Prof.
A K Sethis EORCAPS 2008
Prof. A K Sethis EORCAPS 2008
ANAESTHESIA MACHINE
Purpose of Anaesthesia Machine
To Select & mix measured flow of gases to
vapour and administer gases safely
To allow placement of drugs and devices which
are for immediate use
To serve as a frame for placement of various
accessories such as ventilator and monitor
Dr. RAJIV GAMBHIR
Prof. A K Sethis EORCAPS 2008
Prof. A K Sethis EORCAPS 2008
High Pressure System
Pressure Division of Machine
Intermediate Pressure System
High Pressure
Cylinder - O2: 2000 PSI, N20: 750 PSI
Pressure reducing device
Intermediate Pressure
Cylinder 35 50 PSI
Pipe line 45-60 PSI
Low Pressure
14 20 PSI
Prof. A K Sethis EORCAPS 2008
Brief Note on Cylinder
Pipeline Connections
Pipe / Cylinder Pressure Gauge
Gas power outlet
Master Switch
Oxygen Pressure alarms
Oxygen flush
Flow Control Valves
Low Pressure System
flow meter
Hanger yoke assembly
Cylinder Pressure Gauge
Pressure reducing device
Flow meters
Vapourizer circuit central valves
Back pressure safety devices
Low pressure pipe line
Common gas outlet
Prof. A K Sethis EORCAPS 2008
Capacity of Cylinder
Compressed gas cylinder: material / mixture container
at an absolute pressure exceeding 40 pounds / Sq inch at
70oC
Size: Letter A to G - with size increasing
Construction: Steel with chrome molybdenum, which
makes it 20% lighter
Service pressure: The pressure at which gas is
pressurized the cylinder should be able to withstand
1.66 times the service pressure
Woods metal: Each valve stem has a safety device
which allows the cylinder to become exhausted during
excess heat / pressure - bismuth, lead, tin, cadmium
Prof. A K Sethis EORCAPS 2008
High pressure system
Prof. A K Sethis EORCAPS 2008
High pressure system
Hanger Yoke Assembly
Hanger yoke assembly is to:
Pin Index Safety System
BODY
1. Orient and support the cylinder,
2. Provide a gas tight seal and
3. Ensure unidirectional flow of gases to
machine parts of yoke
SCREW
Hanger yoke assembly consists of:
1. Body which is threaded into the frame
of machine
2. Retaining screw which tighten the
cylinder in the yoke
3. Nipple
4. Index Pins
5. Washer
O2: 2 & 5
INDEX
PINS
CO2: 1 & 6
Prof. A K Sethis EORCAPS 2008
High pressure system
Prof. A K Sethis EORCAPS 2008
High pressure system
Pressure Gauge
Components:
Pressure Regulator
38 mm
1. Diameter 38 mm
2. A robust flexible coiled tube in
cross section
3. Tube sealed at inner end and
connected to needle pointer
4. Other end open to gas supply
Safety features:
N2O: 3 & 5
NIPPLE
WASHER
Purpose:
To deliver gases at constant pressure to patient and
maintain constant flow
Types:
1. Pneumatic balance
2. Demand valve
a. fixed pressure
b. adjustable spring pressure
RESTING
POSITION
1. Colour coded / calibrated
2. During sudden increase in
pressure, gas vents to
atmosphere from the back
Mode of working:
Analogy two children of different weight on a teeter
totter balancing each other
Prof. A K Sethis EORCAPS 2008
High pressure system
Pressure Regulator
Prof. A K Sethis EORCAPS 2008
High pressure system
Pressure Regulator
A pneumatic balance is one in which
the torque form a high pressure side
is balanced against the torque form a
low pressure side
The torque on the high pressure side
is force times lever arm
Force is the product of pressure and
area
The lever arm is d1
Thus a high pressure acting over a
small area and a short lever arm may
be balanced by a lower pressure
operating on a large area with a large
lever arm d2
Prof. A K Sethis EORCAPS 2008
Intermediate pressure system
Prof. A K Sethis EORCAPS 2008
Intermediate pressure system
Central Pipelines & Connections
Oxygen Pressure Failure Protection
The fail safe device
O2
AIR
N20
VACUUM
GAS SPECIFIC WALL OUTLETS
NON INTERCHANGEABLE SCREW
THREAD (NIST)
ensures that:
"Whenever oxygen pressure reduces and until flow ceases,
the set oxygen concentration shall not decrease
at the common gas outlet"
In addition, the loss of oxygen pressure results in
alarms, audible and visible
Fail-safe systems don't prevent hypoxic mixtures,
Which is a function of Hypoxic Guards
Prof. A K Sethis EORCAPS 2008
Intermediate pressure system
Prof. A K Sethis EORCAPS 2008
Intermediate pressure system
Oxygen Pressure Failure Protection
Oxygen Pressure Failure Protection...
