thinking.
PlaneIII: total Anesthesia (analgesia)
-Achieved with 45-65% concentrations
-Analgesia is complet. patients may
undergo extraction procedure.

-Marked amnesia develops.

-Zone between analgesia and light
anesthesia.
-federmesser has sub-divided this into
3 planes.
a. Lightest plane
b. Somnolent state
c. Deepest plane
Plane IV: Many develop beyond 65-85%
Light anaesthesia- contact with patient lost.
For the Patient
1. If enclosed space-contraindicated such as
pneumothorax.
2. Upper Respiratory tract infection.
3. Respective depression where respiration is on
CO2 drive, as O2 increase will diminish this
drive e.g. Bleomycin therapy-pulmonary
fibrosis.
4. Pregnancy as spontaneous abortions may
occur.
5. Diffusion hypoxia, which can be avoided by
keeping the patient on 100% oxygen.
Patient/personnel
1. DNA synthesis affected- Vitamin B12
oxidation may be suppressed even with
brief exposure of at least 6 hours.
2. Altered Hematopoesis, pernicious Anaemia.
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Shobha Tandon, 1st Edition 2001.
2. Essentials of Medical Pharmacology,
K.D. Tripathi, 5th edition 2003.
3. Textbook of Pediatric Dentistry,
S.G. Damle, 2nd Edition.
4. www.google.co.in.
5. Dentistry for the child & adolescent,
Ralph E. Mcdonald, David R. Avery,
8th Edition.