HOW SAFE

IS

SAFE?

Mel M. Tekavec, D.D.S.

In 1844 when Dr. Horace Wells first used nitrous oxide as an anesthetic agent for dental surgery, it was an extremely dangerous procedure. The unconscious state was brought about by the combined action of the anesthetic gas and hypoxia. The gas was impure and asphyxiation was a possible consequence. In 1868 Dr. Edmund Andrews computed that the minimum safe proportions were a mixture of 20% oxygen and 80% nitrous oxide. Using less than a metabolic supply of oxygen with the nitrous oxide for anesthesia was improper procedure. We are all familiar with the diameter and pin index safety systems that prevent accidental interchanging of different gas cylinders on the same gas line. The oxygen flush (50 liters per minute) that is available on all new dental anesthesia equipment is a ready source of a high flow of 100% oxygen if needed. Nitrous oxide tanks and the high pressure tubings are always color-coded blue, while oxygen components are color-coded green. This allows for easy recognition of gases and lines used. Many older anesthesia machines do not have a fail-safe mechanism. If the oxygen line pressure fails, it is possible to deliver 100%v nitrous oxide. This could cause asphyxiation and death if allowed to continue for a prolonged period of time. It is improper to have such outdated equipment in any dental office. If there is a failure in the delivery of oxygen, the nitrous oxide should always be shunted from the patient. In 1970 a modification was made on all existing continuous flow dental nitrous oxide

anesthesia machines. A flow-safe device

was added. It is now mechanically impossible to deliver less than a metabolic supply of oxygen at all times. When the anesthesia machine is switched on, the oxygen will automatically flow at a minimum of three
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liters per minute. There is a mechanical stop that prevents lowering the oxygen liter flow below this amount. The nitrous oxide flow cannot be activated until this minimum flow of oxygen is present. The nitrous oxide cylinder regulator is adjusted to give a maximum flow of 12 liters or less of nitrous oxide. This will always guarantee a 20% or greater mixture of oxygen to the dental patient. In the past it was possible for the dentist to inadvertently turn the oxygen completely off and still have a flow of 100% nitrous oxide to the patient. This is no longer possible. If your anesthesia machine does not have this safety feature, your present equipment should be modified by the manufacturer. With anesthesia our primary purpose is to bring about unconsciousness and thus eliminate interpretation of painful stimuli. With nitrous oxide sedation (relative analgesia) our primary purpose is to eliminate fear and apprehension in a conscious patient. It has been said that the only two similarities between these two procedures is that the same gases and the same gas machines can be used. From this point on there is no similarity in the procedures because the primary purposes are different. If our purposes are different, why not modify the armamentarium for these two different procedures? All present dental gas machines can bring about the unwanted unconscious state on some patients. This is improper procedure if sedation is our primary goal. Why not limit the nitrous oxide to the 60%o range? This would now be a true sedation gas machine. High speed cars can be made safer by placing a governor on the accelerator. Why not place a governor on our anesthesia machines and make them safer? It is possible to adjust the nitrous oxide line pressure to give a maximum flow of four to five liters per minute nitrous oxide at the flowmeter. With the minANESTHESIA PROGRESS

imum three liter flow of oxygen and additional air dilution if needed, we will still maintain an adequate minute volume flow for our patient. This is always essential or rebreathing could possibly occur and thus bring about possible hypercapnic problems. Dentists who are using nitrous oxide sedation at higher elevations will need to use a higher percentage of nitrous oxide to bring about the same sedative effect because the barometric pressure is less. For example, if we were administering a 50%c mixture of nitrous oxide in Los Angeles, California, (sea level - barometric pressure of 760 mm. Hg), the eventual partial pressure of nitrous oxide (pN2O) at the alveolus would be computed: 760 mm. Hg (Total pressure exerted by all gases) -40 mm. Hg (pCO2) -47 mm. Hg (water vapor pressure) 673 mm. Hg (pressure exerted by gases delivered from flowmeter) x5O% 336.5 mm. Hg (pN2O) If we were administering a 60% mixture of nitrous oxide in Pueblo, Colorado, (4,650 feet - barometric pressure of 641 mm. Hg.), the eventual (pN2O) at the alveolus would be computed: 641 mm. Hg (total pressure exerted by all gases) -40 mm. Hg (pCO2) -47 mm. Hg (water vapor pressure) 554 mm. Hg (Pressure exerted by gases delivered from flowmeter)
60%

332.4 mm. Hg (pN2O) A 50% nitrous oxide mixture at sea level will have approximately the same sedative effect as a 60% nitrous oxide mixture in Pueblo. In over five hundred different patients being administered nitrous oxide sedation (closed inhaling valve technique) in Pueblo, adequate sedation has been accomplished in 97%o of the cases when administering 20% to 60% nitrous oxide. Mathematically, the same result could be achieved at sea level with a 50% or less nitrous oxide mixture.

