GOOD MORNING…

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CONSCIOUS SEDATION
PART - II

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 CONTENTS
• Introduction to Inhalational Agents

• History

• Rationale of using N2O

• Basic properties of N2O gas

• Mechanism of action

• Technical considerations for its use

• Clinical applications

• Sedation using N2O

• Conclusion

• References
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 INTRODUCTION

Nitrous oxide

Desflurane Chloroform

Sevoflurane
INHALATIONAL Ether
AGENTS

Isoflurane Halothane

Cyclopropane

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 HISTORY

DISCOVERY OF N2O AND O2

Sir Joseph Priestley

“Dephlogisticated Nitrous Air”

Good Air - Fit For Respiration,

and he titled this discovery
“Dephlogisticated Air,” which is
now known as OXYGEN

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 INHALATION OF N2O
 First to chronically inhale pure
N2O

 Most voluptuous sensations

Ideal existence
Overwhelming joy

 Experienced diminished pain from

a toothache while using N2O that
he began to believe it could affect HUMPHREY DAVY
pain sensations
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 THE REVELATION AT
DR. COLTON’S GRAND EXHIBITION

It was an exhibition to demonstrate the

exhilarating effects of inhaling N2O

GARDNER
COLTON

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 “The greatest discovery ever made”
“A new era in tooth pulling”

• For the next several years Wells

continued to provide anesthesia
for surgeons in the area.

• Dentists began to give attention

“Father ofN2O.
to the use of Anesthesia”
• In fact, advancing dentistry’s
reputation hinged on the success
of extracting teeth with pain
relief.

HORACE
Bust of WELLS
Horace Wells in the Etats Unis
Park near the Arc de Triomphe in Paris,
France (2002). 8
 RESURGENCE OF N2O

• In 1868, Dr. Edmund Andrews

suggested that, when 100% N2O
is used, the blood is not
appropriately oxygenated.

• Andrews added O2 to the N2O

and claimed one fifth of the
volume should be O2.

EDMUND ANDREWS

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EVOLUTION OF ANESTHESIA
ETHER ANESTHESIA

“ETHER DOME” WILLIAM MORTON

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 CHLOROFORM ANESTHESIA

• Chloroform continued to be
a major anesthetic agent
into the 1860s

• Became standard issue to

soldiers who, when injured in
battle, could self-administer
it.
JAMES SIMPSON

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CYCLOPROPANE
 1929
 General anesthetic.
 Its use declined because of flammability
issues

LIDOCAINE
 1940
 Local anesthetic not associated with
allergies and other potential medical
problems
 Management of pain and anxiety

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 RATIONALE OF USING N2O
OBJECTIVES
Reduce or eliminate anxiety.

Reduce untoward movement and reaction to dental treatment.

Enhance communication and patient cooperation.

Raising the pain threshold

Increasing the tolerance for longer appointments

Aid in treatment of the disabled or medically compromised patient

Potentiate the effect of sedatives

Reduce gagging. 13
 INDICATIONS
CONTRAINDICATIONS
POSSIBLE ABSOLUTE
Fearful, anxious, or obstreperous patient
Sinus infections/ Recent eye surgery
congestion
Patients with special health care needs
Upper respiratory tract Recent ear surgery
infection
Gag reflex interfering with dental care
Ear infection Latex allergy
Profound
Mental local
illness, anaesthesia Bleomycin
autism, cannot be obtained
therapy
psychiatric disorders
A cooperative child undergoing a lengthy dental
procedure
Claustrophobia Cobalamin deficiency

Nitrous Oxide in Pediatric Dentistry - A Clinical Handbook Kunal Gupta,

Dimitrios Emmanouil, Amit Sethi 14
 ADVANTAGES

Fast Onset

Ease of Administration

Sedation Level Can Be Adjusted Based on Response (Titratable)

