Anesthesia

Workstation

Are Anesthesia Providers

Receiving Adequate Training in
Equipment?

1975: Dorsch and Dorsch's book,

Understanding Anesthesia Equipment,
1980: The introduction of oxygen analyzers
was a significant advance.
1995: the Food and Drug Administration
(FDA) published an anesthesia apparatus
checkout procedure.

Hazards

Breathing circuit 39%

Vaporizer 21%
Ventilator 17%
Oxygen supply 11%
Basic component 7%

Objectives

Anesthesia Machine
Ventilators
Scavenging Systems
System Checkout

ventilator

Flow
meter
bellow

Corrugate
d tube

Soda lime

vaporizer

APL valve

Scavengin
g system

High

Intermediate

Low Pressure
Circuit

High Pressure System

Receives gasses from the high

pressure E cylinders attached to the
back of the anesthesia machine
(2200 psig for O2, 745 psig for N2O)
Consists of:
Hanger Yolk (reserve gas cylinder
holder)
Check valve (prevent reverse flow of
gas)
Cylinder Pressure Indicator (Gauge)
Pressure Reducing Device (Regulator)

Usually not used, unless pipeline

gas supply is of

E Size Compressed Gas

Cylinders
Cylinder
Oxyge Nitrous
Carbon
Air
Cylinder
Characteristic
s

Oxyge
n

Color

Nitrous
Oxide

Carbon
Dioxide

Air

White
Blue
(green)

Gray

Black/Whi
te (yellow)

State

Gas

Liquid and
gas

Liquid and
gas

Gas

Contents (L)

625

1590

1590

625

Empty Weight
(kg)

5.90

5.90

5.90

5.90

Full Weight
(kg)

6.76

8.80

8.90

Pressure Full
(psig)

2000

750

838

1800

Cylinders Tank

Pressure gauge

Hanger Yolk

Hanger Yolk: orients and

supports the cylinder,
providing a gas-tight
seal and ensuring a
unidirectional gas flow
into the machine
Index pins: Pin Index
Safety System (PISS) is
gas specificprevents
accidental
rearrangement of
cylinders (e.g..
switching O2 and N2O)

Pressure Reducing
Device

Reduces the high and variable pressures found

in a cylinder to a lower and more constant
pressure found in the anesthesia machine (45
psig)
Reducing devices are preset so that the machine
uses only gas from the pipeline (wall gas), when
the pipeline inlet pressure is 50 psig.

This prevents gas use from the cylinder even if

the cylinder is left open (i.e. saves the cylinder
for backup if the wall gas pipeline fails)

Pressure Reducing
Device

Cylinders should be kept closed

routinely. Otherwise, if the wall
gas fails, the machine will
automatically switch to the
cylinder supply without the
anesthetist being aware that the
wall supply has failed (until the
cylinder is empty too).

Intermediate Pressure
System

Receives gasses from the

regulator or the hospital
pipeline at pressures of 4055 psig
Consists of:

Pipeline inlet connections

Pipeline pressure indicators
Piping
Gas power outlet
Master switch
Oxygen pressure failure
devices
Oxygen flush
Additional reducing devices
Flow control valves

Pipeline

Pipeline Inlet
Connections

Mandatory N2O and O2,

usually have air and
suction too
Inlets are noninterchangeable due to
specific threading as per
the Diameter Index
Safety System (DISS)
Each inlet must contain
a check valve to prevent
reverse flow (similar to
the cylinder yolk)

Oxygen Pressure
Failure Devices

Machine standard requires that an anesthesia

machine be designed so that whenever the
oxygen supply pressure is reduced below
normal, the oxygen concentration at the
common gas outlet does not fall below 19%

Oxygen Pressure
Failure Devices

A Fail-Safe valve is present in the gas line

supplying each of the flowmeters except
O2. This valve is controlled by the O2
supply pressure and shuts of or
proportionately decreases the supply
pressure of all other gasses as the O2
supply pressure decreases
Historically there are 2 kinds of fail-safe
valves
Pressure sensor shut-of valve (Ohmeda)
Oxygen failure protection device (Drager)

Pressure Sensor ShutOff Valve

Oxygen supply
pressure opens the
valve as long as it is
above a pre-set
minimum value (e.g..
20 psig).
If the oxygen supply
pressure falls below
the threshold value
the valve closes and
the gas in that limb
(e.g.. N2O), does not
advance to its flowcontrol valve.

Oxygen Failure
Protection Device
(OFPD)
Based on a proportioning principle rather

than a shut-of principle

The pressure of all gases controlled by the
OFPD will decrease proportionately with the
oxygen pressure supply

Oxygen Supply Failure

Alarm

The machine standard specifies

that whenever the oxygen supply
pressure falls below a
manufacturer-specified threshold
(usually 30 psig) a medium
priority alarm shall blow within 5
seconds.

Limitations of Fail-Safe
Devices/Alarms

Fail-safe valves do not prevent

administration of a hypoxic mixture
because they depend on pressure and
not flow.

