William Thomas Green Morton (August 9, 1819 – July 15, 1868) American dentist used inhaled ether as a

surgical anesthetic.
FEAR is “False Evidence Appearing Real”
Procaine problem: ester not amide
Five universal human fears: fear of pain, the unknown, helplessness and dependency, body
change/mutilation, and death
Represents a subjective psychological state rather than an activity induced by noxious stimulation. If a
patient regards his or her experience as pain, accept it as pain. Nociception: Noxious stimulus originating
from the sensory receptors and carried into the CNS by the primary afferent neurons.
Pain: An unpleasant sensory and emotional experience associated with actual or potential tissue damage,
or described in terms of such damage.
Acute pain 1 month
Chronic pain 4-6 months
Analgesia: The diminishing or elimination of pain in the conscious patient.
Conscious: Capable of a rational response to command with the protective reflexes intact, including the
ability to maintain a patent airway
Sedation: The calming of a nervous, apprehensive individual through the use of drugs, without inducing
the loss of consciousness
Local anesthesia: The elimination of the sensation of pain in one part of the body by topical application
or regional injection of a drug.
General anesthesia: The elimination of all sensations, accompanied by the loss of consciousness.

Onset Peak Effect Depth of Duration Recovery Titration

Sedation

N2O 2-3 min 3-5 min Readily flexible 3-5 min possible
change levels

Other Oral 30 Oral 60 min Oral Oral & rectal Oral & rectal Oral & rectal
min fixed durations, 2-3 hrs titration not
Rectal 60 Rectal 2-3 hours (residual possible
Rectal 30 min effects
min IM cannot Significant drug IM same as
IM 30 min easily deepen possible)
variation: oral and rectal
IM 10-15 or lighten IM 2-3 hours;
min IV 1 -20 min IM fixed IV titration is
IV deepen same as oral
duration, 2-4 and rectal possible
IV ≥1 min but not easily hours; IV fixed
lighten 45 min. IV 15 min. – 3
hrs.; may have
Inhalation - residual effects
varied duration

N2O is not very potent; fails in 5-10% of patients.

Relative Contraindications indicate pts in which there would be an increased risk for complication or
adverse reactions. If there is a better method, it should be used. Absolute Contraindications indicate pts at

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risk for complications and adverse rxns; they should not be subjected to N2O-O2 sedation.
Contraindicated conditions:
Upper Respiratory Infections - N20 must be inhaled through the nose; (patent airway is mandatory); any
patients with respiratory problems would be contraindicated; also pts with any nasal obstruction.
TB - active, a Contraindication for inhalation sedation.
Patients with contagious diseases may have N20 sedation but need to provide them with a disposable
mask and tubing at their own cost.
Children with Severe Behavior problems - Handicapped children or adults who do not understand the use
of the mask or cannot communicate their feelings.
Compulsive type A personality - take charge type of person who does not like to lose control may not
enjoy N2O.
Patients with severe personality disorders - psychiatric pts who receive medication for mood elevation or
antidepressants.

Relative Contraindicated Conditions:

