Guideline on Use of Nitrous Oxide for Pediatric Dental Patients

Guideline on Use of Nitrous Oxide for Pediatric Dental Patients

Background
· Nitrous is a colorless and virtually odorless gas with a faint sweet smell. It’s effective as an analgesic/anxiolytic agent causing CNS depression and euphoria with little effect on the respiratory system. It’s taken up rapidly and absorbed quickly for alveoli. Diffusion hypoxia can occur because it is 34 times more soluble than nitrogen in blood. Children can desaturate faster then adolescents which is why administration of oxygen 3-5 minutes post-op is important.

Disadvantages
· Lack of potency
· Dependant largely on psychological reassurance
· Interference of the nasal hood with injection to the anterior maxillary region
· Pt must be able to breath through the nose
· Occupational exposure hazards

Patient Selection
· Fearful / anxious patient
· Mentally, physically, or medically compromised
· Gag reflex
· A cooperative child undergoing a large procedure
· If profound anesthesia cannot be found

Assessment
· Allergies / previous allergic reaction
· Current meds, dose, time, route, and administration site
· Disease, disorders, or physical abnormalities
· Previous hospitalizations

Contraindications
· Comes COPD
· Emotional disturbance or drug related dependencies
· First trimester pregnancy
· Treatment with bleomycin

Technique
· Flow rate 5 to 6 L/min
· Bag should pulsate gently with each breath and should be neither over- or underinflated.
· 100% O2 for 1-2 min followed by nitrous in 10% intervals; 50% concentration should routinely not be decreased
· 100% O2 for 3-5 minutes post-op
Monitoring
· Clinical observation: resposiveness, color, respiration rate and rhythm, response to commands

Adverse effects of nitrous oxide/oxygen inhalation
· Excellent safety record with rare incidence of adverse reactions
· Nausea and vomiting is the most common adverse effect occurring in 0.5% of cases
· Fasting is not required for patients undergoing treatment under nitrous; the practitioner may recommend that a light meal be consumed in the 2 hours prior to nitrous administrations.
· Diffusion hypoxia can result from a rapid release of N2O from the blood stream into the alveoli, thereby diluting the O2 concentration. This may lead to headache and disorientation (can be avoided by administration of O2).

Documentation
· Informed consent should be obtained and documented in chart
· Patients record should include indication for use of nitrous oxide / inhalation, nitrous oxide dosage, duration of the procedure, and post treatment oxygenation procedure

Facilities / personnel / equipment
· All equipment must be able to deliver 100% O2 (never less then 30%)
· Fail-safe system that is checked and calibrated regularly according to state laws
· Practitioner and personnel must have appropriate credentials
· BLS required
· Emergency cart/kit must be accessible; emergency equipment must be able to accommodate peds
· Positive-pressure O2 delivery system capable of >90% O2 administration at a 10L/min flow rate for at least 60 min. is needed