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Liu Y, Lee-Archer P, Sheridan NM, Seglenieks R, McGain F, Eley VA. Nitrous Oxide Use in Australian Health Care: Strategies to Reduce the Climate Impact. Anesth Analg 2023; 137:819-829. [PMID: 37471292 DOI: 10.1213/ane.0000000000006620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
Nitrous oxide is a useful inhaled analgesic. Due to its high global warming potential and ozone-depleting properties, the nitrous oxide emissions related to health care are being increasingly scrutinized. In this narrative review, we will discuss the clinical uses of nitrous oxide relevant to anesthetists, in addition to its contribution as a greenhouse gas. Using available data from Australia, we will explore potential strategies for reducing the impact of those emissions, which are likely to be applicable in other countries. These include destruction of captured nitrous oxide, minimizing nitrous oxide waste and reducing clinical use. Anesthesia clinicians are well placed to raise awareness with colleagues and consumers regarding the environmental impact of nitrous oxide and to promote cleaner alternatives. Reducing use is likely to be the most promising reduction strategy without large-scale changes to infrastructure and subsequent delay in action.
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Affiliation(s)
- Yigang Liu
- From the Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Paul Lee-Archer
- From the Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Anaesthesia and Pain Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Nicole M Sheridan
- Department of Anaesthesia, Pain and Perioperative Medicine, Western Health, Melbourne, Victoria, Australia
| | - Richard Seglenieks
- Department of Anaesthesia, Pain and Perioperative Medicine, Western Health, Melbourne, Victoria, Australia
- Department of Anaesthesia, Grampians Health, Ballarat, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Forbes McGain
- Department of Anaesthesia, Pain and Perioperative Medicine, Western Health, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
- Department of Intensive Care, Western Health, Melbourne, Victoria, Australia
| | - Victoria A Eley
- From the Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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Dimic N, Djuric M, Nenadic I, Bojic S, Bobos M, Janicijevic A, Bojanic M, Mijovic M, Stevanovic P. Nitrous Oxide — Application in Modern Anesthesia. CURRENT ANESTHESIOLOGY REPORTS 2023. [DOI: 10.1007/s40140-023-00554-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2023]
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Rübsam ML, Kruse P, Dietzler Y, Kropf M, Bette B, Zarbock A, Kim SC, Hönemann C. A call for immediate climate action in anesthesiology: routine use of minimal or metabolic fresh gas flow reduces our ecological footprint. Can J Anaesth 2023; 70:301-312. [PMID: 36814057 PMCID: PMC10066075 DOI: 10.1007/s12630-022-02393-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 10/28/2022] [Accepted: 10/31/2022] [Indexed: 02/24/2023] Open
Abstract
PURPOSE Climate change is a global threat, and inhalational anesthetics contribute to global warming by altering the photophysical properties of the atmosphere. On a global perspective, there is a fundamental need to reduce perioperative morbidity and mortality and to provide safe anesthesia. Thus, inhalational anesthetics will remain a significant source of emissions in the foreseeable future. It is, therefore, necessary to develop and implement strategies to minimize the consumption of inhalational anesthetics to reduce the ecological footprint of inhalational anesthesia. SOURCE We have integrated recent findings concerning climate change, characteristics of established inhalational anesthetics, complex simulative calculations, and clinical expertise to propose a practical and safe strategy to practice ecologically responsible anesthesia using inhalational anesthetics. PRINCIPAL FINDINGS Comparing the global warming potential of inhalational anesthetics, desflurane is about 20 times more potent than sevoflurane and five times more potent than isoflurane. Balanced anesthesia using low or minimal fresh gas flow (≤ 1 L·min-1) during the wash-in period and metabolic fresh gas flow (0.35 L·min-1) during steady-state maintenance reduces CO2 emissions and costs by approximately 50%. Total intravenous anesthesia and locoregional anesthesia represent further options for lowering greenhouse gas emissions. CONCLUSION Responsible anesthetic management choices should prioritize patient safety and consider all available options. If inhalational anesthesia is chosen, the use of minimal or metabolic fresh gas flow reduces the consumption of inhalational anesthetics significantly. Nitrous oxide should be avoided entirely as it contributes to depletion of the ozone layer, and desflurane should only be used in justified exceptional cases.
