Anesthesia Machine

Technology

Anesthesia
Machine
Technology
Prepared By:
Dr.Sherif El Gharry
Cairo University
Second Year

2018-2019
 Anesthesia Machine
Technology

Acknowledgments

This two-year curriculum was developed through a participatory and collaborative approach
between the Academic faculty staff affiliated to Egyptian Universities as Alexandria University, Ain
Shams University, Cairo University , Mansoura University, Al-Azhar University, Tanta University, Beni
Souef University , Port Said University, Suez Canal University and MTI University and the Ministry of
Health and Population(General Directorate of Technical Health Education (THE). The design of this
course draws on rich discussions through workshops. The outcome of the workshop was course
specification with Indented learning outcomes and the course contents, which served as a guide to
the initial design.

We would like to thank Prof.Sabah Al- Sharkawi the General Coordinator of General Directorate of
Technical Health Education, Dr. Azza Dosoky the Head of Central Administration of HR
Development, Dr. Seada Farghly the General Director of THE and all share persons working at
General Administration of the THE for their time and critical feedback during the development of
this course.

Special thanks to the Minister of Health and Population Dr. Hala Zayed and Former Minister of
Health Dr. Ahmed Emad Edin Rady for their decision to recognize and professionalize health
education by issuing a decree to develop and strengthen the technical health education curriculum
for pre-service training within the technical health institutes.
 Anesthesia Machine
Technology

Contents

Chapter 1: Gas supply and Distribution Systems ........................... 14

Chapter 2: Anesthesia Machines and Breathing Systems ................. 30

Chapter 3: Monitoring Devices ................................................ 46

Chapter 4: Airway Equipment ................................................ 74

Chapter 5: Equipment Care ................................................... 82

Chapter 6: Equipment Related to Environmental Situations ........... 90

References: ...................................................................... 95
 Anesthesia Machine
Technology

‫توصيف مقرر دراسى‬

‫ بيانات المقرر‬-1

2: ‫المستوى‬/ ‫الفرقة‬ ‫ تكنولوجيا أجهزة وحدات التخدير‬: ‫اسم المقرر‬ : ‫الرمز الكودى‬

9 ‫عملى‬ 3 ‫نظرى‬ 12 : ‫عدد الوحدات الدراسية‬ : ‫التخصص‬

:‫ هدف المقرر‬-2

This course introduces students to the main principles and

components of Anesthesia Equipment. The Anesthesia
Equipment class is designed for hospital professionals
responsible for operating, maintaining and/or repairing
anesthesia equipment. A balanced application of practical
theory and hands-on exercises provides maximum exposure
for learning the operation and maintenance of equipment.
The aim of the course is to provide students with an insight
into the problems and challenges of medical Anesthesia
equipment within a healthcare system.

Students for Technical Health Institutes : ‫ المستهدف من تدريس المقرر‬-3

Having successfully completed this module, students will be ‫ المعلومات‬.‫ا‬

able to: : ‫والمفاهيم‬

 Recognize principles and concepts of Anesthesia

equipment.
 Describe how anesthetic breathing circuits work and how
to choose them.
 Explain the operation and functions of the anesthesia
machine sub-systems including the gas delivery,
scavenging system and ventilator.
 Identify the basics of artificial ventilation and ventilator
machines.
 Explain the use of low-flow Anesthesia with circle
circuits
 Gain a deep insight through basic to advanced system
monitoring

Structured hands-on labs are designed to reinforce skills needed ‫ المهارات‬-‫ب‬

to find and troubleshoot leaks in the breathing system, perform
user-scheduled maintenance and complete the preoperative : ‫الذهنية‬
checkout procedures.

Having successfully completed this module, students will be able

 Anesthesia Machine
Technology

to:

 Use analytical and reasoning skills in practical problems

solving.
 Formulate knowledge derived from the course basics and
principles for decision making in practical problems
related to equipment maintenance.
 Analyze and evaluate anesthesia equipment operation for
early prediction of failures.

‫ المهارات المهنية‬-‫ج‬
Having successfully completed this module, students will be able :‫الخاصة بالمقرر‬
to:

 Install, operate, diagnose, resolve problems, and complete

machine repairs and checkouts to comply with all
manufacturer recommendations.
 Use medical engineering standards to assess equipment
failure.
 Troubleshoot anesthesia equipment for any failure.
 Prepare technical reports and fill in the anesthetic record
correctly
 Anticipate potential problems and avoid pitfalls.
 Adopt minimal monitoring in ‘general practice’.
 Perform calibrations and adjustments according to
technical reference manuals.
 Perform all planned maintenance procedures.

 Use problem solving skills

 Work effectively within a team ‫ المهارات‬-‫د‬
: ‫العامة‬
 Manage effectively time, resources and set priorities
 Participate in ongoing educational activities related to
professional issues.

Section 1: Gas supply and Distribution Systems

Medical Gas Cylinders and Containers :‫ محتوى المقرر‬-4
Medical Gas Pipeline Systems
Suction Equipment and Oxygen Concentrators

Section 2: Anesthesia Machines and Breathing Systems

The Anesthesia Machine Structure
Manual Resuscitation
 Anesthesia Machine
Technology

Block Diagram of Anesthesia Machine

Function of Anesthesia Machine Components
The Breathing System: General Principles and Common
Components
Vaporizers
Anesthesia Ventilators
Humidification Equipment
Controlling Gas delivery

Section 3 Monitoring Devices

Gas Monitoring
Airway Volumes, Flow and Pressure
Alarm Devices
Temperature Monitoring

Section 4: Airway Equipment

Face Masks and Airways
Laryngoscopes
Tracheal Tubes and Associated Equipment
Devices for Managing the Difficult Airway

Section 5: Equipment Care

Hazards of Anesthesia Machines and Breathing Systems
Equipment periodic calibration
Equipment Checkout and Maintenance
Cleaning and Sterilization

Section 6: Equipment Related to Environmental Situations

Temperature Control Equipment
Operating Room Fires and Personnel Injuries Related to Sources
of ignition
Equipment for the Magnetic Resonance Imaging Environment

‫ أساايب التعليم والتعلم‬-5

 Lectures
 Multimedia material ( Datashow, videos,…)
 Discussions
 Group work
 Practical laboratory work
 On-site training

‫ أساليب التعليم والتعلم للطالب‬-6

 Individual guidance ‫ذوى القدرات المحدودة‬
 Individual feedback

: ‫ تقويم الطالب‬-7
 Anesthesia Machine
Technology

 Assignments and practical work ‫ األساليب المستخدمة‬-‫أ‬

 Quizzes
 Midterm
 Final exam

 Assignments and practical work (biweekly) ‫ التوقيت‬-‫ب‬

 Quizzes (occasionally)
 Midterm (week 8)
 Final exam (at the end of the semester)
‫ توزيع الدرجات‬-‫ج‬
: ‫ قائمة الكتب الدراسية والمراجع‬-8
‫ مذكرات‬-‫أ‬

“Anesthesia Equipment for Technical Health ‫ كتب ملزمة‬-‫ب‬

Institutes”

‫ كتب مقترحة‬-‫ج‬
“Understanding Anesthesia Equipment” , Fifth
Edition (2007), by Jerry A. Dorsch MD, Susan E.
Dorsch MD

...... ‫ دوريات علمية أو نشرات‬-‫د‬

IEEE Transactions on Biomedical Engineering ‫الخ‬
 Anesthesia Machine
Technology

Course Description

This course introduces students to the main principles and components of Anesthesia

Equipment. The Anesthesia Equipment class is designed for hospital professionals

responsible for operating, maintaining and/or repairing anesthesia equipment. A balanced

application of practical theory and hands-on exercises provides maximum exposure for

learning the operation and maintenance of equipment. The aim of the course is to provide

students with an insight into the problems and challenges of medical Anesthesia

equipment within a healthcare system.

Core Knowledge

By the end of this course, students should be able to:

 Recognize principles and concepts of Anesthesia equipment.

 Describe how anesthetic breathing circuits work and how to choose them.

 Explain the operation and functions of the anesthesia machine sub-systems including the gas
delivery, scavenging system and ventilator.

 Identify the basics of artificial ventilation and ventilator machines.

 Explain the use of low-flow Anesthesia with circle circuits

 Delineate the various types and functions of system monitoring devices including gas, airway
volumes, flow, pressure, alarm devices and temperature monitoring.
 Anesthesia Machine
Technology

Core Skills

By the end of this course, students should be able to:

 Install, operate, diagnose, and resolve problems in machine operation.

 Complete machine repairs and checkouts to comply with all manufacturer

recommendations.

 Use medical engineering standards to assess equipment failure.

 Troubleshoot anesthesia equipment for any failure.

 Prepare technical reports and fill in the anesthetic record correctly

 Anticipate potential problems and avoid pitfalls.

 Adopt minimal monitoring in ‘general practice’.

 Perform calibrations and adjustments according to technical reference manuals.

 Perform all planned maintenance procedures.

 Anesthesia Machine
Technology

Course Overview

Methods of Teaching/Training with

Number of Total Hours per Topic

Assignments
Field Work
Interactive

Research
ID Topics

Lecture

Class

Lab
Gas supply and Distribution Systems
1 6 6 3 6

Anesthesia Machines and

2 16 9 5 9
Breathing Systems

Monitoring Devices
3 16 9 4 9

Airway Equipment
4 9 3 9
4
5 Equipment Care 3
3 3 3
6 Equipment Related to Environmental 3
3 0 3
Situations

TOTAL HOURS (144) 48 39 18 39

 Medical equipment

Gas supply and Distribution Systems

Objectives
 Describe the gases which are used in anesthesia practice.
 Explain the sources of medical gases to anesthesia machine.
 Describe the methods of connecting cylinder with anesthesia machine.
 Explain the methods of identifying medical gases.
 List the safe practices in using the cylinder.
 Describe the difference of hospital pipeline system and compressed gas cylinder.

Gas supply and Distribution Systems

Medical gas supply systems in hospitals and other healthcare facilities are utilized to
supply specialized gases and gas mixtures to various parts of the facility. Products
handled by such systems typically include Oxygen, Medical air, Nitrous oxide, Nitrogen,
Carbon dioxide, Medical vacuum, Waste Anesthetic Gas Disposal (US) or Anesthetic Gas
Scavenging System.
Medical gas supply takes the form of either cylinders or a piped gas system, depending on
the requirements of the hospital.

1- MEDICAL GAS CYLINDERS AND CONTAINERS

Gas cylinder is a term that is commonly used to describe a pressurized container used for
storage and transport. They are designed to withstand considerable internal pressure

a. CONSTRUCTION OF CYLINDERS

Medical gas cylinders were traditionally constructed of low carbon steel. Now they are
constructed of light weight chrome molybdenum steel, aluminum or a composite (such as
aluminum wrapped in carbon fiber). Special cylinders made from aluminum are useful in
magnetic resonance imaging (MRI) room.

b. COMPONENTS OF CYLINDERS
Body
The cylinder has a body, shoulder, and a neck. The curved upper part of the body is called as
shoulder which tapers in a neck. The neck ends in a tapered screw thread into which the
valve is fitted. When the valve is screwed to cylinder neck, a fusible material (Wood's Metal)
is used to seal leaks between the valve and the cylinder which melts if the cylinder is exposed
to intense heat. This allows gas to release and lessens the risk of explosion.

14
 Medical equipment

Valve
Cylinders are filled and discharged through the valve (spin die valve) attached to the neck.
The valve is made of bronze or brass and is most fragile part of cylinder, therefore provided
with a metal protection cap to protect. It allows the cylinder to be turned on and off and
provides a means by which the cylinders are filled and connected to yoke assembly on
anesthesia machine or to regulator [Figure 1.1]. When the valve is opened the stem moves
upward and gas flows to the port. During closure, the stem seals against the seat.

Figure 1.1 Cylinder valve

Port The port is the point of exit for the gas. It should be protected in transit by a covering.
Stem Each valve contains a stem or a shaft, that is rotated during valve opening or closing.

Pin index safety system

It has a unique configuration of holes and pins which match precisely to eliminate connection
of the wrong cylinder to equipment, thus prevents delivery of wrong gas to patients. This
system is also used by supplier to fill correct gas in the cylinder. It incorporates two holes in
specific positions on the cylinder valve below the outlet port. The cylinder can only be
connected to a yoke or pressure regulator with a matching pair of pins [Figure 1.2]. The
holes in the cylinder valve accept pins 4 mm diameter by 6 mm long. Unless pins and holes
are aligned, the port will not seal, and gas will not pass to the anesthesia machine.

15
 Figure 1.2 pin index and in cylinder of medical gases

c. COLOR OF CYLINDERS

An international color code to aid in identification of gas cylinders was adopted by medical
gas industry in 1949. Unfortunately, this has not been adopted by many countries, US uses
green and Germany uses blue color for oxygen cylinders. International color code of various
cylinders and that used in India are given in Table 1.1.
Due to variation in color tones, chemical changes in paint pigments, color should not be
used as a primary means for identification of cylinders.

Table 1.1 Color coding, pin index and physical state in cylinder of medical gases

d. CYLINDER IDENTIFICATION

Each cylinder should have a label which has all the information about the cylinder for the users
[see Figure 1.3]. The label has the following information:
 Name and chemical symbol of gas.
 Product specification.
 Hazard warning diamond shaped figure denoting hazard class contained gas.
 Name and address of cylinder manufacturer.
 Cylinder contents in liters.
 Tare weight (weight when empty).
 Maximum cylinder pressure.
 Cylinder size code.

16
  Directions for use.

The cylinders have a tag attached which has three sections labeled, FULL, IN USE and EMPTY.

Figure 1.3 cylinder labels

e. PERIODIC TESTING
Before releasing for distribution, a random cylinder from each batch is examined and tested
by the manufacturer to verify that appropriate design and standard was followed. Each
cylinder is visually checked before filling. The cylinder should be inspected endoscopically for
cracks and defects on their inner side and can also be tested ultrasonically. The cylinders
undergo various tests to ensure safety. The test is carried out every 10 years for steel
cylinders and every 5 years for composite cylinders. A specific shape and color-coded plastic
ring around the cylinder neck indicates the time of next testing.
Hydraulic test
Is a measure of cylinder's elasticity. The cylinder is connected by a thread to testing unit,
filled with water and the water level is measured by gauge. The gauge is isolated, and
cylinder pressurized to 240 atmospheres. The pressure is released, and gauge opened. The
cylinder should stretch less than 0.02%.
Tensile test
Done in one out of 100 cylinders. The yield point should not be less than 15 tons per square
inch.
Flattening test
The cylinder is kept between two compression blocks and pressure is applied from both sides
until the distance between blocks remains 6 times the thickness of the wall of cylinder. The
walls should not crack.
Impact test
Three of each, longitudinal and transverse stripes are taken from a finished cylinder and
struck by mechanical hammer. Mean energy to produce the crack should not be less than 5
and 10 lb/ft for transverse and longitudinal strips, respectively.

