Nitrous Oxide


Article Author:
Kayla Knuf


Article Editor:
Christopher Maani


Editors In Chief:
Anantha Padmanabhan
Aakash Gajjar
Burt Cagir


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
4/4/2019 3:26:33 PM

Indications

Nitrous oxide is an odorless, colorless, non-flammable gas.  While nitrous oxide is not flammable, it will support combustion to the same extent as oxygen does.  It leads to a state of euphoria explaining its nickname ‘laughing gas.’  Nitrous oxide is the least potent inhalational anesthetic.  Nitrous oxide requires a concentration of 104% to reach one minimum alveolar concentration (MAC). Thus it cannot be a sole anesthetic agent, and it is often combined with a more potent and volatile anesthetic.  The combination of analgesic and anesthetic effects make nitrous oxide a valuable adjunct.  Nitrous oxide has a low blood solubility (blood-gas partition coefficient of 0.47) leading to quick onset and offset.  The low solubility leads to a concentrating effect for additionally administered volatile agents in the lungs and is known as the second gas effect. [1]

Nitrous oxide can be used for general anesthesia, procedural sedation, dental anesthesia, and to treat severe pain.  Nitrous oxide's potent analgesic properties can be used to provide analgesia in settings such as the obstetrical ward or emergency department.  In these settings it is often administered as a 50% mixture with oxygen. 

Compared to other anesthetic agents, nitrous oxide causes minimal effects on respiration and hemodynamics.  It leads to decreased tidal volume and increased respiratory rate but has a minimal effect on overall minute ventilation.  Nitrous oxide leads to direct myocardial depression, but this effect is reduced by nitrous oxide's sympathetic stimulation and the net effect is minimal.  Unlike other volatile anesthetics, nitrous oxide has no muscle relaxation properties.

Mechanism of Action

Nitrous oxide has multiple supraspinal and spinal targets.  The anesthetic effect of nitrous oxide is through non-competitive NMDA inhibition in the central nervous system.  The analgesic effects occur through the release of endogenous opioids that act on opioid receptors; its analgesic actions are like morphine.  The anxiolytic effects are through GABA-A activation.  Nitrous oxide has a central sympathetic stimulating activity which supports blood pressure, systemic vascular resistance, and cardiac output.  Nitrous oxide stimulates cerebral blood flow and increases intracranial pressure.  [2]

Administration

Nitrous oxide is administered via inhalation.  It can be given with a simple face mask, laryngeal mask airway, or an endotracheal tube.  Excretion of nitrous oxide is primarily unchanged through the lungs.  A small amount diffuses through the skin. 

Adverse Effects

Adverse effects of nitrous include: 

  • Respiratory Depression: When used alone nitrous has limited respiratory effects, but when used in combination with other sedatives, hypnotics, or opioids it can potentiate the respiratory depressant effects of these agents. 
  • Diffusion hypoxia: Following discontinuation of nitrous oxide, the concentration gradient between the gases in the lung and alveolar circulation rapidly reverses.  This can lead to rapid dilution of the oxygen in the alveoli, and subsequent hypoxia and 100% oxygen administration should follow nitrous oxide cessation.
  • Postoperative Nausea and Vomiting: Nitrous has an increased risk of postoperative nausea and vomiting (PONV) compared with other agents, but this can be controlled with prophylactic anti-emetics.[3] The ENIGMA I trial showed an increased incidence of PONV with nitrous oxide use.  The ENIGMA II trial showed that severe PONV with nitrous oxide use is more common in procedures lasting over 2 hours.  This study also showed that the use of nitrous oxide is not associated with increased mortality, cardiovascular complications, or wound infections.[4]

Contraindications

Many contraindications to nitrous use are relative and may vary based on the provider.  These include: 

