GRCC Dental Clinic | Nitrous Oxide Analgesia

GRCC Dental Clinic | Nitrous Oxide Analgesia

Articles Blog


(music)
>>Hi, I am Dr. Colette Smiley, and this is
Kyra Postma, and we are in GRCC’s
Dental Clinic today. I am going to go
through nitrous oxide inhalation sedation
with you. With this video, I am
going to demonstrate the proper administration
of nitrous oxide analgesia. We will begin with the
equipment and opening the tanks. Next step, we will go on
to preparing our patient, including blood
pressure and pulse. We will determine the
patient’s proper tidal volume. And then, begin
nitrous oxide administration. Once nitrous oxide
analgesia has taken effect, we will, of course,
perform the dental procedure, complete the procedure
with 100% oxygen, and dismiss the
patient after, again, taking their blood
pressure and pulse. Prior to seating
the patient, in fact, we are going to
spend a little bit of time with the nitrous
oxide equipment. I am going to open the tanks,
start the scavenging system, and fill the
reservoir bag. So, the very first thing you do,
Kyra, is turn on the tanks.>>Okay.
>>Okay? This is our wrench. And green tanks are
always oxygen. Blue tanks are
always nitrous oxide. And you turn the valve
on top counterclockwise to open the tanks. All right? On top of this– this is a
portable nitrous oxide system. And on top, you will see
tank pressure gauges– tank pressure gauges– which will show you,
in the case of oxygen, how much oxygen is
available in the tank. The pressure gauge
on an oxygen tank represents
very accurately how much oxygen is
remaining in the tank. That is not the case
for nitrous oxide. The nitrous oxide
tank will look full. The pressure
will show “full” until it’s about a quarter full,
and then it will drop. So I have confirmed that we
have oxygen and nitrous oxide in our tanks. The next step is setting
up the scavenging system. Scavenging system works with our
normal high-volume evacuation, so our normal suction. All right? We turn the
suction on… (suction noise) and then insert this end of the
scavenger into the suction, just as if you were
inserting a suction tip– just as if you were
inserting a suction tip. There is an on/off valve,
which of course we want “on.” And to determine that we
have adequate suction, we need to make sure that the
black ball is in the green zone. You can now go ahead
and seat your patient. We always review our
patient’s medical history and take their blood
pressure and pulse. I have already done
that with Kyra. And she’s good and healthy
and ready for our care today. Now, it’s time to
explain to your patient what is going to happen
with their nitrous oxide sedation treatment, and answer, of course,
any questions they may have. So, Kyra, today, we are going
to use nitrous oxide sedation. Our patients that find
it helps them treat– get through treatment very
relaxed and very comfortably. You should feel
comfortable at all times. If at any point,
you feel uncomfortable, anything makes
you uncomfortable, please let me
know right away.>>Okay.>>Do you have any
questions for me?>>No.
>>Wonderful, wonderful. All right, so I am
going to go ahead and sit the
chair back a bit. After reviewing the
patient’s medical history, taking their blood
pressure and pulse, and explaining the
procedure to them, we can now begin the
sedation procedure. First, you will turn
on the flow meter. And then, fill the reservoir
bag about two-thirds full, using the oxygen
flush valve… (gas filling bag
sound) Like so. The next step is to insert the
liner inside the nasal hood. There are
disposable liners. There are
autoclavable liners. We have autoclavable
liners here. There are disposable
liners that fit children. There are disposable
liners that fit adults. You should
hear it snap in. (click) We start the oxygen flow
to the nasal hood prior to placing it over
the patient’s nose. So, Kyra, I am going
to have you go ahead and rest your
head back for me. Thank you,
thank you. I am going to place
this over your nose. You are then welcome to
adjust it, to touch this, make sure that it is
comfortable for you, or as comfortable
as it can be. So go right ahead, yup, and feel
free if it is pushing somewhere or uncomfortable somewhere–
does that feel okay to you? Great. We definitely allow
our patients to adjust that nasal hood
to their comfort. You should feel
comfortable. You should not feel any
kind of air coming out underneath the nasal hood
or kind of blowing up toward your eyes. Are you feeling
that anywhere?>>Up here.