17
Bend test
A ring of 25 mm width is cut from the cylinder and divided into strips. Each strip is bent
inward until inner edges are a part, not greater than the diameter of strip.

f. STORAGE OF CYLINDERS
 The storage area should be cool, dry, ventilated, clean area constructed of fire
resistant material.
 Have good access for deliveries and a reasonable level floor surface
 Should have segregation of “Full” and “Empty cylinders”
 Cylinders with an oldest fill date should be used first
 Cylinders should not be stored in direct sunlight
 Easily visible sign such as no smoking, no open flames or sparks, no oil or grease etc.,
should be displayed
 Cylinders should not be exposed to dampness, corrosive chemicals, fumes as they may
damage cylinders and/or cause valve protection caps stick
 The temperature should not go below 10°C where Entonox cylinders are stored
 Cylinders should always be kept in place with chain or any other restraining device
 The suitable trolley/cart should be used to transport and support the cylinders.

g. HANDLING AND INSTALLATION

 Before using, the contents of the cylinder must be identified by reading the label and
seeing the color of the cylinder
 Full cylinders are fitted with tamper evident seal, usually a shrink wrapped around the
valve, should be removed immediately before use
 Before connecting to yoke, the cylinder valve be cracked (i.e., Opened only slightly) to
blow away any dust or flammable silting on the valve.
 The person opening the cylinder should be positioned so that the valve outlet and/or
the face of pressure gauge points away from self, patient and machine
 Care should be taken to see that sealing washer (Bodok Seal) is present on the yoke and
is in good condition to prevent leakage. More than one washer should never be used as
it can default PISS
 The valve should be opened slowly to release the pressure gradually. Sudden opening
can produce a shock wave in the pressure gauge and regulator and can damage parts.
Also, if gas passes quickly in the space between the valve and yoke or regulator, it can
generate a large amount of heat. As there is almost no time to dissipate, this
constitutes an adiabatic process (no heat is lost or gained from surrounding). The heat
generated can ignite grease or any dust particle present, causing flash fire or explosion
 The cylinders should never stand upright without support
 Handling should only be by trained staff.

18
 h. PROBLEMS AND HAZARDS OF MEDICAL GASES AND CYLINDERS
 Wrong cylinder despite pin index safety system has been attached to yoke or regulator
due to altered or broken pins or the use of more than one washer
 Problems due to improper maintenance or checking
 Problems of filling of wrong gas and over or under filling of cylinder.
 Wrong color coding – cylinder painted with other than standard color
 Wrong or ambiguous label
 Faulty delivery of oxygen
 Damaged valve
 Chemical contamination or moisture in gas
 Hazard due to fire and explosion
 Physical injury to hospital personnel or patient if unrestricted cylinder falls.

19
 2- MEDICAL GAS PIPELINE SYSTEMS
A medical gas pipeline system (MGPS) is installed to provide a safe, convenient and cost-
effective system for the provision of medical gases to the clinical and nursing staff at the
point-of-use. It reduces the problems associated with the use of gas cylinders such as safety,
porterage, storage and noise.
Systems are provided for:
Anesthetic Gas Scavenger System (AGSS), Carbon Dioxide (CO2), Entonox (50%/50% O2N2O),
Medical Air (MA), Medical Vacuum (Med Vac), Nitrous Oxide (N 2O), Oxygen(O2) and Surgical
Air (SA).

Medical Gas pipeline system components

I. Medical gas pipeline.

II. Medical Oxygen plant.
III. Medical Nitrous oxide.
IV. Medical compressed air plant.
V. Vacuum plant.
VI. Terminal units.
VII. Regulators.
VIII. Shutoff valves.
IX. Bedhead unit.
X. Ceiling pendant.
Figure 1.4 Medical gas pipeline system
XI. Warning and alarm system. component

XII. Accessories [See Figure 1.4]

20
I. Medical gas pipeline

Material:
Copper seamless pipes with fluxless silver brazing are used which
should be as per ASTM standard and Lloyd's certification [Figure 1.5].

Safety consideration
-Pipes must transported with a sealing at the two ends keeping it safe
from dust, pollution and other pollutants.
-Delivering it cleanly and must be for medical purposes only (medical
degreased) Figure 1.5 medical gas pipelines

II. Oxygen Plant:

Oxygen plants are industrial systems designed to generate oxygen [Figure 1.6].

Sources:
a) Oxygen main station.
b) Liquefied oxygen tank.

Figure 1.6 industrial oxygen plant

Oxygen station components:

1. Reducer / Changeover: Allow the gas to pass from the both sides according to the pressure
difference. (Automatic switching). [Figure 1.7.a]

2. Manifold: allows gas to be branched through several pipes [Figure 1.7.b].

3. Cylinder rack: allows secure transportation and storage of industrial and respiratory gas
bottles for a wide range of offshore applications [Figure 1.7.c]

21
 a
b c

Figure 1.7 oxygen station component a. reducer b. manifold c. cylinder rack

III. Medical compressed air plant

Medical Air Plants used to supply medical quality air for Respiration and Surgical needs.

Medical Air Plant Main Parts [Figure 1.8]:

1. Air Compressors.
2. Heatless Desiccant Duplex Dryer.
3. Electrical Control Panel including Alarm Systems.
4. 4 Bar and 7 bar Regulation Group.
5. Filter Group, Oil, Odour, Bacteria and Sterile Filters Group.
6. Pressed Air Receiver.
7. Connection Equipment between units.

Figure 1.8 medical air plant parts

IV. Terminals units

Medical terminal units provide quick and easy connection of hospital ward gas equipment to the

22
hospital gas source. These terminal gas outlets are color coded, labelled with gas name and have
self-sealing socket [Figure 1.9].

 Outlets of hospital:
 Oxygen outlets
 Nitrous oxide outlets
 Compressed air 4bar
 Compressed air 7bar
 Vacuum outlet

 Types of outlets:
 Wall outlets.
 Trunking mounted. Figure 1.9 terminal gas outlets

V. Bedhead units

The bed head unit is placed on the wall above the patient bed. It includes all the elements that
are required for patient treatment and from nursing personnel and provides lighting (general and
local), electrical energy (sockets), data (telephone, nurse call etc.), medical gases and vacuum
[Figure 1.10].

Figure 1.10 Bedhead unit

VI. Warning and alarm system

The system always monitors the remains of medical gas, troubles of machines, and abnormalities in
pressure in a lump to perfectly operate equipment which directly link to life [Figure 1.11]. It
consists of two types:
• Area alarm panel: monitor pipeline pressure within a ward.
• Master alarm panel: provides continuous monitoring of medical gas installations across hospitals

23
Area alarm
Figure 1.11 Warming and alarm system

24
Suction Equipment and Oxygen Concentrators

1. Suction Equipment

Coughing is important to clear out secretions from the airway.

Some patients with respiratory illness have weak coughs and have
difficulty getting the secretions out of the airway. In medicine,
devices are sometimes necessary to create suction. Suction may
be used to clear the airway of blood, saliva, vomit, or
other secretions so that a patient may breathe. Suctioning can
prevent pulmonary aspiration, which can lead to lung infections

 Principle of suction:

Suction is the flow of a fluid into a partial vacuum, or region of low pressure. The pressure
gradient between this region and the ambient pressure will propel matter toward the low pressure
area.

 Components of suction devices:

It is the power source and hence the pump that distinguishes the variety of suction apparatus
available, conveying the efficiency and portability features of each model. The other components
used in the assembly of a medical suction device are common to all types of equipment Thus, the
basic components include (Figure 1.12):

 Pump

 Suction controller

 Collection vessel

 Transfer tubing

 Suction nozzle or catheter

25
 Figure 1.12 Component of suction system

 Types of medical suction pumps:

However, based on the vacuum principle that they operate on, suction pumps may be divided into
3 categories, which include:

 Electric motor pump, which is an electrically powered motor that drives a pump to create
the required vacuum.

 Pneumatically driven pumps that primarily work on the Venturi principle. The driving force
may be attributed to air, stream or water.

 A manually operated pump with bellows and unidirectional valves to create the necessary
vacuum effectively [Figure 1.13].

Figure 1.13 Manual operated suction pump

26
  The factors those affect the flow rate of a suction system:

The flow rate of suction equipment refers to the amount of fluid moved through the unit per unit
time. This is influenced by the pressure gradient between the regulator and suction catheter,
the resistance of the equipment and the viscosity of the fluid.

Vacuum regulators vary the maximum amount of negative pressure supplied from the vacuum
source to the patient end of the suction apparatus (collection canister and suction tubing). They
often comprise an adjustable spring/diaphragm to set and maintain a constant vacuum level.
Adjusting the regulator to increase the pressure gradient from the vacuum source to the patient
end will increase the flow rate through the system.

The viscosity of fluids suctioned affects flow rate. Highly viscous and cohesive fluids such as thick
mucus decrease flow because they move less readily through the tubing.

 Troubleshooting

Problem Possible cause Corrective action

 Check for adequacy of suction

Machine does not  Suction pressure may be pressure.
suction as per less  Change tubing if leaky or broken,
requirement  Tubing may be leaking  Check fuse, cord, earthing.
 Fuse may be altered  Sometimes, in case fluid jar cannot
 Fluid jar already full be emptied immediately when full,
to prevent overflow of fluid into the
bellows, open the alternate suction
inlet.

Unit does not turn  Power source problem  Check power source and connection.
on  Wall outlet faulty  Ensure that the wall outlet is live.
 Bottle leaking  Check power cord is not damaged

Motor runs with no  Tubing leaky or broken  Verify tubing connection is on

vacuum  Bottle leaking or broken securely.
 Check for leaks or tubing kinks.
 Check for bottle leaks and cracks.

27
 2. Oxygen Concentrator

An oxygen concentrator (also sometimes called “oxygen generator”) is a

medical device [Figure1. 14] used to provide supplementary oxygen for
patients with chronic obstructive pulmonary disease (COPD) and, in higher
concentrations, for severe chronic hypoxemia and pulmonary edema. They
may be used as an adjunct treatment for severe sleep apnea (in
conjunction with a continuous positive airway pressure unit). Oxygen
concentrators are typically used as stationary or portable sources to
provide long-term oxygen therapy (LTOT) to patients at home.
Figure 1.14 oxygen concentrator
machine

 How does an Oxygen Concentrator Work?

An oxygen concentrator works much like a window air conditioning unit: it takes in air, modifies it
and delivers it in a new form. An oxygen concentrator takes in air and purifies it for use by people
requiring medical oxygen due to low oxygen levels in their blood [Figure 1.15]. It works by:

1. Taking in air from its surroundings

2. Compressing air, while the cooling mechanism keeps the concentrator from overheating

3. Removing nitrogen from the air via filter and sieve beds

4. Adjusting delivery settings with an electronic interface

5. Delivering the purified oxygen via a nasal cannula or mask

Figure 1.15 oxygen concentrator work flow

28
  Oxygen Concentrator Main components:

Oxygen Concentrator has six main components for generation concentrated oxygen [Figure 1.16].

These components are:

 Series of filters: To filter out impurities present in air

 Air Compressor: To push room air into the machine and forward it to the molecular sieve
beds.

 Two Molecular Sieve Beds – Zeolite (Micro porous Aluminosilicate mineral): Have the ability
to trap Nitrogen.

 Switch valve: Switches the output of compressor between the 2 molecular sieve beds

 Oxygen outlet: An opening that gives out oxygen to the patient

 Flow meter: To set the flow in Liters Per Minute (LPM)

Figure 1.16 The main components of the Oxygen Concentrator

29
 Anesthesia Machines and Breathing Systems

Objectives
 Identify the common features of anesthesia machine.
 Explain the different pressure system in anesthesia machine.
 Describe the use and character of different types of anesthetic breathing systems.

Anesthesia Machines
Anesthesia machine refers to all the medical equipment used to deliver inhalational
anesthesia. Inhalational anesthetics are gases that, when inhaled, produce a state of general
anesthesia, a drug-induced reversible loss of consciousness during which the patient is not
arousable, even in response to painful stimulation. Inhalational anesthetics are supplied as
either compressed gases (e.g., nitrous oxide), or volatile liquids (e.g., diethyl ether,
sevoflurane, or desflurane).

A. The Anesthesia Machine Structure

Anesthesia machine has a complex structure which comprises gas source, gas mixing system,
anesthetic gas vaporizer, breathing circuit, ventilator, exhaust gas emission system,
monitoring system and information management system, etc.
A modern anesthesia machine includes the following components [Figure 2.1 and Figure 2.2]:
 Inlet of hospital pipeline for compressed gases (oxygen, nitrous oxide, and air)
 Inlet of compressed gas cylinders
 Pressure regulators to reduce pipeline and cylinder pressure to safe and consistent levels
 Fail-safe device
 Flow meters to control the amount of gases delivered to the breathing limb
 Vaporizers for adding volatile anesthetic gas to the carrier gas
 Common gas line through which compressed gases mixed with a volatile agent enter the
breathing limb
 Breathing limb, including an oxygen analyzer, inspiratory one-way valve, circle system, gas
sampling line, spirometer to measure the respiratory rate and volume, expiratory one-way
valve, adjustable pressure-limiting valve, carbon dioxide absorbent, reservoir bag,
mechanical ventilator, and scavenging system.
 Figure 2.1 Front view of anesthesia machine

Figure 2.2 Back view of anesthesia machine

The machine components can also be logically conceptualized by the amount of pneumatic
pressure [Figure 2.3] they are exposed to:

1. The High-pressure circuit consists of those parts which receive gas at cylinder
pressure
o hanger yoke (including filter and unidirectional valve)
o yoke block
o cylinder pressure gauge
o cylinder pressure regulators
2. The Intermediate pressure circuit receives gases at low, relatively constant
pressures (37-55 psi, which is pipeline pressure, or the pressure downstream of a
cylinder regulator)
o pipeline inlets and pressure gauges
o ventilator power inlet
o Oxygen pressure-failure device (fail-safe) and alarm
o flowmeter valves
o oxygen and nitrous oxide second-stage regulators
o oxygen flush valve
3. The Low-pressure circuit includes components distal to the flowmeter needle
o valves
o flowmeter tubes
o vaporizers
o check valves (if present)
o common gas outlet

Figure 2.3 anesthesia machine components according to amount of pneumatic pressure

 B. Block Diagram of Anesthesia Machine
The anesthesia delivery system consists of four components: a breathing circuit, an anesthesia
machine, a waste gas scavenger system, and an anesthesia ventilator. The breathing circuit is
the functional center of the system, since it is physically and functionally connected to each
of the other components and to the patient’s airway [Fig. 2.4]. There is a one-way flow of gas
from the anesthesia machine into the breathing circuit, and from the breathing circuit into
the scavenger system. There is a bidirectional flow of gas between the breathing circuit and
the patient’s lungs, and between the breathing circuit and the anesthesia ventilator or
reservoir bag. The ventilator and the reservoir bag are functionally interchangeable units,
which are used during different modes of ventilation. During spontaneous and manually
assisted modes of ventilation, the elastic reservoir bag is used as a source of inspired gas and
a low impedance reservoir for exhaled gas. The anesthesia ventilator is used during
mechanically controlled ventilation to automatically inflate the lungs using prescribed
parameters.

Figure 2.4 Block diagram of anesthesia delivery system components. The arrows show the direction of
gas flow between components.

C. Anesthetic Breathing System

The function of anesthetic breathing systems is to deliver oxygen and anesthetic gases to the
patient and to eliminate carbon dioxide. Conceptually, the anesthetic breathing system is a
tubular extension of the patient’s upper airway. It allows the continuous flow from the
anesthesia machine to be converted into an intermittent flow; allows spontaneous,
controlled, or assisted respiration; and provides for other functions such as gas sampling and
airway pressure, flow, and volume monitoring.
Anesthetic breathing systems are classified as open, semiopen, semiclosed, and closed (Table
2.1) according to the presence or absence of:
 Gas reservoir bag in the circuit
 Rebreathing of exhaled gases
 Means to chemically neutralize exhaled carbon dioxide
 Unidirectional valves.
 Fresh gas inflow rate.
Table 2.1 Anesthetic breathing systems classification

System Breathing bag Rebreathing Co2 absorber

Open No No No

Semiopen Yes Partial No

Semiclosed Yes Partial Yes

Closed Yes Total Yes

 Anesthesia 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 [Figure 2.5]. Volatile anesthetics
are liquids at room temperature and atmospheric pressure. Vaporization, which is the
conversion of a liquid to a vapor, takes place in a closed container, referred to as a
vaporizer. The vapor concentration resulting from vaporization of a volatile liquid anesthetic
must be delivered to the patient with the same accuracy and predictability as other gases
(oxygen, nitrous oxide).

