Entonox (nitrous oxide)

The Use of Entonox for Nail Surgery

Hello Members
I am a member of the team of Podiatrists at Solihull Hospital and regularly carry out Nail surgery.
Recently I looked into the subject of 'Alternative Analgesia' for those patients who find local anaesthetics a painful procedure.....This turned out to be complicated and expensive.
The most simple, cheap and save method would be to introduce Entonox. This is self administered by the patient
ie When they have had enough they automatically lower their supporting hand which holds the Entonox. Recovery is very fast.
I would wish to introduce this for mainly children who sometimes find accepting local anaesthetics a traumatic experience.
At present if a child refuses the injection we have no alternative but to refer on so the patient has treatment under a general anaesthetic.
Does any one else use Entonox and what training did you have?
Thank you for reading my first thread
PT

 

Re: The Use of Entonox for Nail Surgery

Hi PT (Please consider adding a name, I have difficulty addressing anyone as 'Tool'. Unless of course you were driving a silver corsa south on the M1 last sunday that is!)

Anyway...... :welcome: to Podiatry Arena

The search bar along the top of the page can be really useful in helping to identify particular areas of interest. The following thread involved discussion about Entonox. I hope it is of use:

http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=12653&highlight=entonox

Kind regards,

Mandy.

 

This is a very interesting subject for a student of Podiatry who once was a Dental Hygienist (Therapist)... now podiatrists can join the great debate

Certainly nitrous oxide is a handy substance which is routinely used in dentistry and I am gob-smacked it wouldn't widely be used in Podiatry. The depth of analgesia, can often be enhanced by use of IV or anxyolytic drugs (see: "relative analgesia"). I do like this link (http://www.dentalfearcentral.org/laughing_gas.html)... as you can see... the poor dents are so used to pain management issues they have to be using the very best stuff otherwise they'd never get any work done with a phobic. :bang:

For the skilled operator, the use of nitrous can save a lot of time (= MONEY) with even the most terrified of patients. Note: Under a clinician's supervision with use of 1:1 mix nitrous oxide: oxygen = SAFE. Lunatic that steals it and uses the nitrous on its own = LETHAL (they will reach a level of analgesia you won't get them out of).

There is a lot of publicity (again in dentistry) over the use of Penthrox (methoxyflurane) in Australia. And in practice, I have heard a lot of praise and dismissal of this relatively new drug for the dental industry. Really, for those routinely dealing with phobics I'd be heading straight for the nitrous. For easy of storage, good pain management practices, stealthy LA administration, and "easier" phobics the methoxyflurane might be sufficient.

Penthrox comes in a canister inhaler, you can charge a fee for the canister, and if other work is to be done you can store the inhaler in a zip-locked LABELLED bag with patient details. Really though, for pods and dents who are accustomed to taking routine thorough Med Hx. the issue of kidney complications with Penthrox SHOULD be low but should not be ignored as a bit of a minus to using it.

Interesting 2 biggies for the dents is not so much for the pods... but what an amazing opportunity for an industrious pod willing to use these drugs?! It can save a lot of costly day surgery and cost you less heartache with good pain management strategies. Good luck to those in the UK that are fighting the battle to use nitrous. With appropriate training and supervision why should we not all benefit from such a simple strategy?!

 

Hello Mandy
No I don't drive a Corsa!!!

I can see now perhaps my user name is not quite appropriate, too much playing on the X-box......... though thank you for the useful reply.

To be honest I actually feel cruel not using Entonox and will try and get it set up at Solihull.

(PS My name is Colin....You may not think thats much better!!)

 

Hi Colin,

Much more appropriate, thank you.

Please keep us updated on your progress in Solihull.

Many thanks,

Mandy.

 

Hi

As soon as you sedate patients you are going to have to have a nurse/assistant present in the room with you as a chaperon. Dentists have to have a nurse present to even work.

The risk and consequences of an unfounded accusation of assalt is far too high, even though you think it will never happen.

In private practice you will have to factor in any extra cost.