>>A little bit there. Okay. How is that? Good, wonderful. At this point, we estimate what
the patient’s tidal volume is. Tidal volume is the amount
of gas that you would inhale in liters–
in liters. So almost your
lung capacity for gas. So, Kyra, right now, all
I have on right now is oxygen. And of course, when you think
someone is watching you breathe, you breathe
differently, right? So you should just
breathe through your nose as best you can, and you should be able
to breathe comfortably. In other words, you shouldn’t
feel like you are having to– (inhaling)
either gasp for air, like you are not
getting enough air, or you shouldn’t feel as though
you are getting so much air that it is almost
filling your chest. Okay?>>I kind of feel like
I am not getting enough.>>Okay. So if the patient feels that
she is not getting enough, we go ahead and increase
the liters of oxygen. I started for Kyra
at six liters, which was my guesstimate,
my educated guess. But now, we are going to
bring it up to seven liters. And again, we wait for some
time just to allow the patient to develop a comfortable
inhale and exhale. You should be able to see the
reservoir bag move a little bit. You should be able to
see the reservoir bag expand and
contract. If you are seeing movement
with the reservoir bag expanding
and contracting, you are getting close
to being correct as far as the
tidal volume goes. So I am looking at
the green tube here. Of course, the green goes with
the green of the oxygen tanks. And there is a black ball
that I have adjusted to equal seven liters. So our markings are one,
two, three, four, five, six, eight, ten. So I am at the line
between six and eight. So, Kyra, are you still feeling
like you are not getting quite enough air or are you–
>>Yeah… um, yeah.>>Okay, like you
need a little more?>>Yeah.
>>Okay. So great, great. The reserve bag, as I said–
you should see movement in the reservoir bag,
inhaling and exhaling. Should the bag look like it’s
filled tight like a balloon, that means you are
putting too much oxygen– you are putting too much
air into the patient, and the patient is just not
able to breathe all of that. So what they are
not able to breathe stays in the reservoir bag,
fills it up like a balloon. What you should also not
see is a collapsed bag. If the reservoir bag
is collapsed, it means the patient isn’t
getting enough oxygen. It means they are
sucking in everything that you’re giving them
through the flow meter plus the extra in
the reservoir bag. If your bag
collapses, then that is when you want to
increase the amount of oxygen. That’s what we
are doing here. All we are doing here is
working toward determining the patient’s proper
tidal volume. So how is my
patient doing?>>Good.
>>Good, good. You are feeling
comfortable breathing?>>Yup.>>Like you are not having
to suck in extra air?>>No.
>>Okay. So we have determined
the patient’s tidal volume to be eight–
eight liters. Eight liters is Kyra’s
tidal volume today. That doesn’t mean
that eight liters would be Kyra’s
tidal volume if she comes for a
subsequent appointment. Each and every appointment,
the tidal volume needs to be determined
individually for that person and that patient
on that day. So, Kyra, I am
going to go ahead and begin administering
the nitrous oxide. We begin administering
nitrous oxide by adding one liter
of nitrous oxide. So we’re gonna look for
that black ball to come up. And I am going to
bring the black ball in the oxygen
down to seven. So we have the black ball
at nitrous at one liter. We have the black ball at
oxygen at seven liters. The reason I have done
that is to maintain our proper
tidal volume. We determined Kyra’s tidal
volume to be eight liters. I have added one liter
of nitrous gas. I have decreased the
oxygen to seven liters. Seven liters plus one liter
equals eight liters. That is Kyra’s
tidal volume. The first liter of nitrous oxide
we administer for a full minute. So we allow a full minute
of nitrous oxide before we begin adding other
doses of nitrous oxide. After the first liter,
we will add one-half liter of nitrous oxide
every minute. This method of dosing
is called “titration.” Titration allows you
to give the patient the amount of drug
they need but just the amount
of drug they need, not over-sedating, not giving them more
drug than they need. So we just add the nitrous
oxide incrementally. We try to also– and Kyra
is doing a great job here. We generally ask the patients
not to chat a whole lot, not to talk
a whole lot. When patients talk,
when patients exhale, that puts excess
nitrous oxide into the room, into the
environment, and in addition to
our scavenging system, we want to minimize the
amount of nitrous oxide in the ambient air. So I will be asking Kyra some
questions as we continue the sedation process,