Figure 2.5 Design of vaporizer

Vaporizers are often constructed of metals with high thermal conductivity (copper, bronze) to
further minimize heat loss. As a result, vaporizer output is nearly linear between 200C and
350C. Designation of vaporizers as agent specific and out of circuit emphasizes that these
devices are calibrated to accommodate a single volatile anesthetic and are isolated from the
anesthetic breathing system.

 Manual Resuscitation

Manual resuscitation is a form of artificial respiration that uses a

breathing bag (manual resuscitator) to assist patients with
breathing. It is usually used when the lungs are not functioning
properly. The breathing bag is filled with oxygen and is squeezed
by hand by the doctor, nurse or respiratory therapist. You may
also hear the members of the ICU staff refer to the breathing
bag as an Ambu bag. Once squeezed, the bag self-inflates. One
end of the bag is attached to an oxygen source and the other
end to a facemask or breathing tube

Method of operation
Manual resuscitators cause the gas inside the inflatable bag portion to be force-fed to the
patient via a one-way valve when compressed by the rescuer; the gas is then ideally
delivered through a mask and into the patient's trachea, bronchus and into the lungs. In
order to be effective, a bag valve mask must deliver between 500 and 800 milliliters of air to
a normal male adult patient's lungs, but if supplemental oxygen is provided 400 ml may still
be adequate. Squeezing the bag once every 5 to 6 seconds for an adult or once every 3
seconds for an infant or child provides an adequate respiratory rate (10–12 respirations per
minute in an adult and 20 per minute in a child or infant.

Manual Resuscitation parts

 Bag made of plastic materials that re-expand after being manually collapsed
 oxygen inlet nipple
 air intake valve
 oxygen reservoir with two one-way valves
 non-rebreathing valve that directs fresh flow of oxygen to the patient and prevents exhaled
gas re-entering the bag
 Face Masks with different sizes and designs [see Figure 2.6]
 Figure 2.6 manual resuscitation parts

 Anesthesia Ventilators
A medical ventilator is a machine designed to move breathable air into and out of the lungs,
to provide breathing for a patient who is physically unable to breathe or breathing
insufficiently.
Most modern anesthesia machines are fitted with a mechanical ventilator that uses a
collapsible bellows within a closed chamber [Figure2.7]. The bellows is compressed
intermittently when oxygen or air is directed into the chamber, thereby pressurizing it.

Ventilator’s work
 During inspiration, the size of the thoracic cage increases overcoming the elastic forces
of the lungs and the thorax and resistance of the airways.
 As the volume of the thoracic cage increases, intrapleural pressure becomes more
negative, resulting in lung expansion.
 Gas flows from the atmosphere into the lungs as a result of trans airway pressure
gradient.
 During expiration, the elastic forces of the lung and thorax cause the chest to decrease
in volume and exhalation occurs as a result of greater pressure at the alveolus compared
to atm. Pressure.

Terms related to mechanical ventilation:

 Respiratory rate (f): Number of breaths per minute (10 to 20 bpm).

 Tidal volume (VT): Volume of air inhaled /exhaled during each respiratory cycle (7 to 12
ml/kg).
 Minute ventilation (VE): Volume of air expired per minute. (VE=VT x f; 6 to 8L/min)
 Fraction of inspired oxygen(FIO2) -: amount of oxygen delivered to the patient. It can
range from 21% (room air) to 100%.
 I: E Ratio: The inspiratory time compared to the expiratory time; I + E = total cycle time.
 (1:2 or less).

 Maximal Inspiratory pressure (MIP): Maximal negative pressure generated during

inhalation. (15 -20cmH2O)
 Flow rate: Flow rate is the speed with which the tidal volume is delivered. (40 to 100
L/min).
 Compliance: the lung expansion (volume change) per unit pressure change (work of
breathing) V/ P. Abnormal high or low compliance impairs the patient ability to maintain
effective gas exchange
 Cycling: what cycles, or changes, the ventilator from one phase of the respiratory cycle to
the other. (volume, time, pressure, flow)
 Positive end expiratory pressure(PEEP): keeps the air way open at the end of expiration
( 5 to 20 cms of H2O).
 Peak Inspiratory Pressure (PIP): the maximum pressure obtainable during active gas
delivery.
 Plateau Pressure: the end inspiratory pressure during a period of no gas flow.

Classification of ventilators
A. Negative Pressure Ventilators (Extrathoracic)
Negative-pressure ventilation (NPV) works by exposing the surface of the thorax to
subatmospheric pressure during inspiration. This pressure causes thoracic expansion and a
decrease in pleural and alveolar pressures, creating a pressure gradient for air to move from
the airway opening into the alveoli. When the pressure surrounding the thorax increases and
becomes atmospheric or greater, expiration occurs passively owing to the elastic recoil of
the respiratory system as it mimics spontaneous ventilation. Examples of this type of
ventilator include: lron Lung (Body Tank) and Chest Cuirass.
It is used mainly in chronic respiratory failure associated with neuromuscular conditions such
as poliomyelitis, muscular dystrophy and mysthenia gravis.

B. Positive Pressure Ventilators (intrapulmonary Pressure)

Positive-pressure ventilators work by increasing the patient's airway pressure through an
endotracheal or tracheostomy tube. The positive pressure allows air to flow into the airway
until the ventilator breath is terminated. Then, the airway pressure drops to zero, and the
elastic recoil of the chest wall and lungs push the tidal volume — the breath-out through
passive exhalation.
Modern ventilators are mainly PPV and are classified based on related features, principles
and engineering.

Classification of PPV:
There are three (3) types of positive pressure ventilators.
1. Pressure cycled ventilators
 ventilator pushes air until a preset pressure is reached.
 Tidal volume (Vr) is adjusted by increasing or decreasing the pressure limit.
  Although peak pressure will remain constant, the volume will change as lung
compliance and/or airway resistance change.
 These ventilators are normally pneumatically powered (50 PSI).
 It is used for short periods such as in the post anesthesia care unit and for respiratory
therapy.

2. Volume Cycled ventilators

 Pressure is applied to the airways until a preset volume is delivered.
 Minute volume will remain constant to provide stable blood gases. Airway pressure
will increase or decrease with changes in the patient's compliance and/or airway
resistance.
 Volume cycled ventilators can be used with most patients.
 Most common approach for mechanical ventilation.

3. Time Cycled ventilators

 These ventilators apply positive pressure until a preset time is reached.
 The peak inspiratory pressure (PlP) is usually limited by an adjustable pop-off valve.
 Tidal Volume (V1) is adjusted by increasing or decreasing the peak inspiratory
pressure, inspiratory time, or flow.
 Commonly used for infant ventilation.

Modes of Mechanical ventilation

The Mode is how the machine will ventilate the patient in relation to the patient’s own
respiratory efforts. There are different modes of Mechanical ventilation as the following:

 ASSIST CONTROL MODE(AC)

o Most commonly
o knowns as resting mode, in which ventilator takes over the work of breathing for the
client.
o Machine initiated and /patient-initiated breaths.
o A preset tidal volume and respiratory rate are delivered.

 INTERMITTENT MANDATORY VENTILATION(IMV)

o Ventilator delivers a preset number of mechanical breaths.
o Allows the client to breath spontaneously in between with no assistance from the
ventilator and at varying tidal volume.
 SYNCHRONIZED INTERMITTENT MANDATORY VENTILATION (SIMV)
o Delivers preset breaths that are synchronized with the patient’s spontaneous breaths.
o preferred mode of weaning.

 INVERSE RATIO VENTILATION (IRV)

o Normal inspiratory: expiratory ratio is reversed to 2:1 or greater (the maximum is
4:1).
o Longer inspiratory time increases the amount of air in the lungs at the end of
expiration
o Improves oxygenation by re-expanding collapsed alveoli.

 PRESSURE SUPPORT VENTILATION (PSV)

o Preset pressure augments the patient’s spontaneous inspiration effort and decreases
the work of breathing
o Patient completely controls the respiratory rate and tidal volume.

 CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)

o Keeps the alveoli open during inspiration and prevents alveolar collapse during
expiration.
o Used in the spontaneous breathing patient.
o Used as a method for weaning patients from mechanical ventilation.
o Improves gas exchange and improves oxygenation.
o Normal range for CPAP is 5 to 15 cm of H 2O.

Figure 2.7 anesthesia ventilator

Ventilation waveforms:

Ventilation waveforms are graphical representation that reflects the patient-ventilator system and
their interaction. The purpose of monitoring graphics includes:
 Allows user to interpret, evaluate, and troubleshoot the ventilator and the patient’s
response to ventilator.
 Monitors the patient’s disease status.
 Assesses patient’s response to therapy.
 Monitors ventilator function.
 Allows fine tuning of ventilator, optimize ventilation, and maximize patient comfort.

Types of Waveforms:

1. Scalars: waveform representation of pressure, flow or volume on the y axis vs time on the x
axis.
2. Loops: representations of pressure/volume/flow against each other (i.e. pressure vs volume
or flow vs volume).

There are six basic waveforms: Square (rectangular or constant wave), Ascending Ramp
(accelerating ramp), Descending Ramp (decelerating ramp), Sinusoidal (sine wave), Exponential
rising and Exponential decaying (see Figure 2.8).

Figure 2.8 Examples of waveforms for pressure, volume, and flow. Pressure waveforms usually are the rectangular or
rising exponential (similar to an ascending ramp) type. Volume waveforms usually are the ascending ramp or sinusoidal
(sine-like) type. Flow waveforms can take various forms; the rectangular, ramp (ascending or descending), sinusoidal,
and decaying exponential types are seen most often.

Pressure waveform:

The pressure waveform displays changes in airway pressure over time [Figure 2.9]. If positive end-
expiratory pressure is utilized, the baseline pressure will serve as the starting point for inspiration.
As airway pressure increases during inspiration, the waveform will increase until it reaches its
highest value, referred to as the peak inspiratory pressure (PIP). Pressure subsequently declines
until it reaches the end-expiratory level. The area under the curve represents the mean airway
pressure. Since oxygenation is a function of mean airway pressure, ventilatory maneuvers which
increase the area under the curve may improve oxygenation. These include raising the PEEP,
increasing the PIP, lengthening the inspiratory time, and to a lesser extent, increasing the rate.
 Figure 2.9 Pressure waveform. Solid line represents pressure-targeted
ventilation, which produces a square waveform. Dotted line represents
volume-targeted ventilation, which produces a triangular or “shark’s
fin” pressure waveform. Note that the expiratory portion of the
waveform is above the baseline representing positive end-expiratory
pressure (PEEP). The area under the curve, bounded by the peak
inspiratory pressure (PIP) and PEEP, is the mean airway pressure

Volume waveform:

The volume waveform looks similar to the pressure waveform, except that in the ideal situation,
the waveform should reach the zero baseline at end expiration. Failure to do so indicates the
presence of a volume leak around the endotracheal tube. The volume waveform peaks earlier in
inspiration when pressure is controlled in contrast to the situation in which volume or flow is
controlled, where the slope will be less.

Flow waveform
The flow waveform differs from both the pressure and volume waveforms by having components
that are both above the baseline (inspiration) and below the baseline (expiration)(see Figure 2.10).
In other words, positive flow represents gas delivered into the airway, and negative flow
represents gas egressing from the airway. As inspiration commences, there is a rapid flow of gas
into the airway producing a sharp upswing in inspiratory flow, referred to as accelerating
inspiratory flow.

Figure 2.10 Anatomy of the flow waveform.

A Closer Look at the Flow-Time Scalar in Volume-Controlled Continuous Mandatory Ventilation

Figure 2.11 illustrates several important points about the flow-time scalar. At point A, the
inspiratory valve opens, and inspiratory gas flow begins. This is also the point where expiration
ends. Flow rises quickly to point B, which is the peak inspiratory flow set on the control panel of
the ventilator. At point C, inspiratory flow delivery stops.

Figure 2.11 Flow-time graph showing inspiration and expiration during VC-CMV with a
constant flow. (See text for explanation.)

Scalars for flow, pressure, and volume:

Figure 2.12 shows another set of scalars for flow, pressure, and volume. Look first at the
inspiratory portion of the pressure-time curve. Note that the baseline pressure is 5 cm H 2O,

Figure 2.12 Flow, pressure, and volume scalars during

VC-CMV with constant flow and an inspiratory pause.
(See text for explanation.)
indicating that there is positive end-expiratory pressure (PEEP) set at 5 Cm H2O. It is important to
remember that even though the baseline pressure is positive, the flow and volume curves start
from a zero baseline and end at a zero baseline.

 Humidification Equipment
Humidification is a process of adding water vapor to a volume of one or more gases. Natural
humidification is achieved in the nasal cavity, but this process is often bypassed
during anesthesia and critical care. Due to the dryness of medical gases, it is recommended
when oxygen is delivered more than 4 l/min, or when using a Nasal Cannula, that
humidification is used to prevent damage to the respiratory tract and to improve patient
comfort and compliance. Various devices are used for artificial humidification, the most
common is heat and moisture exchanger combined with a microbial filter.

Physical principles governing humidifier function:

o Temperature – the higher the temperature of gas, the more water it can hold
o Surface area – affects rate of evaporation
o Time of contact – evaporation increases as contact time increases
o Thermal mass - the greater the amount of water in humidifier, the greater the thermal
mass & capacity to hold and transfer heat to therapeutic gas

Types of humidifiers:
Humidifiers are either active (actively adding heat or water or both to the device-patient
interface) or passive (recycling exhaled heat and humidity from the patient).
Active humidifiers typically include:
a. Bubble humidifiers: Gas passes through tube to bottom of water reservoir and unheated
bubbles through humidifier Provides humidity for oxygen therapy. [Figure 2.13.a]
b. Passover humidifiers: Direct gas over liquid or over surface saturated by liquid [Figure
2.13.b]
c. Nebulizers of bland aerosols: Pressurized air passes through tube and turns the liquid
medicine into a mist.
d. Vaporizers.

Passive humidifiers refer to typical heat and moisture exchangers (HMEs). Often passive
humidifier that has been described as “artificial nose “does not add heat or water to system.
Types of HMEs:
e. Simple condenser humidifiers
f. Hygroscopic condenser humidifiers
g. Hydrophobic condenser humidifiers
 Figure 2.13 types of humidifiers a. Bubble humidifiers b. Passover humidifiers

Controlling Gas delivery

Respiratory gas analysis has now become a standard monitoring technique in anesthesia: in
theatres, intensive care unit, and for the transfer of ventilated patients. Several methods are
used to monitor concentrations of oxygen, carbon dioxide, and anesthetic gases in the
breathing system.

 The oxygen analyzer is the single most important monitor for detection of a hypoxic
gas mixture. Oxygen analyzers continuously measure and indicate FIO 2 in the
breathing system. They also indicate when inspired O2 deviates from desired limits.
Paramagnetic oxygen analyzers are the most common form of oxygen analyzer used
in the operating theatre.

 Carbon dioxide analysis can be performed using either mainstream or sidestream

capnography. Capnometry has many uses, including monitoring the adequacy of
ventilation and detection of breathing system faults. [ Figure 2.14]
 Breath-to-breath monitoring of anesthetic concentrations provides tracking of
anesthetic uptake and distribution.
 Most gas analyzers incorporate alarms. Among the techniques for measurement are
the following: Mass spectrometry., infrared analysis and oxygen concentrations
analysis

Figure 2.14 capnometer system

 Monitoring Devices

Objectives

 Identify the different types of monitoring devices.

 Understand the basis of monitoring anesthesia gas, pressure, volume, and flow in the
anesthesia breathing system.
 List the alarms triggered in anesthesia machine and its causes.