These devices do not prevent hypoxia

from accidents such as pipeline
crossovers or a cylinder containing the
wrong gas

Limitations of Fail-Safe
Devices/Alarms

These devices prevent hypoxia from

some problems occurring upstream in the
machine circuitry (disconnected oxygen
hose, low oxygen pressure in the pipeline
and depletion of the oxygen cylinder)
Equipment problems that occur
downstream (for example leaks or partial
closure of the oxygen flow control valve)
are not prevented by these devices.

Oxygen Flush Valve (O2)

Receives O2 from
pipeline inlet or cylinder
reducing device and
directs high, unmetered
flow directly to the
common gas outlet
(downstream of the
vaporizer)
Machine standard
requires that the flow be
between 35 and 75 L/min
The ability to provide jet
ventilation
Hazards
May cause barotrauma
Dilution of inhaled
anesthetic

Second-Stage
Reducing Device

Located just upstream of the flow

control valves
Receives gas from the pipeline inlet or
the cylinder reducing device and
reduces it further to 26 psig for N2O
and 14 psig for O2
Purpose is to eliminate fluctuations in
pressure supplied to the flow indicators
caused by fluctuations in pipeline
pressure

Low Pressure System

Extends from the flow control

valves to the common gas outlet
Consists of:

Flow meters
Vaporizer mounting device
Check valve
Common gas outlet

Flowmeter assembly

When the flow control

valve is opened the gas
enters at the bottom
and flows up the tube
elevating the indicator

The indicator floats

freely at a point where
the downward force on
it (gravity) equals the
upward force caused by
gas molecules hitting
the bottom of the float

Arrangement of the
Flow-Indicator Tubes

In the presence of a flowmeter leak

(either at the O ring or the glass
of the flow tube) a hypoxic mixture
is less likely to occur if the O2
flowmeter is downstream of all
other flowmeters

In A and B a hypoxic mixture can

result because a substantial portion
of oxygen flow passes through the
leak, and all nitrous oxide is
directed to the common gas outlet

* Note that a leak in the oxygen

flowmeter tube can cause a
hypoxic mixture, even when
oxygen is located in the
downstream position

Proportioning Systems

Mechanical
integration of the
N2O and O2 flowcontrol valves
Automatically
intercedes to
maintain a
minimum 25%
concentration of
oxygen with a
maximum N2O:O2
ratio of 3:1

Limitations of
Proportioning Systems

Machines equipped with proportioning

systems can still deliver a hypoxic
mixture under the following conditions:
Wrong supply gas
Defective pneumatics or mechanics (e.g..
The Link-25 depends on a properly
functioning second stage regulator)
Leak downstream (e.g.. Broken oxygen
flow tube)
Inert gas administration: Proportioning
systems generally link only N2O and O2

Vaporizers

A vaporizer is an
instrument designed
to change a liquid
anesthetic agent into
its vapor and add a
controlled amount of
this vapor to the fresh
gas flow

Classification of
Vaporizers

Methods of regulating output concentration

Concentration calibrated (e.g. variable
bypass)
Measured flow
Method of vaporization

Flow-over
Bubble through
Injection
Temperature compensation

Thermocompensation

Generic Bypass
Vaporizer

Flow from the flowmeters enters the inlet of the

vaporizer

The function of the concentration control valve

is to regulate the amount of flow through the
bypass and vaporizing chambers
Splitting Ratio = flow though vaporizing
chamber/flow through bypass chamber

VARIABLE BYPASS
Patient
Flowmeter

Patient
Flowmeter

Patient
Flowmeter

Factors That Influence

Vaporizer Output

Flow Rate: The output of the vaporizer is

generally less than the dial setting at very
low (< 200 ml/min) or very high (> 15 L/min)
flows
Temperature: Automatic temperature
compensating mechanisms in bypass
chambers maintain a constant vaporizer
output with varying temperatures
Back Pressure: Intermittent back pressure
(e.g. positive pressure ventilation causes a
higher vaporizer output than the dial setting)

Factors That Influence

Vaporizer Output

Atmospheric Pressure: Changes in

atmospheric pressure afect variable
bypass vaporizer output as measured by
volume % concentration, but not (or very
little) as measured by partial pressure
(lowering atmospheric pressure increases
volume % concentration and vice versa)
Carrier Gas: Vaporizers are calibrated for
100% oxygen. Carrier gases other than
this result in decreased vaporizer output.

Hazard

Simultaneous administration of more than

one anaesthetic agent. Vapour interlock
systems are installed to prevent.
Tipping of the vaporizer can result in
liquid anaesthetic flowing into the bypass
chamber. This may occur while the
vaporizer is detached from the backbar of
the machine; the result is delivery of
extremely high anaesthetic concentration
to the patient.

Misfilling of the vaporizers with incorrect

agent will result in delivery of incorrect
concentrations of anaesthetics. Keyed
fillers are used to prevent this

Breathing System

Maplesons
fresh gas inlet, breathing tube, APL valve,
reservoir bag

Circle system
add features: unidirectional valve, CO2 arsobent
and CO2 absorber

Non Rebreathing
Circuit

Advantages
Less resistance to breathing
Less mechanical dead space
They are simple devices, with less potential for
malfunction, and they are inexpensive
The light weight and less bulk

Disadvantages
deliver a high flow of dry cool gas which causes
significant heat and humidity loss. (Hypothermic)
higher requirement of carrier gas and anesthetic
results inincreased cost.