and we will go from there. So Kyra, we have
waited a minute. I am going to go ahead
and increase the amount of nitrous oxide
by a half liter. So we have gone up to
1.5 liters with nitrous, and we are going to go
down to 6.5 with oxygen. Great. The signs of
nitrous oxide sedation that we will be
looking for– we will look to make sure
that the patient is relaxed, the patient
is comfortable. Some patients just
appear kind of chill. They are just not
bothered by anything. Some patients will describe
tingling in their arms or legs. Some patients will describe
tingling around their mouth or even an overall
warm feeling. So those are some of
the signs and symptoms– not “symptoms,” but
signs that you will see for proper
nitrous oxide sedation. The eyes really
tell the story. The eyes really tell
the story. Eye movement will
be decreased, and also the eyes will
start to appear real glassy. So watching eyes
is key to making sure that the patient is sedated,
and properly sedated. With a tidal volume
of eight liters, we may end up adding a bit
more nitrous oxide for you to achieve our
proper sedation. Again, we have
waited a full minute. We can go ahead and add our next
half liter of nitrous oxide. We are up to two liters
now of nitrous oxide and adjusted our
oxygen to six liters. Remember six plus two
is eight. We are maintaining our
eight liter tidal volume. Signs that we don’t want
to see in our patient. The patient should
not feel dizzy. The patient should
not feel lethargic. The patient should not feel
headachy or a little nauseous. The patient should not feel like
they are floating or flying, having sort of an
out-of-body experience. Should the patient be
feeling any of those things, then that is a sign they
are becoming over-sedated, and the nitrous oxide needs
to be adjusted downward. When sedation is
becoming evident, it makes sense to wait a little
bit longer between doses. So if you are beginning to
observe some of those signs that we talked about, particularly
the glassy eyes sign, in your patient, then we
wait a little bit longer than one minute in between
doses, in between adding a dose, to allow the peak effect
of one dose to take effect before we add more
nitrous oxide. So that is really what
we are doing now. I am beginning to see–
you might have noted this. I am beginning to
see in Kyra’s eyes sort of a glassier appearance,
a moist appearance. Eye movement is
slowing down. So we are just starting to
get the very beginning signs of nitrous oxide
sedation. Well, we definitely
see it in your eyes. You are smiling a
little bit easier. These are all signs
that the sedation is beginning
to take effect, the sedation is beginning
to take effect.>>I do feel really relaxed.
>>Great. The patient has told us
she feels really relaxed. In fact, there is no need to
add any more nitrous oxide. We have achieved the level
of sedation that we want to. In practice, you can go ahead
and begin your dental treatment. Whatever treatment you are
going to perform that day, go ahead and begin
your dental treatment, of course always keeping
an eye on your patient, making sure that they are
still feeling relaxed, they are still
feeling comfortable. As I said
earlier, Kyra, if, at any time, you feel
uncomfortable at all, please let us know. What happens, as the
patient achieves sedation, they tend to breathe
a little bit slower. When they breathe
a little bit slower, they are exhaling
the nitrous oxide a little
bit slower and in fact almost increase
their sedation rate a little bit. That’s why, throughout
the procedure, we want to make sure they are
still feeling comfortable and not moving into those signs
and symptoms of over-sedation, of nauseous to their
stomach or feeling dizzy or headachy
or lethargic. As you near the end of
your dental treatment– so we have completed
your treatment today. You go ahead and turn
off the nitrous oxide, and turn up the oxygen to
the original tidal volume. So, again, we determined early
on that Kyra’s tidal volume was eight liters. I have turned off
the nitrous oxide. The patient is now on
their tidal volume– eight liters
of pure oxygen. And the patient should
receive 100% oxygen for five minutes. This can very easily be done
at the end of the appointment. So let’s say you are performing
a scaling and root planing. You have completed your
scaling and root planing. Perhaps you are going to
polish that quadrant today. It’s very likely you don’t need
sedation for the polishing. Go ahead and turn
off your nitrous, turn on the
100% oxygen, and begin your five minutes
of 100% oxygen as you finish up
your treatment. While the patient is
having 100% oxygen, we will go ahead and
take her blood pressure and we will
take pulse again. Kyra, I am going to push up
your sleeve a little bit–>>Okay.