Gas monitoring
The overriding concern for patient safety during surgery has given rise to the development and
adoption of a number of technologies, whose use is taken for granted every time a patient
undergoes general anesthesia. These technologies include airway pressure monitoring and
breathing system disconnect alarms, monitoring of inspired oxygen, monitoring of expired CO2,
and pulse oximetry. The ongoing technical advancements in the field of respiratory gas
monitoring of the five-potent inhaled anesthetic agents, N2O, CO2 and O2.

A. Ventilation parameters Monitoring

1- Measurement of carbon dioxide

Respiratory gases can be potentially analyzed according to different measuring principles. Most
commonly, either a dispersive infrared (DIR) method, or a non-dispersive infrared (NDIR)
method are used to isolate the absorbance characteristics of the gas sample. This measuring
principle is based on the fact that many gases absorb infrared energy at a wavelength specific
to the gas being analyzed. Figure 1 shows the infrared absorbance spectra for CO 2 , N2O, and
the five potent inhaled anesthetic agents, halothane, enflurane, isoflurane, sevoflurane and
desflurane. It can be seen from this figure that the absorbance peaks for CO 2 and N20 are
located at the 4-5 μm range, and the anesthetic agents are found at the 8-13 μm range, in five
different wavelengths.

46
This technique, as with other absorption spectrometers, is based on the principle of the Beer–
Lambert Law, which defines the quantitative relationship between the absorbance of radiant
energy, the concentration of the absorbing species and the length of the path through the
sample. Carbon dioxide selectively absorbs specific wavelengths (4.3 μm) of IR light. Since the
amount of light absorbed proportional to the concentration of the absorbing molecules, the
concentration of a gas can be determined by comparing the measured absorbance with the
absorbance of a known standard. The absorption peaks for some gases (e.g. nitrous oxide and
carbon dioxide) overlap [Figure 3.1]. This kind of interference is corrected either independently
by monitoring the concentration of the second gas with an additional wavelength of light or by
manual correction switches.

Figure 3.1 Absorbance spectra for commonly monitored respired

gases and anesthetic agents.

2- Measurement of oxygen
Oxygen is a paramagnetic gas because of the unpaired electrons in its outer orbit. Three types
of paramagnetic oxygen analyzers are commonly seen. They are the magneto dynamic or
‘dumbbell ‘type, the thermomagnetic or ‘magnetic wind’ type and the magneto-pneumatic
type. The magneto-dynamic sensor consists of a cylindrical container with a glass dumbbell. The
dumbbell is filled with inert gas such as nitrogen and suspended via a taut platinum wire within
a nonuniform magnetic field [Figure 3.2]. The dumbbell is kept in balance and it can move
freely. When an oxygen-containing gas sample is placed in the chamber, the oxygen molecules
are attracted to the stronger magnetic field, causing a displacement of the dumbbell.
An optical system is used to measure the degree of dumbbell rotation. Alternatively, an
opposing current can be applied to restore the dumbbell to its normal position. The amount of
current required to maintain the dumbbell in its normal position is directly proportional to the
partial pressure of oxygen. This device has a good response time and sensor life. It is very
precise but very delicate because of its moving parts. This position and vibration-sensitive
device requires temperature control and compensation. The gas sample should be dried by
silica gel before analysis. This analyzer can be affected by the magnetic susceptibility of the
background gases. The thermomagnetic analyzer is based on the principle that the magnetic
susceptibility of oxygen decreases inversely with the square of its temperature. When an
oxygen-containing gas mixture is heated in a non-homogeneous magnetic field, a flow of gas
(magnetic wind) is created that can be measured by its thermal effect on an electrical
resistance element. The magneto pneumatic type operates on the principle that a test sample
containing oxygen molecules, when drawn into a non-homogeneous magnetic field and mixed
with a reference gas with a different oxygen content, will generate a differential pressure. The
amplitude of the signal from a differential pressure transducer is proportional to the difference
in the partial pressure of oxygen between the two gas flows.

Figure 3.2 Magnetodynamic analyzer

3- Measurement of inhalational anesthetic agents

Apart from the IR techniques discussed above, many other methods such as mass spectrometry
that measure the concentration of gases largely based on their molecular weight, Raman
scattering, refractometry and gas chromatography are used to measure inhalational agents.

B. Medical Gas System Monitoring

Medical gas system is known as one of the life support system, whose normalization, safety,
reliability and reasonability directly related to the patient’s life safety. So, the Centralized
hospital medical gas monitoring system is designed to:

 Control the hospital medical gas system pressure in the gas sources, in the closure

points of pressure regulation.

 Control supplied medical gas flows detecting possible gas leaks, while analyzing

earlier periods of gas flow quantities.

 Perform consumed medical gas calculation for a day, a week, a year.

 Analyze the obtained information in the central computer about cause of fault

alarm signals and their correction methods.

Medical gas monitor and alarm systems can vary in what they report and measure, NFPA and
other agencies set the minimum standards, but with current technologies many alarm panels
display more than the minimum requirements [Figure 3.3]. Medical gas alarm panels come in
three general descriptions or level of protection:
1. Master alarm panels that monitor source equipment, manifolds and main oxygen supply.
2. Zone alarms that will protect a section of the hospital and typically monitor the presence
and pressure of oxygen.
3. Area alarms that monitor at least oxygen and vacuum in surgical, procedure and recovery
rooms. Critical care and antihazing locations are required to have area alarms to monitor
each gas in that zone. With newer sensors and digital internal components, pressures can be
read directly on the alarm screen along with other values.

Each kind of alarm is associated with a valve and a visual gauge to allow isolation of part of the
system in emergency or for maintenance purposes. Modern alarms can be connected by wireless
signals to the sensors and to other alarm panels. There are a multitude of restrictions and
safety requirements with this method to avoid radio frequency interference and even hacking.
 Figure 3.3 Different gas alarm panels

C. Other monitors

I. Muscle relaxant monitor

The use of muscle relaxant is an integral part of anesthetic management in present-day

practice. In 1958, Christie and Churchill-Davidson described how nerve stimulators could be
used to assess neuromuscular function objectively during anesthesia. Clinically, the
neuromuscular blockade(NMB) is evaluated by determining the thumb twitching to train-of-four
(TOF) ulnar nerve stimulation at elbow. There are many ways for the assessment of twitch
response, such as the use of electromyography, force displacement transducer techniques, and
most recently and the acceleration transducer-based system of neuromuscular monitoring.

Principles of Peripheral Nerve Stimulation

 Each muscle fiber to a stimulus follows an all-or- none pattern

 In contrast, response of the whole muscle depends on the number of muscle fibers activated
 Response of the muscle decreases in parallel with the numbers of fibers blocked
 Reduction in response during constant stimulation reflects degree of NM Blockade
 For this reason, stimulus is supramaximal

How does the “train of four” machine work?

The train of four received its name because the machine delivers four electrical impulses one after
the next. For the baseline, you want to start with as low of electrical impulse as the machine can
give and let it deliver its four shocks. Four successive stimuli are delivered at 2Hz (every 0.5 sec).
Look at the patient’s pinkie finger (if ulnar nerve stimulated) or eyebrow (if facial nerve
stimulated) [Figure 3.4 ] and see how many times they twitched. Did they twitch four times with
the four electrical impulses (4/4)? Did they twitch only with two of the impulses (2/4)?

a b

Figure 3.4 nerve stimulator placement: (a) ulnar nerve stimulated (b) facial nerve
stimulated

Under normal conditions, the amplitude of all four motor responses will be equal. With an
increasing degree of NMB (induced by non-depolarizing NMBAs), the amplitude of the latter
twitches decreases, relative to the first twitches, a phenomenon called fade. Eventually, as NMB
increases, all twitches will become absent (see Figure 3.5). Thus, the number of detectable thumb
twitches and the degree of fading correspond with the intensity of the NMB. The degree of fading
can be further expressed as a ratio, by dividing the motor response of the fourth twitch (T4) to the
first twitch (T1), i.e. the T4:T1 ratio or the so-called TOF ratio. When high doses of NMBAs are
given, measurement of the NMB at the ulnar nerve will show zero thumb twitches (TOF equals

Figure 3.5 Levels of neuromuscular blockade after admission of non-depolarizing NMB at a single intubation dose

zero).

Types of Peripheral Nerve Stimulation

As neuromuscular function is monitored by evaluating the muscular response to supramaximal

stimulation of a peripheral motor nerve, two types of stimulation can be used: electrical and
magnetic.
Magnetic nerve stimulation has several advantages over electrical nerve stimulation. It is less
painful and does not require physical contact with the body. However, the equipment required is
bulky and heavy, it cannot be used for train-of-four (TOF) stimulation, and it is difficult to achieve
supramaximal stimulation with this method.

Assessment of Responses to Nerve Stimulation

For assessment of responses to nerve stimulation, five methods are available:

1. Measurement of the evoked mechanical response of the muscle (mechanomyography [MMG])

2. Measurement of the evoked electrical response of the muscle (electromyography [EMG])
3. Measurement of acceleration of the muscle response (acceleromyograph [AMG])
4. Measurement of the evoked electrical response in a piezoelectric film sensor attached to the
muscle (piezoelectric neuromuscular monitor [PZEMG]
5. Phonomyography [PMG]).

II. Depth of Anaesthesia monitoring

Many surgical procedures would not be possible without the patient entering a state of general
anaesthesia (GA). The essential features of a successful GA, displayed by the patient, are a
reversible loss of consciousness with a lack of movement, a lack of awareness, unresponsiveness to
painful stimuli and a lack of recall of the surgical intervention. So, one of the current challenges in
medicine is monitoring the patients’ depth of general anaesthesia (DGA). Accurate assessment of
the depth of anaesthesia contributes to tailoring drug administration to the individual patient, thus
preventing awareness or excessive anesthetic depth and improving patients’ outcomes.

Methods of monitoring depth of anaesthesia

There are various ways to measure or monitor depth of anaesthesia based on clinical/conventional
monitoring or brain electrical activity monitoring

A. Clinical techniques and conventional monitoring:

Among the clinical techniques used to assess intraoperative consciousness are checking for
movement, response to commands, eyelash reflex, pupillary responses or diameters, perspiration,
and tearing. Conventional monitoring systems include ASA standard monitoring as well as end-tidal
anesthetic analyzer.

I. Clinical signs: The most commonly used scoring system incorporates the PRST or Evan's
score. This assesses autonomic activity related to P(systolic blood Pressure), R (heart Rate),
S( Sweating) and T ( Tears). This system has the advantages of being simple and not
requiring any specialized equipment, but the parameters are not specific for the effects of
anaesthesia and the values can vary widely among individuals.
II. Skin conductance: Measurement of skin conductance is, in effect, a quantification of the
clinical sign of sweat production. Goddard GF found a reasonable correlation with
anesthetic depth in 67 patients. Skin conductance was initially low and increased as
anesthetic depth was increased, reducing again with surgical incision. Other factors
affecting sweating (e.g. atropine, autonomic neuropathy) can reduce the accuracy of this
monitoring.
III. Spontaneous surface electromyogram (SEMG): In patients who are not completely
paralyzed, spontaneous surface electromyogram (SEMG) can be recorded from various
muscle groups, especially facial, abdominal and neck muscles. Frontalis muscle is inner-
vated by a branch of the facial nerve and is less affected by the neuromuscular blockade. A
stick-on electrode positioned over the frontalis muscle can record the frontalis
electromyogram (FEMG). The level of FEMG has been observed to fall during anaesthesia
and to rise to pre-anesthetic levels just before awakening .
IV. Lower esophageal contractility (LOC): The non-striated muscles in the lower half of
esophagus retain their potential activity even after full skeletal muscle paralysis by
neuromuscular blocking agents. Measurements of LOC therefore, provide two prime
derivatives.

B. Brain electrical activity monitoring:

Most of the devices designed to monitor brain electrical activity for assessing anesthetic effect
record EEG activity from electrodes placed on the forehead. Systems can be subdivided into those
that process spontaneous EEG and EMG activity and those that acquire evoked responses to
auditory stimuli i.e. auditory evoked potential (AEPs). After amplification and conversion of the
analog EEG signal to the digital domain, various signal processing algorithms are applied to the
frequency, amplitude, latency, and/or phase relationship data derived from the raw EEG or AEP to
generate a single number, often referred to as an "index," typically scaled between 0 and 100. This
index represents the progression of clinical states of consciousness ("awake," "sedated," "light
anaesthesia," "deep anaesthesia"), with a value of 100 being associated with the awake state and
values of 0 occurring with an isoelectric EEG (or absent middle latency AEP)[Figure 3.6].

Artifact recognition algorithms intended to avoid contaminated and therefore spurious "index"
values are an important component of the software in most monitors. Although EMG activity from
scalp muscles can be considered an artifact from the viewpoint of pure EEG analysis, it may be an
important source of clinically relevant information. Sudden appearance of frontal (forehead) EMG
activity suggests somatic response to noxious stimulation resulting from inadequate analgesia and
may give warning of impending arousal. For this reason, some monitors separately provide
information on the level of EMG activity.
 Figure 3.6 Stylized common EEG patterns from frontal EEG channel seen with progressively increasing
anaesthetic depth. BIS, bispectral index.

III. Cardiac output monitoring

The hemodynamic status monitoring of high-risk surgical patients and critically ill patients in
Intensive Care Units is one of the main objectives of their therapeutic management. Cardiac
output is one of the most important parameters for cardiac function monitoring, providing an
estimate of whole body perfusion oxygen delivery and allowing for an understanding of the causes
of high blood pressure.

Cardiac output is the volume of blood pumped by the heart per minute and is the product of the
heart rate and stroke volume. The stroke volume of the ventricle is determined by the interactions
between its preload, contractility and afterload.

There are many methods of monitoring the hemodynamic status of patients, both invasive and non-
invasive, the most popular of which is thermodilution. The invasive methods are the Fick method
and thermodilution, whereas the non-invasive methods are esophageal Doppler, transesophageal
echocardiography, lithium dilution, pulse contour, partial CO2 rebreathing and thoracic electrical
bioimpedance. All of them have their advantages and disadvantages, but thermodilution is the
golden standard for critical patients, although it does entail many risks. The ideal system for
cardiac output monitoring would be non-invasive, easy to use, reliable and compatible in patients.
INVASIVE METHODS

Fick method
This method is based on the principle described by Adolfo Fick in 1870, according to which the
total uptake or release of a substance by an organ is the product of the blood flow through the
organ and the arteriovenous concentration difference of the substance.

The oxygen uptake in the lungs is the product of the blood flow through the lungs and the
arteriovenous oxygen content difference. Therefore, cardiac output can be calculated using the
equation:
CO =
–

Where VO2 is the oxygen consumption by the lungs and CaO 2–CvO2 is the arteriovenous difference in
oxygen.
Oxygen consumption is measured with special devices. The arteriovenous difference is computed
by receiving samples of arterial blood, and mixed venous blood by receiving blood from the
pulmonary artery. The mixed venous blood is received via a catheter that reaches up to the right
ventricular and the pulmonary artery. Mathews & Sigh stated that “the arteriovenous oxygen
content difference can be measured in situ using a pulmonary artery catheter having fiberoptic
bundles incorporated in the catheter”

Thermodilution method

This is an intermittent technique widely accepted in clinical settings. It is a method relying on a

principle similar to indicator dilution, but it uses heat rather than color as an indicator.

This method uses a special thermistor – tipped catheter (Swan-Ganz catheter) inserted from a
central vein into the pulmonary artery. A cold solution of D/W 5% or normal saline (temperature 0
o C) is injected into the right atrium from a proximal catheter port. This solution causes a decrease
in blood temperature, which is measured by a thermistor placed in the pulmonary artery catheter).
The decrease in temperature is inversely proportional to the dilution of the injectate. The cardiac
output can be derived from the modified Stewart-Hamilton conservation of heat equation. The
pulmonary artery catheter is attached to the cardiac output computer, which displays a curve and
calculates output and derived indices automatically [see Figure 3.7].

