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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