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Affiliation(s)
- Marie-Luise Rübsam
- Department of Anaesthesia, Intensive Care, Emergency and Pain Medicine, University Medicine of Greifswald, Greifswald, Germany
| | - Philippe Kruse
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Yvonne Dietzler
- Department of Anaesthesia, St. Marienhospital Vechta, Marienstraße 6-8, 49377, Vechta, Germany
| | - Miriam Kropf
- Department of Anaesthesia, Intensive Care, Emergency and Pain Medicine, BG Klinikum Hamburg, Hamburg, Germany
| | - Birgit Bette
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Alexander Zarbock
- Department of Anesthesiology and Critical Care, University Hospital of Muenster, Münster, Germany
| | - Se-Chan Kim
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Christian Hönemann
- Department of Anaesthesia, St. Marienhospital Vechta, Marienstraße 6-8, 49377, Vechta, Germany.
- Department of Anesthesiology and Critical Care, University Hospital of Muenster, Münster, Germany.
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Protective Effect of Oxygen and Isoflurane in Rodent Model of Intestinal Ischemia-Reperfusion Injury. Int J Mol Sci 2023; 24:ijms24032587. [PMID: 36768910 PMCID: PMC9917127 DOI: 10.3390/ijms24032587] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 01/22/2023] [Accepted: 01/27/2023] [Indexed: 01/31/2023] Open
Abstract
Animal research in intestinal ischemia-reperfusion injury (IRI) is mainly performed in rodent models. Previously, intraperitoneal (I.P.) injections with ketamine-xylazine mixtures were used. Nowadays, volatile anesthetics (isoflurane) are more common. However, the impact of the anesthetic method on intestinal IRI has not been investigated. We aim to analyze the different anesthetic methods and their influence on the extent of intestinal IRI in a rat model. Male Sprague-Dawley rats were used to investigate the effect of I.P. anesthesia on 60 min of intestinal ischemia and 60 min of reperfusion in comparison to hyperoxygenation (100% O2) and volatile isoflurane anesthesia. In comparison to I.P. anesthesia with room air (21% O2), supplying 100% O2 improved 7-day survival by cardiovascular stabilization, reducing lactic acidosis and preventing vascular leakage. However, this had no effect on the intestinal epithelial damage, permeability, and inflammatory response observed after intestinal IRI. In contrast to I.P. + 100% O2, isoflurane anesthesia reduced intestinal IRI by preventing ongoing low-flow reperfusion hypotension, limiting intestinal epithelial damage and permeability, and by having anti-inflammatory effects. When translating the aforementioned results of this study to clinical situations, such as intestinal ischemia or transplantation, the potential protective effects of hyperoxygenation and volatile anesthetics require further research.
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Mittal A, Singh G, Panwar V, Kumar A, Talwar H. Inner ear barotrauma: A case report of rare post-operative complication following robot-assisted radical prostatectomy. J Minim Access Surg 2022; 19:310-313. [PMID: 35915540 DOI: 10.4103/jmas.jmas_95_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
To highlight a rare case of inner ear barotrauma as a post-operative complication following robot-assisted radical prostatectomy (RARP). A 65-year-old man diagnosed with localised prostate carcinoma underwent elective RARP in a steep Trendelenburg position. Postoperatively, the patient complained of bothersome dizziness and spinning of surroundings associated with nausea. The patient was diagnosed to have vestibular symptoms secondary to inner ear barotrauma. He was started on prochlorperazine 12.5 mg and antibiotics, following which the patient improved. Vestibular rehabilitation exercises were taught to the patient. After 3 days of treatment, the patient did well with no episodes of dizziness. The patient was discharged on tablet cinnarizine 25 mg thrice daily for a week. On follow-up, the patient is asymptomatic. Inner ear barotrauma can be a rare complication of a combination of prolonged steep Trendelenburg during robotic surgery and pneumoperitoneum. Only further reporting of such incidents can help determine predisposing factors and precautions for preventing such incidents.