Claustrophobic patients – may not be able to manage wearing nasal mask
Severely phobic patients – may resist calming effect of N2O, their situation might worsen; better to avoid
N2O in these pts
Pregnant pts in 1st or 3rd trimester; treatment in first (absolute CI) to avoid spontaneous abortion and
fetal malformation (organogenesis); tx in third may cause delivery and medical emergency; elective
Dental tx in 2nd trimester; Note: treatment of pregnant pts need medical consult from OBGYN physician
Middle ear disturbance i.e. surgery or grafting
Recent eye surgery using perfluoropropane or sulfur hexafluoride
Patients who do not want N2O; do not force these pts into using N2O
Medically compromised pts – this category is questionable and may not be true relative contraindications
Myocardial infarction (heart attack) – general rule: need a medical clearance from pt’s cardiologist and
delay all tx for 6 months post heart attack
Heart failure (congestive heart failure, CHF)
Patients with known Dx of Vit B12 deficiency
Myocardial infarction (heart attack) – general rule: need a medical clearance from pt’s cardiologist and
delay all tx for 6 months post heart attack.
Management of fear and anxiety is successful in 90-95% of patients
Including Chronic Bronchitis and Emphysema
These patients have elevated CO2 levels resulting in a loss of ability to respond to CO2 stimulus
Healthy pts are stimulated by the respiratory center (Medulla) alter the rate of ventilation due to
changes in CO2 levels
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COPD patients are stimulated to breathe by activation of peripheral aortic and carotid body
chemoreceptors, which react to lowered blood O2 levels
Administration of an O2 enriched mixture of gases will raise the blood O2 saturation and remove stimulus
for involuntary breathing
Hepatic disease – includes hepatitis and cirrhosis; represents a CI for many sedation agents; hepatic
dysfunction results in a slow rate of which can lead to prolonged drug effects and overdose; there is no
biotransformation with N2O and is safe for these pts.
Epilepsy and Seizure disorder – hypoxia and stress in these pts can ppt a seizure; N2O reduces anxiety
and inc blood flow (perfusion) and O2 saturation.
Anxious pt will have an increased heart rate. N2O-O2 inhalation analgesia reduces anxiety and elevates
pain threshold; this sedative procedure is ideal for dec myocardial O2 requirement; a pt at N2O-O2 35:65%
receives far more O2 than the normal atmospheric O2 concentration of 20.9%.
Hematopoietic System – long term exposure to N2O can cause bone marrow depression. Interferes with
Vitamin B12 (Cobalamin) dependent enzyme methionine synthase; which is necessary for DNA synthesis
and RBC production
N2O depletes stored up Vitamin B12 ; converts the active monovalent form of Vitamin B12 to its inactive
bivalent form; it cannot fulfill its enzyme function in methionine synthesis and reactivation of folic acid
Vitamin B9 ; induces deficiency of Vitamin B12 and possibly Vitamin B9.
Functions of Vitamin B12 (Cobalamin). Works closely with Folate or Folic Acid (Vitamin B9) for
development i.e. maturation of RBCs; helps to make iron work better in the body. Important in DNA and
RNA synthesis. Vitamin B12 responsible for development of protective coating (myelin sheath) for nerves;
important for nerve health. Important for development of neurotransmitters. Responsible for reactivation
of Folic Acid by converting it into tetrahydrofolate, a form which the body can use. Plays a role with Folic
Acid in the deconstruction of homocysteine to methionine; reduces levels of homocysteine in the body;
inc levels can result in hypertension; heart attack and stroke.
Caution when treating elderly pts, alcoholics, those with modified diets i.e. vegetarians/vegans,
pernicious and megaloblastic anemias, gastrointestinal problems and Hx of GI surgery, known Vitamin B12
deficiency; all of these pts need special management and may be a relative contraindication for N2O-O2
sedation.
Pharmacology of N2O and O2
Preparation Nitrous Oxide is prepared by heating ammonium nitrate crystals to 240o C (462 o F) to form
𝐻𝑒𝑎𝑡
Nitrous oxide and water. NH4NO3 𝑜 N2O + 2H2O. It is compressed and stored in a metal cylinder with
240 𝐶
30% of the N2O being in liquid form.
Physical Properties Non-irritating, sweet smelling, colorless gas. Only inorganic gas that produces
anesthesia. CO2 and N2O are the only non-organic compounds to produce CNS depression.
Chemical properties N2O is marketed and stored as a gas/liquid compressed under pressure 750 psi.
Returns to gaseous state upon release from the cylinder. Requires heat for vaporization into a gas, which
is acquired from the cylinder walls; causes regulator and cylinder to become cold and develop frost when
gas is being used long term. N20 is non-flammable, non-explosive but will support combustion; above
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450 degrees C (842 degrees F) N2O breaks down to N2 and O2.
Other properties N2O is relatively insoluble in blood Carried in the blood in physical solution only and
does not combine with any elements. It is carried in the blood in physical solution only and does not
combine with any elements. 99% of N2O that enters the body leaves the body through the lungs
unchanged; there is no biotransformation of N2O in the body. As blood travels through various tissues
of the body, the N2O is given up and the venous blood returns to the lungs which has a decreased N2O gas
tension (High to Low). Because of the rich cerebral blood supply, onset of action is rapid and rate of
recovery is rapid. The O2 in N2O molecule is not available for use by the body.
Potency: N2O is the least potent anesthetic gas, but the most frequently used in Medicine and Dentistry
N2O is 35 times more soluble in plasma then N2. N2O is 100 times more soluble in plasma than O2. A 20%
N20 80% O2 mixture produces analgesia equal to 10-15 mg morphine; 60 mg codeine = 10 mg morphine.
The optimum concentration of N2O for the production of analgesia is 35%. All individuals have biological
variability.

