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Anesthesia Delivery Systems What Do I Need to Know About My Machine?
A Workshop
James H. Philip, MEE, MD, CCE Anesthesiologist and Director Bioengineering
Department of Anesthesiology, Pain, and Peri-operative Medicine, Brigham and Women’s Hospital
Medical Liaison, Department of Biomedical Engineering Partners HealthCare System
Associate Professor of Anaesthesia Harvard Medical School
© Copyright 2000-2010, James H Philip, all rights reserved
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Anesthesia Delivery Systems What Do I Need to Know About My Machine?
A Workshop
Answer: A great deal, and more than most of us know.
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Anesthesia Delivery System (ADS)
Life Support with oxygen spontaneous breathing mechanical ventilation
Inhalant Drug Delivery Gas Vapor
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N O2 O2Air
(Continuous Flow) Anesthesia Machine
Vaporizer
1 2 3..
5
21
34
6789
21
34
6789
55
21
34
6789
mL/mL/mL/mL/m
300
200100
400
50
600900
000
IsofluraneSevofluraneDesflurane FGF
(FreshGasFlow)
CommonOutlet
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Anesthesia Machine
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Anesthesia Machine
Schematic
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Anesthesia Machine
Schematic
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O2
2000psi
O2 SERVICE
INLET55psi
35 psi
35 psi
50 or 250ml/min
NEEDLEVALVE
FAILSAFEVALVE
CALIBRATEDVAPORIZERS
Fresh Gas Flow (FGF)
OXYGEN FLUSHVALVE[first]
ON/OFFSWITCH
CHECKVALVE PRESSURE
REGULATOR
N2 OSERVICE
INLET 55 psi
O2
N2 O
FRESHGAS HOSE
Flush Flow(last)
[Anesthetizinggases flow]
COMMON OUTLET
N2 O
750psi
N2 O
750psi
O2
2000psi
FILTER
WALL
DISSdiameter
indexsafetysystem
CONNEC-TION
O2
N2 O
D S I
SIMPLIFIED ANESTHESIA MACHINE SCHEMATIC DIAGRAM
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Patient Breathing Circuit
Allows cyclic flowTo and from the patient
(AKA Breathing)
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A Manual Resuscitator
is one of the few Open Circuit
ventilation systems you will ever use
Manual Resuscitator
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Rebreathing Circuit
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Circle absorption anesthetic breathing circuit
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flipped
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Normal flow in breathing circuit
Flow goes forwardIn the direction of the valvesEmptying and filling reservoir bagand lungsalternately
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Sampled
Exhaust
CO2
Ab- sorb-ant
200 mL/min
Fresh
Normal flow in the breathing circuit - Inspiration
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Sampled
Exhaust
CO2
Ab- sorb-ant
200 mL/min
Fresh
Normal flow in the breathing circuit - Expiration
1
2
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The Circle-Absorber System
ExhaustExpired
CO2
Ab- sorb-ant
InspiredFresh
Gas Flows
VE
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Gas is sampled from circuit near patient for I/E measures
Sampled
ExhaustExpired
CO2
Ab- sorb-ant
200 mL/min
InspiredFresh
Gas Flows
VE
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Low FGF
More rebreathingInspired more dependent on ExpiredInspired less dependent on Vaporizer
View the Breathing Circuit The Circle-Absorber System
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Partial Rebreathing Circuits are used in Anesthesia
Don’t throw away all the exhaled gasIt contains expensive anesthetic vapors Reuse as much as possible
somehow (learn more later) Remove (Absorb) CO2 and Rebreathe the anesthetic
Partial rebreathing = semi-closed circuitAll ADSs use them
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Rebreathing Ventilation
Is not for dummiesRequires knowledge and skillMakes us different from other care providers
EMT, Sedation RN, ED MD, Hospitalist, Others
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Common Outlet for FGF
Common Outlet is a virtual or real location where Fresh Gas Flow (FGF) leaves the Anesthesia Machine and enters the Breathing Circuit
Absent or hidden on new ADSsFGF reaches breathing circuit by a hidden pipe or hose
Common Outlet is a virtual or real location where Fresh Gas Flow (FGF) leaves the Anesthesia Machine and enters the Breathing Circuit
Absent or hidden on new ADSsFGF reaches breathing circuit by a hidden pipe or hose
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Ventilation ModesVCV Volume-Controlled Ventilation
PCV - Pressure-Controlled Ventilation
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Inspiratory Pause
Useful in VCVAllows you to compute Static ComplianceAllows you to see the effect of resistance
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Inspiratory Pause
Useful in VCVAllows you to compute Static ComplianceAllows you to see the effect of resistance
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Inspiratory Pause
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Alarms
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Alarms
Level Sound Text LEDWarning continuous !!!