Pressure sensor shut off valve:
At 20 psi oxygen, the flow of all
other gases are shut off
Oxygen failure protection device (OFPD):
Flow is reduced proportionally
Second-stage O2 pressure regulator:
Ensures constant oxygen flowmeter
input until supply pressure is less
than 12-16 psi
Oxygen ratio monitor controller (ORM):
It shuts off nitrous oxide when
oxygen pressure is less than 10 psi
Prof. A K Sethis EORCAPS 2008
Intermediate pressure system
Oxygen Flush Valve
Prof. A K Sethis EORCAPS 2008
Intermediate pressure system
Oxygen Flush Valve
Objective:
To supply 100% oxygen
at high flow rates (35 75 lt / min) & at intermediate pressure
Standards:
Single purpose for oxygen only
Self closing
Permanently marked
Placed in a recess / collar
Should not produce back pressure effects
Hazards:
Baro trauma
Altered anaesthetic gas concentration
Prof. A K Sethis EORCAPS 2008
Intermediate pressure system
Prof. A K Sethis EORCAPS 2008
Intermediate pressure system
Flow Control (Needle) Valve
Flow Control Valve
Electronic flowmeters:
Flow rate is indicated with a bar graph on
a monitor screen
Standards:
Placed below flow meter
Colour coded
Touch coded
Separated by 2.5 cm
Opened anti-clock wise
Electronic flowmeters allow automated
anesthesia record-keeping
5-10 times more accurate
Prof. A K Sethis EORCAPS 2008
Intermediate / Low pressure system
Prof. A K Sethis EORCAPS 2008
Low pressure system
Flow Control Valve
Flow meters
Principle of working:
Float is buoyed by flowing gas that
passes between the float and walls of
the tube
Narrowing of cross sectional area at the
float creates resistance to flow and
causes pressure drop
Float will settle where the force
represented by pressure difference
multiplied by cross section area equals
to gravity
Purpose is to measure flow
Early flow meters:
Tube under water
Inside water meter
Outside water meter
Rate of flow depends upon:
Pressure drop wt. Of float / cross
section area
Size of opening
Physical properties of gas normally
calculated at 760 mmHg at 20oC
F1 = Fo X do / d1
Prof. A K Sethis EORCAPS 2008
Low pressure system
Prof. A K Sethis EORCAPS 2008
Low pressure system
Flow meters
Hypoxic Guard
Modern Flow meter:
Variable angle & constant pressure
Extended range flow meters:
Dual taper
Dual floats
In series
In parallel
Flow meter with 25 : 75
design
DUAL TAPER
DUAL FLOATS
IN SERIES
Mandatory minimum oxygen
flow
Minimum oxygen ratio device
Slave Mechanism
Link 25
1. Mechanical linkage
2. Pneumatic linkage
Prof. A K Sethis EORCAPS 2008
Prof. A K Sethis EORCAPS 2008
Low pressure system
Safety Features of Anaesthesia Machine
Other Components
Back bar (Selectatec)
Back pressure safety devices
Bulk storage / pipe line supply:
Indicators system / Service area alarms
Shut off valves
Gas specific wall outlets
Cylinders:
An Empty Selectatec Bar
Selectatec Series Mounted Manifold Bypass Circuit
DISS for large cylinders
PISS for small cylinders
Relief valves woods metal
Colour coding of cylinder
A Non Return Pressure
Relief Valve
Prof. A K Sethis EORCAPS 2008
Prof. A K Sethis EORCAPS 2008
Safety Features of Anaesthesia Machine
High pressure system:
Safety Features of Anaesthesia Machine
Vapourizers
Pressure regulating valves
Pressure relief valves
Construction of advanced Tec series
Bimetallic strip for temp. compensation
Colour coded Key filling system
Intermediate pressure system:
Gauges of manometer
Low oxygen pressure cut off systems
Miscellaneous
Low pressure systems:
Antistatic wheels
Flow meters
Placement of knobs at distance
Down stream placement of knob
Back light display
Link devices
Back pressure check valves
Audible alarms etc
This list is by no means exhaustive and newer anaesthesia
machines have added lots of new features
to enhance the safety
Prof. A K Sethis EORCAPS 2008
Prof. A K Sethis EORCAPS 2008
New Concerns Regarding
Modern Machines
Newer Safety Features
Reduced external connections: internal modular or
manifold
Electronic control and measurement of vaporization
(Anaesthesia delivery units)
Automated checkout and monitoring
Streamlined communication with information management
systems (IMS)
Consumption of oxygen from an open cylinder ?
Monitor of ventilation in a hidden-piston ventilator ?
Emergent and rapid initiation of the machine ?
Wrong agent into a vaporizer ?
Mixture of modern and conventional machines ?