The loss of CO2 control to stimulate breathing and

the introduction of O2 decreases breathing. When
N2O is first inhaled there is a high partial pressure in
the alveolus and within the capillary it will be zero.
N2O is absorbed rapidly from the lungs into the
cardiovascular system; primary sat of blood and
brain w/ N2O is accomplished by the displacement of
N2 from the alveoli and blood; occurs w/ in 3-5 min
from onset of administration. Tissues with greater
blood flow (ie brain, heart, liver, and kidneys) receive
the greatest amount of N2O. Fat, muscle and
connective tissue, absorb smaller portions of the
N2O. Vast majority of N2O is exhaled through the
lungs within 3-5 min after termination; N2O does
NOT undergo biotransformation. Approximately 1% will be eliminated over 24 hours through the lungs
and skin; it is eliminated unchanged.
Diffusion Hypoxia Occurs when N2O is turned off suddenly and patient breaths room air; Symptoms -
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headaches, nausea, and lethargy. “Hangover effect” results from N2O rapidly diffusing from the blood, out
of alveoli and the lungs. The alveoli become filled w/ exhaled N2O, O2, CO2, N2 and water vapor; the conc
effect occurs as these gases rush out; blood level of CO2 is greatly decreased> this reduces stimulus for
breathing producing respiratory depression; upon inhalation, residual N2O diffuses back into the alveoli
thus diluting the O2 present from normal 14% to about 10%; this hypoxia produces hangover effect.
Hypoxia can cause vomiting in some pts. Adverse effects of diffusion hypoxia can be prevented by giving
100% O2 for at least 3-5 minutes upon termination of the procedure. The exact mechanism of action N2O
is unknown. N2O may act directly on the opioid receptor and/or activate the release of endogenous
opiates. N2O is known to cause CNS depression primarily in the cerebral cortex (memory, intelligence
areas).
Physical Properties of O2 A clear, colorless, odorless gas and makes up 20.9% of the atmosphere (and
room air). It is stored as a compressed gas at 2000 psi, delivered at 50 psi. O2 is not flammable but will
support combustion. Under pressure in the presence of oil or grease, O2 may cause an explosion.
Oxygen is commonly prepared by fractional distillation of liquid air; N2 is boiled off leaving liquid O2
(LOX). Other methods of Oxygen Preparation:
Heating Barium peroxide to 800°C (1472°F) BaO2 -----BaO + O2
Reaction between sodium peroxide and water 2Na2O2 + 2H2O -----4NaOH + O2
Electrolysis of water 2H2O -----2H2 + O2. The decompression of H2O into H2 and O2 is caused by an
electric current passing through water.
𝑂2may cause constriction of cerebral blood vessels, may decrease blood flow by 10%.

Gas Inspired Air Expired Air

O2 20.90% 16.30%
CO2 0.04% 4.00%
N2 79.00% 79.70%

The trachea is about 10-12 cm long, 2-2.5 cm in diameter.

Surfactant is a surface-active substance.
Oxygenation attaches the hemoglobin.
Physical property No.1 : Beer’s Law - amount of light absorbed is proportional to the concentration of the
light absorbing substance.
Physical property No.2 : Lambert’s Law - amount of light absorbed is proportional to the length of the
light path.
Physical property No.3 : oxyhemoglobin absorbs more infrared light than red light & deoxyhemoglobin
absorbs more red light than infrared light.
Red light 650 nm Deoxygenated Hb absorbs more red light .
Infrared light 950 nm Oxygenated
Hb𝑂2absorbs more infrared light.
Naked eyes cannot see infrared
light.
The composite graph shows the
absorbance of both forms of Hb at
different wavelengths.

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To summarize things so far, the absorbance of light depends on:
1. concentration of the light absorbing substance.
2. length of the light path in the absorbing substance.
3. oxyhemoglobin and deoxyhemoglobin absorbs red and infrared light differently.
The PO computer takes these things factors and computes the saturation.

