THE ANESTHESIA MACHINE

Moderator: Prof. Jaishree Bogra Presented By: Dr Rajesh Raman & Dr. Hemant Rastogi
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7/7/2011

A device which delivers a precisely known but variable gas mixture

Types of anesthesia machine

Intermittent-Gas flows only during inspiration
Operate on demand system Used rarely: obstetric & dental analgesia, OPD diagnostic procedures Eg.: Entonox apparatus

Continuous-Gas flows both during inspiration and expiration. Eg. :

Boyle s apparatus Forregar Dragger

Boyle s apparatus
Invented in 1917 by Henry Gaskin Boyle Anaesthesia workstation consists of the anesthesia machine, vaporizers, ventilator, breathing system, scavenging system, and monitors. ASTM F1850-00: Defines the requirements for designing of anesthesia workstations and their components
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To receive compressed gases from their supplies.

To create a safe gas mixture of known composition and flow rate

To deliver a gas mixture to patient at a safe pressure.

Flowmwter
Data management system

Monitor

Ventilator
Vaporiser
Breathing circuit

System Components
A. Electrical Components:
1. 2. 3. 4. Master Switch: activates both pneumatic & electrical functions. Power Failure Indicator: audible & visible Reserve Power: rechargeable and dual supply Electrical Outlets: to power monitors, does not provide electricity during power failure 5. Circuit Breakers: when activated, electrical load should be reduced before resetting the circuit breaker 6. Data Communication Ports: communicate b/w the machine, monitors and the data management system

B. Pneumatic System:
1. High pressure circuit 2. Medium pressure circuit 3. Low pressure circuit

Simplified Diagram of 2 gas anesthesia machine

High pressure

Intermediate pressure

Low pressure

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THE HIGH-PRESSURE CIRCIUT

Receives gases from cylinders at high, variable pressures and reduces those pressures to lower, more constant pressure suitable for use in the machine.

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COMPONENTS
Hanger yoke assembly Cylinder pressure gauge Pressure reducing device

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 Ori ts a s rts t cyli r, r vi s a gass r sa tig t s al, a i ir cti al gas fl ASTM r ir s t at t r st at l ast one yoke eac for oxygen and nitrous oxide

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7 parts:
1. Body: principal framework and the supporting structure 2. Retaining screw: tightens cylinder in yoke 3. The nipple: entrance of gas into the machine 4. Index pins: prevent accidental placement of an incorrect cylinder 5. The washer (Bodock seal): helps to form a gas-tight seal 6. Filter: to remove particulate matter 7. Check valve assembly: prevent retrograde flow of gases

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CHECK VALVE ASSEMBLY

It is a one way valve located just upstream to cylinder pressure gauge Prevents retrograde flow of gas through the yoke Allows an empty cylinder to be replaced with a full one without losing gas from the machine Prevents gas from being transferred from a cylinder with a higher pressure to another one with lower pressure Minimizes leakage (but does not completely stop) from an open cylinder to atmosphere if one cylinder is absent from its yoke: use yoke plug
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Pin Index Safety System

It consists of 2 holes on the cylinder valve positioned in an arc below the outlet port and pins on the yoke or pressure regulator to fit into these holes. Pins:
4 mm diameter 6 mm long.

The seven hole positions are on the circumference of a circle of 9/16 inch radius with the outlet port as centre The position of pins and corrosponding holes are different for different gases To prevent placement of wrong gas cylinder in yoke

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Nipple

Retaining screw

The wrong cylinder may be fitted by: Using extra sealing washers or by Removing the safety pins, Inverting the gas cylinder

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Cylinder Pressure Indicator (Gauge)

ASTM Standard requires presence of pressure indicator which displays the cylinder pressure for each gas supplied by cylinders Most indicators are made of the bourdon tube

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Bourdon pressure gauge

A Bourdon tube is a hollow metal tube (copper alloy) bent into a curve, then sealed on one side and linked to a clocklike mechanism

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Bourdon Pressure Gauge

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MECHANISM
As gas pressure within the flexible tube increases, the tube tends to straighten. The motion is translated through the gearing mechanism so that the indicator shows a higher pressure.
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Electronic cylinder pressure indicator

Light emitting diodes(LED)in electronic pressure gauge indicate
Cylinder valve is close :
Dark color

Cylinder valve is open:

Pressure adequate Green Pressure inadequate-Red

Pressure Regulators
Reduces high and variable pressure of cylinder to a lower, more constant pressure suitable for use in an anesthesia machine
O2 : 2200 psig 45 psig N2O: 750 psig 45 psig

ASTM Standard requires a pressure regulator for each gas supplied from cylinders

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BASIC PRINCIPLE
A higher pressure acting over a small area is balanced by a smaller pressure acting over a large area A1 x Pc = A2 x Pr

Cylinder

Pressure regulator

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Safety features
PISS for small cylinders DISS for large cylinders Pressure Relief valves Color coding of cylinder Pressure regulator

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INTERMEDIATE PRESSURE SYSTEM

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1. 2. 3. 4. 5. 6. 7. 8. 9.

