PASS WAY

Basic Sciences

For the first two stations

Section 1

Quick review for common

Physical Principles

Humidity

What do you understand by the term Humidity?

The term humidity refers to the amount of water vapor present in the atmosphere and is subdivided into two types:

Absolutehumiditythetotalmassofwatervaporpresentsintheairperunitvolume.(AH.kg.m−3org.m−3)

Relativehumiditytheratiooftheamountofwatervaporintheaircomparedwiththeamountthatwouldbepresentatthesametemperatureiftheairwasfullysaturated.(RH,%)or

Theratioofthevaporpressureofwaterintheaircomparedwiththesaturatedvaporpressureofwateratthattemperature.(RH,%)

What is Dew point?

Dew point is the temperature at which the relative humidity of the air exceeds 100% and water condenses out of the vapor phase to form liquid (dew).

How is humidity measured?

By the Hygrometer. It is an instrument used for measuring the humidity of a gas.

Explain Humidity graph

The humidity graph demonstrates how a fixed amount of water vapor in the atmosphere will lead to a variable relative humidity depending on the prevailing temperature. It also highlights the importance of the upper airways in a room fully humidifying by the addition of 27 g.m−3 of water vapor.

Figure 1.1.1. The Humidity Graph

100% RH       The 100% line crosses the y axis at 8 g.m−3 and rises as a parabola crossing the points shown. These points must be accurate.

50% RH       curve crosses each point on the x axis at a y value half that of the 100% RH line. Air at 50% RH cannot contain 44g.m−3 water until over 50°C.

The graph demonstrates that a fixed quantity of water vapor can result in varying RH depending on the temperature concerned.

Remember the absolute humidity of air at body temperature.

Is there any clinical relevance of humidity?

If cold or dry anesthetic gasses are delivered to a patient, heating and humidification will occur as the gas passes down the respiratory tract. This process removes both heat and moisture from the patient’s airway. About 10 watts. Hour-1 can be consumed from the patient's airway for warming and humidifying the cold dry

Heat loss

What is the mechanism of heat loss during surgery?

Heat may be lost from a patient in five main ways during anesthesia and surgery.

Radiation

The loss of heat energy from the body via transfer of infrared radiation from it to a second system that is not in direct contact with it and that has a lower temperature. It is proportional to the fourth power of the temperature difference between the body and its surroundings. (40–60% heat loss)

Convection

The loss of heat energy from the body via air movement across an exposed area acting to remove previously warmed air and bring un-warmed air into contact with it. The effect is proportional to both the exposed body surface area and the degree of air movement. (25–30% heat loss)

Conduction

The loss of heat energy from the body by direct transfer of that energy to an adjacent system that is in direct contact with it and that has a lower temperature. (5% heat loss)

Evaporation

The loss of heat energy from the body via the latent heat of vaporization that is required to be taken from it as liquids in contact with the body move to the vapor phase. (15–50% heat loss)

Respiration

The loss of heat energy from the body caused by the humidification (8%) and warming (2%) of inspired air. (5–10% heat loss)

The processes at work in heat loss through respiration are really evaporative and conductive losses happening within the airway, although they are often considered separately because to minimize these losses requires different treatment – HMEF, warming and humidifying inspired gasses – than other types of heat loss from the body.

Heat loss from convection is treated by passive insulation, for example a blanket, to trap warm air close to the patient. Loss from radiation is achieved by minimizing the temperature gradient between patient and surroundings, either by increasing the theatre temperature or by forced air warming. Evaporative loss may be major, for example during laparotomy, and is often difficult to

Heat loss during surgery

Figure 1.1.2 Heat Loss during Surgery

Phase 1

Between 37°C and 35.5° Cover the course of 1hour. Reduction in core body temperature during this phase is due to the loss of the core-periphery temperature gradient leading to re- distribution of body heat.

Phase 2

A shallower gradient over a further 2.5 hours representing actual heat losses from the body during surgery as listed on the previous page. The slope of this phase may be altered by passive or active warming and this can be drawn as a warming line as shown.

Phase 3

The final plateau line is at a temperature of around 34 °C, this represents the point at which altered thermoregulatory mechanisms begin to act to stabilize temperature.

Causes of hyperthermia in operating room include:

Patient related: sepsis

Drug induced: Malignant Hyperthermia

Environmental.

Physiological implications of hypothermia:

1-      Cardiovascular: arrhythmias, direct myocardial depressant effect, and hypotension peripheral vasoconstriction

2-      Respiratory: hypoventilation, respiratory alkalosis, left shift of OHDC

3-      Hematological: coagulopathy

4-      Renal: increased renal blood flow and diuresis

5-      Neuronal: CNS depressant effects

6-      Gastrointestinal: impaired liver function, pancreatitis, and ileus.