4 stages of general anesthesia (ADAM)

Stage 1: Analgesia. Note: during conscious sedation a patient is in this stage.
Stage 2: Delirium – unconscious; reflexes are exaggerated (inspiration); hyper-response to stimuli
Stage 3: Surgical anesthesia. Know different planes.
Plane 1: lower plane 1/ upper plane 2 – ideal surgical anesthesia
Plane 2: eyeballs fixed, respiration remains regular but depth of breathing is diminished
Plane 3: paralysis of intercostal (chest wall) muscles; diaphragm breathing only; pupillary rxn to light is
lost; not recommended for surgery
Plane 4: respiration diminishes progressively; pupils dilate; no muscle tone.
Stage 4: Medullary paralysis – “death”
Note: Stages I and II are the induction stages for general anesthesia.
It is possible possible to render a patient unconscious with 𝑁2𝑂/𝑂2

Safety Handling Use no grease, no oil, no lubricant around cylinder, valves, gauges, regulators – can cause
explosion. When gas from a 2000 psi tank is reduced to 50 psi at a regulator, the frictional heat produced
can exceed 1500 degrees F which is well above the ignition temp of grease and oil. Cylinders are stored
upright; do not drop. Stored in constant temperature. Open cylinder counter-clockwise. Close valve tightly
when not in use.
Oxygen cylinder - present in a gaseous state. “E” weighs 21 lbs. and 2000 psi. “H” weighs 131 lbs. and
2200 psi. Pressure gauge measures contents of the tank . Color green.
Nitrous oxide cylinder – present as both liquid and gas. Full cylinder contains 30% in liquid state. “E”
weighs 21 lbs. and 750 psi. “G” and “H” weigh 130 lbs. and contain 750 psi, when full. Color blue.
Full N2O cylinder contains 95% liquid and 5% vapor and will have a pressure reading on gauge of approx.

Safety features 750 psi at 50-70%. Storage temperature and rapid release of N2O can change cylinder
pressure eg at 50 degrees F, pressure would be approx. 575 psi. Because liquid is vaporized as gas is used,
the reading on pressure gauge is not proportional to the amount of gas available in the cylinder. When the
tank contains about 20% N2O pressure reading on the gauge will show a decrease and approximate
amount of N2O in the cylinder.
For O2, a full cylinder is 2000 psi. The pressure gauge will accurately indicate the amount of gas present in
the cylinder. It is important to monitor the amount of left in the cylinder as the N2O-O2 is driven by O2
flow. If a tank goes empty during procedure there will be no flow of N2O (a very important safety feature,
no O2 flow, no N2O flow).
Purpose of safety features is to prevent giving 100% N2O and to prevent giving less oxygen than
room air at 20.9%, i.e. pin index system; diameter index system; oxygen fail safe minimum O2 flow (%
delivered is 30%), equipment is designed to deliver no more than 70% N2O; alarm (sounds when O2
decreases below 30% or below 2.5-3 liters per min); emergency air inlet; reservoir bag; oxygen flush
button (fill the bag with O2).
The Scavenger system takes out all N2O that is exhaled through the mask.
Mouth breathing is the most critical measure to control pt talking is primary source trace gas
contamination.

Pre-op instructions: No heavy meal should be eaten up to 4 hrs, no liquids 2 hrs prior to tx. A light meal
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is okay; no fatty or greasy foods. A fasting pt could pose a hypoglycemic problem w/ syncope in
combination w/ stress; a little protein snack might reduce risk of crisis.

Technique Start to administer N2O > 1.5 L (about 20-25%) for 5 min. Slow titration of N2O is the best
method to ensure ideal sedation to the greatest number of patients. This method will ensure a higher
success rate and prevent the undesirable effects of nausea and vomiting. Effective N2O-O2 sedation is
capable in 90-95% of all pts; 70% will be successfully sedated at 30-40% N2O concentration.
Approximately 10% pts will require more than 50% to feel any appreciable sedative effects. Remember
that pt’s response to drug effects are biologically variable; N2O-O2 sedation is not potent enough for all pts.
Always give 100% O2 3-5 min before and after the procedure.

LPM N2O LPM O2 % N2O Time Seconds

0.0 5.0 0% 60…4 min
1.0 4.0 20% 60…4 min
1.5 3.5 30% 60…4 min
2.0 3.0 40% 60… 4 min
2.5 2.5 50% 60… 4 min

The method is the delivery of drug in incremental dosage until the desired endpoint or effect is reached.
For N2O-O2 sedation this is the “standard of care.” Specific to N2O-O2 titration, an increase in N2O by
10-15% (1-1.5 L) every 60 seconds is suggested. Titrate to the level of sedation that is determined by pt
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comfort and relaxation; watch the pt closely. Remember there is no “preset percentage” or “fixed dose” for
N2O-O2 sedation for a given pt or experience; the same pt may require different conc of N2O next visit to
achieve ideal sedation. Titration allows for individual bioavailability. It uncovers idiosyncratic reactions
early. Only the amount of drug required by the pt is given; titrating a drug to appropriate level of sedation
is a valuable learned skill. Minimizes negative experience with over-sedation. Remember over-sedation is
usually the fault of the provider.