Pneumatic part of the master switch, Pipeline inlet connections and check valves, Pipeline pressure indicators, Piping, The gas power outlet, Oxygen pressure failure devices The oxygen flush, Additional pressure regulators, and The flow control valves

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Master Switch (Pneumatic Component)

Downstream of the inlets for the cylinder and pipeline supplies The oxygen flush is usually (but not always) independent of this switch

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Pipeline Inlet Connections

Receives medical gases at a pressure of 50-55 psig Have a filter with a pore size of 100 m or less Have unidirectional check valve to prevent retrograde gas flow Gas flow can get obstructed when check valve is stuck in closed position or the filter becomes clogged with dirt These inlets are fitted with threaded non-interchangeable Diameter Index Safety System (DISS) fittings

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 Each DISS connection consists of a Body Adaptor, Nipple, and Nut Diameters of the Body Adaptor and nipple increase/decrease proportionally. In this way, only properly mated and intended parts fit together to permit thread engagement

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Piping
Connects components inside the machine Must be able to withstand 4 times the intended service pressure Leaks between the pipeline inlet or cylinder pressure reducing system and the flow control valve (intermediate pressure circuit) not exceed 25 ml/minute If the yoke and pressure reducing system are included (intermediate + high pressure circuit), the leakage should not exceed 150 ml/minute.

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Gas Power Outlet

Serve as the source of driving gas for the anesthesia ventilator or to supply gas for a jet ventilator Either oxygen or air may be used Present only in older machines DISS connection is identical to that of oxygen inlet connection: use carefully

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Oxygen Pressure Failure Devices

FAIL-SAFE VALVES
ASTM standard requires that whenever the oxygen supply pressure falls, the delivered oxygen concentration shall not decrease below 19% at the common gas outlet

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 To prevent decrease of oxygen concentration at common gas outlet The pressure from O2 supply is used to keep a valve open through which N2O is allowed to pass through When the pressure of O2 falls in the intermediate circuit, the valve closes and flow of N2O stops

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Pressure Sensor Shut-off Valve: Datex Ohmeda

Operates in a threshold manner: either open or closed O2 pressure moves the piston and pin upward and the valve opens for N2O When pressure of O2 falls below preset value, force of the valve return spring completely closes the valve

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Oxygen failure protection device :Drger

Based on a proportioning principle rather than a threshold principle Pressure of N2O falls in proportion of decrease of O2 pressure Seat nozzle assembly connected to a spring-loaded conical tapered piston

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 Do not prevent delivery of hypoxic gas mixture in following situations:

Leaks and defects downstream Pipeline crossovers & presence of wrong gas in cylinder Dilution of gas mixture by inhaled anesthetics

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Oxygen Supply Failure Alarm

ASTM standard specifies that whenever the oxygen supply pressure falls below a certain threshold (usually 30 psig), a alarm must get activated within 5 seconds. It should not be possible to disable this alarm.

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Pneumatic alarm (Bowman s Whistle): Uses a canister with whistle in the tip. Normally it gets filled with pressurized O2 at 50 psig. When the oxygen pressure falls in the intermediate circuit, the O2 flows back in the circuit through the whistle in its tip which causes whistling alarm.