7-      Metabolic: increased metabolic rate due to shivering, followed by decreased metabolic rate with further decrease in temperature.

Bernoulli, Venturi, Coanda, and gas laws

What is the Bernoulli principle?

An increase in the flow velocity of an ideal fluid will be accompanied by a simultaneous reduction in its pressure.

What is the Venturi effect?

The effect by which the introduction of a constriction to fluid flow within a tube causes the velocity of the fluid to increase and, therefore, the pressure of the fluid to fall (Figure 1.1.3.)

What do you know about the law of conservation of energy?

Energy cannot be created or destroyed but can only change from one form to another.

Do you know the Coanda effect?

The tendency of a stream of fluid flowing in proximity to a convex surface to follow the line of the surface rather than its original course.

What is Henry’s law?

The amount of gas dissolved in a liquid is directly proportional to the partial pressure of the gas in equilibrium with the liquid.

Define Fick’s law of diffusion

The rate of diffusion of a gas across a membrane is proportional to the membrane area (A) and the concentration gradient (C1 − C2) across the membrane and inversely proportional to its thickness (D).

What do you know about the three gas laws?

Boyle’s law (1st gas law)

At a constant temperature, the volume of a fixed amount of a perfect gas varies inversely with its pressure.

PV = K      or      V ∝ 1/P

Charles’ law (the second gas law)

At a constant pressure, the volume of a fixed amount of a perfect gas varies in proportion to its absolute temperature.

V/T= K      or      V ∝ T

Gay–Lussac’s law (The third gas law)

At a constant volume, the pressure of a fixed amount of a perfect gas varies in proportion to its absolute temperature.

P/T = K      or      P ∝ T

Remember that water Boyle’s at a constant temperature and that Prince Charles is under constant pressure to be a king

What is the Perfect gas?

A gas that completely obeys all three gas laws. Or:

A gas that contains molecules of infinitely small size, which, therefore, occupy no volume themselves, and which have no force of at traction between them

It is important to know that this is a theoretical concept and no such gas actually exists. Hydrogen comes the closest to being a perfect gas as it has the lowest molecular weight. Most commonly used anesthetic gases obey the gas laws reasonably well.

What is Avogadro’s hypothesis?

Equal volumes of gases at the same temperature and pressure contain equal numbers of molecules

Do you know the universal gas equation?

The universal gas equation combines the three gas laws within a single equation

PV = nRT

What are the types of the flow? And what is the difference between them?

Laminar flow

Laminar flow describes the situation when any fluid (either gas or liquid) passes smoothly and steadily along a given path, this is described by the Hagen– Poiseuille equation.

Hagen–Poiseuille equation

The most important aspect of the equation is that flow is proportional to the 4th power of the radius. If the radius doubles, the flow through the tube increases by 16 folds (2⁴).

Turbulent flow

Turbulent flow describes the situation in which fluid flows unpredictably with multiple eddy currents and is not parallel to the sides of the tube through which it is flowing. As flow is, by definition, unpredictable, there is no single equation that defines the rate of turbulent flow as there is with laminar flow. However, there is a number that can be calculated in order to identify whether fluid flow is likely to be laminar or turbulent and this is called Reynold’s number (Re).

How would you know if the flow was laminar or turbulent?

By calculating the Reynold’s number

When Re < 2000 flow is likely to be laminar and when Re > 2000 flow is likely to be turbulent.

Let's talk about another physical principle, what do you understand by the term surface tension?

Surface tension is the tendency of liquid surfaces to shrink into the minimum surface area possible.

Is it clinically important?

Of course! The pressure applied on the alveoli by the surface tension tends to decrease their size and shrink them, this leads to alveolar collapse following expiration. The surfactant (dipalmitoyl phosphatidylcholine) DPPC, a mixture of phospholipids is produced by type II pneumocytes and works to decrease the pressure applied on the alveoli by decreasing the surface tension.

Section 2

Principles of special equipment

Oxygen storage

Oxygen (O2) is manufactured by the fractional distillation of air or by means of an oxygen concentrator in which a zeolite mesh adsorbs N2 so that the remaining gas is about 97% of Oxygen

How oxygen is being stored in hospitals?

Oxygen is stored mainly in two forms:

Asagasincylinders(insmallerfacilitiesforlimiteduse)

AsaliquidinVacuumInsulatedEvaporator(VIE)providingmoresufficientandcost-effectivewayforlargercenters.

Can you describe oxygen cylinders?