The Circuit: Circle

System

Arrangement is variable,
but to prevent rebreathing of CO2, the
following rules must be
followed:
Unidirectional valves
between the patient
and the reservoir bag
Fresh-gas-flow cannot
enter the circuit
between the
expiratory valve and
the patient
Adjustable pressurelimiting valve (APL)
cannot be located
between the patient
and the inspiratory
valve

Circle System

Advantages:

Relative stability of inspired concentration

Conservation of respiratory moisture and heat
Prevention of operating room pollution
PaCO2 depends only on ventilation, not fresh
gas flow
Low fresh gas flows can be used

Disadvantages:
Complex design = potential for malfunction
High resistance (multiple one-way valves) =
higher work of breathing

The Adjustable Pressure

Limiting (APL) Valve

User adjustable valve that releases

gases to the scavenging system
and is intended to provide control
of the pressure in the breathing
system
Bag-mask Ventilation: Valve is
usually left partially open. During
inspiration the bag is squeezed
pushing gas into the inspiratory
limb until the pressure relief is
reached, opening the APL valve.
Mechanical Ventilation: The APL
valve is excluded from the circuit
when the selector switch is
changed from manual to automatic
ventilation

Scavenging Systems

Protects the
breathing circuit
or ventilator from
excessive positive
or negative
pressure.

Scavenging Systems

Ventilators

Four phases of the ventilatory cycle:

Inspiration
The transition from inspiration to expiration
Expiration
Transition from expiration to inspiration

Inspiratory phase

Constant pressure (constant-pressure

generators) or constant gas flow rate
(constant-flow generators)
Nonconstant generators produce pressures or
gas flow rates that vary during the cycle but
remain consistent from breath to breath.
An increase in airway resistance or a decrease in lung
compliance would increase peak inspiratory pressure
but would not alter the flow rate generated by this type
of ventilator

Transition Phase from

Inspiration to Expiration

Triggered by
Preset limit of time (fixed
duration)
Set inspiratory pressure
Predetermined tidal volume

Expiratory Phase

Reduces airway pressure

Preset value of positive end-expiratory
pressure (PEEP).
Exhalation is passive

Transition Phase from

Expiration to
Inspiration
Preset time interval or a change in

pressure
Controlled ventilation

Volume-control mode, the ventilator adjusts gas

flow rate and inspiratory time based on the set
ventilatory rate and I:E ratio
Pressure-control mode, inspiratory time is also
based on the set ventilator rate and inspiratory-toexpiratory (I:E) ratio, but gas flow is adjusted to
maintain a constant inspiratory pressure

Intermittent mandatory ventilation

(IMV) allows patients to breathe
spontaneously between controlled breaths
Synchronized intermittent mandatory
ventilation (SIMV) is a further refinement
that helps prevent "fighting the ventilator"
and "breath stacking"

Checking Anesthesia
Machines
8 Categories of check:
Emergency ventilation equipment
High-Pressure system
Low-Pressure system
Scavenging system
Breathing system
Manual and automatic ventilation
system
Monitors
Final Position

Three most important

preoperative checks

Oxygen analyzer calibration

The low-pressure circuit leak test
The circle system test

The end

Case Discussion:
Unexplained Light
Anesthesia

An extremely obese but otherwise healthy 5-yearold girl presents for inguinal hernia repair. After
uneventful induction of general anesthesia and
tracheal intubation, the patient is placed on a
ventilator set to deliver a tidal volume of 7 mL/kg at
a rate of 16 breaths/min. Despite delivery of
2%halothane in 50%nitrous oxide, tachycardia (145
beats/min) and mild hypertension (144/94 mm Hg)
are noted. To increase anesthetic depth, fentanyl (3
g/kg) is administered. Heart rate and blood
pressure continue to rise and are accompanied by
frequent premature ventricular contractions.

What Should Be Considered in the Diferential

Diagnosis of This Patient's Cardiovascular
Changes?
Could Any of These Problems Be Related to
an Equipment Malfunction?
How Are Unidirectional Valves Checked
before the Anesthesia Machine Is Used?
What Are Some Other Consequences of
Hypercapnia?

Case Discussion:
Detection of a Leak

After induction of general anesthesia and

intubation of a 70-kg man for elective
surgery, a standing bellows ventilator is set
to deliver a tidal volume of 700 mL at a rate
of 10 breaths/min. Within a few minutes, the
anesthesiologist notices that the bellows fails
to rise to the top of its clear plastic enclosure
during expiration. Shortly thereafter, the
disconnect alarm is triggered.

Why Has the Ventilator Bellows Fallen and

the Disconnect Alarm Sounded?
How Can the Size of the Leak Be Estimated?
Where Are the Most Likely Locations of a
Breathing-Circuit Disconnection or Leak?
How Can These Leaks Be Detected?

Thank you