Thoughts on safety of in office nitrous oxide?

[DoctwoB]

Surgeon popping by to ask a question. I’m considering joining a practice that performs some in office procedures (vasectomies, prostate biopsies, etc) using a patient administered 50% nitrous/50% O2 system. I know similar things have been used in dentists offices forever, but lacking anesthesia training this made me a bit uneasy. Assuming adequate knowledge of contraindications to nitrous, any thoughts on the safety of in office nitrous use?

---

Members don't see this ad.

 

[leaverus]

?? what do you mean lacking anesthesia training. are you not an anesthesiologist? do you mean lacking experience using N2O? Has it disappeared entirely from training programs?

Edit: I misread your post. YOU are a surgeon. I don't see a particular problem with its use - some L&D wards are using it without anesthesia personnel present. I think it depend on the protocol for its use at your site.

 

[AdmiralChz]

Safe. As you said, dentists (+/- formal anesthesia training of some length) use it all the time. Especially if it's solo nitrous administration with no other sedative (or just PO Ativan), won't be very harmful but also don't expect a typical "room air general MAC" that one gets with many sedation cases.

You're unlikely to encounter the contraindications to nitrous in the office - namely: intracranial pathology/air, pneumothorax, small bowel obstruction, middle ear pathology.

 

[deleted875186]

Agreed, when it’s done on the labor and delivery floor anesthesia isn’t usually directly involved. As long as the patient holds the mask themselves. They won’t get too sedated.

 

[ethilo]

I think you might run into NIOSH issues with it in the office environment. NIOSH requires certain room ventilation standards to be good enough to pass a cutoff for a certain ppm in the air where N2O is used. If your air circulation system isn't strong enough you may get too high of a concentration of N2O in the air from patients exhaling it without a scavenging system for it to be safe.

When we implemented N2O on the L&D floor in my residency, one concern was that many L&D RNs are ALSO pregnant and the teratogenicity of volatile anesthesia / N2O is still up for debate. There are studies that show PACU nurses have a exposure to N2O that exceeds NIOSH standards just by being in the same room as patients (Here's a study http://www.or.org/bibliography/PDF/2871631723/Sessler-1998.pdf). If these RNs are themselves in early stages of their pregnancy (like, pregnant and not even know it yet) it could be harmful to the fetus.

Here's some information from a CDC pamphlet about waste gases I just found:

https://www.cdc.gov/niosh/docs/2007-151/pdfs/2007-151.pdf?id=10.26616/NIOSHPUB2007151

In the pamphlet, they say in recovery rooms there should be an HVAC system doing 6 air changes an hour. In the OR it's 15 air changes an hour.

Ever wonder why you get so dehydrated working in the OR environment? You can thank NIOSH and OSHA for that!

 

[Robotic Wis-Hipple]

Agreed with the safety of nitrous and the possible issue with air handling/scavenging. But apparently you could charge a fortune!!

https://www.google.com/amp/s/www.nbcnews.com/news/amp/ncna1011336

 

[ethilo]

Agreed with the safety of nitrous and the possible issue with air handling/scavenging. But apparently you could charge a fortune!!

https://www.google.com/amp/s/www.nbcnews.com/news/amp/ncna1011336

Hah, awesome.