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O 2 vs N 2 O. Whos the bad guy?? YEE L. KWAN, RN, CCRN DUNAP, CLASS OF 2013 OCTOBER 22, 2012.

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Presentation on theme: "O 2 vs N 2 O. Whos the bad guy?? YEE L. KWAN, RN, CCRN DUNAP, CLASS OF 2013 OCTOBER 22, 2012."— Presentation transcript:

1 O 2 vs N 2 O. Whos the bad guy?? YEE L. KWAN, RN, CCRN DUNAP, CLASS OF 2013 OCTOBER 22, 2012

2 How many of you… Always use 100% O 2 for emergence? 1.Yes 2.No

3 I routinely… Titrate the FIO 2 to the lowest amount my patient needs to maintain their baseline sat. 1.Yes 2.No

4 Whats the point? By the end of this presentation you should be able to……. 1.Discuss the pros & cons of O 2 and N 2 O use 2.Identify risks for and s/s of O 2 toxicity 3.Discuss various methods/techniques to prevent atelectasis in our pts

5 O 2 IS GOOD B/C Well, its essential to life! Possible prevention of surgical site infection (SSI) Can reduce incidence of PONV Prevention of hypoxia

6 Meyhoff, C.S., Staehr, A. K., & Rasmussen L. S. (2012)

7 HAZARDS OF O 2 THERAPY Oxygen toxicity Absorption atelectasis* Induced hypoventilation Fire hazard Retinopathy of Prematurity (ROP)

8 Atelectasis….did you know? In 90% of anesthetized pts Both with spontaneous ventilation and paralysis Edmark et al. – CT of lungs of anesthetized patients PEEP – 10 cmH 2 O VC maneuver – 40 cmH 2 O, 7-8s Benoit et al. – postop atelectasis

9 Atelectasis….did you know? Benoit et al. (2002)

10 I typically…. Use N 2 O regularly as part of my anesthetic (assuming no contraindications). 1.Yes 2.No 3.Depends on who Im working with that day

11 I dont use N 2 O because….. 1.Im not comfortable with it 2.I prefer to keep things simple 3.Risk of N&V 4.My preceptors dont like it

12 N 2 0 IS GOOD B/C Has analgesic effects Rapid uptake and elimination Little cardiac or respiratory depression Nonpungent Additive effect with co-administration of other volatile agents Can speed up the rate of lung collapse for OLV

13 2 nd gas effect…in reverse Using the 2 nd gas effect to speed up emergence Peyton et al. found Time to eye opening and extubation were significantly shorter Partial pressure of Sevo 39% higher

14 N 2 0 CONTRAINDICATIONS ABSOLUTE Known deficiency of enzyme or substrate in methionine synthase pathway Gas filled spaces Increased ICP RELATIVE Pulmonary HTN Prolonged anesthesia >6hrs 1 st trimester High risk PONV Risk of MI

15 Do you use recruitment maneuvers during your anesthetics? 1.Yes 2.Not usually 3.No

16 When I use a recruitment maneuver I apply pressure to 1.20cmH 2 O 2.30cmH 2 O 3.40cmH 2 O 4.I dont know. I just squeeze until it feelsabout right

17 After this presentation I will definitely think about using N 2 O on my next patient 1.Yes 2.No

18 In summary….. Lots of evidence already exists both pro and con Every patient requires individual consideration There never is a right or wrong choice Think about why you do what you do – is there a good rationale?

19 References: Edmark, L., Kostova-Aherdan, K., Enlund, M., & Hedenstierna, G. (2003). Optimal oxygen concentration during induction of general anesthesia. [Clinical Trial Randomized Controlled Trial]. Anesthesiology, 98(1), Edmark, L., Auner, U., Enlund, M., Ostberg, E., & Hedenstierna, G. (2011). Oxygen concentration and characteristics of progressive atelectasis formation during anaesthesia. [Research Support, Non-U.S. Gov't]. Acta anaesthesiologica Scandinavica, 55(1), doi: /j x Grocott, H. P. (2008). Oxygen toxicity during one-lung ventilation: is it time to re-evaluate our practice? [Review]. Anesthesiology clinics, 26(2), , v. doi: /j.anclin Hedenstierna, G., & Edmark, L. (2010). Mechanisms of atelectasis in the perioperative period. [Research Support, Non-U.S. Gov't Review]. Best practice & research. Clinical anaesthesiology, 24(2), Hedenstierna, G., & Rothen, H. U. (2000). Atelectasis formation during anesthesia: causes and measures to prevent it. [Review]. Journal of clinical monitoring and computing, 16(5-6), Meyhoff, C. S., Jorgensen, L. N., Wetterslev, J., Christensen, K. B., & Rasmussen, L. S. (2012). Increased Long-Term Mortality After a High Perioperative Inspiratory Oxygen Fraction During Abdominal Surgery: Follow-Up of a Randomized Clinical Trial. Anesthesia and analgesia. doi: /ANE.0b013e a51 Rothen, H. U., Sporre, B., Engberg, G., Wegenius, G., Hogman, M., & Hedenstierna, G. (1995). Influence of gas composition on recurrence of atelectasis after a reexpansion maneuver during general anesthesia. [Clinical Trial Comparative Study Randomized Controlled Trial Research Support, Non-U.S. Gov't]. Anesthesiology, 82(4),

20 Staehr, A. K., Meyhoff, C. S., & Rasmussen, L. S. (2011). Inspiratory oxygen fraction and postoperative complications in obese patients: a subgroup analysis of the PROXI trial. [Comparative Study Multicenter Study Randomized Controlled Trial Research Support, Non-U.S. Gov't]. Anesthesiology, 114(6), doi: /ALN.0b013e31821bdb82 Vimlati, L., Kawati, R., Hedenstierna, G., Larsson, A., & Lichtwarck-Aschoff, M. (2011). Spontaneous breathing improves shunt fraction and oxygenation in comparison with controlled ventilation at a similar amount of lung collapse. [Comparative Study Research Support, Non-U.S. Gov't]. Anesthesia and analgesia, 113(5), doi: /ANE.0b013e31822ceef8

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