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Wong J, Viyasar T, Layton B, Lauder J. The dangers of recreational inhalation of nitrous oxide. Br J Hosp Med (Lond) 2021; 82:1-8. [PMID: 34983231 DOI: 10.12968/hmed.2021.0322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Nitrous oxide, also known as 'laughing gas', is one of the most widely used recreational drugs among teenagers in the UK. Copious inhalation of nitrous oxide may increase intra-alveolar pressure, resulting in barotrauma secondary to alveolar rupture. Pneumomediastinum and subcutaneous emphysema are common clinical findings in nitrous oxide-associated barotrauma. Prolonged nitrous oxide misuse may inactivate vitamin B12 through the alteration of its metabolism, causing demyelination of the central and peripheral nervous system. A spectrum of neurological manifestations has been reported, including peripheral neuropathy, myelopathy and subacute combined degeneration of the spinal cord. Medical therapies and psychosocial interventions aiming at nitrous oxide cessation are important treatment steps to achieve partial or complete recovery from the adverse effects associated with inhalation of nitrous oxide.
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Affiliation(s)
- Joshua Wong
- School of Medicine, University of Central Lancashire, Preston, UK
| | | | - Benjamin Layton
- Department of Radiology, Royal Blackburn Hospital, Blackburn, UK
| | - Joshua Lauder
- Department of Radiology, Royal Blackburn Hospital, Blackburn, UK
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Towards Quantum-Chemical Modeling of the Activity of Anesthetic Compounds. Int J Mol Sci 2021; 22:ijms22179272. [PMID: 34502179 PMCID: PMC8431746 DOI: 10.3390/ijms22179272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 12/16/2022] Open
Abstract
The modeling of the activity of anesthetics is a real challenge because of their unique electronic and structural characteristics. Microscopic approaches relevant to the typical features of these systems have been developed based on the advancements in the theory of intermolecular interactions. By stressing the quantum chemical point of view, here, we review the advances in the field highlighting differences and similarities among the chemicals within this group. The binding of the anesthetics to their partners has been analyzed by Symmetry-Adapted Perturbation Theory to provide insight into the nature of the interaction and the modeling of the adducts/complexes allows us to rationalize their anesthetic properties. A new approach in the frame of microtubule concept and the importance of lipid rafts and channels in membranes is also discussed.
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Mooney KL, Brooks Peterson M, Skirko JR, Friedman NR. The Quest for a DISE Protocol. Otolaryngol Head Neck Surg 2021; 167:590-599. [PMID: 34399647 DOI: 10.1177/01945998211036645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The objective of this quality initiative project was to modify our existing institutional drug-induced sleep endoscopy (DISE) protocol so that the surgeon could consistently determine obstructive breathing patterns while minimizing children's discomfort. METHODS A quality initiative study utilizing the well-described plan-do-study-act (PDSA) process was conducted at a tertiary hospital for children with polysomnogram-documented obstructive sleep apnea who were undergoing DISE. A 4-point Likert measurement tool was created. Change in each Likert rating with subsequent PDSA cycle was tested with the Wilcoxon rank sum test (Mann-Whitney), and change across all PDSA cycles was tested with the Kruskal-Wallis equality-of-populations rank test. RESULTS After a series of 4 PDSA cycles with 81 children, the DISE protocol was streamlined from 14 to 9 steps. There was significant improvement for all aspects of the DISE, with a final overall median rating of 1 (excellent) for intravenous (IV) placement, scope insertion, and anesthesiologist and surgeon satisfaction (P < .01). DISCUSSION For sleep surgeons, DISE is quickly becoming what bronchoscopy is to the airway surgeon. Utilizing inhalational agents to obtain IV access and insert the flexible scope in the rapid "on-off" fashion optimizes DISE success regardless of the primary sedation medication and allows ample time for these agents to dissipate. IMPLICATIONS FOR PRACTICE Adoption of a DISE protocol that includes nasal premedication and inhalational volatile gases for IV and scope insertion at the onset provides a more predictable level of sedation that is well tolerated by the patient, enabling the otolaryngologist to create an obstructive sleep apnea treatment plan.