Quick Recovery

Ability to Communicate During Procedures

Safe Compared to Other Agents

No Impact on Daily Duties

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 DISADVANTAGES

Poor acceptance of the nasal mask

Difficulty in introducing nasal mask in children of precooperative age

Associated with nausea or vomiting

No role in post-treatment pain

Children with behavioral problems

Dependence on psychological assurance

Occupational hazard for the dental personnel

Cost of equipment

Not an alternative to local anesthesia

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BASIC PROPERTIES OF N2O

Nitrous oxide is relatively insoluble in blood. It is carried in

blood without combining with any other constituents of blood

1. Nonirritating
2. Slightly sweet-tasting
3. Colorless gas
4. One and a half times heavier than air
5. It is not inflammable but supports combustion (because at
temperatures above 450 °C it breaks down into nitrogen
and oxygen and the latter will support combustion)
6. It is very stable and rather inert at room temperature.
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MANUFACTURE AND STORAGE OF NITROUS OXIDE

CLAUDE LOUIS BERTHOLLET

NH4NO3 N2O + 2H2O

2NO+H2O+Fe N2O+Fe(OH)2.
JOSEPH PRIESTLEY’S APPARATUS
Nitrous Oxide in Pediatric Dentistry - A Clinical Handbook Kunal
Gupta Dimitrios Emmanouil Amit Sethi 18
Nitrous oxide, actually synthesized in 1772, soon faded into
background until it was revived by
HUMPHREY DAVY

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 Modern Processes
for the Manufacture of Nitrous Oxide
Solid Ammonium Nitrate
Ammonium Nitrate Solution
NH4NO3
250 C

N2O + 2H2O
(steam)
Steam is
condensed, water
& contaminants
are removed

N2O
Nitrous Oxide in Pediatric Dentistry - A Clinical Handbook Kunal
20
Gupta Dimitrios Emmanouil Amit Sethi
 Storage of Nitrous Oxide

• Low carbon steel (traditionally used)

• Light weight chrome molybdenum
steel
• Aluminum
• Aluminum wrapped in carbon fiber

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 Precautions to be taken during handling and
storage of medical gas cylinders
 Oxygen (2000–2015 psi) is stored as compressed
gas in cylinder, but nitrous oxide (750 psi) is
liquefied under pressure.

 Most dental offices using portable nitrous oxide

delivery system require size E cylinders and those
with centralized supply need size H cylinders

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While opening the cylinders, “cracking the
valve” technique should be followed

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 Solubility of Nitrous Oxide
Blood gas partition coefficient/
Ostwald solubility quotient

It is the ratio of “anesthetic concentrations in each of

the two compartments when equilibrium exists (partial
pressure of the agent in both the compartments is
same) between these compartments

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 ALVEOLAR CONCENTRATION
Agents with higher blood gas partition coefficient

Will have more molecules being soluble in blood and alveolar concentration
of the gas remains low as most of the gas is taken up by the blood.

Since blood can accommodate more of gas molecules due to its higher
Within 1–2  min, equilibration of
solubility, it takes a longer time for blood to get saturated with the gas
alveolar and inspired
molecules.
concentrations of nitrous oxide
Once the blood gets reaches almost
saturated with 95%.
anesthetic molecules, the alveolar
concentration of the gas begins to rise and the additional molecules get
transferred to the brain.

This explains for a delayed onset of the anesthetic effect

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Nitrous oxide should be delivered at a particular
concentration (20–25% nitrous oxide) for 3–5 min
before increasing the concentration, to understand
the right concentration for achieving the desired
clinical signs in a child.
CONCENTRATION EFFECT

EGER - “higher the

inspired concentration of
nitrous oxide, more rapidly
the alveolar concentration
approaches the inspired
concentration”

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 Potency of Nitrous Oxide
MAC or minimum alveolar concentration is “the concentration of
the gas in alveolus at 1 atmospheric pressure that will render
50% of patients unresponsive to a surgical stimulus”
Nitrous oxide with a MAC of 104 is least potent of all
the anesthetic gases.