Oxygencylindershaveblackbodywithawhitetop

Pressurevariesfromcylindertocylinder

Typicallystoredat13,700KPa(137bar).Itmayvarybetween12,000–17,000kPadependingonthecylinder.

Containsgaseousoxygen(pressuredropslinearlyasoxygenisdepleted)

Can you explain the principle of vacuum insulated evaporator?

Vacuum insulated evaporator (VIE) is a form of pressure vessel that allows the bulk storage of cryogenic liquids including oxygen, nitrogen and argon for industrial processes and medical applications.

Oxygen is stored in VIE at 10 bar and −180°C

The purpose of the vacuum insulation is to prevent heat transfer between the inner shell, which holds the liquid, and surrounding atmosphere. Without functioning insulation, the stored liquid will rapidly warm and undergo a phase transition to gas, increasing significantly in volume and potentially causing a catastrophic failure to the vessel due to an increase in pressure. To combat such an event, VIE are installed with a pressure safety valve.

To remain a liquid, the vessel contents must be kept at or below its critical temperature. The critical temperature of oxygen is −118 °C; above this temperature, applying more pressure will not result in a liquid, but rather a supercritical fluid.

Physiochemical properties of the Oxygen:

Boilingpoint:−182°C

Criticaltemperature−119°C

Criticalpressure50bar

The critical temperature of a gas is the temperature above which vapor of the gas cannot be liquefied, no matter how much pressure is applied

The critical pressure of a gas is the pressure required to liquefy a gas at its critical temperature.

Ventilator profiles

Ventilators

Ventilators are devices with the ability to move gases into and out of the lungs in order to provide or assist ventilation.

Negative pressure ventilation

A form of ventilation in which negative pressure is applied intermittently to the thorax within a sealed compartment in order to expand the rib cage and cause the in-drawing of air or other gas into the lungs. Now superseded by positive pressure ventilation.

Intermittent negative pressure applied to the chamber caused the thoracic cage to expand thereby drawing air into the lungs in a very physiological way.

Positive pressure ventilation

A form of ventilation in which intermittent positive pressure is applied to the lungs during inhalation and exhalation is allowed to occur passively.

Here we consider the function of a ventilator by dividing it into three stages:

Trigger

The event that starts each ventilator breath.

When the patient is making no spontaneous effort, the trigger is usually time which, in turn, is dependent on the set respiratory rate. When the patient is making spontaneous effort the trigger is usually minimum flow or fall in pressure caused by the patient’s effort.

Limit

The factor that controls the inspiratory flow

Cycling

The factor that governs when the change from inspiratory to expiratory phase (or to inspiratory pause) occurs.

Common cycling signals are volume, time and flow. Pressure cycling is rarely used as a primary function although may be used as a secondary cycle factor when a high-pressure alarm is triggered. In volume-cycled ventilation inspiration is arrested when the pre-set volume is attained. If there is an inspiratory pause expiration will begin after a set time (time-cycled) rather than immediately following inspiration so there may be mixed cycling present. In pure time-cycled ventilation the change from inspiration to expiration occurs after a pre-set time related to the desired respiratory rate. In flow cycled ventilation, inspiration is arrested once inspiratory flow falls to a minimum level (usually determined by the manufacturer) towards the end of inspiration.

Ventilator waveforms

In addition to an understanding of the terminology of ventilators, common waveforms may be tested. For clarity, the description of the ventilator traces below refers to the limit applied to the ventilated breath, either pressure or flow (volume). These are what are commonly called pressure control (PCV) or volume control (VCV) ventilators. The traces are exaggerated in order to more clearly describe the underlying principles.

Breathing Systems

There are many ways to classify breathing systems – open, semi-open, semi-closed, and closed. The Mapleson classification is still in use and is covered here.

Mapleson A system is efficient during spontaneous ventilation (SV) and inefficient during controlled ventilation (CV). During SV, the patient breathes in fresh gas from the inlet and the reservoir bag. During expiration, dead space gas passes back along the circuit to fill the tubing whilst fresh gas fills the reservoir bag. When the bag is full, the system pressure rises and further exhaled air is forced out from the APL valve. During the inspiratory pause fresh gas pushes any residual alveolar gas in the tubing out of the APL valve. As long as the FGF is equal to the patient’s alveolar minute volume (0.7 x minute volume), rebreathing of CO2 will be avoided. During CV, fresh gas is forced from the APL due to high circuit pressure and so the system becomes inefficient. A coaxial or parallel version of this system is called a Lack circuit and makes scavenging gases more convenient.