Prof. A K Sethis EORCAPS 2008
New Solutions to Old Problems
Might Raise New Problems
Prof. A K Sethis EORCAPS 2008
Critical Incidents
1980
HENCE
WE MUST ALWAYS REMAIN
EDUCATED
PREPARED
AND
VIGILANT
TO AVOID CRITICAL INCIDENTS
90
80
70
60
50
40
30
20
10
0
81
TOTAL
MISADVENTURES
53
HUMAN ERROR
27
FAILURE TO
CHECK
ANAESTHESIA
MISADVENTURES
Craig & Wilson (1981)
Prof. A K Sethis EORCAPS 2008
1980
Critical Incidents
1980
1200
Prof. A K Sethis EORCAPS 2008
1089
1000
TOTAL
MISADVENTURES
800
600
400
223
200
1.
2.
3.
FAILURE TO
CHECK
0
ANAESTHESIA
MISADVENTURES
4.
Cooper et al (1984)
5.
How Well Are Equipment
Faults Recognized?
190 Attendees
To Identify Five Deliberate Faults
Within 10 Minutes
Discs Removed From Unidirectional Valves
Pin Index System Altered To Allow O2/n2o Switch
Oxygen-failure Shut-off Valve Disabled So That Nitrous
Oxide Continued To Flow When Oxygen Source Pressure
Fell To Zero
Cyclopropane And Oxygen Flowmeter Tubes Interchanged,
Reducing Oxygen Flow To 10% Of Indicated
Halothane Vaporizer Filled With Methoxyflurane
Prof. A K Sethis EORCAPS 2008
How Well Are Equipment
Faults Recognized?...
1980
200
180
160
140
120
100
80
60
40
20
0
190
1980
100%
TOTAL
PARTICIPANTS
SUCCESSFUL
PARTICIPANTS
UNSUCESSFUL
PARTICIPANTS
6
13
PARTICIPANTS
80%
Prof. A K Sethis EORCAPS 2008
56
How Well Are Equipment
Faults Recognized?
188 Anaesthesiologists
To Identify Four Deliberate Faults In Two Machines
Number Of Faults Were Not Known To Them
PERSONAL CHECKLISTS Vs. FDA 1986 Checklist
50
60%
NOT DETECTED
45
40%
DETECTED
40
20%
44
35
30
PERSONAL
CHECKLIST
FDA 1986
CHECKLIST
29.9
25.8
25
0%
FAULT DETECTION
20
15
10
FAULT DETECTION
Buffington et al. (1984)
March & Crowley (1991)
Prof. A K Sethis EORCAPS 2008
Pre-use Training
1990
81%
62%
PRE-TRAINING
POST-TRAINING
RESIDENTS
Survey Of Pre-use Check
2000
A Test Group Of 16 Residents Were Exposed To
Instructional Review (Including Videotaped Sessions)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Prof. A K Sethis EORCAPS 2008
This
Performance Improvement
Underlines The Need For
Training
Required For
Anaesthesioloists On A
Continuous Basis
To
Enhance
Patient Safety
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
100%
80%
29%
50
60%
POOR
EXCELLENT
12%
DONE
NOT DONE
40%
20%
50
0%
TRAINING
RESPONDERS
WORLD WIDE WEB, Lampotang et al (2005)
Olympio et al. (1996)
Prof. A K Sethis EORCAPS 2008
Prof. A K Sethis EORCAPS 2008
Anaesthesia Machine
Pre-use checklists
Modified Anesthesia Machine
Pre-use Checklist FDA 1993
The Anesthesia Gas Machine Must Be Equipped with:
An Ascending Bellows Ventilator
FDA GUIDELINES 1986
REVISED FDA GUIDELINES 1993
AAGBI GUIDELINES
EUROPEAN GUIDELINES
NO GUIDELINES IN INDIA
&
Monitors (5)
Capnograph
Pulse Oximeter
Oxygen Analyzer
Spirometer
Breathing System Pressure Monitor
If Not So Equipped, The Checklist Must Be Modified suitably
Prof. A K Sethis EORCAPS 2008
Prof. A K Sethis EORCAPS 2008
Modified Anesthesia Machine
Pre-use Checklist FDA 1993
1.
2.
3.
4.
5.
6.
7.
Verify Backup Ventilation Equipment
Check Oxygen Cylinder Supply (One Cylinder Must Be
At Least Half Full~ 1000 Psi )
Check Central Pipeline Supplies
Check Initial Status Of Low Pressure System
Perform Leak Check Of Low Pressure System
Turn Master Switch On
Test Flowmeters
Modified Anesthesia Machine
Pre-use Checklist FDA 1993
8.
9.
10.
11.
12.
13.
14.
Calibrate Oxygen Monitor
Check Initial Status Of Breathing System
Test Ventilation Systems And Unidirectional Valves
Perform Leak Check Of Breathing System
Adjust And Check Scavenging System
Check, Calibrate, Set Alarm Limits Of All Monitors
Check Final Status Of Machine