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Gas Selector Switch

Prevents air and nitrous oxide from being used together

In the N2O position, only oxygen and nitrous oxide can be used. In the air position, only oxygen and air can be administered

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Reduce gas pressures further to around 26 psig for nitrous oxide and 14 psig for oxygen Just upstream of the flow indicators. Eliminates the fluctuations occurring in the intermediate pressure circuit Also plays a role in O2-N2O interlock

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Oxygen Flush (O2+)

Directs a high Oxygen flow directly to the common gas outlet It must be a single-purpose, self-closing device operable with one hand and designed to minimize unintentional activation A flow between 35 and 75 L/minute is delivered at 45-55 psig On most anesthesia machines, the oxygen flush can be activated regardless of whether the master switch is turned on or off Hazards

Accidental activation Barotrauma Leakage/excessive use Awareness under anesthesia

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It consists of a button and stem connected to a spring loaded ball. The ball is in contact with the seat. When the button is depressed, the ball is forced away from the seat, allowing the oxygen to flow to the outlet. A spring opposing the ball will close the valve when the button is not depressed

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Flow Control Valve

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 The needle Valve: A finely threaded rod with tapered end which fits into cylindrical tube permitting gas flow to occur between the needle shaft and the seat When the rod is fully screwed down, it occludes the flow completely
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Safety features
DISS for pipeline connection Color coded pipelines Gauges of manometer Low O2 pressure cut off system Alarms Fail safe valves Shut off valves

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 Flow meters, Hypoxia prevention safety devices, Pressure relief devices Vaporizers Unidirectional valves Common gas outlet.

LOW-PRESSURE CIRCUIT
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Flow meters
Indicates the rate of flow of a gas passing through them Can be electronic or mechanical Constant pressure/variable orifice Flowmetres are calibrated at atmospheric pressure and 20C

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Flow meter assembly

Thorpe s tubes. Indicators. Indicator Stop. Scale.

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Thorpe s Tube
Glass: conical tapering

Single / double taper Dual tubes: fine and coarse flow.

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 There is a decrease in cross sectional area at the float which leads to a drop of pressure across the float Pressure exerted on the float depends on 2 factors:
Gas flow rate Cross sectional area of annular space b/w float and walls of the tube

The float settles in position where upward force represented by product of pressure difference across the float and cross sectional area of float = the downward force exerted by gravity When the flow through the tube increases, the difference in pressure b/w the two ends of float increases and hence the float raises to a height where cross sectional area b/w the tube and float increases sufficiently to restore the pressure drop to its former value
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upper and lower indicator stop

To prevent float from ascending to top of tube and plugging the outlet Ensures that float will be visible even at max. flow instead of getting hidden in the manifold. Bottom stop provides a central foundation for the float when flow control valve is in off position

: a. Marked on (Drager) / Right side (Datex Ohmeda) of the tube. b. In L /min. Greatest accuracy is in the middle half of tube. Having one series for low flow and one for high flow results in higher accuracy.

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FLOW METER SEQUENCE

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Problems with flow meters

Inaccuracy

Back pressure from breathing circuit Dirt Static electricity Tilting of machine Damaged float/tube

Leak.

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Electronic flow meter

Real/ virtual flow control knobs Dependent on electrical supply Advantage is that information can be sent to the data management system

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 Manadatory Minimum oxygen flow. Minimum oxygen ratio

Ohmeda link 25 proportioning system Drager Sensitive-oxygen ratio controller

Electronic linkage Alarms

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: 50 250 ml / min of oxygen flows before the other gases start. : Device to prevent gas mixture having low oxygen conc. in inspired gas.

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The Datex Ohmeda has Link 25 system which uses a chain to connect sprockets having 28 and 14 teeth on the identical flow control valves of O2 and N2O respectively Revolution of N2O flow control valve by two rounds results in revolution of O2 flow control valve by 1 round. The N2O Flow control valve is supplied by gas at 26 psig whereas the O2 flow control valve is supplied by gas at 14 psig This combination of mechanical and pneumatic aspects of the system result in a minimum 25% O2 concentration Either gas can be adjusted independently, but the mechanical linkage maintains a minimum ratio of 1:3 of O2 to N2O It is a system that increases the oxygen flow when necessary to prevent delivery of gas mixture with low O2 conc.

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Drager machines have OXYGEN RATIO MOTION CONTROLLER(ORMC) and similar SENSITIVE OXYGEN RATIO CONTROLLER(S-ORC, in newer machines) as proportioning system These are pneumatic O2-N2O interlock system using linear resistors designed to maintain a fresh gas oxygen concentration of 253% The resistors are located downstream to flow control valves The value of O2 resistor is 3-4 times the value of N2O resistor Maintain O2 conc. substantially higher than 25% at O2 flow rates of less than 1 L/min. Limit the flow of N2O to prevent delivery of hypoxic mixture.

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Computer continuously calculates the minimum allowable O2 to be given Alerts if the ratio falls below the preset value.