Nice idea though.

Luke

 

Hi Luke,

As I understand the situation ( and certainly in my practice) there are 2 staff present during nail op' procedures.

Regards,

Mandy.

 

Hi

An update on my last post.

I spoke to the tame dentist here this morning to ask how they get on with entonox sedation.

If a dentist wants to use sedation they have to run a sedation clinic with a recovery room, have an trained anaesthetist to administer the sedation in addition to their nurse. The patient has to be supervised for 24 hours afterwards either by the clinic or by a responsible person.

It make some patients sick which is known to mothers who are given it during childbirth. It can also cause some children to stop breathing.

She also confirmed that they are not allowed to work without a nurse assisting.

I cannot see the Society having any lower standard for the administration of sedation than that required of other health professionals.

As allways full of good cheer.

Luke.

 

Yes, it is being used, though infrequently, by some practitioners in the area. I personally know three Podiatrists and six or seven dentists who use it. They use it prior to minor in-office surgery. Most podiatrists are taking their cases- even minor procedures- to a surgery center or hospital, where anesthesiologists or nurse anesthetists manage any anesthesia beyond local.
- Dr. John

 

Hi Luke,

Are you still referring to NO2 inhalation or IV sedation?

As far as i'm aware you don't need an anaesthetist to let someone puff on a bit of entonox + 24hr monitoring??

This may be the case when dentists use IV sedation.

I don't think it would apply to entonox.

e.g a person dislocates his finger, paramedics attend and give him entonox whilst travelling to hospital. Medic manipulates and discharges. I'm sure 24hr monitoring would not be needed?

 

Hi.

G Flanagan

I asked about the dentist rules and procedures for the administration of entonox not IV sedation. I will get this clarified at work tomorrow.

A paramedic is acting in an emergency and this cannot be compared to a planned office procedure. They are also very rarely alone and take the patient to a hospital where they will be seen by some other qualified person.

Cheers

Luke

 

Luke,

thanks for your reply.

my example was referring to the patient having been taken to the hospital, the dislocation resolved and discharged. Subsequently having not been monitored for 24 hours.

From my own experience we often utilise entonox prior to podiatric surgery for anaesthetic block, the courses i have been on have noted everyone and their friend can administer entonox, no need for anaesthetist or 24hr monitoring which i think is a bit ott, but in these NICE, protocol ridden, gold standard times may be the case. Again your friend may have been referring to IV sedation?

Anyway that aside, i look forward to your further post having spoken to your dental surgeon friend.

 

Hi G Flanagan and others,

My tame dentist has not been available this morning and so I rang Mr Swithern a BDA man who teaches and inspects dental practices.

He referred me to the web site of the Society for the Advancement of Anaesthesia in Dentistry at: http://www.saad.org.uk/

Go there, you will find much of what you need by way of standards, courses, protocols, etc. I hope the Society take a look.

You may feel you have some "wriggle room" with the administration of entanox to an adult, but best practice may dictate that you arrange for the patient to have an escort. I will look into this.

Mr Swithern's opinion was that it wasn't worth the expense unless you are using it a lot. The equipment is expensive, you have to hire the cylinder and have it refilled, there are training and CPD requirement and the extra staff you may need etc. He also felt that it introduced another thing that can go wrong.

Most dentists seem to refer to another practice which runs a full clinic. The NHS may be able to run a clinic but in private practice the cost must be met by the procedure. You could of course try and carve out a niche for yourself.

I suspect that if it use becomes widespread by all and sundry with little if any training then we will see regulation introduced from above.

Cheers

Luke

 

Hi All,

Bearing in mind our brother Dentists on gas down the throat instead of the needle I wonder whether the risk factor in dentistry has been taking into account here?

My local dentists depend on the needle as an anesthetic these days instead of the needle? A policy brought about by having a few patients kicking the bucket under gas. Now they tend to send the patient needing or demanding gas into our local hospital rather than on site in their surgery!