Thermodilution technique remain the most common approach in use today and is considered as the
golden standard approach to cardiac output monitoring
 Figure 3.7 Thermodilution method for intermittent cardiac output (CO) measurements. After injecting a cold
indicator (usually saline) into the right atrium (RA) via a central venous catheter, the resultant
thermodilution curve can be derived in the descending aorta (transpulmonary thermodilution). AUC area
under thermodilution curve, m0 = amount (or mass) of injected cold at the time of injection (t0 ) = (blood
temperature minus injectate temperature) × (injectate volume minus dead space volume of catheter), −∆T =
decrease in blood temperature, °C = degree Celsius, SVC superior vena cava, RA right atrium

Minimally (or less invasive) methods

Esophageal Doppler
Esophageal Doppler provides real-time estimation of blood flow in the descending thoracic aorta
from the aortic blood velocity and the aortic diameter. On the basis of the hypothesis of a constant
distribution of CO between the upper territories and the descending aorta, the CO value is inferred
from the descending aorta blood flow value using a flexible ultrasound probe about the size of a
nasogastric tube.

The precision of this measurement depends on the following three conditions: the cross-section
must be accurate, the ultrasound beam must be directed parallel to the blood flow, the beam
direction may not undergo major alteration between measurements.

Pulse contour cardiac output

This technique calls for the insertion of an arterial catheter, and hence is considered a minimally
invasive procedure. A long arterial catheter (with a thermistor) placed in the femoral axillary, or
brachial artery, and connected to a pulse contour device. With this catheter, a continuous pulse
waveform contour analysis is obtained. The technique is calculated by analysis of the area under
the systolic portion of the arterial pressures waveform, from the end-diastole to the end of the
ejection phase; this corresponds to stroke volume. Also, by virtue of a pulse contour analysis
device, a beat-to-beat analysis of cardiac output, averaged at 30 seconds, is displayed. Calibration
requires a central venous cannulation, using a transcardiopulmonary thermodilution technique.
(see figure 3.8)
This method offers a level of accuracy comparable to thermodilution.

Figure 3.8 Top, A diagram showing the thermodilution cardiac output measurement as a reference
for the continuous pulse contour cardiac output measurement. Bottom, The PiCCO monitor pulse
contour cardiac output analysis algorithm, which incorporates the aortic compliance, the area
under the systolic portion of the arterial waveform, a patient-specific calibration factor based on
the thermodilution measurement of cardiac output, and the shape of the pressure curve.

Non-invasive methods

Thoracic electrical bioimpedance

In the 1960s, the National Aeronautical and Space Administration (NASA) and William Kubicek
developed impedance cardiograph, using the thoracic electrical bioimpedance. Based on changes
in electrical resistance of the thoracic cavity occurring with change in aortic blood volume during
systole & diastole.

This technique employs four pairs of electrodes. Two pairs are applied to the neck base on
opposite sides and two pairs are placed at the level of the xiphoid junction. Each pair of electrodes
comprises transmitting and sensing electrodes. With these electrodes, low-level electricity
conducted by body fluid is transmitted. Another set of two electrodes is used to monitor a single
ECG signal. This electricity is harmless and not felt by the patient. The first derivative dZ/dt of the
impedance waveform is related linearly to aortic blood flow [See figure 3.9]. Changes in
impedance correlate with stroke volume, calculated using the following formula:

SV=ρ L2 (dZ/dt)max×T /(Z20)

where SV=stroke volume ρ=resistivity of blood (Ω/cm) L= mean distance between the inner
electrodes (the thoracic length) Z o=basal thoracic impedance (dZ/dt)max=the maximum value of
the first derivative during systole (Ohms/second) T=ventricular ejection time (sec) Cardiac output
is calculated from the stroke volume and heart rate and the equation is: CO=SVxHR, where
HR=Heart Rate.

Cardiac output is easier to measure by impedance cardiography than by thermodilution with a

pulmonary artery catheter, can be applied quickly, and does not pose a risk of infection, blood loss
or other complications associated with arterial catheters.
 Figure 3.9 the electrodes placement for thoracic electrical bioimpedance

Capnography

Capnography is the graphic record of instantaneous carbon dioxide (CO 2) concentrations

(capnogram) in the respired gases during a respiratory cycle. Its main development has been as a
monitoring tool for use during anesthesia and intensive care. It is usually presented as a graph of
expiratory CO2 (measured in millimeters of mercury, "mmHg") plotted against time, or, less
commonly, but more usefully, expired volume. The plot may also show the inspired CO 2, which is
of interest when rebreathing systems are being used [Figure 3.10 ].

The capnogram is a direct monitor of the inhaled and exhaled concentration or partial pressure of
CO2, and an indirect monitor of the CO2 partial pressure in the arterial blood. In healthy
individuals, the difference between arterial blood and expired gas CO 2 partial pressures is very
small. In the presence of most forms of lung disease, and some forms of congenital heart disease
(the cyanotic lesions) the difference between arterial blood and expired gas increases and can
exceed 1 kPa.

Figure 3.10 Typical capnogram. Expiration phase on the left, inspiration on the right.
Working mechanism

Capnographs usually work on the principle that CO 2 absorbs infrared radiation. A beam of infrared
light is passed across the gas sample to fall on a sensor. The presence of CO 2 in the gas leads to a
reduction in the amount of light falling on the sensor, which changes the voltage in a circuit
[Figure 3.11 ]. The analysis is rapid and accurate, but the presence of nitrous oxide in the gas mix
changes the infrared absorption via the phenomenon of collision broadening. This must be
corrected for measuring the CO2 in human breath by measuring its infrared absorptive power.
[more details illustrated at “Ventilation parameters Monitoring” at “measurement of carbon dioxide” section]

Figure 3.11 Schematic overview of a capnograph

Airway Volumes, Flow and Pressure

The anesthesia breathing system is an enclosed environment with which the patient makes
respiratory gas exchange. By controlling the composition of the gases in the breathing circuit, as
well as ventilatory parameters, the anesthesia caregiver can control the tensions of oxygen, carbon
dioxide, nitrogen, and the inhaled anesthetics in the patient’s arterial blood. Monitoring of the
respired gases has been discussed in the previous section. This section addresses the monitoring of
pressures, volumes, and gas flows in the breathing system. Monitoring of these parameters is
important in enhancing the safety of ventilation and verifying the appropriateness of ventilatory
settings.

A. Measurement of respiratory pressures, volumes, and flows

I. Pressure

Pressure is defined as force per unit area (e.g. pounds per square inch). Pressures are usually
measured using either a simple mechanical device or an electromechanical transducer. Simple
analog gauges have been commonly used to measure and display breathing system pressure. The
gauge may be based on a Bourdon tube (Figure 3.12), diaphragm, or bellows (Figure 3.13).

In the Bourdon tube design, an indicator needle mechanism is attached to the closed, free end of a
curved piece of flattened soft metal tubing. The open end of the tubing is in communication with
the breathing circuit. Pressure in the circuit causes the flattened tubing to become more circular.
This causes the tubing to uncoil and move the indicator needle mechanism (Figure 3.12). A small
adjustment screw is often used to align the indicator needle to the zero-pressure mark when the
gauge is exposed to atmosphere. A high-quality Bourdon tube is accurate and reliable and requires
no mechanical stop at zero. The gauge is usually calibrated to measure negative as well as positive

Figure 3.12 Bourdon tube pressure gauge.

pressures.

The principle of the bellows pressure gauge is that the volume of a bellows changes according to
the pressure that is applied to it. If the bellows is sealed, its volume is a function of the ambient or
surrounding pressure (Figure 3.13A). If the interior of the bellows is in communication with the
breathing system, the volume of the bellows is determined by the difference in pressures across
the bellows (Figure 3.13B) and is termed gauge pressure.

Figure 3.13 Bellows-based pressure gauges. A: The bellows is sealed and therefore measures absolute
or atmospheric pressure (PB). B: The bellows is connected to the system whose pressure is to be
measured and therefore measures pressure in relation to ambient (PB)

The advantage of the analog pressure gauge is that it is simple and mechanical and requires no
warmup time or electrical energy to function. Such gauges were widely used on traditional
anesthesia machines. Disadvantages are that they cannot be interfaced with electronic anesthesia
care stations or to trigger alarms. Although modern electronic anesthesia care stations use
sophisticated electronic pressure transducers to measure pressures, some manufacturers still offer
a mechanical analog gauge as an optional extra.

Contemporary anesthesia workstations use electromechanical transducers to measure pressure.

When used in combination with pneumotachometers, Pitot tubes, or variable orifices, the pressure
measurements can be used to measure gas flows and volumes. The most common
electromechanical transducer is the metal or semiconductor strain gauge. When a metal wire or
thin segment of semiconductor material is stretched within its elastic limit, its resistance is altered
because of dimensional changes and a change in the material’s resistivity. The change in
resistivity is called the piezoresistive effect. Fine wires made from such alloys as constantan,
nichrome, and karma are particularly appropriate for metal strain gauges. In one common design,
the bonded-wire strain gauge, the wires are cemented to a backing (Figure 3.14). A flexible
diaphragm attached to the bonded-wire strain gauge is exposed to the pressure to be measured on
one side and the ambient pressure on the other.
As the diaphragm bends, the wires are stretched and the change in resistance corresponding to the
change in pressure is measured.
In the semiconductor strain gauge, the materials used are usually crystals of silicon or germanium.
The advantage of semiconductor materials is that they exhibit 50 to 100 times the change in
resistance per unit of strain compared to metals.1 However, the temperature sensitivity is
substantially greater in semiconductor gauges, and accurate compensation is a major factor in
their design.

Figure 3.14 Bonded wire strain gauge. A length of metal strain gauge
wire is cemented to a backing that is fixed at one end. As pressure is applied
to the flexible diaphragm, the backing and strain gauge wire are stretched.
The change in resistance of the wire is measured and displayed as a change
in pressure. P, applied pressure; Pam, ambient pressure.

Figure 3.15 Wheatstone bridge circuit used for strain gauge transducers.
Voltage from a battery is applied between points A and B. One or more
of the variable resistors shown (R1–R4) are resistance elements of the
transducer. The remaining resistor values are selected so that the
voltage difference measured between points C and D is very small, or
“balanced,” when zero pressure is applied to the transducer. As the
pressure applied to the transducer changes, the bridge becomes
“unbalanced,” and a voltage appears between points C and D.
Appropriate selection of resistance elements and temperature-sensitive
elements as resistors in the Wheatstone bridge can result in highly
sensitive, temperature-compensated measurement
In both the metal and semiconductor strain gauges, the change in resistance of the elements is
measured via an electrical circuit called a Wheatstone bridge [Figure 3.5. This arrangement is
particularly useful for several reasons. First, the Wheatstone bridge allows the simultaneous
measurement of resistance
changes in multiple elements when they are used as legs of the bridge. Second, temperature
compensation can be incorporated directly into the bridge by way of metal or semiconductor
elements that are sensitive to temperature but not exposed to the strain. Third, a small change in
resistance can be measured as a relative change in voltage near zero between the two balance
points of the bridge.

II. Volume and flow

Flow is defined as volume per unit of time; therefore, measurement of flow and time permits
calculation of volume. Like pressure, flow can be measured using a simple mechanical device or by
electronic means.

a. Mechanical

The simplest flow measurement device is the vane anemometer. This was originally introduced into
respiratory measurement by B. Martin Wright in England. Using adaptors, this is a freestanding
device that can be inserted into the breathing system, where it is commonly used to measure tidal
volume and minute ventilation. This device uses a low-mass rotating vane in the gas stream [Figure
3.16]. Gas molecules colliding with the blades of the vane transfer their momentum in the
direction of flow and cause the vane to rotate. In the mechanical version, the rotation of the vane
is connected to the dial via a gear mechanism, similar to that in a watch. In an electronic
implementation, two pairs of light-emitting diodes (LEDs) and silicon photodetectors are used to
measure the rate and direction of the vane’s rotation. The rotation rate is integrated
electronically to determine the volume of gas passing the transducer over time.

Figure 3.16 Wright’s respirometer. Respired gas is directed through

oblique slots in a small cylinder enclosing a small vane that is made to
rotate. The spindle on which the vane is mounted drives a gear train
connected to a pointer that moves over a dial indicating the volume of
gas passed. Gases that flow back through the device do not register
because they enter along the axis of the vane spindle.
A number of physical factors limit the accuracy of the vane anemometer. Because the principle of
operation is momentum, the density of the gas affects the measurement. The gas flow is directed
to the blades of the vane by tangential slots; thus, the viscosity of the gas also influences the
measurement. Additionally, inertia and momentum of the vane are problematic. Accuracy is poor
at low flows because of inertia, and at high flows because of momentum.

A sealed mechanical volumeter [Figure 3.17] was used by Dräger in some older delivery systems
to measure tidal volume and minute ventilation. This device consists of a pair of rotating elements
in the gas flow path, configured much like a revolving door at the entrance to a building. A fixed
volume of gas is passed across the volumeter with each quarter-rotation of the dumbbell-shaped
elements. A seal is formed between the polystyrene rotating elements and the interior wall of the
tube. The sealed volumeter provides substantially more resistance to flow than does the vane
anemometer. The accuracy of the volumeter is affected by gas density and by the inertia of the
rotating elements. However, it is not influenced substantially by the flow pattern of the gas. The
number of fixed volumes of gas transferred from inlet to outlet is measured mechanically. The
Dräger Spiromed is an electronic version of the mechanical spirometer. Gas flow through the
device determines the rate of rotation of the rotors, which is measured using an electromagnetic
sensing system. The Spiromed is direction-sensitive and can alert to reversal of gas flow in the
circle system. The accuracy of the Spiromed for tidal volumes is ±40 mL, and for minute
ventilation, ±100 mL or±10 percent of the reading.

Figure 3.17 Sealed volumeter. Polystyrene rotating elements form a seal against the
interior of the volumeter. Gas flow causes rotation of the elements, transferring fixed
volumes of gas from the inlet to the outlet. Measured volume is displayed on a gauge
that is mechanically connected to the rotating shaft of the volumeter. The device is
bidirectional and can alert to reversed flow. If the number of fixed volumes of gas
transferred is measured electronically, measured volume may be read on a remote
display, as well as being connected to an alarm system. This is the principle of operation
of the Dräger Spiromed.
 b. Pneumotachometer

The principle of operation of the pneumotachometer is to measure the loss of energy of the
flowing gas as it passes through a resistive element. The resistive element is designed to ensure
that the flow of gas is laminar, so the energy loss is completely the result of viscosity and the flow
is directly proportional to the pressure difference. The energy loss is measured as a pressure
difference from the inlet to the outlet of the resistive element. The most common type of resistive
element, designed by Fleish,4 consists of narrow, parallel metal tubes aligned in the direction of
the flow [Figure 3.18]. Nominally, for laminar flow, the pneumotachometer obeys the Hagen-
Poiseuille law:
F = [π × r 4 × (P1 − P2] / [8 × ƞ× L], where F = gas flow, r and L = radius and length of the
element, P1 and P2 = inlet and outlet pressures, and ƞ = viscosity of gas flowing through the
device. Measurement of flow is independent of gas density and total pressure.

Figure 3.18 Cross-sectional views of a Fleisch pneumotachometer. (A)

Longitudinal section showing the parallel paths that constitute the laminar

flow resistance element. Ports P1 and P2 are used for measurement of the

pressure differential across the resistance element. The device can be used

bidirectionally. The heating element surrounds the device and is used to

prevent condensation. (B) Cross-sectional view of laminar flow elements.

