Analysis of nitrous oxide concentrations in whole blood: an evaluation of an equilibration technique

Nitrous Oxide Abuse: Clinical Outcomes, Pharmacology, Pharmacokinetics, Toxicity and Impact on Metabolism

The recreational use of nitrous oxide (N2O), also called laughing gas, has increased significantly in recent years. In 2022, the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) recognized it as one of the most prevalent psychoactive substances used in Europe. Chronic nitrous oxide (N2O) exposure can lead to various clinical manifestations. The most frequent symptoms are neurological (sensitive or motor disorders), but there are also other manifestations like psychiatric manifestations or cardiovascular disorders (thrombosis events). N2O also affects various neurotransmitter systems, leading to its anesthetic, analgesic, anxiolytic and antidepressant properties. N2O is very challenging to measure in biological matrices. Thus, in cases of N2O intoxication, indirect biomarkers such as vitamin B12, plasma homocysteine and plasma MMA should be explored for diagnosis and assessment. Others markers, like oxidative stress markers, could be promising but need to be further investigated.

Comparison of biomarker for diagnosis of nitrous oxide abuse: challenge of cobalamin metabolic parameters, a retrospective study

BACKGROUND

Recreational use of nitrous oxide (N₂O) leads to neurological disorders including combined subacute degeneration of spinal cord, psychological disorders, and thrombosis. Serum or urine N₂O assays could not be routinely performed. Hence, it is necessary to investigate other biological markers such as metabolic markers. We aimed here to challenge the three main biological markers used for the diagnosis of nitrous oxide abuse as total vitamin B12, homocysteine, and methylmalonic acid.

METHODS

We retrospectively collected clinical and biological data from 52 patients with known, documented chronic N₂O abuse and associated clinical signs (peripheral neuropathy disability score or thrombosis event). Sera and plasma total vitamin B12, methylmalonic acid (MMA), and homocysteine were performed to identify the most specific marker of chronic N₂O intoxication and related clinical outcomes.

RESULTS

Plasma homocysteine was almost consistently increased in case of N₂O chronic consumption, whereas MMA increase and total vitamin B12 decrease are not systematically found. Our results showed that none of the markers are correlated with levels of N₂O consumptions. However, homocysteine and MMA are correlated with clinical severity, but MMA seems to be a better marker of clinical severity.

CONCLUSION

There is no specific marker of nitrous oxide abuse according to levels of consumption, total vitamin B12 decrease could not be used either as consumption or as severity marker. However, we showed that homocysteine is consistently increased and could be used as marker of recent N₂O consumption. On the other hand, we showed that MMA could be used as a marker of clinical gravity.

Methodology for in situ gas sampling, transport and laboratory analysis of gases from stranded cetaceans

Gas-bubble lesions were described in cetaceans stranded in spatio-temporal concordance with naval exercises using high-powered sonars. A behaviourally induced decompression sickness-like disease was proposed as a plausible causal mechanism, although these findings remain scientifically controversial. Investigations into the constituents of the gas bubbles in suspected gas embolism cases are highly desirable. We have found that vacuum tubes, insulin syringes and an aspirometer are reliable tools for in situ gas sampling, storage and transportation without appreciable loss of gas and without compromising the accuracy of the analysis. Gas analysis is conducted by gas chromatography in the laboratory. This methodology was successfully applied to a mass stranding of sperm whales, to a beaked whale stranded in spatial and temporal association with military exercises and to a cetacean chronic gas embolism case. Results from the freshest animals confirmed that bubbles were relatively free of gases associated with putrefaction and consisted predominantly of nitrogen.

Diffusion-limited, but not perfusion-limited, compartmental models describe cerebral nitrous oxide kinetics at high and low cerebral blood flows

This study aimed to evaluate the relative importance of diffusion-limited vs. perfusion-limited mechanisms in compartmental models of blood-tissue inert gas exchange in the brain. Nitrous oxide concentrations in arterial and brain efferent blood were determined using gas chromatographic analysis during and after 15 min of nitrous oxide inhalation, at separate low and high steady states of cerebral blood flow (CBF) in five sheep under halothane anesthesia. Parameters and model selection criteria of various perfusion- or diffusion-limited structural models of the brain were estimated by simultaneous fitting of the models to the mean observed brain effluent nitrous oxide concentration for both blood flow states. Perfusion-limited models returned precise, credible estimates of apparent brain volume but fit the low CBF data poorly. Diffusion-limited models provided better overall fit of the data, which was best described by exchange of nitrous oxide between a perfusion-limited brain compartment and an unperfused compartment. In individual animals, during the low CBF state, nitrous oxide kinetics displayed either fast, perfusion-limited behavior or slow, diffusion-limited behavior. This variability was exemplified in the different parameter estimates of the diffusion limited models fitted to the individual animal data sets. Results suggest that a diffusion limitation contributes to cerebral nitrous oxide kinetics.