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 Concentration Delivered
Second Gas Effect/
MAC sparing effect

Equipment leakage
Second gas effect is• ofPoorly
significance in masks
fitted nasal anesthesia
• Dead
when another inhalational space
agent is administered along
with nitrous oxide gas,• making
Mouth breathing
use of the property of
• Ventilatory
rapid uptake of nitrousstatus
oxideof the patient

In other words, it is unlikely that one can deliver

greater than 0.3 to 0.5 MAC with the use of
typical dental nitrous oxide units 28
 Systemic Effects of Nitrous Oxide
• Depresses - sight, hearing,
Central Nervous System smell, and touch (> 20%
oxygen)
• Vomiting center in medulla is
not affected
Respiratory System Used alone - does not affect
respiration adversely
Cardiovascular System Not known to produce any
changes
Cause cutaneous vasodilation
Skeletal System • Isoflurane, desflurane, and
sevoflurane - muscle
relaxation
• Nitrous oxide – no such
effect
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 Elimination
Tissues Venous blood Alveoli

Expiration

Biotransformation is negligible (does not combine with hemoglobin)

Inhalation anesthetics
• Lowest partition coefficients
• Most rapid onset and termination of effects
• Most suitable for cases that require intermittent alterations in
anesthetic depth
Becker DE, Rosenberg M. Nitrous oxide and the inhalation
anesthetics. Anesthesia progress. 2008 Dec;55(4):124-31. 30
 Diffusion Hypoxia

Avoided by administering 100% oxygen for 3–5 min at the

termination of the procedure 31
MECHANISM OF ACTION

Analgesic –
opioid
receptors

Anesthetic &
Anxiolytic –
amnesia –
BDZ
NMDA
receptors
receptors

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INHALATION SEDATION
EQUIPMENT
TYPES OF INHALATION SEDATION
UNITS

Demand-
Flow Units Continuous-
Flow Units

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 DEMAND-FLOW UNITS
1. Jectaflow
Advantage – 2. Walton
3. McKesson
• The economy obtained from Euthesor
the decreased volume
4. McKesson Nargraf
of compressed gases used
5. McKesson Narmatic
Disadvantages –
• Volume flow of anesthetic gases per minute is not
visible or registered anywhere on the machine
• Lack of accuracy of the mixer valve

Gauert • At an indicated O2 percentage of 75%, the

actual delivered O2 percentage ranged from 80%
and to 45%,
• 50% indicated O2, the actual delivered
Husted percentage ranged from 75% to 22%

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CONTINUOUS-FLOW
UNITS
Accuracies to within plus or
minus 2% can be achieved.

Three subgroups
1. Portable System
2. Central Storage System
3. Central Storage System
With Mobile Heads

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Armamentarium of nitrous oxide –
oxygen inhalational sedation:

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 BREATHING APPARATUS
(NASAL HOOD OR FACE MASK)

Contoured masks

Scented masks

Low profile “sizer masks”

Masks of varying sizes 37
SCAVENGING NASAL HOOD
Air dilution valve is opening below
Internal view of nasal
exhaling valve (arrow), which
hood permits entry of atmospheric air
during inhalation
Exhaling valve on nasal hood.
Thin wafer (dotted arrow) seals
orifice while patient inhales, but
is forced off orifice when patient
exhales gases
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 Alarms
Quick
connect for Color
positive coding
pressure

Diameter
index
Locks
safety
system
SAFETY
FEATURES
Oxygen fail Pin index
safe safety
system system

Oxygen
Emergency
flush
air inlet
button Reservoir
bag

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PRE-INHALATION SEDATION CHECKLIST

Wilson, K. E. (2013). Overview of paediatric dental

sedation: 2. nitrous oxide/oxygen inhalation
sedation. Dental Update, 40(10), 822–
829. doi:10.12968/denu.2013.40.10.822 
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 TITRATION OF N2O/O2
GASES
Gillman and Lichtigfeld advocate the use of the titration
technique

The 2006 Joint guidelines of the AAP and AAPD state that
“the concept of titration of drug to effect is critical”
and specifies that practitioners must know the full effect of a drug
dosage before adding another.

 The titration technique is regarded as the current standard of
care when administering N2O/O2 for sedation.

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 ADVANTAGES OF N2O TITRATION

Only the amount of drug required by the patient is given

Allows for individual biovariability

Uncovers idiosyncratic reactions early

Minimizes negative experiences with over sedation

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 Mild to
Mild to moderately
moderately anxious,
anxious but potentially
cooperative cooperative
children Standard Rapid (edge of losing
titration Induction coping abilities)
technique Technique

The technique involves

Nitrous oxide should be administering 50% nitrous
started at 10% concentration oxide immediately to the
patient without any titration
steps.