Is this common policy or just local to here I wonder. As one who has just quickly scanned this thread I did not pick up on any cross reference?

Definitely not for the patient's front room carpet I suspect!

Training is a good protection too, although sometimes oppressively pursued in the name of control and CPD.?

Yours,

Colin.

PS. Just had a shell of a tooth out this week with it's abscess in root with needle and permission to scream!

 

Hi C Bain and others,

Difficult to parse early Saturday morning.

Dentist in the UK cannot give GA for the reasons stated.

Dentists do use both inhalational and IV sedation. The standards of training and practice for the use of IV sedation may be higher than that for Inhalational sedation. But sedation is sedation however performed.

When administered by a podiatrist in the course of treatment you will have to be able to demonstrate appropriate levels of competence and safe practice. While this may not include the requirements for the administration of IV sedation the standard for competence and safety can be no less. The effect is sedation.

To the poster who says that it is alright as it is self administered, this is nonsense. You as a professional have both prescribed and administered it. See the protocols at: http://www.saad.org.uk/

Indeed If you are going to use entonox why not go the whole way and use IV sedation? Are podiatrists less able than dentists? Whatever you do you will have to do the training, provide the premises, buy equipment, produce protocols and consent forms, and arrange your indemnity just the same. Why not do it.

Cheers,
Luke.

 

There is a huge difference betweeen self administered sedation (analgesia) using entonox or methoxyflurane and using either as an anaesthetic or using IV sedation. Using 'patient self administered' entonox in a fixed 50:50 mixture or methoxyflurane is safe because the very nature of self administration prevents the patient from becoming deeply sedated and losing their own protective airway reflexes. It is also safe because it has such a short duration of effect that even if a complication occurrred such as vomiting while sedated, or any other concern, once it is removed the patient will be back to a normal level of alertness within 1-2mins. Also once the procedure is over the patient will only require a brief period of observation and can then be safely discharged (although they probably shouldn't drive or operate any machinery etc for at least a few hours).

IV sedation on the other hand generally results in a greater depth of sedation, has many more side effects including loss of protective airway reflexes, respiratory depression, respiratory arrest, cardiac arrhythmias, hypotension etc etc, depending of course on what particular sedating agent you use. The other downside to IV sedation is that once the drug is in its there, so if you have a patient who becomes apnoeic then you have to manage that problem until the effects of the drug resolve, which can be a considerable length of time. Administering any of the currently available and widely usd IV sedative agents generally requires that the patient be observed for a period of several hours following the administration of the sedative.

The other downside to IV sedation is the considerable costs assoicated with its use. Read any protocols regarding the use of IV procedural sedation and at a minimum you need a dedicated health practitioner who is skilled in airway and ventilation management (with all the requisite equipment available) with the patient during and in the immediate post operative period, as well as being readily available during the period of observation. Generally this person would be an anaethetist or medical practitioner with experience and training in airaway management and advanced life support skills, however in some cases an eperienced nurse or other appropriate health practitioner may suffice. As a minimum you would also need equipment to monitor blood pressure, pulse oximetry and cardiac rhythm during and immediately following the procedure. All this makes IV sedation a very expensive and far more complicated option.

There is little comparison between self administered analgesia using entonox or methoxyflurane and IV sedation. They are worlds apart and require an entirely different approach to management and implementation.

I also wonder how often podiatrists feel they need to use any sedation when performing surgical procedures such as nail avulsions and curettage. Whilst I could see that there will be the occassional person who is so needle phobic that some inhalational analgesia might be benficial I would think that by far the majority of patients can be adequately reassured and with good injection techniques not be too phased by the whole ordeal. I wonder whehter the rush to start sedating patients is more about the podiatrist having the ability to do something more (i.e. the I can so I will mentality) rather than it really improving patient care or even patient comfort. Whilst entonox and methoxyflurane are relatively safe drugs it must always be remembered that every thing that is done adds a new complexity to the patient care process and with that the increased risk that something else will go wrong.