Mapleson B system is inefficient for both SV and CV. During exhalation a mixture of alveolar and fresh gas passes out via the APL valve and during inspiration a mixture of fresh gas and retained alveolar gas in breathed in. Adequate flushing of alveolar gas within the circuit can only be achieved with a FGF of 2–3 times minute volume.

Mapleson C (Water’s) circuit is most commonly found in the recovery room. The flow dynamics are similar to a Mapleson B and, as such, it is also an inefficient system for both SV and CV. Nevertheless, it is compact and lightweight making it a useful circuit for urgent or emergent situations.

The Mapleson D system and its coaxial Bain modification are relatively inefficient for both SV and CV. In the case of SV, during exhalation, fresh gas and exhaled gas enter the tubing and as the pressure increases some venting will occur via the APL valve. On inspiration the patient will receive a mixture of gas with the amount of fresh gas dependent on the flow rate, duration of the patient's expiratory pause and tidal volume. With longer pauses, more fresh gas will be available. At least 2x minute ventilation FGF is required to minimize or prevent rebreathing. The picture is similar for CV and the FGF requirements are the same.

Mapleson F system is a modification of a common T-piece system by Jackson and Rees. A double ended bag is attached to the expiratory limb of the circuit to allow visualization of the respiratory pattern and to enable intermittent positive pressure ventilation if required. The system itself has a low resistance to breathing and, although inefficient, is used commonly in pediatric anesthesia.

Safety features of anesthesia machine

Can you list Safety features of anesthesia machine?

This is a common question in EDAIC 2 examination. Remember to start from the wall of the operating theater and go toward the patient's airway.

The most important safety feature is an expert, vigilant, and well-trained anesthesiologist and technician. The safety features of anesthesia machine itself include:

Powersupplyandaback-upbattery

Gassupplysafetyfeaturesinclude:

Color-coded,flexiblepipesconnectedtothewallvianon-interchangeablespecificvalves,andtothemachinevianon-interchangeablescrewsthreads(NISTsystem)

Back-up,filledoxygenandgascylindersarefixedonthebackofthemachineandconnectedviapin-indexsystem.

Gasflowmeasurementandcontrol

Flowcontrol:needlevalvereducesthepressurefrom4barto1bar

Flow-meters:O2isthelastflowmeteraddedtothefreshgas

Modernelectronicflowmeters

Anti-hypoxicmixturedevices:

Mechanical(flail safevalve)

Electronic

Vaporizers:newelectronic,colorcoded,andagentspecific

Oxygenfailurewarningalarms

AdjustablePressureReleasingvalve(APL)

Sodalime

Built-inmonitoringandalarmsinnewermachines

CommongasoutletthatiscannotbeconnectedexcepttotheBreathingsystem.

Vaporizers

What is Saturated Vapor Pressure (SVP)?

SVP is the partial pressure that the vapor of a liquid will exert when the liquid and the vapor of that liquid are in equilibrium.

What is the vaporizer?

The vaporizer is a device that produces the required concentration of an Inhalational anesthetic to the patient.

And why do you think we need vaporizers?

Because the saturated vapor pressure for inhalational anesthetics is much higher than required to produce anesthesia at room temperature.

Can you classify vaporizers?

Vaporizers are divided mainly into two types:

Variablebypassvaporizers

Measuredflowvaporizers

Tell me about variable bypass vaporizers

Remember to draw a simple diagram while you explain

The fresh gas flow is split into two streams, one enters the vaporizing chamber and one that bypasses the vaporizing chamber. The two streams then rejoin to give the required concentration of vapor to the patient. The vapor concentration is controlled by using a flow splitting valve which determines the fraction of the gas entering the vaporizing chamber.

What is the difference between variable bypass vaporizer and measured flow vaporizer?

Measured flow vaporizers produce a separated flow of vapor that is independently added into the patient's fresh gas flow to produce the required concentration of volatile agent. An example of measured flow vaporizer is the TEC6 Desflurane vaporizer

What are the problems with variable bypass vaporizers?

Theyareextremelyflowdependent.Athighflow,theconcentrationofanestheticgasbecomesmuchlowerthanthedesired

Overfillingofthevaporizermayresultonincreasedconcentrationofinhalationalanesthetics.

Becausesomeofthose gaseswillescapethrowthebypassingchamber

DuringtheIPPV,somegasflowsbacktothevaporizerandthatgascarriesaninhalationalagent.Thecarriedinhalationalagentwillthenbeaddedtotheoriginalconcentrationthatisproducedfromthevaporizer.Asaresult,the netconcentrationdeliveredtothepatient willbehigherthanthedesired.Thisisknownas(Bumpingeffect)

Thereisnotemperaturecompensationbytheeffectofthelatentheatofvaporization.

