Guidelines for Best Practice
Upon completion of this chapter, the reader should be able to:
1. Recognize the historical safety record of N2O/O2 sedation.
2. Recognize current practice guidelines established for non-anesthesiologists working in an ambulatory setting.
3. Formulate an initial understanding of the virtuous characteristics of N2O/O2 sedation.
Clearly, the safety of nitrous oxide use in early days was related more to the inherent safe characteristics of the drug rather than sophisticated insight. Since its discovery more than 170 years ago, nitrous oxide (N2O) has been used to provide pain and anxiety relief for patients undergoing surgical procedures with a remarkable safety record.1,2 Gardner Quincy Colton (1814-1898), an itinerant professor, documented 193,000 cases with no adverse reactions.3 Ruben,4 a Danish researcher, cites 3 million cases in which N2O/O2 was used in the dental office with no adverse reactions noted. Niels Bjorn Jorgensen5 attests to 4 million episodes without complications. To date, there is no evidence of any mortality associated with N2O/O2 sedation in a dental office when used solely and appropriately.6 More than 48 million inpatient surgical procedures are performed each year in the United States,7 and 53 million ambulatory surgical and nonsurgical procedures have been performed,8 many having used nitrous oxide/oxygen (N2O/O2) in combination with other drugs that facilitate general anesthesia. In addition to its use as a general anesthetic adjuvant, myriad health disciplines use N2O/O2 sedation alone as an effective means of alleviating patient anxiety and mild discomfort during ambulatory and outpatient procedures. The dental profession was the first to use N2O/O2 sedation and, therefore, has historically been involved in the development of criteria for its safe administration. In Langa’s classic text published in 1968, an attempt was made to provide certain guidelines for nitrous oxide/oxygen administration.9 Today, there are well-established fundamental guidelines for practitioners who provide all types of sedation, including nitrous oxide and oxygen. In 2002 the American Society of Anesthesiologists (ASA) Task Force generated and published guidelines that serve as the foundation for all who administer nitrous oxide. These guidelines are promulgated to assist safe and successful administration experiences and to maintain this tremendous historical safety record far into the future.
The above-reference guidelines for best practice entitled “Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists,” published in Anesthesiology10 in 2002, continue to serve as the overriding policy for defining, directing, and ensuring the trends and practice of N2O/O2 administration into the foreseeable future. The guidelines are meant to direct those who are not specialists in anesthesiology, and they are mandatory for non-anesthesiologists practicing in hospitals (e.g., physicians, dentists, podiatrists). They are clearly useful and set the standard of care for future practice. The guidelines will be referred to throughout this text, because they represent an extensive evaluation and a synthesis of expert opinion by numerous academic and clinical anesthesiologists from across the United States.
In addition to the ASA guidelines, the American Academy of Pediatrics (AAP) and the American Academy of Pediatric Dentistry (AAPD) have established practice guidelines for the sedation of pediatric patients because of the ubiquitous use of nitrous oxide and oxygen in nontraditional settings. This document, published in Pediatrics in December 2006, is titled “Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Proce/>