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Affiliation(s)
- Kristin L Mooney
- Department of Surgery, Children's Hospital Colorado, Broomfield, Colorado, USA
| | - Melissa Brooks Peterson
- Department of Anesthesiology, School of Medicine, University of Colorado, Aurora, Colorado, USA.,Division of Pediatric Anesthesiology, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Jonathan R Skirko
- Division of Otolaryngology-Head and Neck Surgery, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Norman R Friedman
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of Colorado, Aurora, Colorado, USA.,Department of Pediatric Otolaryngology, Children's Hospital Colorado, Aurora, Colorado, USA
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Fu VX, Sleurink KJ, Janssen JC, Wijnhoven BPL, Jeekel J, Klimek M. Perception of auditory stimuli during general anesthesia and its effects on patient outcomes: a systematic review and meta-analysis. Can J Anaesth 2021; 68:1231-1253. [PMID: 34013463 PMCID: PMC8282577 DOI: 10.1007/s12630-021-02015-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 03/06/2021] [Accepted: 03/29/2021] [Indexed: 12/03/2022] Open
Abstract
PURPOSE Interest in implicit memory formation and unconscious auditory stimulus perception during general anesthesia has resurfaced as perioperative music has been reported to produce beneficial effects. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) evaluating explicit and implicit memory formation during general anesthesia and its effects on postoperative patient outcomes and recovery. SOURCE We performed a systematic literature search of Embase, Ovid Medline, and Cochrane Central from inception date until 15 October 2020. Eligible for inclusion were RCTs investigating intraoperative auditory stimulation in adult surgical patients under general anesthesia in which patients, healthcare staff, and outcome assessors were all blinded. We used random effects models for meta-analyses. This study adhered to the PRISMA guidelines and was registered in PROSPERO (CRD42020178087). PRINCIPAL FINDINGS Fifty-three (4,200 patients) of 5,859 identified articles were included. There was evidence of implicit memory formation in seven out of 17 studies (41%) when assessed using perceptual priming tasks. Mixed results were observed on postoperative behavioural and motor response after intraoperative suggestions. Intraoperative music significantly reduced postoperative pain (standardized mean difference [SMD], -0.84; 95% confidence interval [CI], -1.1 to -0.57; P < 0.001; I2 = 0; n = 226) and opioid requirements (SMD, -0.29; 95% CI, -0.57 to -0.015; P = 0.039; I2 = 36; n = 336), while positive therapeutic suggestions did not. CONCLUSION The results of this systematic review and meta-analysis show that intraoperative auditory stimuli can be perceived and processed during clinically adequate, general anesthesia irrespective of surgical procedure severity, leading to implicit memory formation without explicit awareness. Intraoperative music can exert significant beneficial effects on postoperative pain and opioid requirements. Whether the employed intraoperative anesthesia regimen is of influence is not yet clear.
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Affiliation(s)
- Victor X Fu
- Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
- Department of Neuroscience, Erasmus MC, University Medical Centre Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
| | - Karel J Sleurink
- Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
- Department of Neuroscience, Erasmus MC, University Medical Centre Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Joséphine C Janssen
- Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
- Department of Neuroscience, Erasmus MC, University Medical Centre Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Johannes Jeekel
- Department of Neuroscience, Erasmus MC, University Medical Centre Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Markus Klimek
- Department of Anesthesiology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
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Dang XT, Nguyen TX, Nguyen TTH, Ha HT. Nitrous Oxide-Induced Neuropathy among Recreational Users in Vietnam. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18126230. [PMID: 34207586 PMCID: PMC8296096 DOI: 10.3390/ijerph18126230] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/03/2021] [Accepted: 06/05/2021] [Indexed: 11/29/2022]
Abstract
Nitrous oxide (N2O) commonly referred to as laughing gas, has significant medical uses. This study aims to describe the neurological disorders associated with N2O. We conducted across-sectional study that enrolled patients with nitrous oxide toxicity admitted to Vietnam Poison Control Center, Bach Mai Hospital, Hanoi, Vietnam from June 2018 to July 2019. The questionnaire included demographic characteristics, characteristics of using N2O, signs and clinical symptoms, neuroimaging findings, injury on electromyography (EMG) and the Total Neuropathy Score clinical version (TNSc) criteria. A total of 47 participants were included with mean age: 24.38 ± 6.20 years. The number of balloons used per week was 130.59 ± 117.43. The mean duration of N2O exposure was 8.79 ± 7.1 months. Multivariate linear logistic regression revealed that the number of N2O balloons used per week was significantly associated with TNSc point (Beta: 0.315; 95% CI: 0.001–0.022). We found that myeloneuropathy and peripheral neuropathy were the main neurological disorders related to N2O abuse, which should improve the awareness of the appearance of neurological disorders associated with N2O abuse.