Red blinkingCaution
q 30 sec
!!
Yellow blinkingAdvisory
once
!
Yellow continuous
Silence button silences for two minutes
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Fabius Pressure Monitoring to detect disconnection
RulesIf peak pressure exceeds the pressure threshold every 15 seconds then the ventilator is not disconnected
If peak pressure does not cross pressure threshold for 15 seconds there is apnea based on failure to meet the pressure criterion - APNEA PRESSURE alarm sounds and flashes
If pressure threshold is more than 6 cmH2O below peak pressure, PRES THRESHOLD LOW advisory lights up
Press AUTO SET to set pressure threshold to 4 cmH2O below peak pressure. Alarm is now properly sensitive to apnea
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PRESSURE THRESHOLD LOW alert
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APNEA PRESSURE alarm
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Fabius Sample Gas Return Port Can leak
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Fabius Sample Gas Return Port Can leakFabius has a new Sample Gas Return Port
A new solution A new problem
New solution - very low and closed circuit fresh gas flow is OK Sampled airway gas (300 mL/min) is returned to circuit New, built-in connection in Absorber Assembly Self sealing so it is OK if not connected
New problem If sample gas return tubing is connected to circuit but is not connected to Gas Monitor Circuit gas leaks out the Sample Gas Return tubing > 350 mL / min Fails leak test
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Fabius fails leak test
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Here is the leak
1 Sample Gas Return Port is opened by connector
2 Tubing is disconnected
3 Later, connected here
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Here is the leak
Later, connected here
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Disconnect Sample Gas Return Connector from circuit to seal connector
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No Leak
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Sample Gas Return and Gas Sample can both connected during leak test
No loss or gain of volume from circuit. Sample gas to Monitor
Return gas from Monitor
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Still get no Leak
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Fabius Sample Gas Return Port Can leakSAM (Smart Anesthesia [Gas] Monitor) has Sample Gas Outlet
Formerly connected to ScavengerSample Gas Return connector on absorber self-seals
Leave connector and tubing disconnected during leak testConnecting Sample Gas Return Connector opens seal and leaks
Leave it disconnected during leak testOption 2Connect both Sample Gas and Sample Gas Return tubingsA Connect Sample Gas Return Tubing from SAM to AbsorberB Connect Gas Sample line to breathing circuit YNo gain and no loss of volume. Thus, no leak
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Advanced Ventilation Modes
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Modes available on 7900 Smart Vent for AISYS:
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New Ventilation Mode
Pressure-cycled, Volume-controlledGE calls it Pressure Control Volume Guarantee
PCV - VGDraeger calls it Volume Ventilation with Auto-Flow
V V - Auto Flow
Pressure Ventilation but delivers the Tidal Volume you setUseful in Laparoscopy where compliance changes but, you want constant tidal volume and, you want constant-pressure breathsHigh-end machines only
No: GE Aestiva, Aespire Draeger Tiro, Fabius Yes: GE Avance, Aisys Draeger Apollo
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Pressure Control Ventilation Volume Guarantee
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Breathing Circuit FGF
Interaction or
Lack thereof
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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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Low FGF Saves money because of less wasteLimits our ability to control inspired concentration
Therefore limits control of expired conc. and brain conc.