Increased in increments
ranging from 5% to 10%

Until the patient becomes

comfortable and clinical signs
of optimal sedation are noted.
The end point in terms of maximal
concentration - < 50% for children
Pinkham JR, Casamassimo PS. Pediatric
Dentistry: infancy through adolescence. 4th
ed. Phildelphia, Pa: WB Saunders Co; 375-90,
2005.
 SOAPME” –Preparation Routine –AAPD
Recommendation
S: Size appropriate suction catheter and apparatus

O: Adequate oxygen supply and functioning flow meters/other devices to

allow its delivery

A: Size appropriate airway equipment (nasopharyngeal and oropharyngeal

airway, laryngoscopes blades, endotracheal tubes, stylets, face mask, bag-

valve-mask)

P: Pharmacy - all the basic drugs to support life during an emergency

M: Monitors; functioning pulse oximeter with size appropriate oximeter

probes and other monitors (e.g.: Noninvasive blood pressure, end-tidal

carbon dioxide, ECG, and stethoscope)

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E: Special equipment or drugs for a particular case (e.g.: Defibrillator)
 TECHNIQUE
The child is seated in a reclining position, the nasal hood is
introduced with proper explanation

The bag is filled with 100% oxygen, delivered for 1 to 2 minutes

with a flow rate of 5 to 6 L/ min

After thorough oxygenation for two or three minutes, nitrous

oxide and oxygen should be adjusted for 10% nitrous oxide and
90% oxygen

Concentration can be reduced to approximately 30% nitrous

oxide and 70% oxygen

Once the flow of N2O is reduced to 0, the patient should be

allowed to breathe 100% oxygen

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DESIRABLE CHARACTERISTICS
CHAPMAN mixture of 20%
N2O and 80% O2 has the
same analgesic equipotence as
Analgesic 15 mg of morphine

Rapid and Rapid

complete onset of
• JACKSON AND JOHNSON - “excellent choice” for
recovery action
managing mild fear
• Minimal
ZACNY - positive side in patients with high
mood changes
effects
anxiety and in those with low anxiety.
• KANAGASUNDARAM - Children older than 6 were less
Relative
Titration
distressed during nitrous oxide administration
amnestic

Anxiolytic

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 CLINICAL EFFECTS
PSYCHOLOGICAL SIGNS
 Relaxed and comfortable BODY MOVEMENT
 Relaxed.
 If asked, the patient
 Signs of relaxation may include
acknowledges a reduced
shoulders dropping, legs uncrossing,
sense of fear and anxiety.
 patient’s mood - happy, and arms laying looser on arm rests
 take deeper respirations
pleasant, satisfied, or even
ambivalent
Expressions on face
EYES RESPONSE • Face appears less tense and relaxed
 Eye ball movements - reduce.
 Slight drooping of upper eye • “flat” expression rather than “alert.”
lid • Tonicity of facial muscles reduces.
 Blink rate may reduce.
• Child may begin to giggle or may
 may have watery eyes have a smile on face
 may have a dazed or staring
look • Voice changes

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Cognitive ability
• slowing of response in children though not clinically
significant
• It also causes increase in reaction time
• It may even have characteristics of CNS stimulant

Knowledge about surroundings

• Child will be fully aware about surroundings.
• With relaxation, patients surroundings are no longer
threatening, and patients will have a sense of well-
being

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 OVER SEDATION
PSYCHOLOGICAL SIGNS BODY MOVEMENT
 Very uncomfortable feeling.  Agitated,
 Dreaming / Hallucinations.  restless
 Sexual fantasizing.  Sluggish in their
motions.

EYES
 Fixed and non responsive.
 Feel like sleeping and have
difficulty keeping their eyes
open.
 “Blacking out” vision.
FACIAL EXPRESSION
 Fits of uncontrolled laughter are
a sign of over sedation.
 Roller coaster sedation effect.