>>Okay? Thank you. And you can go ahead
and rest your arm. (air pumping in
blood pressure cuff) (air pressure
releasing) Kyra, your blood pressure
now is 128 over 74. When we started it
was 118 over 78. It’s very normal to
have the blood pressure vary about ten points or so
in either direction, either increase ten points
or decrease ten points. That doesn’t cause us
any kind of alarm.>>Okay.
>>All right. I am going to go ahead
and take your pulse then. Great. And your pulse
is 64. After the patient has had
100% oxygen for five minutes, we want to make sure that
they feel 100% normal. It hasn’t quite been five
minutes for you yet, Kyra, so we are going to continue
that for a little bit. Again, if the patient feels
lethargic, headachy, nauseous, sick to their stomach, dizzy even after
five minutes of oxygen, then keep the oxygen on them
for some additional time. So we keep the oxygen on
as long as we need to until the patient
feels back to normal. Once the patient has told you
they feel 100% back to normal, you can remove
the nasal hood, slowly sit
the chair up, and in fact dismiss the patient
to home, work, or school, wherever they
are going to go. There are really no special
postoperative precautions with nitrous oxide
sedation. Nitrous oxide sedation has
been used over 160 years with a remarkable
safety record. There are no known
cases of allergy to nitrous oxide
sedation. So once the patient
has been dismissed, you will turn off
the tanks. You will complete
the patient record and, of course, sterilize
or disinfect the tanks. So, Kyra, you now have
been on 100% oxygen for about three minutes or so–
three, four minutes. How are you feeling now?
>>I feel back to normal.>>You feel back
to normal?>>Mmm-hmm.
>>Great. Even if the patient has told
you they feel back to normal at three or
four minutes, we wait the full five minutes
with 100% oxygen. How did you find the
overall experience? This has been
the first time you’d had nitrous oxide
sedation. Did it– how did you feel,
how did you find it?>>I liked it. I mean, it is something I would
use in the dental office.>>Okay. Didn’t feel
uncomfortable at all?>>Not at all.>>Many patients report
experiencing dizziness, a stomach upset, or they
have experienced that, and again, generally,
those have been signs that they have
been over-sedated. We use– and you will be
taught the titration technique where we are
just adding a little bit of nitrous
periodically every minute or so until we achieve just the
amount of sedation we need. Try to avoid the
“fixed dose” technique. A number of practitioners will
use the “fixed dose” technique. In other words, everyone
gets 40% nitrous oxide, 60% oxygen. In those cases,
that is when people begin to feel over-sedated,
sick to their stomach, dizzy, floating,
and so on. So… great job. Thank you very, very much
for letting us do this.>>No problem.
>>You are just a peach. So we will go ahead and we
will remove the nasal hood. Great. We can turn off
the oxygen. We can turn off
the suction. And slowly sit
the chair back up. (music) Great. So thank you for letting
me care for you, Kyra. You can go ahead and do what
you would normally do today. So school work, work, home,
whatever you were going to do, by all means just
go right ahead.>>Okay.
>>All right… thank you.>>Thank you.
>>You are welcome. You are welcome. (music)

Leave a Reply

Your email address will not be published. Required fields are marked *