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Affiliation(s)
- Xuan Thi Dang
- Vietnam Poison Control Center, Bach Mai Hospital, Hanoi 100000, Vietnam
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi 100000, Vietnam
| | - Thanh Xuan Nguyen
- Geriatrics Department, Hanoi Medical University, Hanoi 100000, Vietnam
- Scientific Research Department, National Geriatric Hospital, Hanoi 100000, Vietnam
- Dinh Tien Hoang Institute of Medicine, Hanoi 100000, Vietnam
| | - Thu Thi Hoai Nguyen
- Geriatrics Department, Hanoi Medical University, Hanoi 100000, Vietnam
- Scientific Research Department, National Geriatric Hospital, Hanoi 100000, Vietnam
| | - Hung Tran Ha
- Vietnam Poison Control Center, Bach Mai Hospital, Hanoi 100000, Vietnam
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi 100000, Vietnam
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Winstock AR, Ferris JA. Nitrous oxide causes peripheral neuropathy in a dose dependent manner among recreational users. J Psychopharmacol 2020; 34:229-236. [PMID: 31679459 DOI: 10.1177/0269881119882532] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Nitrous oxide (N2O) has been used in clinical and recreational settings for over 150 years. Through inactivation of the Vitamin B12 dependent enzyme, methionine synthase, N2O can lead to the development of peripheral neuropathy. This study sought to determine the relationship between the exposure and risk of neurological symptoms in the largest ever sample of users. DESIGN Data are drawn from the Global Drug Survey (GDS) over three consecutive years (2014-2016). The Global Drug Survey is an online, cross-sectional survey of substance use, translated into multiple languages. PARTICIPANTS Respondents to the Global Drug Survey who provided details on N2O use and the experience of paraesthesia in the previous 12 months. MEASUREMENTS Questions relating to N2O use, peripheral neuropathy, age and gender were explored among last year's users. FINDINGS Of 241,566 respondents, 41,181 (17.0%) indicated that they had ever used nitrous oxide; of these, 42.1% had used in the last 12 months. For the final model, data from 16,124 participants who had used N2O in the last 12 months and had provided responses on age, dose, gender and paraesthesia were used. Of these, the number of respondents reporting persistent numbness/tingling (paraesthesia) in their hands or feet was 537 (3.3%). Although the risk was very low among infrequent users, there was a strong dose-response relationship. For people indicating one or two doses per session, the probability of reporting paraesthesia was approximately 0.018 by comparison; for people indicating 100 doses per session the probability was approximately 0.085. The association, between dose and paraesthesia was influenced by gender and age. CONCLUSION While infrequent, episodic users are not at risk, a minority of heavy users are at dose-dependent risk of developing serious neurological consequences. Better education and raised awareness of early symptoms are required.
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Affiliation(s)
- Adam R Winstock
- Institute of Epidemilogy and Health Care, University College London, London, UK.,Global Drug Survey, London, UK
| | - Jason A Ferris
- Centre for Health Services Research, Faculty of Medicine, University of Queensland, Woolloongabba, QLD, Australia
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Yee R, Wong D, Chay PL, Wong VYY, Chng CK, Hosey MT. Nitrous oxide inhalation sedation in dentistry: An overview of its applications and safety profile. ACTA ACUST UNITED AC 2019; 39:11-19. [PMID: 31672093 DOI: 10.1142/s2214607519500019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Nitrous oxide in oxygen (N2O/O2) inhalation sedation is used less commonly by Singapore dentists than their counterparts in the United Kingdom and the United States. Using this technique, trained dentists often perform the dual roles of a sedationist and an operating dentist. This paper describes the mechanism of action of N2O and highlights the modern gas delivery system commonly used in dentistry. The built-in safety features of this unique system helps to ensure that patient-specific therapeutic dosages are effectively and safely administered by dentists. Existing evidence for adverse events and the safety profile of the N2O/O2 inhalation sedation is discussed. Finally, recommendations of equipment, training and techniques for safe N2O/O2 inhalation sedation are provided.