Fleish pneumotachometers have been used widely in respiratory physiology and pulmonary
function studies and are available in various sizes (resistances) to accommodate the appropriate
flow range. The resistance of the element must be chosen so the pressure difference produced in
the flow range of interest is large enough to be measured accurately by the available pressure
transducer(s). Too resistive an element will impede ventilation. The Fleish pneumotachometer
usually uses a heating element to raise the temperature of the device to about 40◦C, thus
preventing condensation of moisture in expired gas.
The pressure difference across the resistive element (or head) is measured using a differential
pressure transducer with sufficient sensitivity and frequency response. The transducer must be
zeroed (nulled) electronically by reserving a measurement made with zero flow. The pressure
difference is typically in the range of 2 cm H 2O. Pressure transducer output readings tend to drift,
and the measured signal is small; therefore, they must be renulled periodically. For vigorous
ventilatory flows, the rate of change in gas flow is great, and the frequency response of the
transducer must be adequate to follow these changes. The respiratory volume is computed by
integrating the flow with respect to time (because flow = volume/time). The pneumotachometer is
calibrated by setting a gain coefficient according to a volume produced by manually emptying a
calibrated (usually 1 L) syringe through the device. Often, the calibration syringe is emptied
several times at different rates to simulate the range of gas flows expected during clinical use. In
practice, the characteristics of the Fleish pneumotachometer are dependent on the geometry of
the tubing on the upstream side of the resistive element. This results in a distinctly nonlinear
deviation from the Hagen-Poiseuille law. The other disadvantage of the pneumotachometer in an
anesthesia circuit is its propensity to accumulate mucus and water in its narrow tubes. It must be
repeatedly calibrated because its effective resistance changes with fouling. In addition, the
pneumotachometer must be cleaned and sterilized between clinical uses.

c. Pitot tube flowmeter

The Pitot tube measures the difference in kinetic energy of the gas impinging on a pressure port
facing in the direction of the gas flow and on a pressure port perpendicular to the flow.5 The
pressure difference, nominally proportional to the square of the flow rate, is sensitive to the
density of the gas. Viscous losses around the pressure ports and small pressure differences at low
flows are limitations of the Pitot tube flowmeter [Figure 3.19].

Figure 3.19 Longitudinal cross-section of a Pitot tube flowmeter. The pressure P2 measured at
port P2 facing the flow direction is greater than P1 because of the kinetic energy of the gas
impinging on the port. The pressure difference (P2-P1) is proportional to the square of the
flow rate
 d. Ultrasonic flow sensor
The ultrasonic flow sensor is used on certain models of Dräger anesthesia workstations (e.g.
Narkomed 6400). Ultrasonic flow measurement uses the transit time principle, whereby opposite
sending and receiving transducers are used to transmit signals through the gas flow. The signal
travels faster when moving with the flow stream rather than against the flow stream. The
difference between the two transit times is used to calculate the gas flow rate. The device is
sensitive to gas flow direction and has no moving parts, and accuracy is independent of gas flow
composition.

B. pressure, flow, and volume monitoring

Monitoring breathing system pressure and its integration with a prioritized alarm system is one of
the most important safety monitors in the anesthesia delivery system. The basic pressure alarm
modalities are (1) low peak pressure, (2) continuing pressure, (3) high pressure, and (4)
subatmospheric pressure.

I. Pressure monitoring

Many traditional anesthesia breathing systems incorporate an analog pressure gauge, as well as an
electronic pressure monitoring and alarm system. The pressure gauge, if present, is usually
mounted on the CO2 absorber and may measure the pressure at that site (Dräger). In the Ohmeda
GMS Absorber system, pressure is sensed on the patient side of the inspiratory unidirectional valve
and piloted to the pressure gauge and pressure monitoring system. Depending on circuit
configuration, the pressure monitor may fail to detect certain abnormal pressure situations. Thus,
monitoring pressure at the absorber will not detect positive end-expiratory pressure (PEEP)
produced by a free-standing PEEP valve that has been placed between the expiratory limb of the
circle system and the expiratory unidirectional valve. Ideally, pressure is monitored at the patient
’s airway. Some newer electronic anesthesia workstations use only electronic monitoring and
display of pressures, some on a virtual analog flowmeter displayed on the monitor screen.

Low-pressure alarm: Because breathing system disconnects and misconnects are not uncommon
occurrences, monitoring of breathing system integrity is essential. Circuit low-pressure monitors
have sometimes been referred to as disconnect alarms, but this may be a misnomer because they
monitor pressure, and the user may infer circuit integrity only if the monitor is used appropriately.
They annunciate an audible and visual alarm within 15 seconds when a minimum pressure threshold
is not exceeded. The pressure threshold should therefore be set by the user to be just less than the
normally expected peak inspiratory pressure (PIP) so any slight decrease will trigger the alarm
[Figure 3.20]. If the threshold is not bracketed close to the PIP, a circuit leak or disconnect may go
undetected if the low-pressure alarm threshold is exceeded. Thus, a small-diameter tracheal tube
(e.g. 3.0 mm ID) connected to a circle system might be pulled out of the patient’s airway, leaving
the lungs unventilated. Because the 3.0-mm tube has high resistance to gas flow, the pressure
increase in the circuit with each positive pressure inspiration may exceed the low-pressure alarm
threshold.
 Figure 3.20 Tracing of airway pressure against time during positive pressure ventilation. The dotted line represents the
threshold for the low airway pressure alarm. In tracing (A), a partial disconnect in the breathing system results in a smaller
pressure increase that does not cross the low-pressure alarm threshold; an alarm is annunciated. In tracing (B), the low-
pressure alarm threshold has not been set correctly; that is, just below the normal peak pressure when the circuit is intact.
In this case, a partial disconnects results in a lower pressure that does cross the alarm threshold. No alarm is annunciated
with this partial disconnect.

Continuing-pressure alarm: Annunciated when circuit pressure exceeds 10 cmH 2O for more than
15 seconds, it alerts to more gradual increases in pressure, such as that caused by a ventilator
pressure relief valve malfunction (i.e., valve stuck closed) for a scavenging system occlusion. In
these situations, fresh gas continues to enter the breathing system from the machine flowmeters
but is unable to leave. The rate of rise of pressure therefore depends on the fresh gas flow rate.

High-pressure alarm: This alarm is annunciated immediately whenever the high-pressure threshold
is exceeded. On modern machines, this threshold is adjustable by the user, with a default usually
set to 40 cmH2O. Some older pressure monitors are not user-adjustable and have a default setting
of +65 cmH2O. This might be too high to detect an otherwise harmful high-pressure condition, such
as total obstruction of the tracheal tube, in which the breathing system pressure fails to exceed
+65 cmH2O.

In contemporary workstations, the ventilator incorporates a high-pressure relief valve, the

opening threshold pressure of which is set in conjunction with the high-pressure alarm limit.

Subatmospheric pressure alarm: This annunciates an immediate alarm when pressure is below−10
cmH2O. It should alert to potential negative pressure barotrauma situations owing to suction being
applied to the circuit. Negative pressure in the circuit may be caused by spontaneous respiratory
efforts by the patient, a malfunctioning waste gas scavenging system, a sidestream sampling gas
analyzer when fresh gas flow into the circuit is too low, a suction catheter passed into the airway,
or suction via the working channel of a fiberscope passed into the airway via a diaphragm.

II. Volume monitoring

In traditional anesthesia delivery systems, monitoring of expired tidal and minute volumes is
achieved using a spirometer placed in the vicinity of the expiratory unidirectional valve.
Spirometry is used to monitor ventilation and circuit integrity.
A breathing system disconnect should result in annunciation of the low-volume alarm if an
appropriate alarm limit for low volume has been set. Limitations of older spirometers are that the
alarm thresholds may not be user-variable. Thus, one older model of machine has a spirometer
that has a low-volume alarm threshold fixed at 80 mL. Particularly when a hanging bellows design
of ventilator is used, a circle system disconnection may fail to trigger a low-volume alarm
condition because as the weighted bellows descends during exhalation, it may draw a normal tidal
volume through the leak site and through the spirometer, thus satisfying the low-volume alarm
threshold. A spirometer located by the expiratory unidirectional valve at the absorber does not
measure the patient’s actual exhaled tidal volume; rather, the volume measured includes both
that exhaled by the patient and the gas volume compressed in the breathing system during
inspiration.

Contemporary workstations measure breathing system compliance during the automated preuse
checkout and use flow sensors located by the inspiratory and expiratory unidirectional valves to
accurately monitor inspired (VI) and expired (VE) tidal volumes. These values can be used to
automatically compensate for small leaks in the breathing system and changes in the fresh gas
flow, respiratory rate, and I:E ratio, which otherwise might unintentionally change set tidal
volume.

III. Flow monitoring

Measurement of gas flow is used to measure tidal and minute volumes (because flow =
volume/time) The flow-time signal is used to identify timing of events, such as the beginning and
end of inspiration and beginning and end of expiration, duration of breath, and respiratory rate.
Resistance is defined as pressure per unit of flow, so both inspiratory and expiratory airway
resistances can be derived from the corresponding pressure and flow signals. The flowtime tracing
can be used to recognize the existence of auto- PEEP, when exhalation is incomplete. Auto-PEEP is
recognized when the flow tracing does not return to zero at end-exhalation. This may be the result
of an expiratory time that is too short, or of lung disease. The ventilator is then reset to eliminate
the auto-PEEP.
Temperature Monitoring

Administration of general anesthesia requires continuous monitoring of vital parameters of the

body specially the body temperature as temperature fluctuations have harmful physiological
effects and can adversely affect patient outcome.

There are different thermal sensors [figure 3.21] used for intraoperative body temperature such
as:

 Mercury-in-glass thermometers but they are slow, cumbersome, and no longer recommended.
 Electronic thermometers use thermistors and thermocouples. They are sufficiently accurate
(±0.5°C), inexpensive, and most dependable modality.
 Infrared monitors as they can detect heat given off by radiation and can measure
temperature from tympanic membrane and forehead skin but are less reliable.
 Thermotropic liquid crystals incorporated in disposable sheets are also available but less
accurate.

a b
Figure 3.21 thermal sensors used for intraoperative body temperature a.
Mercury-in-glass thermometers b. Electronic thermometers
Alarm Devices

An alarm is an automatic warning that results from a measurement, or any other acquisition of
descriptors of a state, and indicates a relevant deviation from a normal state. An ideal alarm
should only detect immediate or threatening danger that requires prompt attention. The alarm
design should adequately represent the underlying situation. The announcement of the alarm
should be instantly perceptible in critical situations. Additionally, the user should be informed of
circumstances that impair the reliability of the alarming system.

Alarms and expected causes:

Alarm Expected causes

Hypoxic inspired gas mixture. Is the fraction of inspired gas (Fi02) >= 21%?
If not, consider:
adequate oxygen (02) delivery
- Check 02 gas supply pressures
- Check gas flow settings on anesthesia machine
- Check flow meter on anesthesia machine
- Check anesthesia machine for leaks
- Check for obstructed fresh gas supply line ?
Contaminated 02 supply
- Check for misconnection(s) at the anesthesia
machine
- Check for wrong gas in pipeline.
Hypoventilation Look at the capnogram. If no capnogram present,
consider:
Disconnection
- Check pressures in the breathing system
- Check all connecting points in the system?
esophageal intubation
- Check position of endotracheal tube (ET)
Mechanical ventilation present
- Check mechanical ventilator for proper operation
Occlusion
- Check for gas flow in breathing system
- Check unidirectional valves
- Check for presence of foreign body in the system
- Check pressures in the breathing system

If a capnogram can be observed, consider:

Leaks
- Check pressures in the breathing system
- Check all interconnections for leaks
- Check ET cuff for leaks
Obstructions
- Check pressures in the breathing system
- Check for a kink or other obstruction in the ET
CO2 rebreathing
 - Check for valve insufficiency
- Check for exhausted CO2 absorber
- Check possible rebreathing valve

Ventilation to perfusion mismatch If The partial pressure of 02 in arterial blood is

less than that in alveolar gas consider:

Endobronchial intubation
- Check breath sounds
-Check position of ET
Occlusion in the lung due to mucus or aspirated
stomach contents
- Check for foreign bodies in the bronchia
Patient’s position has changed
- Check position of the patient
Embolism
- Check for clues of embolism due to air, blood
clot, fat, or tumor
- Check trend in end-tidal CO2
Pulmonary diseases
- Check patient history
- Check for partial occluded airway
Surgical interference
- Check surgical field
 Airway Equipment

Objectives

 Provide an overview of airway management

 Identify different types of airways and face masks and the cases it used in it.
 Identify the aids tool associated with airway equipment.

Airway management

Safe airway management requires safe, effective and reliable equipment use to provide gas
exchange, protects the lungs from injury and permits treatment, either surgery or critical care.

There are five approaches and equipment are used for each:
 Facemask ventilation.
 Airway clearance.
 Supraglottic airway device use.
 Tracheal access above the vocal cords (intubation)
 tracheal access below the vocal cords (tracheostomy or cricothyroidotomy).

These approaches may be used alone or in sequence. There is sometimes overlapped, for example
a supraglottic airway can be used for intubation.

Face Masks and Airways

Facemask is an interference device between the patient’s upper airway and the breathing system.
It allows gas administration to the patient from the breathing system without introducing any
apparatus into the patient's mouth. They may be made up of antistatic material to prevent ignition
of anesthetic gases.

1. Hudson mask:

 Used in mild hypoxia and non-acute situations

 Delivers 30-40% O2 (flow rate 5-10L/min)

74
 Mask is positioned over the patient’s nose and mouth with the elastic strap behind their head
[Figure 4.1]

Figure 4.1 Hudson Mask

2. Reservoir mask

 Used for acutely unwell patients

 Aims to provide high FiO2 concentrations as the oxygen is inhaled from the reservoir alongside
the oxygen source
 Delivers approximately 70% O2 when used with a 15L flow rate
 Mask fits over the patient’s nose and mouth and can be secured to the face using elastic
straps[Figure 4.2]
 Ensure the reservoir bag has filled by temporarily obstructing the valve before positioning on
the patient.

Figure 4.2 Reservoir mask

3. Venturi mask

 Designed to deliver constant FiO2 regardless of patient’s respiratory rate and flow pattern
 Often used in patients with chronic obstructive pulmonary disease (COPD)
 Fits over the patient’s nose and mouth like a Hudson mask [Figure 4.3]
 Details of required flow rate and percentage oxygen delivery are detailed on the colored
fittings (see Table 4.1 below).
 Figure 4.3 Venturi mask with its interchangeable valves for delivering
oxygen with variable of flow rates

Table 4.1 colors codes for the Venturi mask valves and their flow rate and percentage oxygen delivery

Flow rate required (L/min) FiO2 delivered

Blue 2-4 24%

White 4-6 28%

Yellow 8-10 35%

Red 10-12 40%

Green 12-15 60%

Laryngoscopes:

Laryngoscopy refers to the process of visualizing the larynx and can be direct or indirect. It is
performed when attempting to pass an endotracheal tube through the vocal cords in order to
achieve a definitive, protected airway
 Laryngoscopes are used to facilitate endotracheal intubation as part of Rapid Sequence
Induction (RSI) or modified induction of anesthesia. This should only be performed by trained
clinicians.
 Macintosh Laryngoscopes consist of a handle (with battery inside) and attachable blades of
different sizes.
 Each blade has a light that allows visualization of the vocal cords [Figure 4.4].
  Laryngoscopes are held in the left hand. The blade is inserted along the right side of
the tongue and positioned in the groove between the tongue and epiglottis. Soft tissues are
lifted in the direction of the handle to reveal the vocal cords.
 Video laryngoscopy refers to a laryngoscope blade with a camera that allows the larynx and
vocal cords to be seen on-screen beside the patient’s bed. Video laryngoscopy is used in
airways where direct visualization of the airway may be difficult. This is often not useful in
patients with blood or secretions in the airway as the camera becomes obscured.

a b

Figure 4.4 Example of laryngoscope a. the main parts of the laryngoscope b.