Local anasesthesia has been used widely and effectively for many years by podiatrists (and other health professionals) performing minor surgical procedures. Whilst I believe that having an alternative available for the occassional patient who needs it is a good thing I would hate to see the situation where this practice becomes the norm 'just because we can'.

 

posalafin sums it up very nicely and certainly the dentists don't use nitrous constantly... nor would they like the reputation I'm sure... it can encourage some "undesireables" in the community around. However, with appropriate training, it can be a good little tool to have on hand. IV sedation on the other hand... I'd probably never want to bother. I've seen it done and know what a pain it would be on too many levels to provide.

 

Yes he does......just want I wanted to say only probably better. I agree with most of the content but at Solihull Hospital when a child refuses a local anaedsthetic we have no alternative but to send him/her off for a GA......In this case a few puffs on Entonox would solve the problem, not only to relax the pt but to act as a good analgesic before the LA.
Colin

 

Hi there!

There seems to be a little confusion of issues going on...

“Relative anaesthesia” is a procedures which DOES require the supervision of a nurse. It involves the use of Entonox and IV sedation. It is expensive to provide but dentists which do offer it often add an additional fee to cover this cost.

Probably a procedure I wouldn’t want to get involved in because of some additional risk and noone will pay me enough to cover for my personal risk. That’s life and that’s my choice I can make.

Use of Entonox usually incurs a lower fee because it does not require the presence of a nurse. For that reason it is really so easy to integrate. I’ve never really worked for any dentist that has given it out like there’s no tomorrow but I’ve certainly never met a dentist particularly fearful of its use.

Also, the person that posted on the nature of Entonox being “self-administered” wasn’t being sinister. The nature of administration means that the patient controls the relative depth of analgesia by the rate at which they breathe... quick breaths giving deeper analgesia and explaining this to the patient probably gives them a greater sense of control... probably one of the best benefits of its use really...?

However, in both cases it is essential to have a female staff member present in the room with you when administering either. “CYA” = “cover your ass”.

I hope that clears some of the issues up!

Emma

 

Thanks Emma, :good:

Exactly my point.

As you have alluded it was 'common sense' I was advocating not pin the buggers down n enforce sedation. Doh! It is all about calming a phobic patient NOT about imposing yet another reason to restrict podiatric practice. I understand the requirement to impose regulation but surely if something has been proven as safe (given certain restrictions) then to utilise that for the benefit of the patient is in their best interest.

I am 100% for safe practice.

Also 100% for practicing within safe boundaries in the patients interest. If that permits inhalation sedation in the appropriate circumstances I personally do not see a problem.

Regards,

Mandy.

 

Re: Entonox

Hi Steve, I am interested in the training and use of Methoxyflurane in Podiatry practice. Can you please pass on details of the company which trains? I work in SA. thanks.

 

Hi Guys,
I spoke last week at podiatry conference to Dr Bothewick, chair of the Medicines committee for the society and apparently Entonox is a pharmacy 'P' item so can be used by podiatrist provided they have the correct training. There is a BOC online course, not sure if that is acceptable (but it is free) or the St John Ambulance run a 1/2 day medical gases course for the public / first aiders.

 

Hi everyone,

This thread has been quiet for some time, but just in case anyone is interested! lol.

Previously as both a nurse and paramedic I used Entonox. When I started my podiatry training I was amazed that hardly anyone used it, or had heard of it outside 'childbirth' lol.

As a result I set about doing some research and for my podiatry degree dissertation looked at the questions 'Could Entonox inhaled analgesia be of use in podiatric practice'.

To cut a long story short here are some findings:

Yes HPC Pods can use entonox (subject to local policy etc if NHS)
Yes it reduces pain, but does not eliminate it.
Therapeutic effect is similar to 10mg Morphine
Anxyiolytic effects are equal to and safer than diazepam etc
If used correctly and self administered, you cannot overdose.
Can be used with children (Provided they can suck the gas from the demand valve)
Effect wear off within 5-10 mins
Generally if they walk into your clinic, they probably dont have the contra indications to its administration.
Side effects - common, nausea and dizzyness - but wear off within minutes
You can drive 30 mins after use (Unlike L/A)

Some of the more common use would seem to be for:

Needle phobics
Anxyiolitic properties
Any quick painful procedure without L/A (Especially if they are driving)
Joint manipulations etc

Those are just some points, if your really interested in finding out more including how it works in terms of pharmocological properties etc drop me a message.