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Backpressure safe guard devices

: a. Near the common outlet to prevent from high pressures b. May limit adequate pressure for jet ventilation : b/w vaporizer and common gas outlet

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Common fresh gas outlet

Accepts gas and vapours
15mm female slip One / two outlets .

 Only one should be functional at one time  Disadvantage wrongly directed.

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Safety features
Larger, Fluted, color coded O2 flow control knob Down stream placement of O2 knob Placement of knobs at a distance Flowmeters Back light display Mandatory Minimum oxygen flow. Link devices Back pressure check valve Audible alarms Oxygen analyzer
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Essential Safety Features on a Modern Anesthesia Workstation

Essential Features Purpose

Noninterchangeable gas-specific connections to pipelinePrevent incorrect pipeline attachments; inlets (DISS) with pressure gauges, filter, and check detect failure, depletion, or fluctuation valve Pin index safety system for cylinders with pressure gauges, and at least one oxygen cylinder Low oxygen pressure alarm Prevent incorrect cylinder attachments; provide backup gas supply; detect depletion

Detect oxygen supply failure at the common gas inlet

Minimum oxygen/nitrous oxide ratio controller device (hypoxic guard) Prevent delivery of less than 21% oxygen

Oxygen failure safety device (shut-off or proportioning device) Prevent administration of nitrous oxide or other gases when the oxygen supply fails
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Entry of O2 downstream to other gases in the common manifold

Prevent hypoxia in event of proximal gas leak

Oxygen analyzer and alarm

Prevent administration of hypoxic gas mixtures in event of a low-pressure system leak; precisely regulate oxygen concentration

Automatically enabled essential alarms and monitors Prevent use of the machine without essential (eg, oxygen concentration) monitors Vaporizer interlock Prevent simultaneous administration of more than one volatile agent Guide ventilation; prevent anesthetic overdose; help reduce awareness

Capnography and anesthetic gas measurement

Oxygen flush mechanism that does not pass through Rapidly refill or flush the breathing circuit vaporizers Breathing circuit pressure monitor and alarm Prevent pulmonary barotrauma and detect sustained positive, high peak, and negative airway pressures Assess ventilation and prevent hypo- or hyperventilation

Exhaled volume monitor

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Pulse oximetry, blood pressure, and ECG Provide minimal standard monitoring monitoring Mechanical ventilator Control alveolar ventilation more accurately and during muscle paralysis for prolonged periods

Backup battery Provide temporary electrical power (> 30 min) to monitors and alarms in event of power failure

Scavenger system Prevent contamination of the operating room with waste anesthetic gases

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Unacceptable/Undesirable Features of Older Anesthesia Machines

Unacceptable features 1. Flowmeter-controlled vaporizer (eg, copper, kettle, Vernitrol) 2. More than one flow control valve for a single gas 3. Vaporizer with a rotary dial that increases concentration with clockwise rotation 4. Connections in the scavenging system that are the same size as breathing circuit connections Undesirable features 1. APL valve that is not isolated during mechanical ventilation 2. Oxygen flow control knob that is not fluted or larger than other flow control knobs 3. Oxygen flush control that is unprotected from accidental activation 4. Lack of main On/Off switch for electrical power to integral monitors and alarms 5. Lack of antidisconnect device on the fresh gas hose (common gas outlet) 6. Lack of airway pressure alarms

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Preanesthesia Checkout Procedures

All To Be Completed Daily

1: The auxiliary oxygen cylinder( separate from the anesthesia machine) and self-inflating manual ventilation device (Ambu bag)

2: Suction adequate to clear the airway 3: AC power availability 4: Presence of required monitors, including alarms

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Required monitors
Oxygenation:
Inspired gas: O2 analyzer and Low O2 conc. alarm Blood oxygenation: pulse oximeter

Ventilation:
EtCO2 Volume of expired gases

Circulation:
ECG Non invasive blood pressure

Temperature monitor
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5: Verify that pressure is adequate on the spare oxygen cylinder mounted on the anesthesia machine 6: Piped gas pressures 50 psig 7: Adequately filled vaporizers with filler ports tightly closed 8: Verify that there are no leaks between the flow meters and the common gas outlet

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The machine's master switch, flow control valves, and vaporizers are turned off Suction bulb is attached to the common fresh gas outlet and squeezed to collapse it fully The low pressure circuit is free of leaks if the bulb remains collapsed for at least 10 seconds Repeat test with each vaporizer in on position