By placing a governor on our nitrous oxide liter flow, (by adjusting our nitrous oxide regulator), we can still bring about adequate sedation but limit the possibility of entering the unwanted unconscious anesthetic stage. I believe that it is important to review some of our present safety devices and consider whether they can be upgraded. Also, we should always be aware of new safety devices that can possibly be added to our present equipment. Are our flowmeters accurate? Are they individually tested at the factory? Are they tested at installation time? Should we periodically test them with an oxygen analyzer? Should our gas machines be certified for accuracy on an annual basis? How safe is safe? When equipment is installed, is it possible for the plumber to solder the connections improperly? Yesl If our gas machines or gas lines are repaired, is it possible to have a cross-over of lines? YESI Always check any installations or repairs personally. How safe is your fail-safe? Since it is not routinely tested every day before use, it is conceivable for it to malfunction without the operator knowing. Possibly, manufacturers could assemble a fail-safe that must be routinely checked each time the equipment is activated. An accurate fail-safe is one that would become active immediately upon the loss of oxygen line pressure. The nitrous oxide flow should drop in the same proportion as or faster than the oxygen drop at all times. Some machines will allow the oxygen to drop considerably (5% to 18%) before the nitrous oxide flow is materially reduced. This could cause a problem over a prolonged period of time. Equipment manufacturers should be encouraged to upgrade their equipment. Many storage room manifolds are arranged to automatically transfer from the service tank to the reserve tank when all the gas has been used on the service side. This is accomplished by a difference in regulator line pressures. With less line pressure, the oxygen liter flow per minute may be reduced at the flowmeter. It is conceivable that the patient could be temporarily carried into the deeper unwanted analgesic plane (total analgesia). A machine
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JULY-AUGUST, 1971

that would maintain the same liter flow per minute of oxygen, even with reduced line pressure, would be best. Again, equipment manufacturers could upgrade their equipment. It would be advantageous to immediately know when the reserve tank of either gas is being used. It would be very feasible to use line pressure gauges or low voltage lights on the flowmeters to indicate this. A low cost automatic cross-over system is preferable to a manual cross-over system. Automatic systems will eliminate loss of time and confusion. You will never have an empty reservoir bag. Vandalism is becoming an increasing problem. Is there a method to prevent vandalism of nitrous oxide cylinders? Possibly our equipment manufacturers or gas suppliers can answer this question. Should there be a standardization of flowmeter tube positions? Should the nitrous oxide always be on the right or left side? Machines now vary. Some gas machines have an air by-pass valve near the reservoir bag. This valve becomes active only if a deep inhalation would empty the contents of the reservoir bag. If the total gas volume (nitrous oxide, oxygen, and air dilution) is always sufficient, it is unnecessary. However if the total minute volume is insufficient or a deep inhalation occurs, it may be activated. It can prevent the apprehensive patient from having the feeling of suffocation. Always give your patient a high total flow of gases to prevent this from happening. This high flow is more necessary with the closed inhaling valve technique than with the 1-4 open valve technique that allows for air dilution. Dentists who have a nitrous oxide-oxygen sedation flowmeter in their operatory can administer oxygen rapidly if the need arises. The flowmeter can be converted into a resuscitation unit by closing all valves, filling the reservoir bag with the oxygen flush, and then intermittently bagging the patient. However, it is much easier to have a quick-connect on the unit or oxygen line leading to the unit to which a resuscitator can be attached. (e.g., Handy or Elder demand valve). Positive pressure oxygen should be available in all dental offices.
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It is always proper to have our exhaling valve at minimum tension. This will bring about easier exhalations for the patient and minimize rebreathing possibilities. Since rebreathing is not recommended in nitrous oxide sedation, would it be safer to have a non-adjustable valve on "analgesia" nosepieces? The question arises whether or not the inhaling valve (air dilution valve) should be full open, half open, quarter open, or closed. The air dilution valve serves three purposes: 1. During inspiration, it allows room air dilution of the gases from the flowmeter. This will help conserve gases and still maintain an adequate minute volume of gases to the patient. 2. During expiration, it allows additional respiratory gas escape along with the minimum tension exhaling valve. 3. If a by-pass valve is present near the reservoir bag, it may prevent your patient from possibly feeling suffocated after a deep inhalation that empties the bag. It could be a help psychologically. What factors must be considered if the inhaling valve is closed? 1. During inspiration, the total minute volume (six to seven liters for an average adult male) must be given from the gas machine. Since there is minimal air dilution (hood leakage and possible mouth breathing) we will be using slightly more oxygen. This higher percentage of oxygen will bring about a higher pO2 in the blood. With a closed valve technique we can more accurately predict the percentage of oxygen and nitrous oxide that our patient is receiving. Would it be important to know this percentage in a malpractice suit? This question has not been answered. 2. During expiration, most of the respiratory gases are eliminated through the exhaling valve. (Some minor gas escapage around the hood and through the mouth). It is essential that the exhaling valve always be set at minimum tension to eliminate rebreathing possibilities. 3. Higher total minute volume flows should be used with the closed valve technique.

ANESTHESIA PROGRESS

Should the inhaling valve (air dilution) be 4 open or closed? As long as the patient is always receiving a metabolic supply of oxygen and has an adequate total minute volume flow, it is not really too important which method you use. Both are correct. It matters little whether the mixture is further diluted with additional oxygen, atmospheric air, or even an inert, innocuous gas such as helium. The advantage of the quarter open valve technique is that you will conserve the gases delivered from the flowmeter, and it is slightly easier for your patient to exhale. The advantage of the closed valve technique is that you will more accurately know the percentage of gases being delivered to the pa-

tient and the pO2 in the blood will be higher. However, the pO2with both methods is always sufficient. Personal preference will dictate your technique. Equipment manufacturers, dental supply distributors, equipment installers, and gas suppliers need our suggestions to improve their products. How safe is safe? We should strive for 100% safety with this sedation technique.
1311 Jerry Murphy Rd. Pueblo, Colorado 81001 For their help in supplying information concerning gas machines and their installation, I would like to thank Dentatron Corporation, Fraser Sweatmen Inc., The Foregger Co., McKesson Co., National Cylinder Gas Division of Chemetron, and Ormco Corporation.

SCIENTIA OMNEM %Moghmw

DLXOREM VINCIT

JULY-AUGUST, 1971

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