AWARENESS
 Detachment or Dissociation.
 Lightweight, floating or flying sensations.
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Adverse reactions and toxicity

Diffusion Hypoxia Nausea and Vomiting Pain in Ears

Head Trauma Malignant

Laryngospasm
and Nitrous Oxide Hyperthermia

Asphyxiation Related
Accidents to Impurities
Fire
with Nitrous Oxide in Nitrous Oxide
Cylinder

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Recovery from N2O sedation
• Physiologically recovery occurs the same way for all the
individuals, potential exists for postoperative symptoms such as
lethargy, headache, and nausea to occur

• Postoperative oxygenation remains a must, 100% for 3-5 minute

Tests for recovery

1. Touching the tip of the nose with the index finger can indicate
recovery

2. Beery criteria for correct drawing of selected figures of the

Bender Visual Motor Gestalt Test

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 Potential biohazards for health
personnel
• Animal studies have shown inactivation of methionine synthase in
rats

• Megaloblastic anaemia was found in patients treated with nitrous

oxide for tetanus

• Neurological disorders associated with chronic N2O exposure

appear as myeloneuropathy

• Frostbite is seen associated with health personnel involved in

handling N2O equipment

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 NITROUS OXIDE ABUSE
• All the drugs that produce euphoria have the potential to be
abused

• N2O is easy to obtain for recreational use and is found in several

forms

• N2O is approved by FDA as food ingredient in whipping cream,

the cans hold up to 4 L of N2O, these products are also misused
for recreation

• Comparatively N2O abuse is low compared to alcohol, nicotine,

which are most commonly used

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 ORAL MIDAZOLAM WITH NITROUS OXIDE

 A study by Al-Zahrani et al reported that combination of oral midazolam

(0.6mg/kg) and nitrous oxide (30-50%) is effective and safe in young
dental patients who need minimal restorative treatment

 Ozen et al have also recently reported similar results with combination of

0.5 mg/kg oral midazolam and nitrous oxide (50%) in 4-6 year old children.
The use of nitrous oxide may prolong the working time to some extent and
simultaneously incorporates its own desirable effects (such as analgesia) in
the clinical situation

Alzahrani AM, Wyne AH. Use of oral Midazolam sedation in Pediatric

dentistry: a Review. Pakistan Oral & Dental Journal. 2012 Dec 1;32(3)
YOKOE et al

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 CONCLUSION
 Quick onset and quick recovery
 Precision with which the anesthetic effect of
nitrous oxide can be controlled is greater than
any other inhaled anesthetic
 Reverse the sedation

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 REFERENCES
 Handbook of nitrous oxide sedation : Morris Clarke

 Sedation – A guide to patient management - Sixth edition Stanley F.

Malamed

 Nitrous Oxide in Pediatric Dentistry - A Clinical Handbook Kunal Gupta,

Dimitrios Emmanouil, Amit Sethi

 Gerald Z Wright and Ari Kupeitzy – Behavior management in dentistry for

children

 Pinkham JR, Casamassimo PS, Mctigue DJ, Fields HW, Nowak AJ. Pediatric
Dentistry: infancy through adolescence. 4th ed. Phildelphia, Pa: WB
Saunders Co; 375-90, 2005.

 Mathewson RJ, Primosch RE Fundamentals of Pediatric Dentistry. 3 rd

edition. Missouri : Quintessence Publishing Co;2014
60
 Mcdonald and Avery: Dentistry for the child and adolescent

 Guideline on Use of Nitrous Oxide for Pediatric Dental Patients - AMERICAN

ACADEMY OF PEDIATRIC DENTISTRY

 Becker DE, Rosenberg M. Nitrous oxide and the inhalation anesthetics.

Anesthesia progress. 2008 Dec;55(4):124-31.

 Alzahrani AM, Wyne AH. Use of oral Midazolam sedation in Pediatric dentistry:
a Review. Pakistan Oral & Dental Journal. 2012 Dec 1;32(3)

 Hurbuz DK, Hollaran MO. Techniques to administer oral, inhalational, and IV

sedation in dentistry. Australas Med J. 2016; 9(2): 25–32

 Attri JP, Sharan R, Makkar V, Gupta KK, Khetarpal R, Kataria AP. Conscious
sedation: Emerging trends in pediatric dentistry. Anesth Essays Res
2017;11:277-81.

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