Macintosh Laryngoscopes with different sizes of blades

Tracheal Tubes and Associated Equipment

Tracheal tubes

A tracheal tube is a catheter that is inserted into the trachea for the primary purpose of establishing
and maintaining a patent airway and to ensure the adequate exchange of oxygen and carbon
dioxide. The tube provides airway patency and protection. Most single use tubes are polyvinyl
chloride and reusable tubes are silicone.

Standard tubes consist of:

 Connector: 15 mm external diameter

 Tube: marked with radio opaque line, cm distance markers from the tip, depth marker 3 cm
from the tip with information on internal (ID) and external diameters.
 Tip: with a left facing beveled opening. Most have an additional opening, a Murphy eye, to
allow ventilation if the main opening is blocked (by mucus, or apposition to the tracheal
wall if the trachea is deviated) and to ensure adequate ventilation of a tracheal bronchus
(up to 5% of the population). [Figure 4.5]
Cuffed or uncuffed tubes are available: the cuff is inflated with air via a pilot tube, balloon and
self-sealing valve and cuff pressure should be less than 30 cm water, measured with a manometer
as nitrous oxide increases pressure by diffusion.
 Figure 4.5 Standard trachea tube

Many different types of tracheal tubes are available[Figure6], suited for different specific
applications:

 An endotracheal tube is a specific type of tracheal tube that is nearly always inserted
through the mouth (orotracheal) or nose (nasotracheal). [Figure 4.6.a]
 Thoracic surgery tubes are used to isolate each lung.
 A tracheostomy tube is 2–3-inch-long (51–76 mm) curved metal or plastic tube may be
inserted into a tracheostomy stoma to maintain a patent lumen. [Figure 4.6.b]
 Reinforced tubes have spiral wire to resist kinking, useful for neurosurgery and
maxillofacial surgery, but they do not prevent crushing by instruments or biting. [Figure
4.6.c]
 Laser tubes are ignition resistant, either metal or silicone/metal wrapped, used for laser
airway surgery. [Figure 6.d]
 Microlaryngeal tubes are 4-6 mm ID, soft walled, large cuffed tube used for laryngeal
procedures. They have a high resistance to gas flow and generate high peak airway
pressures compared to ‘standard’ sized tubes. Resistance to exhalation requires adjustment
to expiratory times to prevent gas trapping.

a b c d

Figure 4.6 different types of trachea tubes a. endotracheal tube b. tracheostomy tube c. Reinforced tubes d. Laser tubes
Associated Equipment

Using a tracheal tube to secure a patient’s airway is still the gold standard. Most routine
orotracheal or nasotracheal intubations are performed with the help of a laryngoscope that has a
curved or straight blade. Other adjuncts such as external laryngeal pressure, a bougie, a stylet or a
pair of Magill’s forceps may also be used.

Aids to tracheal intubation:

Stylet: a malleable, coated wire rod inserted into a tracheal tube to bend it to assist passage of
the tube into the larynx and to give a tracheal tube curved shape and rigidity. The stylet should
not protrude beyond the tube orifice.

Tracheal introducer: a guide for intubation when the laryngeal view is incomplete, or tube
passage is problematic. This is a 60 cm flexible rod with an angled ‘coude’ tip made of braided
polyester with resin coatings. It can be reused six times.

Laryngoscope handles: A short handle may help to insert the laryngoscope blade into a patient’s
mouth when a normal blade is awkward to use due to the presence of large breasts in an obese or
pregnant patient.

Blades: The most commonly used blade in adults is the Macintosh blade. Straight Miller blades are
commonly used when intubating children. The polio blade was designed for intubation of patients
in an “iron lung” and may still be useful today if large breasts pose a problem.

Adaptors: These adjuncts have been developed to fit between the handle and the blade of a
laryngoscope to change the angle between them. They may help to visualize an anterior larynx.

Airway exchange catheters: long (83 cm) hollow catheters are used for tracheal tube exchange.
Adaptors allow for oxygen insufflation, so the catheter tip must remain in the tracheal lumen;
more distal placement risks lung injury, either directly or from barotrauma with administered
oxygen.

Devices for Managing the Difficult Airway

1. Oropharyngeal (Guedel) airway

 An oropharyngeal airway can help prevent the tongue and soft tissues of the pharynx from
obstructing the airway [Figure 4.7].
 There are a variety of sizes available for children and adults
 Size airway by measuring it against a patient’s face – when the tip is placed at the angle of
the jaw the flange should align with the center of the top teeth (hard airway = measure “hard
to hard”)
 Insert into the patient’s mouth upside down, pass to the back of the throat and rotate 180
degrees to fit behind the tongue base. In children, insert the right way up.
 Figure 4.7 Oropharyngeal (Guedel) airway

2. Nasopharyngeal airway (NPA)

 Used to bypass obstructions in the mouth, nose, nasopharynx or base of tongue

 Size the NPA by measuring from the tip of patient’s nose to the tragus of the ear. The
diameter should not exceed that of the patient’s little finger.
 The NPA tip should sit just above the epiglottis and the flange should be at the tip of the
nose. [Figure 4.8]

Figure 4.8 Nasopharyngeal airway (NPA)

3. Nasal cannula

 Used for mild hypoxia and in non-acute situations

 Delivers 24-30% O2 (maximum flow rate of 4L/min)
 Tubing is placed around patient’s face with prongs positioned at nostrils
 Tubing can be secured behind the patient’s head or around their ears [Figure 4.9].
 Figure 4.9 nasal cannula

4. Laryngeal Mask Airway (LMA)

 Reusable supraglottic device

 Used as a primary airway in an unconscious patient and it has also been used for emergency
airway management although it does not protect the airway from regurgitated stomach
contents.
 Silicone rubber tube ending in elliptical, spoon-shaped mask designed to fit over the larynx
 Inflatable mask rim forms a low-pressure seal over the laryngeal inlet
 Reinforced laryngeal masks are available to prevent kinking
 “Proseal” is a type of LMA that has an additional inflatable segment that allows greater seal
within the larynx and a gastric port for drainage of gastric secretions. [Figure 4.

Figure 4.10 Laryngeal Mask Airway

 Equipment Care

Objectives
 Identify anesthesia related risks.
 Explain the methods to enhance patient safety under anesthesia/surgery.
 Perform paranesthesia checkout procedure.
 Explain the commonly used disinfectants
 Describe the methods and procedure of sterilization

Hazards of Anesthesia Machines and Breathing Systems

Modern machines have overcome many drawbacks associated with the older machines. However,
addition of several mechanical, electronic and electric components has contributed to recurrence
of some of the older problems such as leak or obstruction attributable to newer gadgets and
development of newer problems. Although human errors cannot be attributed to machine, several
problems were triggered by the modern machines and their components.

Hypoxic gas delivery due to problems with cylinders, pipelines, anaesthesia machines

Hypoxic gas delivery is still a distinct possibility. Development of a stricture in the O 2 central
supply system outlet as a result of degradation of the O-ring and a structural defect in the pipeline
delivery at the ceiling level of the operating room resulting in accidental switching off of the O 2
supply valve by the N2O pipeline have contributed to delivery of hypoxic gas mixtures.
Misconnection of O2 pipeline hose to N2O cylinder in the manifold room by technical personnel has
resulted in hypoxic gas delivery. Insertion of the Equanox (50% each of O2 and N2O) probe
accidentally into the N2O wall outlet resulted in 100% N2O delivery. These problems were
compounded by either lack of oxygen analyser or failure to recognize the hypoxia early and
changing over to an alternate plan by the concerned anesthesiologist. Fault in the chain-link
mechanism of Ohmeda Excel 210 SE where loosening of the stop screw which placed over the O 2
flow control knob contributed to hypoxic gas delivery. Faulty interface between gear wheels of O 2
and N2 O flow meters in ageing machines contributed to failure of the flow proportionating devices
while defective rubber seal of flow meter control tube was responsible for hypoxic gas delivery.

82
Other reported hazards due to problems within the anesthesia machine or workstation
Advances in technology contributed to the development of piston-driven ventilators in place of
bellow operated ventilators. Resetting of a ventilator piston following suctioning of the airway
during one-lung ventilation resulting in inability to ventilate is reported. Improperly fitted
retaining ring (placed between the expiratory valve assembly and the Spiromed respiratory volume
monitor) of the Narkomed 4 anesthesia system contributed to gas leak. Accidental obstruction to
exhaust gas port of a ventilator by a vinyl bag resulted in ventilatory failure. Awareness under
anaesthesia occurred due to a disconnection of the common gas outflow tract prior to one-way
check valve of the anaesthesia machine while a to-and-fro type of anaesthesia ventilator operated
without any problem. The APL valve has resulted in leak in the breathing system and kinking of the
sampling ports. Improper seating of the vaporizers over the back bar, faulty locking spring on the
vapouriser and broken transverse pin of the desflurane vapouriser contributed to gas leak. During
the process of filling of an isoflurane vapouriser, accidental spillage of the liquid caused corrosion
and damage to the water trap while accidental lifting up of the lever of the Tec 5 isoflurane
vapouriser resulted in damage to the water trap in Draeger machines.

Hazards due to breathing systems and their use with newer anaesthesia machines

Hypercarbia and related problems are reported with faulty Bain’s circuit and adult co-axial
breathing circuits. Most of the modern machines have integrated circle system as one of their main
components to enable the economy of gases and minimize atmospheric pollution. However,
numerous possibilities for misconnections exist with circle system. In fact, a closed claims analysis
revealed problems in breathing circuitry connections contributed to 35% adverse anesthetic
outcomes arising from gas delivery systems. Problems in the CO2 canister resulted in rebreathing
and hypercarbia, significant leak and difficulty in ventilation, and obstruction to ventilation.
Although use of circle system, CO2 absorbents and low-flow anaesthesia are beneficial in economy
of gases, they have inadvertently contributed to ventilator problem due to water condensation and
production of dangerous substances such as compound A.

Inability to detect minor leaks in the machine or breathing circuit is observed with modern
machines having minimum mandatory oxygen flow, while testing for leak with Bain’s circuit was
also found to be difficult with modern Aestiva 5® anesthetic machine. Designing the ratio valve of
the minimum mandatory O2 flow system to vent to the atmosphere on switching the master switch
off resulted in false positive for leaks when the universal leak test was applied in Cavendish
anaesthesia machines. Intraoperative replacement of reservoir bag by new latex-free bag
contributed to difficulty in ventilation due to the presence of a large hole in the newly replaced
bag. Twisting of the bag around its own neck resulted in a tight bag scenario. Increased depth of
corrugations minimizes circuit kinking; however, this can result in leaks as damage to corrugated
tubing is not easily identifiable on inspection. Disposable breathing circuits and airway equipment
minimizes infective risks. However, transparent packaging of the breathing circuit accidentally
caught in the straight connector of the breathing circuit was responsible for obstruction to
ventilation. Scavenging system reduces theatre pollution. However, scavenging equipment has
contributed to obstruction to flow of gases.
Despite significant improvements in the design and safety aspects of anaesthesia machine and its
components, some of the older and well-known problems continue to exist such as water vapour
condensation inside the machine components, bobbins of the flow meters may get stuck to the
inner wall of the flow meter due to dirt and static electricity, possibility of leak from the
selectatec system of vaporizers in the event of accidental removal of O-ring during the process of
mounting or dismounting of the vaporizers, etc.

Equipment Checkout and Maintenance

Checking each component of anesthesia machine for appropriate functioning prior to use is
essential to ensure patient safety. However, a single checklist cannot satisfactorily test the
integrity and safety of all existing anesthesia machines due to their complex nature as well as
variations in design among manufacturers. An in-depth and elaborate anesthesia machine check
should be done following servicing of the anesthesia machine. Further, machine check should be
done daily prior to first use [Figure 5.1]. This should be user friendly and less time consuming while
also ensuring satisfactory check of all components of the machine. Minor check procedure should
be followed between an aesthetic conduct.

Figure 5.1: A concise anaesthesia machine checklist for daily use (content in bold indicates
minor check procedure that should be followed between anesthetic conducts). The checklist
should be modified to suit the type of anaesthesia machine / workstation available at
individual location
First priority is to ensure the machine is placed in a safe area and its electrical wiring safely
secured. Despite advanced technology, a remote but life-threatening possibility of intraoperative
machine malfunction exists. Therefore, presence of a functioning self-inflating bag appropriate for
the patient’s age and alternate O2 source should be ensured. Modern anesthesia machine check
includes the cylinders, pipelines, machine proper (both intermediate and low-pressure systems and
components thereof), vaporizers, breathing circuits, monitors, integrated ventilator, suction
apparatus and the scavenging system. However, several modern machines perform self-check as
soon as the master switch is turned on. Unnecessary repetition and missing of some component
check can be prevented with adequate understanding of the components tested during self-check

The following protocol was developed based on the existing literature and our department
practices, which involves the checking for the pneumatic, electrical, electronic and other
components of the machine in a systematic manner.

1. Checking the pneumatic components of anesthesia machine

I. Checking the integrity of the high-pressure system

a. Ensure the master switch is off, pipelines disconnected, cylinders completely closed and
remaining gases in the system exhausted (pressure gauges reading zero). Confirm each
cylinder by colour coding and label. Confirm proper attachment to the machine through the
hanger yoke assembly.
b. Open O2 cylinder with cylinder key by full 3½ rotations anticlockwise. Confirm the cylinder
is at least half full (>7000 kPa or 1000 psi). Open O 2 flow control valve (anticlockwise
rotation of knob) and confirm the O2 flow meter registers flows (further confirmation of O 2
can be done by O2 analyser). Open N2O flow control valve and confirm N 2O flow meter
doesn’t register flows. Close the O2 cylinder, wait until the flow reaches zero and the O 2
pressure gauge reads zero.

c. Checking the integrity of N2O slave mechanism and oxygen pressure fail-safe mechanism:
With the O2 supply off, open N2O cylinder fully and confirm the N 2O pressure gauge reads >
5000 kPa or 750 psi (lesser pressures mean exhaustion of liquid N2O). Open N2O flow control
valve and confirm the absence of flow in the N2O flow meter (presence of flow indicates a
defect). Open both O2 cylinder and O2 flow control valve (if not already open). Confirm both
O2 and N2O flow meters now register flows. Close the O2 cylinder and flush the O2 to
confirm flows return to zero in both the O2 and N2O flow meters.

d. Oxygen flush should function even with the master switch and O2 flow meter turned off as
long as O2 supply to the machine is ensured. The O2 flush should stop as soon as the pressure
on the O2 flush knob is taken off.

e. Close the O2 and N2O cylinders and turn off the flow control valves for both gases
 II. Checking the integrity of the intermediate pressure system

a. Tug test: Connect O2 pipeline to the oxygen wall outlet using the Schrader quick coupler
system. Correct coupling will not allow detachment of the pipeline from the Schrader coupler
when a tug is given to the pipeline. Similar test can be performed with the N2O pipeline with
N2O wall outlet.

b. Single hose test: Disconnect N2O pipeline while retaining the O2 pipeline intact. Open the O2
flow control valve to note O2 is flowing (further confirmation of O2 can be done by oxygen
analyser). Open N2O flow control valve which may show initial flows (residual N2O in the
system) that subsequently falls to zero. Connect the N2O pipeline to its wall outlet and note
again there is flow in the N2O flow meter. These steps help detect accidental mix up of O2
and N2O pipeline connections. Disconnection of O2 pipeline should result in both flow meters
registering zero flows and activation of the oxygen fail-safe mechanism.

c. Connect O2 and N2O pipelines again and note their pressure gauges read >400 kPa or 55-60
psi (to ensure supply from the manifold room is at correct pressures)

III. Checking integrity of the low-pressure system

This is performed after the following set up is established with the master switch on: Pipelines of
O2and N2O intact, cylinders closed or in the absence of pipelines, cylinders open.

a. Close the flow control valves, place vaporizers in their location on the machine with
vaporizers dial turned off. Confirm sufficient liquid volatile agent and the filler cap is
tightly shut. Ensure vapourisers are upright and not tilted (this prevents unsafe delivery of
vapors).

b. Universal negative pressure leak test: Turn master switch off and close all the flow control
valves, attach suction bulb to the common gas outlet and repeatedly squeeze to empty its
contents until the bulb is well collapsed. The bulb should remain collapsed for at least 10 s.
To test for leaks in the vapourisers, individual vapouriser should be turned on and above-
mentioned steps be repeated. Re-inflation of the bulb within next 10 s indicates a leak in
the low-pressure system (when the vapouriser is off) or vapouriser (if an individual
vapouriser is turned on during the test). At the end of this test, put the master switch on,
remove the suction bulb and connect breathing apparatus.

c. Open individual flow meters to their maximum range to confirm proper functioning of the
Thorpe’s tubes and the float. Confirm anti-hypoxic mechanisms are working satisfactorily
through various ranges of O2 and N2O flows.

