Nitrous Oxide during Abdominal Surgery, Yay or Nay?

Discussion in 'Anesthesiology' started by 0kazak1, Sep 5, 2017.

  1. 0kazak1

    0kazak1 ASA Member

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    I've thought about this and I can't seem to get a straight answer out of anyone. Obviously, you don't want to use nitrous in closed noncompliant spaces (middle ear and intracrainal cases), but what about using it during lap appy/choles, robo hys or during wake ups after a exlap/nephrectomy etc. How significant is the expansion effect for exposures less than 1 hour in duration?
     
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  3. pgg

    pgg Laugh at me, will they?
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    It's fine. Maybe you get a bit more nausea. Maybe. I don't use much nitrous (inhalation inductions in healthy kids and GA sections) but I think the arguments against it are overblown.

    Someday I wish to visit this parallel universe where a robot hysterectomy is less than an all-day case ...
     
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  4. 0kazak1

    0kazak1 ASA Member

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    I had feelings it was overblown, but being so relatively new, and nervous about being too overconfident, I wasn't sure if it was an ignorance thing. One day the robot hysterectomies will not take all day, and one day they will also not only do them in large 250#+ patients.
     
  5. Ezekiel2517

    Ezekiel2517 Anesthesiologist
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    hmm, robot hyst is a 1 hr case around my parts, sometimes 45 min
     
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  6. Maverikk

    Maverikk ASA Member

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    It's an open space, it will be sucked out with excess CO2 that's used to insufflate if that's what you're thinking. The reasoning I've heard is to prevent bowel distension, which with small exposure times won't contribute
     
  7. FFP

    FFP Grunt, body, pompous ass, pissant, buzzkill, jaded
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    I loooove nitrous, but I don't use it during laparoscopic cases. Why? Air embolism. I know it's rare, still I see at least one case every year. Without nitrous, the patient has a higher chances of surviving it intact. I may switch to nitrous once they are closing, but that's it.

    Even in open cases, if there is air in the bowel, nitrous can distend it more, so why bother. If present in nearby vessels, it replaces other gases pretty fast.
     
    #6 FFP, Sep 6, 2017
    Last edited: Sep 6, 2017
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  8. SaltyDog

    SaltyDog Keeping the Forces of Entropy at Bay

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    There's a theoretical risk of fire/combustion with a peritoneal cavity full of nitrous and a bovie. Can't say I've ever seen it, and don't really want to either. I bet it's pretty entertaining for a split second though.
     
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  9. facted

    facted ASA Member

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    I don't use nitrous during these cases. But once trocar's are out, I routinely use nitrous when they close for smooth wakeups and it's great. Interestingly, I have seen a few cases of significant bradycardia when I start it which might be from bowel insufflation leading to parasympathetic tone. Overall, I think it's perfectly safe at the end of a case.
     
  10. FFP

    FFP Grunt, body, pompous ass, pissant, buzzkill, jaded
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    Agree. I once caught a CRNA using it during a lap chole. There were no problems (n=1).
     
  11. fakin' the funk

    fakin' the funk ASA Member

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    I used to use it all the time, with sevo, before I was at a place where there was desflurane. Surgeons don't complain, bowel's not distended (there are papers about blinding surgeons to nitrous/no nitrous and they can't tell), no fires, who knows if there's nausea. CO2 insufflation is continuously washing it out.
     
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  12. amyl

    amyl ASA Member

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    I don't do it until they stop insufflation... reasons as above.
     
  13. zzsleepytinizz

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    Nay. I personally don't like nitrous. Increases the risk of PONV, and is terrible for the environment. I do use it for emergency c-sections, and traumas though. We also started using it for labor at the hospital that I am currently working at. Patients seem somewhat happy with it as an alternative to epidurals.
     
  14. loveumms

    loveumms Senior Member

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    In residency I had a lap nephew Tony need open conversion because the bowel got so distended from nitrous (my then nitrous loving attending insisted we use it). Granted this was a few hours into a long nephew Tony but the bowel distentikn was significant.

    I personally do administer nitrous because I don't feel like it adds much to the anesthetic. Oh and it is terrible for the environment (when combined with des it is even worse).

    Nitrous stays in the atmosphere for 115 years.
     
  15. facted

    facted ASA Member

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    In the Enigma II trial, the risk of nitrous induced nausea is basically zero if you use ANY anti-emetic prophylaxis. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60893-X/abstract

    Agree on the environmental effects, though I personally only use it for a few minutes at the end of a case to wash out the potent agents.
     
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  17. GeorgiaPhDCRNA

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    One of the attending I work with likes to do this, I'm not a fan for all the above mentioned reasons so I avoid it.
     
  18. facted

    facted ASA Member

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    What are the above reasons? Other than environmental, none of the others are true.
     
  19. VA Hopeful Dr

    VA Hopeful Dr Senior Member
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    Jeez, I hope you're at an academic center. The private OBs we worked with in residency usually took 60-75 minutes max.
     
  20. Psai

    Psai Account on Hold
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    Maybe they can teach our residents who routinely take 5 hours.
     
  21. VA Hopeful Dr

    VA Hopeful Dr Senior Member
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    I would expect residence to take a long time, they are still learning after all.
     
  22. Psai

    Psai Account on Hold
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    If only they had that attitude towards anesthesiology trainees.
     
  23. VA Hopeful Dr

    VA Hopeful Dr Senior Member
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    Shut up and lower the table!
     
  24. Psai

    Psai Account on Hold
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    Dawg I'm in charge of moving the table cause I'm the boss. They can only touch the controls when I say it's okay. No one ****s with my tube but me.
     
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  25. zzsleepytinizz

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    I say 'nay'! I only use nitrous for emergency cesarean sections, or hemodynamically unstable patients. It is terrible for the environment nd I don't really see any benefit.
     

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