Colin
:deadhorse:

 

Thank you Colin for your input,

I too agree that analgesic gas has a very valuable place in podiatry. The problem I find is the cost of its use in comparison with ongoing costs. IE. Most patients (in my private practice) do not require its use, although there are some who would benefit. Keeping a supply aboard (so to speak) would not be viable in my small podiatry clinic. BOC quoted a ridiculous amount for its supply. Sadly this prevents me from offering a valuable option to patients.

Kind regards, Mandy.

 

If seems like from left base, please forgive - but you should all be aware of it. Now we live in a world of fast transport, people are often seen "out of context". For instance, scuba divers are reporting to hosptitals far distant to the sea, with decompression sickness. One of their symptoms is joint pain - for which they are being given entonox for relief. This is a disaster for decompression sickness (AKA Bends) as it is caused by an excess of blood nitrogen in the first place. It is because of the "out of context" that it happens - had it been a coastal hospital, the attending physician would be aware of the possibility and ask the right questions. So what I am saying guys (as a retired diving instructor), is for goodness sake check that the person you are about to entonox has not been diving within 48 hours. Rob

 

Hi Rob,

I quite agree with what your saying as an ex Royal Navy Medic. That said anyone using Entonox should only be doing so if they have been trained to do so, and this would include contra indications,including any person who has been diving within 48hrs, suspected pneumothorax, or raised intra cranial pressure, including people who have recently had eye or bowel surgery where gases may have been used to inflate a cavity as part of the procedure.

 

Thank you for your vote of support - it is rare that I get that in response to my posts. Rob

 

Hi Mandy,

Another company you can try is SP Services, they provide ambulance/first aid equipment and supply entonox kits and cylinders.
Another option is to see if there is a St John Ambulance unit near you, they will have spare cylinders, it may be for a donation they will loan you one, then when it needs replacing you pay them the cost of replacement, that is what i have done previously. Or chat to the station manager of the local NHS Ambulance service.

Worse case scenario is they say no lol.

Regards
Colin

 

Many thanks for that Colin. :good:

Regards,

Mandy.

 

Hi, I am happy to try and answer questions about the use of entonox in podiatry, as this was the subject of my dissertation for my podiatry degree. I have also used entonox as both a nurse and paramedic in the past, and I am a medical gases trainer.

Regards
Colin

 

One of the problems of getting old, whether as a Pod or a diving instructer (I am both), is that you become a grumpy old man. I made comment about entonox earlier in this debate. From a pathology point of view there is worse to come; SCUBA diving in my day was done with compressed air - too easy we might say...... an up-and-coming shift is towards altered gas mixtures, commonly known as "Nitrox" which, for the purpose of this address, may be thought of as a nitrogen depleted, oxygen enriched breathing mixture. The divers rationale is to increase bottom times without a need for decompression. It does disgusting things to blood gas tensions, nitrogen absorbtion, oxygen toxicity etc etc. Now that might be fine in a well organised industry such as The Royal Navy. which has the surface support that it needs - recompression chambers, destroyers, medics etc. It is not fine, IMHO for divers like me in a Zodiac. And it does have implications for the dispensers of entonox - much in line with my above comment - for goodness sake make sure they have not been diving with 48 hours - we no longer know what our clients have been breathing.......... and I do not mean illicit substances! Rob

 

Hi Rob,
I agree with you (again lol), but my response to your previous comment remains the same. Entonox should only be used by practitioners who have been trained and are competent to do so, this includes knowing the contra-indications to it's use (including diving). So there should not be a problem.

Regards
Colin