Phase Symptoms Signs

Light headed (dizziness); tingling in BP and heart rate slightly elevate then
Early arms; legs; numbness of mouth; return to baseline. End of this stage eyes
numbness of hands feet are less active; glassy or glazed look.
Feeling of warmth; feeling of floating; Feeling warmth due to peripheral
body feeling heavy; euphoria; analgesia vasodilation; decreased muscle tone
Ideal from decreased anxiety; N2O has no
effect on muscles; N2O has an amnesic
effect; pt has no concept of time.
Hearing distant sounds; Visual images Hearing changes due to pressure of N2O
Heavy on ceiling; Sleepiness; Crying, Laughing; in middle ear space; inc pt movement;
pt dreaming. increased BP and HR; sweating.
Feel like spinning > Nausea Vomiting
Detachment or dissociation from
environment; out of body
experience
Dreaming, hallucinating, fantasizing, Fits of uncontrollable laughter
floating and or flying

Over sedation Inability to move or communicate, or

keep mouth and eyelids open; humming
or vibrating noise getting louder
Uncomfortable body; warmth even hot Facial expressions indicate
uncomfortable diaphoresis (sweating)
Lightheadedness; dizziness; pt trying to Fixed eyes; field of vision narrows;
sleep drowsiness; hard keep eyelids open
Sluggish delayed responses; slurred
words or no verbal sense; agitated or
combative behavior
Tingling felt throughout whole body Approaching light anesthesia;
hyper-response to stimuli;
exaggerated inspiration

Signs & Symptoms of Relative Analgesia Sensation of heaviness of limbs, floating sensation, tingling of
arms, legs, numbness of lips, decrease of fear; pain and memory (amnesic effect), feeling of warmth (due
to vasodilation of peripheral blood vessels), decreased awareness of time, desire to remain in this state.

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Signs & Symptoms of Ideal Sedation Feeling of warmth (due to vasodilation of peripheral blood
vessels), floating sensation, body feeling heavy (due decreased muscle tone from decreased anxiety; N2O
has no effect on muscles), ability to answer when asked questions, euphoria (feeling good, in control,
relaxed and comfortable), analgesia (diminution or elimination of pain in the conscious patient).

Signs & Symptoms of Light “Twilight Anesthesia” Hyper-response to stimuli, exaggerated inspiration,
inability to form new memories (anterograde amnesia), anxiety relief (Anxiolysis) and relaxed, feeling
sleepy; eyelids resist opening when provider asks to open eyes, responsive and able to follow simple
directions, not unconscious but sedated.

Over Sedation Management Decrease the level of N2O by .5-1 LPM and in 30-60 seconds the problem
should be resolved.

Nausea Patients should be encouraged to communicate their feelings particularly if nausea is present;
this can lead to vomiting, aspiration, death. Causes include Over-sedation; length of sedation; emotional
state; food or liquid in stomach, especially children; frequent changing (“sea sawing”) of the N2O
concentration; diffusion hypoxia; patients who frequently get nauseous. Management of Nausea: N2O
concentration should be decreased .5-1 LPM for 60 sec. Patients then should be asked how he/she feels.

Signs of Vomiting: Sweating, cold clammy hands, pallor of skin, increased salivation, active swallowing.
Management of Vomiting: Turn off N2O and turn on 100% O2. If vomiting occurs remove the nasal mask
and hood. Place pt on his/her side; lower head and elevate feet. After vomiting replace the nasal mask and
give 100% O2 for 5 minutes.
The best way to determine the proper level of sedation is to begin treatment and directly and closely
observe the pt’s response.

Long term effects of N2O Usually related to chronic long term use, and effects are usually reversible
Severe bone marrow depression
Peripheral sensory neuropathy of the hands, legs and feet
Complete loss of sensation in the toes
Reduced tactile sensation in the hands
Nitrous is the single most commonly used anesthetic agent in the operating room

Complications noted in Anesthesiologists and other operating room personnel:

Higher rates of spontaneous abortion
More fetal malformations
Increased hepatic disease (Halothane)
Increased renal disease (Methoxyflurane)
Increased neurologic symptoms (headache, fatigue, irritability)