  • Critically ill patients: Nitrous oxide inactivates methionine synthase via oxidation of the cobalt in vitamin B12 and may lead to megaloblastic anemia.  This enzyme is essential for vitamin B12 and folate metabolism and plays a role in DNA and RNA synthesis and synthesis of other substances.  In otherwise healthy patients, the impact is subclinical.  In critically ill patients this may lead to neurologic or hematologic consequences and should be avoided. 
  • Severe cardiac disease: Methionine synthase is also required to convert homocysteine to methionine, and elevated serum homocysteine levels are associated with an increased risk for adverse coronary events. In the setting of severe cardiac disease, nitrous oxide should be avoided, but further studies are needed to determine the actual impact.
  • First trimester of pregnancy: Due to the above-referenced impact on B12 and folate metabolism, nitrous use is not recommended in the first trimester of pregnancy.
  • Pneumothorax, small bowel obstruction, middle ear surgery, and retinal surgeries involving the creation of an intraocular gas bubble: Nitrous oxide is 30 times more soluble than nitrogen.  Nitrous oxide diffuses more rapidly into closed spaces than nitrogen can diffuse out, leading to increased gas volume and pressure within closed spaces.  Thus nitrous oxide is contraindicated in pneumothorax, small bowel obstruction, middle ear surgery, and retinal surgeries involving the creation of an intraocular gas bubble.  In laparoscopic cases, nitrous oxide can accumulate in the pneumoperitoneum, and some avoid its use in these cases.   
  • Severe psychiatric disorders: Nitrous oxide can cause dreaming and hallucinations and should be avoided in patients with severe psychiatric disorders.
  • Pulmonary hypertension: Nitrous oxide can increase pulmonary artery pressures and pulmonary wedge pressures via sympathetic stimulation and is often avoided in patients with pulmonary hypertension.[5]
  • Head and neck procedures with cautery use: While nitrous oxide is non-flammable, it supports combustion, and its use should be avoided in these procedures.  

Monitoring

No specific monitoring is required for nitrous oxide use.  An in-line oxygen analyzer with an alarm should be utilized to prevent delivery of a hypoxic gas mixture.  Modern anesthetic machines have fail-safe mechanisms to prevent this from occurring (nitrous oxide-oxygen proportioning systems).  Standard ASA monitoring should be utilized when administering nitrous oxide for any indication.

Toxicity

While nitrous oxide inactivates methionine synthase, intraoperative use results in a transient metabolic abnormality that soon reverses upon replacement of the degraded enzyme. 

When nitrous oxide is used in recurrently (during occupational exposure or as a drug of abuse), it may lead to megaloblastic anemia with neurologic dysfunction.  This situation also may occur in patients with an unrecognized cobalamin deficiency (vegans, pernicious anemia, hereditary disorders of cobalamin and folate metabolism).[6]

Enhancing Healthcare Team Outcomes

Nitrous oxide is a widely used option for labor analgesia in other countries.  One reason for limited use in the United States is due to the limited availability of anesthesia coverage.  Nitrous oxide administration and management by nursing staff has been shown to be a safe, cost-effective option for labor analgesia.[7] (level 5 evidence)

Administration of nitrous oxide by registered nursing staff has also been used to provide procedural sedation in pediatric radiology and resulted in fewer adverse effects and a quicker return to baseline compared with oral midazolam.[8][9] (level 5 evidence)


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Nitrous Oxide - Questions

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Which gaseous anesthetic can cause acute vitamin B12 deficiency?



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Which hematological side effect can be seen with nitrous oxide?



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A 33-year-old female is being prepared for a cesarean procedure. Which of the following agents possesses the most analgesic activity?



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Which anesthetic gas accumulates in air fluid-filled cavities during surgery?



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Nitrous oxide should be avoided in people who undergo which of the following procedures?



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A 65-year-old is stabbed in the abdomen and undergoes surgery. As soon as the abdomen is opened, there is severe distention of his colon. What is the most likely cause of this finding?



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In which of the following medical scenarios would one use nitrous oxide as an anesthetic gas?



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Which gaseous anesthetic can cause B12 deficiency?



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The anesthetic gas nitrous oxide is metabolized in which of the following sites?



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What percentage of a nitrous oxide tank is used when all the liquid nitrous oxide has evaporated?