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Affiliation(s)
- Ruixiang Yee
- Dental Service, KK Women's and Children's Hospital, Singapore
| | - Danny Wong
- National Institute of Academic Anaesthesia Health Services Research Centre, Royal College of Anaesthetists, UK
| | - Pui Ling Chay
- Dental Service, KK Women's and Children's Hospital, Singapore
| | | | - Chai Kiat Chng
- Cleft and Craniofacial Dentistry Unit, KK Women's and Children's Hospital, Singapore
| | - Marie Therese Hosey
- Centre of Oral, Clinical and Translational Science, Faculty of Dentistry, Oral & Craniofacial Sciences, King's College, London, United Kingdom
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13
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Nouri A, Patel K, Montejo J, Nasser R, Gimbel DA, Sciubba DM, Cheng JS. The Role of Vitamin B 12 in the Management and Optimization of Treatment in Patients With Degenerative Cervical Myelopathy. Global Spine J 2019; 9:331-337. [PMID: 31192102 PMCID: PMC6542160 DOI: 10.1177/2192568218758633] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
STUDY DESIGN Narrative review. OBJECTIVES To discuss the relationship between degenerative cervical myelopathy (DCM) and vitamin B12 deficiency. Specifically, it is the aim to outline the rational for future research into assessment and therapeutic optimization of vitamin B12 in the treatment of DCM. METHODS Literature review. RESULTS DCM is the commonest cause of spinal cord impairment, with an average age of presentation in the sixth decade. Patients at this age have also been reported to have a high prevalence of vitamin B12 deficiency, with estimates of up to 20% in the elderly. Vitamin B12 deficiency can result in subacute combined degeneration of the spinal cord (SACD), and several case reports have pointed to patients with both DCM and SACD. Both SACD and reversible compressive injury due to DCM necessitate remyelination in the spinal cord, a process that requires adequate vitamin B12 levels. Basic science research on nerve crush injuries have shown that vitamin B12 levels are altered after nerve injury and that vitamin B12 along with dexamethasone or nonsteroidal anti-inflammatory drugs can reduce Wallerian degeneration. Furthermore, it has been suggested that a combination of B-vitamins can reduce glutamate-induced neurotoxicity. CONCLUSIONS Given the high prevalence of clinical and subclinical vitamin B12 deficiency in the elderly, the role of vitamin B12 in myelination, and vitamin B12 deficiency as a differential diagnosis of DCM, it is important to investigate what role vitamin B12 levels play in patients with DCM in terms of baseline neurological function and whether optimization of vitamin B12 levels can improve surgical outcome. Furthermore, the routine assessment of vitamin B12 levels in patients considered for DCM surgery should be considered.
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Affiliation(s)
- Aria Nouri
- Department of Neurosurgery, Yale University, New Haven, CT, USA
- Department of Neurosurgery, University of Cincinnati, Cincinnati, OH, USA
| | - Kishan Patel
- Department of Neurosurgery, Yale University, New Haven, CT, USA
| | - Julio Montejo
- Department of Neurosurgery, Yale University, New Haven, CT, USA
| | - Rani Nasser
- Department of Neurosurgery, University of Cincinnati, Cincinnati, OH, USA
| | - David A. Gimbel
- Department of Neurosurgery, University of Cincinnati, Cincinnati, OH, USA
| | - Daniel M. Sciubba
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
| | - Joseph S. Cheng
- Department of Neurosurgery, Yale University, New Haven, CT, USA
- Department of Neurosurgery, University of Cincinnati, Cincinnati, OH, USA
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Zaffina S, Lembo M, Gilardi F, Bussu A, Pattavina F, Tucci MG, Moscato U, Raponi M, Derrico P, Galeotti A, Camisa V. Nitrous oxide occupational exposure in conscious sedation procedures in dental ambulatories: a pilot retrospective observational study in an Italian pediatric hospital. BMC Anesthesiol 2019; 19:42. [PMID: 30917782 PMCID: PMC6438021 DOI: 10.1186/s12871-019-0714-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 03/13/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Nitrous oxide has a proven clinical efficacy in conscious sedation. At certain environmental concentrations it may pose a health risk to chronically exposed healthcare workers. The present pilot study aims at evaluating the exposure to nitrous oxide of dental ambulatory personnel of a pediatric hospital. METHODS A descriptive study design was conducted in two phases: a bibliographic analysis on the environmental safety policies and a gas concentration