What is the Latent Heat of Vaporization?

It is the energy required to convert one Kilogram of a substance from the liquid form to the gaseous form. SI unit is joule.kg-1

What adjustments need to be made of vaporizers at higher altitudes?

None. The partial pressure remains the same at high altitudes because the SVP does not change by the altitude.

Pulse Oximeter and Capnography

What is Beer’s law?

The absorbance (A) of light passing through a medium is proportional to the concentration (c) of the medium and its molar extinction coefficient (ε).

And Lambert’s law?

The absorbance of light passing through a medium is proportional to the path length.

How does the pulse Oximeter work?

The pulse Oximeter is a non-invasive device used to monitor the percentage saturation of hemoglobin (Hb) with oxygen (SpO2) utilizing Beer-Lambert law. The infrared light is absorbed to different degrees by the oxy and de-oxy forms of Hb. Two different wavelengths of light, one at 660 nm (red) and one at 940 nm (infrared), are shone intermittently through the finger to a sensor. As the vessels in the finger expand and contract with the pulse, they alter the amount of light that is absorbed at each wavelength according to the Beer–Lambert law. The pulsatile vessels, therefore, cause two waveforms to be produced by the sensor. If there is an excess of deoxy-Hb present, more red than infrared light will be absorbed and the amplitude of the ‘red’ waveform will be smaller. Conversely, if there is an excess of oxy-Hb, the amplitude of the ‘infrared’ waveform will be smaller. It is the ratios of these amplitudes that allows the microprocessor to give an estimate of the SpO2 by comparing the values with those from tables stored in its memory. In order to calculate the amount of oxy-Hb or deoxy-Hb present from the amount of light absorbance, the absorbance spectra for these compounds must be known.

Oxy-Hb Crosses the y axis near the deoxy-Hb line but falls steeply around 600 nm to a trough around 660 nm. It then rises as a smooth curve through the isobestic point where it flattens out. This curve must be oxy-Hb as the absorbance of red light is so low that most of it is able to pass through to the viewer, which is why oxygenated blood appears red.

Deoxy-Hb Starts near the oxy-Hb line and falls as a relatively smooth curve passing through the isobestic point only. Compared with oxy-Hb, it absorbs a vast amount of red light and so appears ‘blue’ to the observer.

What do you know about Capnograph?

Capnography has become an integral part of monitoring in anesthesia. Monitor can give a numerical reading (capnometry) and a waveform (capnography). It works as follow:

Diatomicgasmolecules(i.e.,containingtwoormoredifferentatoms)absorbinfraredradiation.

Eachdiatomicgasabsorbsradiationofaparticularwavelength.

Bymeasuringtheproportionofinfraredradiationabsorbedbyagasmixture,thepartialpressureofadiatomicgascanbeinferred.

Aninfraredbeampassesthroughafiltertoobtaintherequiredfrequencyoflightabsorbedbythegasofinterest.

Theinfraredbeamsplitsandpassesthroughreferenceandsamplegaschambers.

Sampleandreferencechamberwindowsaremadeofcrystal(silverbromideorsapphire)asglassabsorbsinfrared.

CO2absorbsinfraredradiationandemergentbeamsarecomparedbyphotoelectriccells(thedetector).

Theanalyzeriscalibratedusingair(assumedzeroCO2)andaknownconcentrationofCO2(gascylinder)orelectronically(stepinputvoltage).

Analysisisaffectedbythebarometricandextractionpressureinsystem –achangeinatmosphericpressuredirectlyinfluencesthereadingofcapnographssinceCO2concentrationismeasuredaspartialpressure.

Awatervaportrapisrequired(waterhashighinfraredabsorbance).

Hygroscopictubingisneeded.

Intra-arterial blood pressure monitoring system

What are the components of invasive arterial blood pressure monitoring system?

The system is m-ade up by an intra-arterial cannula that is connected to a column of heparinized saline and a transducer. The heparinized saline is pressurized to 300mmhg.

The transducer converts mechanical energy from the moving of the diagram into electrical signal that is amplified and processed.

The column of saline is responsible for the movement of the diagram in the transducer as arterial pressure changes (Figure 1.2.10.).

What information can you get from arterial pressure waveform?

Bloodpressure(systolic,diastolic,andpulsepressure)

Heartrate

Contractility(fromtheslopeofthesystolicupstroke)

Systemicvascularresistance(theshapeofde-cortic notch)

Strokevolume(bymeasuringtheareaunderthecurve)

Cardiacoutput(fromtheaboveinformation)

Respiratoryswings.

When we use arterial