Asphyxia due to oxygen deficiency by gaseous substances

The determination of the cause of death in asphyxiation gas cases is very difficult because of the variation in circumstances surrounding such deaths. To clarify the cause of death and to identify the factors involved in asphyxia, the symptoms during asphyxia, the concentration of gases at the respiratory arrest, the time to death and the concentration of the gaseous substances in the tissues were studied using rats and six gases. Three inhalations were used: (1) rapid asphyxia (2-3 min) in the exposure chamber in which the oxygen was depleted completely, (2) prolonged asphyxia (20-25 min) by gradually depleted oxygen, and (3) asphyxia by the inhalation of gases saturated with a critical gas concentration, maintaining the O2 at 20% (60 min). In the rapid asphyxia groups, respiratory arrest occurred within 30 to 40 s, followed by cardiac arrest 2 or 3 min thereafter. Severe convulsions were observed only with the use of nitrogen. In the prolonged asphyxia groups, respiratory arrest occurred at the concentration of 4-5% O2 with non-toxic gases (N2, CH4, N2O, and propane). The toxic gases CO2 and Freon-22 produced respiratory arrest at the concentration of 6.6-8.0% O2 (60-67% CO2) and 13-14% of O2 (30-35% Freon-22), respectively. Variations in the concentrations of the gases among the tissues was observed according to the type of asphyxia, type of gas and the duration of exposure. The concentration of the fat-soluble gases in the adipose tissue showed marked variation according to the duration of the exposure. The distribution pattern of methane was different from those of the other gases, in which the variation of concentrations among the tissues except lung were little in both rapid and prolonged asphyxia. These phenomena were considered to be attributable to the solubility of the gaseous substances in blood and tissues. Atrophy in the alveoli was observed after the rapid asphyxia with CO2 and N2O. Local hemorrhaging in the lungs was also observed, especially in CO2 asphyxia. The risks of oxygen-depletion asphyxia are the rapid reaction of loss of consciousness and respiratory and cardiac arrest. This paper presents valuable findings for the diagnosis of the cause of death and estimating the situation of the accident in cases of asphyxia.

A practical method of serial bedside measurement of cerebral blood flow and metabolism during neurointensive care

Acute encephalopathy is a major cause of death and neurological handicap in children. The principle aims of treatment are to provide adequate cerebral blood flow for the brain's metabolic needs and to prevent intracranial pressure rising above the level at which brain herniation occurs. Rational management requires an understanding of the pathophysiological changes in cerebral blood flow and metabolism which occur. The paucity of data on this subject reflects the perceived difficulty of measuring cerebral blood flow and cerebral metabolism in children. A modification of the Kety Schmidt technique of measuring cerebral blood flow and cerebral metabolism is described. This modification makes it possible to perform serial bedside measurements in children receiving intensive care. This method was used to perform 348 measurements in 58 children. The method was reproducible and no significant complications were encountered. The results indicated that appreciable changes in cerebral blood flow and metabolism could occur in individual patients over time, emphasising the importance of serial measurements. This technique may provide a practical means of monitoring cerebral blood flow and metabolism in very sick children receiving neurointensive care and evaluating the efficacy of treatment.

Failure of the Kety-Schmidt nitrous oxide method for determination of myocardial blood flow

1. The reliability of the Kety-Schmidt nitrous oxide (N2O) blood-tissue equilibration method was examined in 50 studies of myocardial blood flow in seven conscious, unrestrained sheep using a newly developed carefully validated gas chromatographic assay for N2O. 2. In 10 studies the arterial and coronary sinus N2O blood concentration-time curves converged as expected at the end of the 10 min sampling period. In 14 studies they crossed over, and in 26 studies, the curves failed to converge. 3. A survey of the literature revealed that such results have been encountered previously but have not been accorded particular significance. An ultimate matching equilibrium between arterial and venous blood N2O concentration-time curves is, however, fundamental to the validity of the method. 4. The results indicate that the use of the Kety-Schmidt method with N2O as the indicator gas is invalid as applied to the measurement of myocardial blood flow in this preparation.

Nitrous oxide sedation in dentistry. A comparison between Rotameter settings, pharyngeal concentrations and blood levels of nitrous oxide

Nitrous oxide concentrations (V/V) at the delivery Rotameters block, nasal mask, pharynx and venous blood, were compared. There was a dilution of approximately 50% of the delivered nitrous oxide at the nasal mask which was further reduced in the pharynx. Venous blood concentrations 10 minutes after inhalation of nitrous oxide were low but as would be calculated from pharyngeal concentrations. After 5 minutes of oxygenation venous blood nitrous oxide concentrations were still relatively high. A total of 92% of subjects experienced a satisfactory effect with 30% nitrous oxide or less in the pharynx.

Estimation of nitrous oxide in blood. Gas chromatographic analysis of trace or analgesic levels

The estimation of nitrous oxide (N20) at trace and analgesic levels in whole blood is described. A micro-ionisation cross section (MICS) detector was used to measure trace levels of N2O (0.69 to 17.88 mumol N20/litre of blood); whilst a thermal conductivity (TC) detector was used to determine levels from 0.17 to 13.34 mmol N20/litre of blood. The coefficient of variation was 1.3% and 3.2% for the TC and MICS detectors respectively. The technique equals the precision of previously described methods but is considerably quicker. It appears to be suitable for use in the measurement of blood levels of N20 in both theatre personnel and patients undergoing anaesthesia.