analysis in the dental ambulatories of a pediatric hospital, detected every 6 months from December 2013 to February 2017 according to law provisions. The surveys were carried out using for gas analysis a photoacoustic spectrometer Innova-B&K "Multi-gas monitor model 1312" and Innova-B&K "Multi-sampler model 1309". The biological analysis and monitoring have been carried out on staff urine. RESULTS The analyses were performed during 11 dental outpatient sessions on pediatric patients. All the patients were submitted to the same dental procedures, conservative care and dental extractions. The pediatric patients were 47 (23 males, 24 females; age range 3-17 years; mean age 6,63, SD ± 2,69) for a mean of 4,27 (SD ± 1,49) per session., The mean environmental concentration of nitrous oxide during the sessions was 24.7 ppm (SD ±16,16). A correlation was found between urinary nitrous oxide concentration of dentists (Pearson's correlation 0.786; p = 0.007) and dental assistants urines (Pearson's correlation 0.918; p < 0.001) and environmental concentrations of nitrous oxide. Weak negative correlations were found between age and sex of patients and environmental concentrations of nitrous oxide. The mean values of the biological monitoring data referring to all the outpatient sessions are lower than the reference values foreseen in accordance to the regulations in force on nitrous oxide concentration. CONCLUSIONS The mean environmental concentration values recorded in our study are below the limit of 50 ppm considered as a reference point, a value lower than those reported in other similar surveys. The results of the present study provide a contribution to the need to implement technical standards, criteria and system requirements for the dental ambulatories, to date not yet completely defined, and cannot be assimilated to the ones established for the surgical rooms.
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Affiliation(s)
- S. Zaffina
- Occupational Medicine, Health Directorate, Bambino Gesù Children’s Hospital - IRCCS, Piazza di Sant’Onofrio 4, 00165 Rome, Italy
| | - M. Lembo
- Risk Management and Technology Assessment Department, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - F. Gilardi
- Occupational Medicine, Health Directorate, Bambino Gesù Children’s Hospital - IRCCS, Piazza di Sant’Onofrio 4, 00165 Rome, Italy
| | - A. Bussu
- Occupational Medicine, Health Directorate, Bambino Gesù Children’s Hospital - IRCCS, Piazza di Sant’Onofrio 4, 00165 Rome, Italy
| | - F. Pattavina
- Section of Hygiene, Institute of Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma - Università Cattolica del Sacro Cuore, Rome, Italy
| | - M. G. Tucci
- Risk Management and Technology Assessment Department, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - U. Moscato
- Section of Hygiene, Institute of Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma - Università Cattolica del Sacro Cuore, Rome, Italy
| | - M. Raponi
- Health Directorate, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - P. Derrico
- Risk Management and Technology Assessment Department, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - A. Galeotti
- Dentistry Unit, Department of Pediatric Surgery, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - V. Camisa
- Occupational Medicine, Health Directorate, Bambino Gesù Children’s Hospital - IRCCS, Piazza di Sant’Onofrio 4, 00165 Rome, Italy
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15
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Abstract
In this paper, the design of experiments and response surface methodology were proposed to study ammonia oxidation process. The following independent variables were selected: the reactor’s load, the temperature of reaction and the number of catalytic gauzes, whereas ammonia oxidation efficiency and N2O concentration in nitrous gases were assumed as dependent variables (response). Based on the achieved results, statistically significant mathematical models were developed which describe the effect of independent variables on the analysed responses. In case of ammonia oxidation efficiency, its achieved value depends on the reactor’s load and the number of catalytic gauzes, whereas the temperature in the studied range (870–910 °C) has no effect on this dependent variable. The concentration of nitrous oxide in nitrous gases depends on all three parameters. The developed models were used for the multi-criteria optimization with the application of desirability function. Sets of parameters were achieved for which optimization assumptions were met: maximization of ammonia oxidation efficiency and minimization of the N2O amount being formed in the reaction.