2. Checking the electrical/electronic components of anesthesia machine

a. Turn the master switch on and confirm proper working of all other associated electrical or
electronic equipment. If the machine has minimum mandatory flows, confirm O2 flow meter
registers a flow of around 50-200 mL with the O2 flow control valve turned off.
 b. Confirm anesthesia machine is connected to the mains (AC source) and the switch is on.
Ensure the battery has at least 30 min back up supply and is charging during machine use.
c. Monitor: Check appropriate functioning of SpO 2, non-invasive blood pressure (NIBP), end
tidal capnogram (ETCO2 ), etc., by using them on self (e.g., SpO 2 on our finger >96%,
exhalation into capnograph port registers a CO 2 waveform, etc.) and adjust alarm settings
according to patient profile. Ensure monitoring equipment including gas sampling lines are
secured leak free and kink free. Gas sampling line must be connected proximal to the airway
filter to avoid frequent obstruction by moisture. Monitoring parameters not required for a
given patient should be turned off.
d. Oxygen analyser calibration (21% to >95%): Calibrate the analyser to read 21% at
atmosphere. With the O2 source from cylinder (pipeline source disconnected), open O 2 flow
control valve and connect the analyser to the common gas outlet and calibrate to register at
least 95%.

3. Checking other components of the anesthesia machine

Most of the modern machines have the facility for connecting both circle system and Mapleson
breathing system in such a way that just by turning a knob the desired breathing system can be put
to use. Ensure the breathing circuit intended for use on the patient is correctly chosen (check the
knob position).
a. Circle system: Verify adequate fresh CO2 absorbent and its proper attachment to the
machine. Make all necessary connections of circle system components. Perform the leak test
by occluding the patient end of the breathing circuit. Either increase O2 flows or use O2 flush
to pressurise the breathing apparatus to >30 cm H 2O. Turn the O2 flow control valve off and
stop O2 flush. Drop in airway pressures to 30 cm H2O. The system pressure should be released
by opening the APL valve. This ensures proper functioning of the APL valve and prevents
accidental entry of the absorbent dust into the breathing system. Simultaneously, evaluate
for appropriate response and functioning of the unidirectional valves.
b. The integrity of individual Mapleson system should be tested but describing these is beyond
the scope of this article.
c. Ventilator: With the breathing system in situ and the patient end occluded, turn on the
ventilator knob to evaluate the integrated ventilator. In case of ascending bellows, ensure
the bellows reach the top of the bottle and then turn off the fresh gas flows. The bellows
should continue to reach the top of the bottle at the end of each ventilator breath. Failure
of the bellows to reach the top indicates leak. However, in case of descending bellows, this
cannot be verified. Verify ventilator settings appropriate for the patient’s weight and adjust
alarm settings accordingly.
d. Check appropriate connection of the scavenging system to the machine and its correct
functioning.
e. Ensure suction apparatus is working appropriately and sufficient negative pressures are
rapidly developed when its port is occluded.
f. Pay attention to any notes attached to workstation such as last servicing date, last time the
CO2 absorbent was changed, etc. g. When the breathing circuit is not in use, patient end
must be covered with sterile layer.
 Cleaning and Sterilization

Cleaning

It`s the first step in decontamination thorough cleaning of equipment which primarily is required
to lower the bioburden before they are subjected to disinfection or sterilization.

Cleaning process usually involving detergent or enzymatic presoak that physically remove all visible
dust, soil blood or other body fluids from inanimate objects as well as removing sufficient number
of microorganisms to reduce risks for those who touch the skin or handle the object. After
decontamination of soiled instruments in 0.5% chlorine solution for 10 minutes, they must be
cleaned to remove organic materials or chemical residue. Using liquid soap, if available, is
preferable. Liquid soap removes grease, oil, and other foreign matters in solution so that they can
be removed easily by the cleaning process. Abrasive cleaners used for household cleaning,
including steel wool, should be avoided as they can result in scratches on the instruments which
can be a potential site for harboring microorganisms. Cleaning should be performed in a designated
location that is separate from other parts of the facility to minimize inadvertent personnel
exposure or exposure of other items to contaminants. The items that cannot be cleaned thoroughly
should not be reused and discarded.

Each cleaned item must be inspected and tested for smooth functioning and disassembled again
before sending for sterilization so that all its surfaces can come in contact with the sterilant.

Sterilization

It is a process which achieves the complete destruction or killing of all microorganisms, including
bacterial spores. Sterilization is principally accomplished by:

a. Steam Under Pressure (Autoclaving)

Steam sterilization is the most common and most preferred method employed for sterilization of
all items that penetrate the skin and mucosa if they are heat stable. Steam sterilization is
dependable, nontoxic, inexpensive, sporicidal, and has rapid heating and good penetration of
fabrics. The steam must be applied for a specified time so that the items reach a specified
temperature. For unwrapped items:
 121 °C for 20 min. at 1.036 Bar (15.03 psi) above atmospheric pressure.
 134 °C for 3-4 minutes at 2.026 Bar (29.41 psi) above atmospheric pressure

b. Dry Heat (Hot Air Oven)

For dry heat-sterilization to be achieved, a constant supply of electricity is necessary. Dry heat is
preferred for reusable glass, metal instruments, oil, ointments and powders. Do not use this
method of sterilization for other items, which may melt or burn.

c. Chemical Sterilizer

Before deciding to use a chemical sterilizer, consider whether a more appropriate method is
available. Chemical sterilizers are primarily used for heat- labile equipment where single use is not
cost effective. Instruments and other items can be sterilized by soaking in a chemical solution
followed by rinsing in sterile water. If an item is sterilized chemically, it should be used
immediately after sterilization, to be sure that it is sterile.
This type of sterilization is commonly used for endoscopes. Few of the most commonly used
disinfectants are discussed below [Table 5.1]

Instructions on the Use of Chemical Sterilization in Steps

1. Decontaminate, clean and dry all instruments and other items to be sterilized using
chemical.
2. Completely submerge items in a clean container filled with the chemical solution and
place the lid on the container.
3. Allow items to soak:
o 10 hours in a glutaraldehyde (check specific product instructions), or
o At least 24 hours in 8% formaldehyde.
4. Remove objects from the solution with sterile forceps; rinse all surfaces three times in
sterile water and air dry. Ideally, three separate (sequential) rinse containers should be
used.
5. Store objects in a sterile container with a tight-fitting lid if they will not be used
immediately

Table 5. 1 Comparative properties of disinfectants

 Equipment Related to Environmental Situations

Objectives

 Identify some of the equipment related to the environmental situation.

 Describe causes of fire and explosion in the operating room.
 Explain the methods to enhance patient safety under anesthesia/surgery.

Temperature Control Equipment

Pharmaceuticals, blood vaccines, tissues, food and other items require strict temperature ranges
for quality patient care and safety. The humidity and temperature in Operating Rooms, IT closets,
Pharmacies and some patient rooms must be monitored, recorded and controlled for safety and
comfort. The Joint Commission and other regulatory agencies regulate the temperature and
humidity management processes:

• Medications must be stored under stable conditions

• Temperature and humidity must be monitored and logged, often up to four times per day
• Logs must be available for a twelve-month period or more
• In case of deviations, corrective actions must be taken and documented
• Audits occur at least every three years plus random, unannounced audits

Body temperature is controlled by balancing heat production against heat loss. Anesthetic-induced
impairment of thermoregulatory control, combined with the operating room environment, imposes
thermal stress on most patients.

Thermoregulation Methods During General Anesthesia

 Forced-air system
A forced-air central heating system is one which uses air as its heat transfer medium.
Forced‐air warmers operate by distributing heated air generated by a power unit through a
specially designed downstream blanket resulting in heat transfer to the covered body surface. This
is the most commonly tested body warming modality and is unsurprisingly associated with
significantly higher postoperative core temperatures when compared with patient control groups
where no warming was used.

90
  Circulating water devices
Circulating water devices operate by passing heated water within mattresses, blankets or garments
in contact with patients. Due to the greater specific heat capacity and thermal conductivity of
water, it is, in theory, a more effective medium to transfer heat when compared with air. This
theoretical advantage is not translated into a clinical one as all of the trials comparing the two
different warming modalities favored forced‐air warming.

 Negative pressure warming systems

Effective heat transfer is not just dependent on the features of the warming device, but also the
ability of tissues to receive and distribute heat. These properties are intimately linked to tissue
perfusion and early pioneers attempted to optimize this by applying subatmospheric pressures to
limbs. The aim of negative pressure warming systems is to apply a subatmospheric pressure with a
thermal load that would improve subcutaneous perfusion and open arteriovenous shunts, thus
promoting peripheral to core heat transfer. Negative pressure warming devices come in the form of
a mitt covering the hand and forearm. When applied to hypothermic vasoconstricted postoperative
patients, the early studies showed a remarkable ten‐fold increase in rewarming core temperature
rates of up to 13.6 °C.

 Heat and Moisture Exchangers (HMEs)

Heat and moisture exchangers humidify, warm arid filter inspired gas. Their incorporation into
pediatric anesthetic breathing system is recommended, however they can cause delay in the
inhalational induction.

Operating Room Fires and Personnel Injuries Related to Sources of ignition

A hundred or so surgical fires occur annually, estimates ECRI, a health-services research agency in
Plymouth Meeting, Pa. The most common ignition sources for surgical fires are electrosurgery (68
percent), cautery (hot wire), light sources and bur sparks (19 percent), and laser (13 percent).
Surgical fires most often occur in the airway (34 percent) or in the face, head, neck and chest (28
percent).

OR fires traditionally require three components [Figure 6.1], known as the “fire triad”: 1) an
oxidizer, 2) an ignition source, and 3) fuel. Oxidizers, usually supplied by the anesthesia provider,
include oxygen and nitrous oxide, and are especially hazardous when an oxidizer-enriched
atmosphere exists within a closed or semi-closed system. Ignition sources are usually the
responsibility of the surgeon, and include electrosurgical or cautery devices, lasers, and heated
probes. Fuel sources are usually supplied by the nurse or scrub technician, and include sponges,
drapes, alcohol-containing solutions, gowns, and a number of other flammable items.

These three areas, when brought together, place the patient and room staff at a very high risk for
a fire and causes burns where the most common sites of fires are the head, face, neck, and upper
chest.
 Figure 6.1 The fire triangle relates surgical team members to
components of surgical fires

Prevention methods of OR fires:

As the fire is often described as containing the three components: an oxidizer, an ignition source,
and a fuel. Whenever these 3 items are in close contact under appropriate conditions and
proportions, a fire will occur. The key to prevention is altering one or more of these components so
combustion is not possible. The Anesthesia Patient Safety Foundation (APSF) and ECRI have
collaborated to release the New Clinical Guide to Surgical Fire Prevention. This guide focuses on 3
specific fire reduction strategies:

1. Recommendations for open oxygen delivery during procedures on the head, face, neck, and
upper chest.
2. Recommendations for the use of supplemental oxygen during procedures on the head, face,
neck, and upper chest.
3. Recommendations for implementing a preoperative time-out to assess fire risk potential for
every patient for every procedure.
Equipment for the Magnetic Resonance Imaging Environment

Magnetic resonance imaging (MRI) is used increasingly to improve accurate diagnosis and define
plans for therapy. The technique of MR imaging makes considerable demands on patients who are
required to remain immobile in a confined space for 30-60 minutes. The long cylindrical
configuration of the MRI tunnel may be frightening to a young child and provides limited access and
visualization of the patient by the anesthesiologist asked to sedate the patient for the scan.
Monitoring equipment has to be specifically made to be MRI compatible and the equipment may
malfunction in proximity to the magnet because of the high magnetic field strength. In addition,
ferrous objects brought into the scanning room may become dangerous missiles, potentially
injuring the patient or MRI technicians, or damaging the scanner. In the last several years, the
applications of the MRI have expanded from a purely diagnostic modality to a tool for the guidance
of minimally invasive diagnostic and interventional procedures. There are several reasons for this
development.

Monitors and Equipment with MRI

1. The electrocardiogram introduces problems with both image degradation from wire leads
acting as antennas and the inability of the ECG monitor to discern the ECG from the
background static magnetic field and radiofrequency pulses Volt4e induced in the wire
leads may pose burn and electrical shock hazards the patient. It is important to keep limb
leads close and in the same plane, parallel the magnetic field Leads V 5 and V maximized
QRS and minimized artifact. It is also important to make sure that all leads are insulated
from the skin of the patient. There are currently several electrocardiograph devices
reported acceptable for use in the MRI at present.

2. Pulse oximetry is essential and is current used on all anesthesiologist -administrated

sedation and general anesthetics. These monitors, however, are susceptible to interference
from the changing" magnetic field and will occasionally be briefly deactivated by radio
frequency pulses. It is very important to use a nonferrous pulse oximeter and to
place the probe on a distal extremity as far from the scan site as possible When an ECG
is not available, it is useful to follow the pulse rhythm and rate with the oximeter.

3. Blood pressure monitoring during MRI can be accomplished using the oscilbmetric method
(Dinamap). Invasive pressure monitoring can also be obtained in the MRI. A high pressure,
low compliance extension tubing connected an arterial catheter, with the transducer placed
at the level of the right atrium, beyond the 50 Gauss line can be used without the field
altering transducer performance.

4. Capnography has been successfully used. However, because of the Ong pathway
the waveform shows a upslope Although the end-tidal C02 concentrations are
not accurate, it is useful to monitor respiratory rate, to folbw trends, and to detect if a
circuit disconnection has occurred.
 5. Temperature monitoring can be accomplished in the MRI with temperature probes that use
radiofrequency filters or with nonferromagnetic skin temperature strips that use a liquid
crystal display Care must be taken to avoid hypothermia in all patients, especially in the
pediatric population. Airflow directed through the scanner can an infant rapidly. Warmed
bags of intravenous fluids. single-use thermal packs. airway humidification, and covering
the patient are ways to avoid excessive heat loss.

Anesthesia Machine with MRI

There are several MRI compatible anesthesia machines available on the market. For example, the
machine currently in use at Stanford is made by Ohmeda and uses a ventilator that is
pneumatically driven by an aluminum oxygen cylinder. The North American Drager anesthesia
machine has an MRI electronic ventilator.
 References

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 Book Coordinator ; Mostafa Fathallah

 General Directorate of Technical Education for Health