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1998
Better ventilation for difficult patients FGF-independent ventilation Corrects for circuit leaks Corrects for circuit compliance
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< 2000, Standard Anesthesia Ventilators
Tidal Volume and FGF were interdependentIncrease FGF and Tidal Volume increased
by the amount of fresh gas that flowed during inspiration
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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 thisFresh Gas Compensation
Active, feedback control of inspired tidal volume GE
Fresh Gas Decoupling Passive separation of FGF during inspiration Draeger
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GE-Datex- Ohmeda Aestiva
GE-Datex-Ohmeda Aestiva and all other models
Pneumatic (oxygen)-driven bellows
Inspiratory and Expiratory Flow Sensors
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
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Aestiva VOSAll GE models have similar differential-pressure flow sensor
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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 factory
P
Variable orifice
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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 factory
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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 factory
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Water Management is important Use an HME or HMEF
Heat and Moisture Exchangerbetween patient and circuit
HMEWet Dry
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Draeger E-VentDraeger Fabius GS
Piston
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Ventilator
Piston
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Fresh Gas Flow Decoupling
During Inspiration Piston pushes gas into lungs Fresh Gas fills Reservoir Bag
During Expiration Lungs empty into Reservoir Bag fast Fresh Gas Flow fills Reservoir Bag slow and constant Piston draws gas from Reservoir Bag simultaneously
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Flow sensor
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Measured Tidal Volume
EXHALED tidal volumeUsually slightly smaller than SET tidal volumeRQ (Vdot CO2 / VdotO2 = 0.8)No alarm on error
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Hot wire
Anemometer is cooled
by flow
Used to Display, not to controltidal volume.
Calibrate for heat conductivity.
Set Desflurane
Y/N
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Fabius has a Water Trap
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Empty the water trap in Fabius ventilator hose
Before using Fabius Observe and empty if full during case
Failure to do this will result in Alarms and Ventilator Failure
Beware of full Water Trap
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First alarm is an incorrect one - Low Fresh Gas Flow
Fabius has misinterpreted what is wrongPiston trying to refill encounters a negative pressure equal to depth of water pool
Negative piston pressure usually means reservoir bag is empty and FGF is low
Low Fresh Gas Flow alarms sounds
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Draeger Ventilation
Fresh Gas Flow DecouplingTiro, Fabius, Apollo
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Mechanical VentilationPiston displacement is constant and provides constant Tidal VolumeFresh Gas fills the reservoir bag during inspiration (“decoupled”)Piston draws in Fresh and Exhaled gas during “refill” in expirationPiston is ready to give the next breath
Draeger Fresh Gas Flow Decoupling
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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 = 12 LPM
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Inspired does not fall to zero
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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 can overcome this)
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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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 can overcome this)
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
Fabius and Apollo are similar
Draeger has not solved it yet
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GE breathing circuits are fasterInductionEmergence
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Constant Volume FGF Decoupling
COSY-2.5
EI
I/ E select
Draeger Fabius and
Apollo CircuitInsp Valve
CircuitExp Valve
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GE Circuit configuration superimposed on
Draeger Circuit
I/E
I/ E select
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GE Circuit
Pneumatic bellows ventilator
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Sevoflurane Induction
High FGF and vaporizer setting
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Second Breath, Inspired = Vaporizer setting
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Tight control of inspired is most important during emergence
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02/27/07 BWH OR Boston6 hour Robot-assisted,Radical hysterectomy, w lymph node dissection
6 hour graphic trend
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02/27/07 BWH OR Boston6 hour Robot-assisted,Radical hysterectomy, w lymph node dissection
Zoom in to 1 hour trend
23
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Better to understand this with slow wave (3 min)
3 minutes3 minutes
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None of this works without power Power switch is with power cord
on back of ADS
Fabius Aisys
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ObservationsGE Circuit is fast Draeger Circuit is slow - use very high FGF for emergence
GE Ventilation Control depends on flow measurements and water makes it fail Draeger Ventilation physically decouples Piston from FGF. Always correct
GE Ventilator ends inspiration when P = Pmax setting, failing and alarming Draeger Vent continues inspiration when P =Pmax, succeeding & alarming
GE Flush will confuse ventilator for the next few breaths of feedback control Draeger Flush is OK any time during mechanical ventilation
GE offers electronic vaporizers with accuracy, agent use, but a total failure mode Draeger mechanical vaporizers do not fail but do not record and display agent use
GE does not return sampled gas to the breathing circuit Draeger returns sampled gas to the breathing circuit and allows true closed circuit
GE Aisys has many ventilation modes Draeger Fabius has VCV, PCV, and some have PSV Draeger Apollo has many ventilation modes All BWH Ventilators have Inspiratory Pause to calculate Compliance & Resistance
Neither GE nor Draeger has a convenient Fresh Gas Outlet you can connect to
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Thank you
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Now, your observations and questions
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End