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16
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Patel KK, Mejia Munne JC, Gunness VRN, Hersey D, Alshafai N, Sciubba D, Nasser R, Gimbel D, Cheng J, Nouri A. Subacute combined degeneration of the spinal cord following nitrous oxide anesthesia: A systematic review of cases. Clin Neurol Neurosurg 2018; 173:163-168. [PMID: 30144777 DOI: 10.1016/j.clineuro.2018.08.016] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 08/03/2018] [Accepted: 08/08/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Vitamin B12 deficiency can lead to subacute combined degeneration (SCD). Nitrous oxide (N2O) is an anesthetic which oxidizes the cobalt ion of vitamin B12, interfering with its function as a coenzyme. In this study, we conduct a systematic review of reported cases of SCD following nitrous oxide anesthesia. PATIENTS AND METHODS A comprehensive search of multiple databases was conducted, and information about patient characteristics, symptomatology, clinical work-up, and treatment was extracted from eligible articles. Univariate analyses were performed to identify predictors of poor neurological recovery following SCD. RESULTS 32 studies, reporting 37 cases of nitrous oxide-induced SCD, were included through the screening process. These cases included 21 male patients and 16 female patients, with an average age of 50.4 years (SD 17.6). An etiology for subclinical B12 deficiency was determined in 30 reports; of these, 25 were due to vitamin malabsorption secondary to a gastrointestinal disorder. Duration of nitrous oxide exposure was described in 19 reports, and ranged from 30 min to 11 h. Univariate analysis failed to find an association between post-operative recovery and age (p = 0.60), sex (p = 0.46), positive MRI findings (p = 0.47), post-operative serum B12 (p = 1.00), post-operative hemoglobin (p = 0.18), type of surgery (p = 0.58), or post-operative high mean corpuscular volume (p = 0.13). CONCLUSION In patients with postsurgical myelopathy, surgeons should evaluate B12 status and consider the possibility that nitrous oxide could cause a subclinical B12 deficiency to become overt, particularly in patients with malabsorptive GI comorbidities. Treatment with B12 in this population can result in significant improvement of neurological function.
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Affiliation(s)
- Kishan K Patel
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA.
| | - Juan Carlos Mejia Munne
- Department of Neurosurgery, University of Cincinnati College of Medicine, PO Box 670515, Cincinnati, OH, 45267, USA.
| | - Vimal Raj Nitish Gunness
- Department of Neurosurgery, University of Toronto, 1 King's College Cir, Toronto, ON, M5S 1A8, Canada.
| | - Denise Hersey
- Cushing/Whitney Medical Library, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA.
| | - Nabeel Alshafai
- Alshafai Neurosurgical Academy, Toronto, ON, M5J 2S2, Canada.
| | - Daniel Sciubba
- Department of Neurosurgery, Johns Hopkins School of Medicine, 733 N Broadway, Baltimore, MD, 21205, USA.
| | - Rani Nasser
- Department of Neurosurgery, University of Cincinnati College of Medicine, PO Box 670515, Cincinnati, OH, 45267, USA.
| | - David Gimbel
- Department of Neurosurgery, University of Cincinnati College of Medicine, PO Box 670515, Cincinnati, OH, 45267, USA.
| | - Joseph Cheng
- Department of Neurosurgery, University of Cincinnati College of Medicine, PO Box 670515, Cincinnati, OH, 45267, USA.
| | - Aria Nouri
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA; Department of Neurosurgery, University of Cincinnati College of Medicine, PO Box 670515, Cincinnati, OH, 45267, USA.
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17
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Abstract
Nitrous oxide, long used during labor in Europe, is gaining popularity in the United States. It offers many beneficial attributes, with few drawbacks. Cost, safety, and side effect profiles are favorable. Analgesic effectiveness is highly variable, yet maternal satisfaction is often high among the women who choose to use it. Despite being less effective in treating labor pain than neuraxial analgesic modalities, nitrous oxide serves the needs and preferences of a subset of laboring parturients. Nitrous oxide should, therefore, be considered for inclusion in the repertoire of modalities used to alleviate pain and facilitate effective coping during labor.
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Affiliation(s)
- Michael G Richardson
- Department of Anesthesiology, Vanderbilt University Medical Center, 4202 VUH, 1211 Medical Center Drive, Nashville, TN 37232, USA.
| | - Brandon M Lopez
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL 32610, USA
| | - Curtis L Baysinger
- Department of Anesthesiology, Vanderbilt University Medical Center, 4202 VUH, 1211 Medical Center Drive, Nashville, TN 37232, USA
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