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9: Test scavenging system function 10: Calibrate or verify calibration of the oxygen monitor and check the low-oxygen alarm 11: Verify that the carbon dioxide absorbent is not exhausted 12: Check for proper breathing system pressure and leaks 13: Verify that gas flows properly through the breathing circuit during both inspiration and exhalation 14: Documentation of checkout procedures 15: Confirm ventilator settings and evaluate readiness to deliver anesthesia care (Anesthesia time-out)

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To Be checked before each case

Suction Monitors Vaporizers Carbon dioxide absorbent Breathing system pressure and leaks Gas flow through the breathing circuit Ventilator settings
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WORKSTATION SELF TESTS

New workstations do automatic self test when they are powering on Components checked vary in different devices Common components checked are:
Gas supply Flow control valve Circle system & Ventilator

Vaporizers are to be checked saperately in almost all machines Read and follow manufacturer s recommendations strictly

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Anesthesia ventilators

classification
Power source Cycling mechanism Bellows classification

Power source
Compressed gas:
Uses O2 or Air as driving force Dual circuit
For anesthetic gases For power source

Electrically powered ventilators:

Use electrical power as driving force Computer controlled motor Piston driven-like a syringe plunger More precise Provide advanced type of ventilatory support: SIMV Single circuit(patient gas only) Consume less compressed gas

Cycling Mechanism
Time cycled: inspiratory phase is triggered by a timing device
Older Pneumatic Vent.: Fluidic (mechanical) timing device Newer electronic vent.: electronic timing device

Pressure cycled:
Have adjustable pressure trigger Pressure sensors provide feedback to computerized vent. control system Required for advanced ventilatory modes

Bellows classification
Direction of movement during expiratory phase Ascending bellow moves upward during expiration and will not ascend if patient disconnection Descending bellow moves upward during inspiratory phase by driving force of the gas and will continue to ascend even if patient disconnection occurs. So patient circuit disconnection may go unnoticed

PROBLEMS AND HAZARDS

- at y piece ,
complete or partial disconnections more readily diagnosed with ascending bellows. Resp. volume Monitors

O flushing

improper sealing leaks hole hyperinflation - barotrauma (high pressure gas enters the circuit ) barotrauma

SCAVENGING SYSTEM
Scavenging is the collection and removal of waste anesthetic gases from the operating room

Gas-Collecting Assembly
Captures excess anesthetic gas and delivers it to the transfer tubing From the APL valve, the ventilator relief valve and from the ventilator drive gas

Transfer Means
Carries excess gas from the gas-collecting assembly to the scavenging interface The tubing must be either 19 or 30 mm The two tubes frequently merge into a single hose before they enter the scavenging interface
Its occlusion can increase baseline breathing circuit pressure: barotrauma can occur

Scavenging Interface
Prevents pressure increase or decrease in the scavenging system from being transmitted to the breathing system Limits the pressure immediately downstream from the gascollecting assembly to between -0.5 and +10 cm H2O Positive-pressure relief is mandatory in all scavenging systems
to vent excess gas in case of occlusion downstream from the interface

If the disposal system is an active system(vacuum), negativepressure relief is necessary to protect the breathing circuit or ventilator from excessive subatmospheric pressure

 Open Interface: contains no valves and is open to the atmosphere, thereby allowing both positive- and negative-pressure relief Should only be used with active disposal systems that have a central evacuation system Open interfaces require a reservoir

 Closed Interfaces: communicates with the atmosphere through valves must have a positive-pressure relief valve to vent excess system pressure if obstruction occurs downstream A negative-pressure relief valve is mandatory to protect the breathing system from subatmospheric pressure if an active disposal system is used

GAS-DISPOSAL ASSEMBLY TUBING

Conducts waste gas from the scavenging interface to the gas disposal assembly

Gas Disposal Assembly

Ultimately eliminates excess waste gas
active or passive

Active assembly: vacuum pump serves as the mechanical flow-inducing device that removes the waste gases
Negative &positive pressure relief valve and reservoir required
Passive disposal system :the weight of the heavier-than-air anaesthetic gases produces flow through the system Negative-pressure relief and a reservoir are not required

SCAVENGING INTERFACE

Open (no valves)

Closed (valves present)

Active disposal (Vacuum)

+ve pressure relief valve

+ve & -ve pressure relief valve

Reservoir required

Passive disposal (weight of the gas)

Active disposal (Vaccum)

Reservoir required

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