anesthesia machine workshopetherweb.bwh.harvard.edu/education/philip/adsworkshop... ·...
TRANSCRIPT
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Anesthesia Machine Workshop
James H. Philip, ME(E), MD, CCE
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Anesthesia Machine Workshop
James H. Philip, ME(E), MD, CCE
Anesthesiologist and Director Bioengineering
Department of Anesthesiology, Pain, and Peri-operative Medicine,
Brigham and Women’s Hospital
Medical Liaison for Anesthesia, Department of Biomedical Engineering
Partners HealthCare System
Associate Professor of Anaesthesia
Harvard Medical School
©
Copyright 2011, James H. Philip, all rights reserved.
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Anesthesia Intranet Site contains all
www.bwhanesthesia.orgEducation
Anesthesia TechnologyEverything
Today (2011-08-18) :Anesthesia Machine Workshop 2011Aisys
Pre-Use Check –
Text and slideshowFabius
Pre-use Check –
Text and slideshow
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Breathing Circuit Review
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The Circle-Absorber System and Fresh Gas Flow
Sampled & measured I, E
ExhaustExpired
CO2
Ab-
sorb-ant
200 mL/min
InspiredFresh Gas
Flow(FGF)
Ventilation Flow
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OR Ventilators
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Old fashioned Uncompensated Bellows Movement
Gas Compression and and tubing expansion
decreased actual tidal volumeFresh gas flow (during inspiration) added to actual tidal volumeOlder Machines
Ohmeda Modulus 2
Draeger Narkomed
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Fresh Gas Flow Independent of Ventilation
1998 - WYSIWYG What You Set
Is What You Get
Set Tidal Volume - patient receives what you set
Two ways to achieve this
GE- Fresh Gas Compensation
Active, feedback-control of inspired tidal volume
Draeger - Fresh Gas Decoupling
Passive separation of FGF during inspiration
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Aestiva Aisys
GE – white with green trim to touch
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Apollo GSFabius
GS
Draeger - white and blue
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Exhaled tidal volume feedbackBellows moves approximately set tidal volumeExhaled volume is measuredNext and subsequent inspired bellows movement changesBellows volume changes based on previous exhaled tidal volumesSmartVent
in GE Aisys
and Aestiva
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GE-Datex- Ohmeda
Aestiva
GE Aestiva
example of all modern GE models
Pneumatic (oxygen)-driven bellows
Inspiratory and Expiratory Flow Sensor
Feedback from flow sensors to bellows drive
Bellows stops pushing when Measured Inspired Tidal Volume =
Set Inspired Tidal Volume
If you press the Flush button Bellows stops
Next breaths are confused
GE has many alarms that stop ventilation
Fresh Gas Compensation
Active, feedback control of inspired tidal volume
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Aestiva VOSAll GE models have
similar differential-pressure flow sensor
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BTW, You only need to slide it out to here to zero the flow sensors
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Flow sensors in manifold
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Flow sensors in manifold
Reversed
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Variable-Orifice flow Sensor (VOS)
Pressure Transducer
P1 P2
Flow
FAccurate over a wide range of flowEach one is calibrated in GE factoryMemory chip stores the calibration curve
P
Variable orifice
GE
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Variable-Orifice flow Sensor (VOS)
Pressure Transducer
P1 P2
Flow
F
P
Variable orifice
This is what makes the SmartVent™
smart
This is GE’s core technology
Accurate over a wide range of flowEach one is calibrated in GE factoryMemory chip stores the calibration curve
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Variable-Orifice flow Sensor (VOS)
Pressure Transducer
P1 P2
Flow
F
P
Variable orifice
One drop of water will make this fail
Accurate over a wide range of flowEach one is calibrated in GE factoryMemory chip stores the calibration curve
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Water Management is important Use an HME or HMEFilter
Heat and Moisture Exchangerbetween patient and circuit
HMEWet Dry
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Empty Aisys water reservoir
Between casesIf full during a caseUnexpected tidal volume readings
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Draeger Ventilation
Virtual Fabius
www.simanest.org
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Draeger Ventilation
Fresh Gas Flow DecouplingPassive separation of FGF during inspiration
Tiro, Fabius, Apollo
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Draeger E-VentDraeger
Fabius
GS, Tiro, or Apollo
Piston
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Fresh Gas Flow decouplingPiston pushes set volume into circuit and lungsFresh gas is stored in reservoir bag during inspirationPiston takes first from reservoir bag Piston takes second from exhaled gasReservoir bag moves with Mech
Vent (V or P mode)
Several phasesDraeger
Fabius, Tiro,
Apollo
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Draeger Circuit
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Draeger
Hot
wire
Anemometer
is cooled
by
flow
Calibrated for heat conductivity. User sets Desflurane Y/N
Fabius –
Used to Display, Expired tidal volume
Apollo –
Sensor #2 Used to measure
and control
inspired tidal volume
Creates “Auto-Flow VV”Same as GE PCVG
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Implications of “Decoupling”
Collateral damageReservoir bag is in the circuit during ventilationAdds a second sequential mixing chamberOld gas stays in-play even when FGF is highThis does not matter much during inductionThis matters a lot during emergenceIn emergence we desire Inspired agent concentration = 0Even with bag ventilation, expired gas contaminates inspired
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Example Fabius, End of case, VCV, FGF = 15 LPM
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Inspired does not = setting even with high FGF (12 LPM)
Set
Set
I
IE
E
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Draeger Circuit
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Draeger has difficulty clearing the last bit of agent
Malignant Hyperthermia PreparationTarget is FI Agent
< 5 ppm Most ADSs require 10 minutesFabius and Apollo require > 1 hour
Inspired Charcoal agent absorber will overcome this
They are on order
Gunter JB, Ball, J Than-Win S. Preparation of the Draeger Fabius Anesthesia Machine for the Malignant–Hyperthermia Susceptible Patient. Anesth Analg 2008;107:1936 –45
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Aisys Inspired = 0 by second breath
3 minutes3 minutes
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GE Circuit
Pneumatic bellows ventilator
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End of Breathing Circuit and Ventilators
Next – Qustions
and Answers
Finally – review of Pre-Use Check