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How long would a standard cylinder tank of nitrous oxide provide a flow rate of 4 L per minute?



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What effect does nitrous oxide anesthetic administration have on intraocular pressure in patients with intraocular gas for after retinal detachment repair?



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What happens to the uptake rate of nitrous oxide when it is administered at a constant rate?



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What occurs with induction of anesthesia using only nitrous oxide?



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The use of nitrous oxide in anesthesia for craniotomy following surgery in the supine position can have which of the following complications?



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A patient undergoes surgery with inhalation anesthetics. Sevoflurane is used in addition to a nonflammable, weak inhalation agent. The high partial pressure in the blood could cause which complication?



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A 0.5 minimum alveolar concentration (MAC) of isoflurane along with a mixture of 50% nitrous oxide in 50% air is administered for a dilation and curettage. At the end of the case, the isoflurane and the nitrous oxide are discontinued. You note that the oxygen saturation drops from 100% to 92%. What is the most likely explanation?



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Nitrous oxide inactivates which of the following enzymes?



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A 27-year-old male arrives at the operating room for an emergent exploratory laparotomy following multiple stab wounds to the chest and abdomen. Before an incision is made, rocuronium is given for paralysis. Maintenance is with nitrous oxide/isoflurane. Approximately 30 minutes into the case, the patient becomes hypotensive, the oxygen saturation falls, and an increase in peak airway pressures occurs. What is the most likely etiology?



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A 34-year-old male arrives at the operating room for an emergent exploratory laparotomy for a positive focused assessment with sonography in trauma (FAST) in the trauma bay following a motor vehicle collision at highway speeds. The patient remained hemodynamically stable throughout induction. Cefazolin is administered and surgery started. Maintenance is with nitrous oxide/isoflurane and intermittent boluses of fentanyl. Approximately 30 minutes into the case, the patient becomes hypotensive, the oxygen saturation falls, and an increase in peak airway pressures occurs. What is the next step in management?



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What is the blood-gas partition coefficient of nitrous oxide?



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Nitrous Oxide - References

References

Emmanouil DE,Quock RM, Advances in understanding the actions of nitrous oxide. Anesthesia progress. 2007 Spring     [PubMed]
Myles PS,Leslie K,Chan MT,Forbes A,Paech MJ,Peyton P,Silbert BS,Pascoe E, Avoidance of nitrous oxide for patients undergoing major surgery: a randomized controlled trial. Anesthesiology. 2007 Aug     [PubMed]
Myles PS,Leslie K,Chan MT,Forbes A,Peyton PJ,Paech MJ,Beattie WS,Sessler DI,Devereaux PJ,Silbert B,Schricker T,Wallace S, The safety of addition of nitrous oxide to general anaesthesia in at-risk patients having major non-cardiac surgery (ENIGMA-II): a randomised, single-blind trial. Lancet (London, England). 2014 Oct 18     [PubMed]
Schulte-Sasse U,Hess W,Tarnow J, Pulmonary vascular responses to nitrous oxide in patients with normal and high pulmonary vascular resistance. Anesthesiology. 1982 Jul     [PubMed]
Layzer RB,Fishman RA,Schafer JA, Neuropathy following abuse of nitrous oxide. Neurology. 1978 May     [PubMed]
Pinyan T,Curlee K,Keever M,Baldwin KM, A Nurse-Directed Model for Nitrous Oxide Use During Labor. MCN. The American journal of maternal child nursing. 2017 May/Jun     [PubMed]
Farrell MK,Drake GJ,Rucker D,Finkelstein M,Zier JL, Creation of a registered nurse-administered nitrous oxide sedation program for radiology and beyond. Pediatric nursing. 2008 Jan-Feb     [PubMed]
Zier JL,Drake GJ,McCormick PC,Clinch KM,Cornfield DN, Case-series of nurse-administered nitrous oxide for urinary catheterization in children. Anesthesia and analgesia. 2007 Apr     [PubMed]
Zafirova Z,Sheehan C,Hosseinian L, Update on nitrous oxide and its use in anesthesia practice. Best practice     [PubMed]

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